Incidence Rate and Prevalence of Systemic Sclerosis and Systemic Sclerosis-Associated Interstitial Lung Disease in Japan: Analysis Using Japanese Claims Databases

Epidemiology of systemic sclerosis in the Asia-Pacific region: a systematic review and meta-analysis

BACKGROUND

The epidemiological profile of systemic sclerosis (SSc) in the population in Asia-Pacific countries might help in planning for improved future care and research direction.

OBJECTIVES

We aimed to estimate the pooled incidence and pooled prevalence of systemic sclerosis (SSc) in Asia-Pacific countries.

METHODS

We conducted and reported the systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement of 2020. Databases searched include PubMed, SCOPUS, CINAHL, and ProQuest, and hand searching, with a focus on publications from 1 January 2000 to 31 July 2023.

RESULTS

A total of 456 records were identified from the searches, 10 articles were included for review: six reported the incidence of SSc; nine reported the prevalence of SSc. We noted considerable heterogeneity. Subgroup analyses categorized by the period of study before and after the launch of the 2013 ACR/EULAR Classification Criteria for SSc demonstrated that both incidence and prevalence of SSc were significantly different between subgroups. The incidence of SSc before and after the launch was 1.85 per 100,000 (4 studies, I2 = 100%, 95%CI 0.53-6.40) and 9.61 per 100,000 (2 studies, I2 = 100%, 95%CI 4.90-18.85), respectively. The prevalence of SSc before and after the launch was 6.47 per 100,000 (6 studies, I2 = 97%, 95%CI 5.09-8.21) and 18.48 per 100,000 (3 studies, I2 = 100%, 95%CI 7.19-47.50), respectively.

CONCLUSION

The epidemiology of SSc varied widely across the Asia-Pacific region depending on the study methodology and study period. The incidence of SSc in the Asia-Pacific region was estimated to be higher after the launch of the new classification criteria.

Rituximab in systemic sclerosis-associated interstitial lung disease: A systematic review and meta-analysis

BackgroundSystemic sclerosis-associated interstitial lung disease (SSc-ILD) is a prominent form of connective tissue disease-associated interstitial lung disease with high prevalence and poor prognosis. The therapeutic use of corticosteroids is often limited, and the efficacy of conventional treatment may be suboptimal in certain cases. This systematic review and meta-analysis assessed the clinical effects of rituximab in SSc-ILD compared to conventional treatments and investigated potential clinical benefits in patients with disease progression despite conventional therapy.MethodsA comprehensive literature search was conducted in Ovid MEDLINE®, Cochrane Library, EMBASE, and KoreaMed databases to identify studies on rituximab in adult SSc-ILD patients. Comparative studies with complete trial results were included. The primary outcome was the effect of rituximab on disease progression, measured by the change in forced vital capacity (FVC) compared to conventional treatments.ResultsFrom 940 articles, six studies (two randomized, four non-randomized) were included for analysis. Standardized mean differences (SMD) were used in analyses due to the varied durations of the included studies. The meta-analysis demonstrated that rituximab reduced the FVC decline in patients with SSc-ILD compared to conventional treatment (SMD 0.65; 95% confidence interval, 0.08-1.22, P = .03), though no significant differences were found in lung diffusing capacity or modified Rodnan skin score. Rituximab showed a significantly lower incidence of leukopenia compared to cyclophosphamide (P = .02) and showed a non-significant trend toward fewer instances of pneumonia and urinary tract infections.ConclusionsThe meta-analysis revealed that rituximab may be clinically beneficial in SSc-ILD that progresses despite conventional treatment. Further research is necessary to validate the clinical benefits of rituximab in SSc-ILD.

Physician-patient communication in the treatment of systemic sclerosis-associated interstitial lung disease: A narrative review and recommendations

