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Velikova T, Sekulovski M, Bogdanova S, Vasilev G, Peshevska-Sekulovska M, Miteva D, Georgiev T. Intravenous Immunoglobulins as Immunomodulators in Autoimmune Diseases and Reproductive Medicine. Antibodies (Basel) 2023; 12:antib12010020. [PMID: 36975367 PMCID: PMC10045256 DOI: 10.3390/antib12010020] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 02/17/2023] [Accepted: 02/24/2023] [Indexed: 03/06/2023] Open
Abstract
Intravenous administration of immunoglobulins has been routinely used for more than 60 years in clinical practice, developed initially as replacement therapy in immunodeficiency disorders. Today, the use of intravenous immunoglobulins (IVIGs) is embedded in the modern algorithms for the management of a few diseases, while in most cases, their application is off-label and thus different from their registered therapeutic indications according to the summary of product characteristics. In this review, we present the state-of-the-art use of IVIGs in various autoimmune conditions and immune-mediated disorders associated with reproductive failure, as approved therapy, based on indications or off-label. IVIGs are often an alternative to other treatments, and the administration of IVIGs continues to expand as data accumulate. Additionally, new insights into the pathophysiology of immune-mediated disorders have been gained. Therefore, the need for immunomodulation has increased, where IVIG therapy represents an option for stimulating, inhibiting and regulating various immune processes.
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Affiliation(s)
- Tsvetelina Velikova
- Medical Faculty, Sofia University St. Kliment Ohridski, 1 Kozyak Str., 1407 Sofia, Bulgaria
- Correspondence:
| | - Metodija Sekulovski
- Medical Faculty, Sofia University St. Kliment Ohridski, 1 Kozyak Str., 1407 Sofia, Bulgaria
- Department of Anesthesiology and Intensive Care, University Hospital Lozenetz, 1 Kozyak Str., 1407 Sofia, Bulgaria
| | - Simona Bogdanova
- First Department of Internal Medicine, Medical Faculty, Medical University of Varna, 9000 Varna, Bulgaria
| | - Georgi Vasilev
- Clinic of Neurology, UMHAT “Sv. Georgi”, Faculty of Medicine, Medical University of Plovdiv, 4000 Plovdiv, Bulgaria
| | - Monika Peshevska-Sekulovska
- Medical Faculty, Sofia University St. Kliment Ohridski, 1 Kozyak Str., 1407 Sofia, Bulgaria
- Department of Gastroenterology, University Hospital Lozenetz, 1 Kozyak Str., 1407 Sofia, Bulgaria
| | - Dimitrina Miteva
- Department of Genetics, Faculty of Biology, Sofia University St. Kliment Ohridski, 8 Dragan Tzankov Str., 1164 Sofia, Bulgaria
| | - Tsvetoslav Georgiev
- First Department of Internal Medicine, Medical Faculty, Medical University of Varna, 9000 Varna, Bulgaria
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Kasitanon N, Hamijoyo L, Li MT, Oku K, Navarra S, Tanaka Y, Mok CC. Management of non-renal manifestations of systemic lupus erythematosus: A systematic literature review for the APLAR consensus statements. Int J Rheum Dis 2022; 25:1220-1229. [PMID: 35916201 DOI: 10.1111/1756-185x.14413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 05/31/2022] [Accepted: 07/03/2022] [Indexed: 11/30/2022]
Abstract
The prevalence of systemic lupus erythematosus (SLE) is higher in Asians than Caucasians, with higher frequency of renal and other major organ manifestations that carry a poorer prognosis. The outcome of SLE is still unsatisfactory in many parts of the Asia Pacific region due to limited access to healthcare systems, poor treatment adherence and adverse reactions to therapies. The Asia Pacific League of Associations for Rheumatology (APLAR) SLE special interest group has recently published a set of consensus recommendation statements for the management of SLE in the Asia Pacific region. The current article is a supplement of systematic literature search (SLR) to the prevalence and treatment of non-renal manifestations of SLE in Asian patients.