Interstitial lung disease is a common complication and cause of mortality in patients with systemic sclerosis. Pharmacotherapy for systemic sclerosis-associated interstitial lung disease was mostly limited to off-label use of immunosuppressive drugs until recently, when two drugs became licenced for this condition: nintedanib, an antifibrotic agent, and tocilizumab, a targeted anti-inflammatory/immunomodulatory therapy licenced in the United States. In chronic diseases, communication between physicians and patients is associated with treatment adherence, patient satisfaction, and clinical outcomes. This review of physician-patient communication during systemic sclerosis-associated interstitial lung disease treatment covers key issues identified by studies in Japan, the United States and Europe, as well as the clinical experience, opinion, and recommendations of the physician and patient advocate authors. As discussed, recent surveys in Japan found low usage of guideline-recommended immunosuppressive drugs for systemic sclerosis-associated interstitial lung disease and physician dissatisfaction with them. Physicians and patients in Japan also had differing perceptions about what had been said during consultations, suggesting the need to improve physician-patient communication. Other studies in Japan, the United States and Europe made several key findings. Notably, most patients feel uneasy at the diagnosis of systemic sclerosis-associated interstitial lung disease, and both physicians and patients avoid discussing prognosis and mortality. Furthermore, a white-coat barrier hinders patients raising topics important to them. For physicians, listening and empathy may be key for building rapport with patients. Importantly, physicians and patients have different cognitive models of systemic sclerosis-associated interstitial lung disease, creating communication challenges. There are also similarities and differences in clinical practice and physician-patient communication between countries that are important to consider. From the patient's perspective, key factors include the quality of the first consultation, physician empathy and active listening, and space to ask questions. Efforts to improve physician-patient communication include peer mentoring, patient self-education (such as the 'Self-Manage Scleroderma' website from the University of Michigan), and shared decision-making - although not all activities will necessarily be appropriate everywhere.

Quantitative Assessment of Systemic Sclerosis-Related Interstitial Lung Disease via 3D-Imaging

BACKGROUND AND OBJECTIVE

Interstitial lung disease (ILD) is a leading cause of morbidity and mortality in patients with systemic sclerosis (SSc). The disease course of SSc-related ILD (SSc-ILD) is heterogeneous, and several risk-based models have been developed. This study aimed to quantitatively measure volume loss and disease extent and subsequently evaluate their associations with the development of end-stage lung disease (ESLD).

METHODS

Lung volume (LV) and disease extent were retrospectively and quantitatively evaluated in two cohorts (exploratory: n = 70; validation: n = 42) using high-resolution computed tomography at the time of SSc-ILD diagnosis, compared to controls (n = 70). LV was quantitatively measured using three-dimensional imaging (3D-image) and standardised by predicted forced vital capacity (standardised LV). The ratio of the normally attenuated LV (range, -950 to -750 Hounsfield units) to the whole-LV (NL%) was also measured using 3D-image. The associations of these variables with ESLD were evaluated.

RESULTS

Volume loss and normal lung area loss were noted in patients with SSc-ILD compared with controls, especially in the lower lobes. Meanwhile, extended ILD lesions without volume reduction were observed in the upper lobes. Both decreased standardised LV and NL% were associated with ESLD development, and age and NL% were significant risk factors for ESLD independent of pulmonary function test parameters and standardised LV. A composite model consisting of age and NL% successfully stratified patients with SSc-ILD based on the risk of ESLD.

CONCLUSION

3D-image may be a useful technique for assessing disease severity and predicting the risk for ESLD in patients with SSc-ILD.

A scoping review of the epidemiology of systemic sclerosis and its organ manifestations: 2018-2024

PURPOSE OF REVIEW

Updates from large, observational cohorts and new statistical techniques have resulted in new data on the epidemiology of systemic sclerosis (SSc). This scoping review uses data from 2018 to 2024 to describe the current understanding of the epidemiology of SSc and several of its organ- manifestations.

RECENT FINDINGS

Our review identified new estimates for the global incidence and prevalence of SSc (1.4-8.6 per 100 000 person-years and 17.6-18.9 per 100 000 individuals, respectively). Mortality rates remain high, though mortality at younger ages has decreased. interstitial lung disease and pulmonary arterial hypertension remain the most common causes of death for patients with SSc. Literature on gastrointestinal (GI) manifestations of SSc was scarce, and we identified significant heterogeneity in results. Furthermore, data on the epidemiology of racial, ethnic and sex-based disparities was lacking.

SUMMARY

New techniques for the evaluation of the epidemiology of SSc highlight the high morbidity and mortality of SSc, and a growing prevalence rate compared with prior eras. Further research is needed to address notable heterogeneity in the reporting of epidemiological data and understudied disease manifestations, including GI disease and health disparities in disease outcomes.

Epidemiology of narcolepsy and idiopathic hypersomnia in Japan: A retrospective analysis of health insurance claims from the Japan Medical Data Center

BACKGROUND

Estimation of prevalence and incidence of narcolepsy and idiopathic hypersomnia (IH) is challenging owing to symptomatic overlap, underdiagnosis, and misdiagnosis, and epidemiological data are lacking in Asian populations. We estimated the prevalence and incidence of narcolepsy and IH in Japan.

METHODS

The Japan Medical Data Center (JMDC) database includes healthcare claims data for employed individuals ≤74 years of age. Narcolepsy and IH cases were defined by ≥2 diagnosis codes within 12 months, or a multiple sleep latency test with ≥1 diagnosis code within 12 months. Estimated point-prevalences of diagnosed narcolepsy and IH were calculated for December 31, 2019. Incidences of narcolepsy and IH were estimated for the period January 1, 2014 to December 31, 2019.

RESULTS

Of 7,075,869 individuals enrolled in the database on December 31, 2019, 6,110,751 (86.4 %) had ≥12 months' continuous enrollment and were eligible for inclusion in the prevalence population. Age-sex standardized overall prevalences of narcolepsy and IH were 37.5 (95 % confidence intervals 35.9-39.1) and 7.7 (7.0-8.4) per 100,000 persons, respectively. Prevalence for both conditions peaked at age 20-29 years and declined with increasing age. Age-sex standardized overall incidences of narcolepsy and IH were 5.1 (4.8-5.4) and 1.2 (1.0-1.5) per 100,000 person-years, respectively. Narcolepsy and IH incidences peaked in the 10-19 and 20-29 years age groups then declined with increasing age.

CONCLUSIONS

This claims-based study provides updated estimates for the prevalence and incidence of narcolepsy in Japan, and the first estimates for prevalence and incidence of IH in Japan.

Efficacy and safety of tocilizumab in Japanese patients with systemic sclerosis and associated interstitial lung disease: A subgroup analysis of a global, randomised, controlled Phase 3 trial

OBJECTIVES

The aim of this article is to investigate the efficacy and safety of tocilizumab in Japanese patients with systemic sclerosis.

METHODS

Post hoc subgroup analysis of a global, randomised, controlled trial in patients treated with weekly tocilizumab 162 mg or placebo subcutaneously in a 48-week double-blind period (tocilizumab and placebo groups) followed by tocilizumab for 48 weeks in an open-label extension (continuous-tocilizumab and placebo-tocilizumab groups).

RESULTS

Among 20 patients, 12 were randomised to tocilizumab (all had interstitial lung disease) and eight were randomised to placebo (six had interstitial lung disease). The modified Rodnan skin score improved in both treatment groups. The mean change in percent-predicted forced vital capacity was 3.3% [95% confidence interval (CI), -2.5 to 9.0] for tocilizumab and -3.8% (95% CI, -9.9 to 2.2) for placebo in the double-blind period and 2.0% (95% CI, -0.7 to 4.6) for continuous-tocilizumab and -1.4% (95% CI, -6.7 to 4.0) for placebo-tocilizumab in the open-label extension. Rates of serious adverse events per 100 patient-years were 19.3 for tocilizumab and 26.8 for placebo in the double-blind period and 0.0 for continuous-tocilizumab and 13.6 for placebo-tocilizumab in the open-label period.

CONCLUSIONS

The efficacy and safety of tocilizumab in patients with systemic sclerosis were consistent between the Japanese subpopulation and the global trial population.

Characteristics and risk factors of mortality in patients with systemic sclerosis-associated interstitial lung disease

BACKGROUND

Systemic sclerosis (SSc) is a heterogeneous autoimmune disease characterized by dysregulation of fibroblast function, which often involves the lungs. Interstitial lung disease (ILD) associated with SSc (SSc-ILD) is a major cause of death among patients with SSc. Our study aimed to identify risk factors for mortality and compare the clinical characteristics of patients with SSc-ILD.

PATIENTS AND METHODS

Patients were retrospectively enrolled between 2010 and 2018 in a tertiary hospital in Korea. Patients with SSc-ILD were classified depending on the first pulmonary function test or radiologic findings: extensive (n = 46, >20% disease extent on computed tomography (CT) or forced vital capacity [FVC] < 70% in indeterminate cases) and limited (n = 60, <20% disease extent on CT or FVC ≥70% in indeterminate cases).