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Affiliation(s)
- Nuntana Kasitanon
- Division of Rheumatology, Department of Internal Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Laniyati Hamijoyo
- Rheumatology Division, Department of Internal Medicine, Padjadjaran University, Bandung, Indonesia
| | - Meng Tao Li
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science & Technology, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Kenji Oku
- Department of Rheumatology, Endocrinology and Nephrology Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Sandra Navarra
- Section of Rheumatology, University of Santo Tomas Hospital, Manila, Philippines
| | - Yoshiya Tanaka
- The First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Japan, Kitakyushu, Japan
| | - Chi Chiu Mok
- Division of Rheumatology, Department of Medicine, Tuen Mun Hospital, Hong Kong SAR, China
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3
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Leone P, Prete M, Malerba E, Bray A, Susca N, Ingravallo G, Racanelli V. Lupus Vasculitis: An Overview. Biomedicines 2021; 9:biomedicines9111626. [PMID: 34829857 PMCID: PMC8615745 DOI: 10.3390/biomedicines9111626] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 10/29/2021] [Accepted: 11/03/2021] [Indexed: 12/21/2022] Open
Abstract
Lupus vasculitis (LV) is one of the secondary vasculitides occurring in the setting of systemic lupus erythematosus (SLE) in approximately 50% of patients. It is most commonly associated with small vessels, but medium-sized vessels can also be affected, whereas large vessel involvement is very rare. LV may involve different organ systems and present in a wide variety of clinical manifestations according to the size and site of the vessels involved. LV usually portends a poor prognosis, and a prompt diagnosis is fundamental for a good outcome. The spectrum of involvement ranges from a relatively mild disease affecting small vessels or a single organ to a multiorgan system disease with life-threatening manifestations, such as mesenteric vasculitis, pulmonary hemorrhage, or mononeuritis multiplex. Treatment depends upon the organs involved and the severity of the vasculitis process. In this review, we provide an overview of the different forms of LV, describing their clinical impact and focusing on the available treatment strategies.
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Affiliation(s)
- Patrizia Leone
- Department of Biomedical Sciences and Human Oncology, “Aldo Moro” University of Bari Medical School, 70124 Bari, Italy; (P.L.); (M.P.); (E.M.); (A.B.); (N.S.)
| | - Marcella Prete
- Department of Biomedical Sciences and Human Oncology, “Aldo Moro” University of Bari Medical School, 70124 Bari, Italy; (P.L.); (M.P.); (E.M.); (A.B.); (N.S.)
| | - Eleonora Malerba
- Department of Biomedical Sciences and Human Oncology, “Aldo Moro” University of Bari Medical School, 70124 Bari, Italy; (P.L.); (M.P.); (E.M.); (A.B.); (N.S.)
| | - Antonella Bray
- Department of Biomedical Sciences and Human Oncology, “Aldo Moro” University of Bari Medical School, 70124 Bari, Italy; (P.L.); (M.P.); (E.M.); (A.B.); (N.S.)
| | - Nicola Susca
- Department of Biomedical Sciences and Human Oncology, “Aldo Moro” University of Bari Medical School, 70124 Bari, Italy; (P.L.); (M.P.); (E.M.); (A.B.); (N.S.)
| | - Giuseppe Ingravallo
- Section of Pathology, Department of Emergency and Organ Transplantation, “Aldo Moro” University of Bari Medical School, 70124 Bari, Italy;
| | - Vito Racanelli
- Department of Biomedical Sciences and Human Oncology, “Aldo Moro” University of Bari Medical School, 70124 Bari, Italy; (P.L.); (M.P.); (E.M.); (A.B.); (N.S.)
- Correspondence:
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4
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Worm M, Zidane M, Eisert L, Fischer-Betz R, Foeldvari I, Günther C, Iking-Konert C, Kreuter A, Müller-Ladner U, Nast A, Ochsendorf F, Schneider M, Sticherling M, Tenbrock K, Wenzel J, Kuhn A. S2k-Leitlinie zur Diagnostik und Therapie des kutanen Lupus erythematodes - Teil 2: Therapie, Risikofaktoren und spezielle Fragestellungen. J Dtsch Dermatol Ges 2021; 19:1371-1395. [PMID: 34541800 DOI: 10.1111/ddg.14491_g] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 02/20/2021] [Indexed: 01/03/2023]
Affiliation(s)
- Margitta Worm
- Allergologie und Immunologie, Klinik für Dermatologie, Venerologie und Allergologie, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin
| | - Miriam Zidane
- Division of Evidence-Based Medicine (dEBM), Klinik für Dermatologie, Venerologie und Allergologie, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin
| | - Lisa Eisert
- Klinik für Dermatologie und Venerologie, Vivantes Klinikum Neukölln, Berlin
| | - Rebecca Fischer-Betz
- Poliklinik und Funktionsbereich für Rheumatologie, Universitätsklinikum Düsseldorf, Düsseldorf
| | - Ivan Foeldvari
- Hamburger Zentrum für Kinder- und Jugendrheumatologie, Hamburg
| | - Claudia Günther
- Klinik und Poliklinik für Dermatologie, Universitätsklinikum Carl Gustav Carus, Dresden
| | - Christof Iking-Konert
- Zentrum für Innere Medizin der III. Medizinischen Klinik und Poliklinik, Universitätsklinikum Hamburg-Eppendorf, Hamburg
| | - Alexander Kreuter
- Dermatologie, Venerologie und Allergologie, Helios St. Elisabeth Klinik Oberhausen, Oberhausen
| | - Ulf Müller-Ladner
- Abteilung für Rheumatologie und Klinische Immunologie, Kerckhoff-Klinik GmbH, Bad Nauheim
| | - Alexander Nast
- Division of Evidence-Based Medicine (dEBM), Klinik für Dermatologie, Venerologie und Allergologie, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin
| | - Falk Ochsendorf
- Klinik für Dermatologie, Venerologie und Allergologie, Universitätsklinikum Frankfurt, Frankfurt am Main
| | - Matthias Schneider
- Poliklinik und Funktionsbereich für Rheumatologie, Universitätsklinikum Düsseldorf, Düsseldorf
| | | | - Klaus Tenbrock
- Klinik für Kinder- und Jugendmedizin, Uniklinik RWTH Aachen, Aachen
| | - Jörg Wenzel
- Dermatologische Klinik, Universitätsklinikum Bonn, Bonn
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Worm M, Zidane M, Eisert L, Fischer-Betz R, Foeldvari I, Günther C, Iking-Konert C, Kreuter A, Müller-Ladner U, Nast A, Ochsendorf F, Schneider M, Sticherling M, Tenbrock K, Wenzel J, Kuhn A. S2k guideline: Diagnosis and management of cutaneous lupus erythematosus - Part 2: Therapy, risk factors and other special topics. J Dtsch Dermatol Ges 2021; 19:1371-1395. [PMID: 34338428 DOI: 10.1111/ddg.14491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 02/20/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Margitta Worm
- Allergology and Immunology, Department of Dermatology, Venereology and Allergology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health
| | - Miriam Zidane
- Division of Evidence-Based Medicine (dEBM), Department of Dermatology, Venereology and Allergology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health
| | - Lisa Eisert
- Department of Dermatology and Venereology, Vivantes Klinikum Neukölln, Berlin
| | | | - Ivan Foeldvari
- Hamburg Center for Pediatric and Adolescent Rheumatology, Hamburg
| | - Claudia Günther
- Department and Clinic of Dermatology, University Hospital Carl Gustav Carus, Dresden
| | - Christof Iking-Konert
- Center for Internal Medicine at the IIIrd Medical Department and Clinic, University Hospital Hamburg-Eppendorf
| | - Alexander Kreuter
- Dermatology, Venereology and Allergology, Helios St. Elisabeth Klinik Oberhausen
| | - Ulf Müller-Ladner
- Department of Rheumatology and Clinical Immunology, Kerckhoff-Klinik GmbH, Bad Nauheim
| | - Alexander Nast
- Division of Evidence-Based Medicine (dEBM), Department of Dermatology, Venereology and Allergology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health
| | - Falk Ochsendorf
- Department of Dermatology, Venereology and Allergology, University Hospital Frankfurt am Main
| | - Matthias Schneider
- Clinic and Functional Division for Rheumatology, University Hospital Düsseldorf
| | | | - Klaus Tenbrock
- Department of Pediatrics and Adolescent Medicine, University Hospital RWTH Aachen
| | - Jörg Wenzel
- Dermatological Department, University Hospital Bonn
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6
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Cutaneous vasculitis in lupus treated with IV immunoglobulin. Clin Rheumatol 2021; 40:3023-3024. [PMID: 33620585 DOI: 10.1007/s10067-021-05637-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 02/01/2021] [Accepted: 02/04/2021] [Indexed: 10/22/2022]
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Uzuncakmak TK, Bayazit S, Askin O, Engin B, Ugurlu S, Sar M, Serdaroglu S. Alendronate induced subacute cutaneous lupus erythematosus successfully treated with intravenous immunoglobulin. Dermatol Ther 2020; 33:e14477. [PMID: 33125828 DOI: 10.1111/dth.14477] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 10/07/2020] [Accepted: 10/26/2020] [Indexed: 11/28/2022]
Abstract
The subacute cutaneous lupus erythematosus (SCLE) is a distinct subtype of lupus erythematosus (LE) representing specific clinical and serological features. Almost 20%-30% of the cases with SCLE are predicted to associated with medications. Thiazide diuretics, terbinafine, antiepileptic, and proton pump inhibitors are the best-known drugs to induce drug-related SCLE. Herein we want to present a 65-year-old female with alendronate induced SCLE, resistant to classical therapies, and respond well to intravenous immunoglobulin (IVIG), suggesting that IVIG could be an alternative treatment in patients resistant to classical treatment protocols.