RESULTS

Patients in the extensive group were younger (mean age ± SD 49.3 ± 11.5) than those in the limited group (53.9 ± 12.5, p = .067) at diagnosis. The extensive group showed frequent pulmonary hypertension (43.5% vs. 16.7%, p = .009) and higher erythrocyte sedimentation rate (61.3 ± 33.7 vs. 42.1 ± 26.0, p = .003) and mortality (32.6%, mean duration of follow-up, 100.0 ± 44.7 months vs. 10.0%, 86.0 ± 53.4 months, p = .011). ILD was detected within five years from the first visit (median years 3.5 (1.0, 6.0) vs. 4.5 (0.6, 9.0), survivors vs. non-survivors), and mortality occurred in 19.8% of all patients during a 15-year follow-up. Older age, lower FVC, and initial disease stage (limited or extensive) were associated with mortality, but FVC decline was similar in the limited and extensive groups, such as 15-20% in the first year and 8-10% in the next year, regardless of the initial extent of the disease.

CONCLUSIONS

Approximately 10% of patients with SSc-ILD in the limited and extensive group showed progression. ILD was detected at a median of less than five years from the first visit; therefore, it is necessary to carefully monitor patients' symptoms and signs from an early stage. Long-term surveillance is also required.Key messagesPatients with systemic sclerosis-interstitial lung disease manifested a heterogeneous disease course.Approximately 10% of the patients in the limited group showed progression, which was similar to the proportion of patients in the extensive group.Interstitial lung disease was detected at a median of less than five years from the first visit.

Prevalence, Incidence, and Clinical Characteristics of Thyroid Eye Disease in Japan

Background

Although thyroid eye disease (TED) can impact social and psychological well-being, the epidemiological evidence of TED is lacking in Japan.

Methods

Nationwide claims databases provided by JMDC Inc. and Medical Data Vision Co., Ltd. and national population statistics are used. Three TED definitions ranging from a strict definition only including a TED diagnosis to a broad definition including a TED diagnosis and considering ocular symptoms are considered. The proportion of patients by severity and disease activity are estimated based on definitions that would allow identification of those patients within the claims data.

Results

The incidence rate per 100 000 person-years ranged from 7.3 to 11.1 for the strict and broad TED definitions, respectively. For fiscal year 2020 (April 2020 to March 2021) the prevalence rate ranged between 24.65 (strict TED) and 37.58 (broad TED) per 100 000 persons. These correspond to 25 383 and 38 697 patients for the strict and broad TED definitions, respectively. Regardless of the definition used, a predominance of female patients was observed, and the highest burden of the disease was seen in the age group of 35 to 59. Mild and inactive forms of TED were predominant (about 85% and 74%, respectively).

Conclusion

The incidence and prevalence of TED in Japan were 7.3 to 11.1 per 100 000 person-years and 24.65 to 37.58 per 100 000 persons, respectively. The robust results of this database study add valuable real-world evidence on the incidence and prevalence of TED in Japan.

Metabolic fingerprinting of systemic sclerosis: a systematic review

Introduction: Systemic sclerosis (SSc) is a chronic autoimmune disease, marked by an unpredictable course, high morbidity, and increased mortality risk that occurs especially in the diffuse and rapidly progressive forms of the disease, characterized by fibrosis of the skin and internal organs and endothelial dysfunction. Recent studies suggest that the identification of altered metabolic pathways may play a key role in understanding the pathophysiology of the disease. Therefore, metabolomics might be pivotal in a better understanding of these pathogenic mechanisms. Methods: Through a systematic review of the literature following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Guidelines (PRISMA), searches were done in the PubMed, EMBASE, Web of Science, and Scopus databases from 2000 to September 2022. Three researchers independently reviewed the literature and extracted the data based on predefined inclusion and exclusion criteria. Results: Of the screened studies, 26 fulfilled the inclusion criteria. A total of 151 metabolites were differentially distributed between SSc patients and healthy controls (HC). The main deregulated metabolites were those derived from amino acids, specifically homocysteine (Hcy), proline, alpha-N-phenylacetyl-L-glutamine, glutamine, asymmetric dimethylarginine (ADMA), citrulline and ornithine, kynurenine (Kyn), and tryptophan (Trp), as well as acylcarnitines associated with long-chain fatty acids and tricarboxylic acids such as citrate and succinate. Additionally, differences in metabolic profiling between SSc subtypes were identified. The diffuse cutaneous systemic sclerosis (dcSSc) subtype showed upregulated amino acid-related pathways involved in fibrosis, endothelial dysfunction, and gut dysbiosis. Lastly, potential biomarkers were evaluated for the diagnosis of SSc, the identification of the dcSSc subtype, pulmonary arterial hypertension, and interstitial lung disease. These potential biomarkers are within amino acids, nucleotides, carboxylic acids, and carbohydrate metabolism. Discussion: The altered metabolite mechanisms identified in this study mostly point to perturbations in amino acid-related pathways, fatty acid beta-oxidation, and in the tricarboxylic acid cycle, possibly associated with inflammation, vascular damage, fibrosis, and gut dysbiosis. Further studies in targeted metabolomics are required to evaluate potential biomarkers for diagnosis, prognosis, and treatment response.

Incidence and prevalence of systemic sclerosis in Thailand in year 2017-2020: a database from the Ministry of Public Health

BACKGROUND

A better understanding of the epidemiological profile of systemic sclerosis (SSc) in Thais could improve care, human resource deployment, and public health budgeting.

OBJECTIVES

We aimed to determine the incidence and prevalence of SSc in Thailand between 2017 and 2020.

METHODS

A descriptive epidemiological study was performed using the Information and Communication Technology Center, Ministry of Public Health database, comprising all types of healthcare providers during the study period. Demographic data of patients having a primary diagnosis of M34 systemic sclerosis and over 18 years of age between 2017 and 2020 were reviewed. The incidence and prevalence of SSc were calculated as well as their respective 95% confidence intervals (CIs).

RESULTS

The number of SSc cases in 2017 was 15,920 from a total Thai population of 65,204,797. The prevalence of SSc in 2017 was 24.4 per 100,000 populations (95% CI 24.0-24.8). The prevalence of SSc among women was 2 times greater than among men (32.7 vs. 15.8 per 100,000). The incidence of SSc was stable from 2018 to 2019 but dropped slightly in 2020 (7.2, 7.6, and 6.8 per 100,000 person-years, respectively). Most SSc cases were in northeastern Thailand (11.6, 12.1, and 11.1 per 100,000 person-years from 2018 to 2020, respectively) and the peak was between 60 and 69 years of age (24.6, 23.8, and 20.9 per 100,000 person-years from 2018 to 2020, respectively).

CONCLUSION

SSc is a rare disease among Thais. The disease was commonly revealed in late middle-aged women with a peak at age 60-69 years, mainly from the northeast regions. The incidence remained stable during the study period, albeit during the emergence of the coronavirus pandemic a slight decline was recorded. Key Points • The incidence and prevalence of systemic sclerosis (SSc) vary across ethnic populations. • There is a lack of epidemiology research of SSc since the 2013 ACR/EULAR Classification Criteria for Scleroderma was adopted among Thais included Asia-Pacific population as the population has some different clinical features than those reported among Caucasians. • SSc is a rare connective disease among Thais and commonly presents in late middle-aged group of both genders, mainly in Thailand's northern and northeastern regions. • When compare to the epidemiology of SSc in Asia-Pacific, the prevalence of SSc in Thais was higher than among East Asians and the Indian population and the incidence of SSc among Thais was greater than the other Asia-Pacific population including Australian.

Clinical Risk Factors for Dysphagia and Esophageal Dysmotility in Systemic Sclerosis

Systemic sclerosis (SSc) is often associated with dysphagia and esophageal dysmotility; however, only a few clinical studies on this topic have been conducted. Patients with SSc who underwent swallowing examinations and esophagography at our institution between 2010 and 2022 were included. A retrospective evaluation of the patients' backgrounds, autoantibody positivity, swallowing function, and esophageal motility was performed using medical charts. The association between dysphagia and esophageal dysmotility in patients with SSc and respective risk factors was investigated. Data were collected from 50 patients. Anti-topoisomerase I antibodies (ATA) and anti-centromere antibodies (ACA) were detected in 21 (42%) and 11 (22%) patients, respectively. Dysphagia was present in 13 patients (26%), and esophageal dysmotility in 34 patients (68%). ATA-positive patients had a higher risk for dysphagia (p = 0.027); ACA-positive patients had a significantly lower risk (p = 0.046). Older age and laryngeal sensory deficits were identified as risk factors for dysphagia; however, no risk factors for esophageal dysmotility were identified. No correlation was found between dysphagia and esophageal dysmotility. Esophageal dysmotility is more common in patients with SSc than in those with dysphagia. Autoantibodies can be predictors of dysphagia, and dysphagia must be carefully considered in ATA-positive and elderly patients with SSc.

Combination of echocardiography and pulmonary function tests could predict no complication of pulmonary hypertension during 5 years in patients with systemic sclerosis

OBJECTIVE

To determine whether complications of pulmonary hypertension (PH) can be predicted by noninvasive screening tests in systemic sclerosis (SSc).

METHODS

Forty-seven of 113 SSc patients underwent right heart catheterization (RHC) during 2011-2014. Clinical data, hemodynamic features, echocardiography, and pulmonary function tests had been followed up from the first RHC until 5 years later.

RESULTS

At the first RHC, out of 44 patients, 8 were diagnosed with pre-capillary PH (mean pulmonary arterial pressure [mPAP] > 20 mm Hg), and 36 patients were defined as no-PH (mPAP ≤ 20 mm Hg). Three patients with >15 mm Hg of pulmonary artery wedge pressure were excluded. Receiver operating characteristic analyses for pre-capillary PH using estimated systolic PAP (esPAP) revealed an area under the curve (AUC) of 0.736, with a sensitivity and specificity of 62.5% and 86.1%, respectively, at a cutoff level of 35.0 mm Hg. The predicted percentage diffusing lung capacity for carbon monoxide (DLCO%) revealed an AUC of 0.840, with a sensitivity and specificity of 85.7% and 80.0%, respectively, at a cutoff level of 70.0%. Six pre-capillary PH patients, including one who died from PH 14 months after the first RHC, indicated exacerbations of mPAP or esPAP within 5 years. When esPAP < 35.0 mm Hg and DLCO% > 70% were met as the cutoff, none had been newly diagnosed with PH over 5 years.

CONCLUSIONS

The conventional screening tests may be useful for detecting pre-capillary PH with SSc, and both esPAP < 35.0 mm Hg and DLCO% > 70% indicated a lower risk of developing PH for at least 5 years.

Impact of Innovative Treatment Using Biological Drugs for the Modulation of Diffuse Cutaneous Systemic Sclerosis: A Systematic Review

Scleroderma or systemic sclerosis (SSc) is an autoimmune disease affecting the connective tissue, characterized by fibrosis of the skin and internal organs. There is currently no curative treatment available, so therapeutic action is aimed at a symptomatic treatment of the affected organs. The development of biotechnology has made it possible to implement certain biological drugs that could represent a window of opportunity to modulate the evolution and symptomatology of scleroderma with greater efficacy and less toxicity than conventional treatments. This study aimed to review the current evidence critically and systematically on the effects of biological drugs on the pulmonary function, skin disease, and health status of patients afflicted by diffuse cutaneous systemic sclerosis (dcSSc). Three electronic databases (Pubmed, Dialnet, and Cochrane Library Plus) were systematically searched until the cut-off date of October 2022. The review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and included original articles in English and Spanish with a controlled trial design, comparing biological drug treatments (tocilizumab, belimumab, riociguat, abatacept, and romilkimab) with a control group. The methodological quality of the studies was assessed using the McMaster quantitative form and the PEDro scale. A total of 383 studies were identified, 6 of them met the established criteria and were included in the present systematic review. A total of 426 patients treated with tocilizumab, belimumab, riociguat, abatacept, and romilkimab were included. The results showed substantial non-significant (p < 0.05) improvement trends after treatment with the biological drugs included in this review for the modified Rodnan Scale Value, Forced Vital Capacity, and Carbon Monoxide Diffusion Test; however, no benefits were shown on the Health Assessment Questionnaire-Disability Index when compared to the control group. Biological drugs, therefore, maybe a new therapeutic strategy for dcSSc and could be recommended as an additional and/or adjunctive treatment that promotes anti-fibrotic activity. This review could further define the clinical rationale for the use of biologics in the treatment of dcSSc and could provide key details on the study protocol, design, and outcome reporting.