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Affiliation(s)
- Tugba Kevser Uzuncakmak
- Department of Dermatology, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Samet Bayazit
- Department of Dermatology, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Ozge Askin
- Department of Dermatology, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Burhan Engin
- Department of Dermatology, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Serdal Ugurlu
- Department of Rheumatology, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Mehmet Sar
- Department of Pathology, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Server Serdaroglu
- Department of Dermatology, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
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8
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Yan D, Borucki R, Sontheimer RD, Werth VP. Candidate drug replacements for quinacrine in cutaneous lupus erythematosus. Lupus Sci Med 2020; 7:7/1/e000430. [PMID: 33082164 PMCID: PMC7577055 DOI: 10.1136/lupus-2020-000430] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 09/22/2020] [Accepted: 10/01/2020] [Indexed: 12/17/2022]
Abstract
Cutaneous lupus erythematosus (CLE) is a disfiguring and potentially disabling disease that causes significant morbidity in patients. Antimalarials are an important class of medication used to treat this disease and have been the first-line systemic therapy since the 1950s. Quinacrine, in particular, is used as an adjuvant therapy to other antimalarials for improved control of CLE. Quinacrine is currently unavailable in the USA, which has taken away an important component of the treatment regimen of patients with CLE. This paper reviews the evidence of available local and systemic therapies in order to assist providers in choosing alternative treatments for patients who previously benefited from quinacrine therapy.
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Affiliation(s)
- Daisy Yan
- Department of Dermatology, Corporal Michael J Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA.,Department of Dermatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Robert Borucki
- Department of Dermatology, Corporal Michael J Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA.,Department of Dermatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Richard D Sontheimer
- Department of Dermatology, The University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Victoria P Werth
- Department of Dermatology, Corporal Michael J Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA .,Department of Dermatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
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9
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Fairley JL, Oon S, Saracino AM, Nikpour M. Management of cutaneous manifestations of lupus erythematosus: A systematic review. Semin Arthritis Rheum 2019; 50:95-127. [PMID: 31526594 DOI: 10.1016/j.semarthrit.2019.07.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Revised: 07/29/2019] [Accepted: 07/30/2019] [Indexed: 12/24/2022]
Abstract
BACKGROUND Cutaneous lupus erythematosus (CLE), occurring with or without systemic lupus erythematosus (SLE), is a group of inflammatory skin diseases that can be very debilitating, causing significant psychological distress, and sometimes scarring. OBJECTIVES We sought to comprehensively present the evidence for different treatment modalities in patients with cutaneous manifestations of lupus erythematosus (LE). METHODS Medline, Embase, Scopus and Cochrane CENTRAL were searched electronically from 1990 to March 2019, using keywords related to cutaneous lupus and synonyms and treatment. Articles retrieved were screened for relevance, including reference lists of retrieved reviews. We included clinical trials, observational studies or case series with ≥5 patients focussing on treatment of CLE, with or without SLE. RESULTS The search identified 6637 studies, of which 107 were included. Each study commonly included a heterogeneous mixture of CLE subtypes, with or without SLE. The 107 included studies investigated 11 different categories of treatment in 7343 patients. Treatments included topical calcineurin inhibitors (13 studies), sun protection (5 studies), R-salbutamol cream (2 studies), antimalarials (22 studies), synthetic DMARDs (10 studies), retinoids (2 studies), thalidomide/lenalidomide (22 studies), biologic therapies (15 studies), intravenous immune globulin (3 studies), laser (6 studies) and other therapies (7 studies). General measures to be considered include smoking cessation, sun protection measures and optimisation of vitamin D levels. Moderate evidence exists for benefit with topical CNIs, particularly as a steroid sparing agent in areas at high risk of steroid complications (e.g. facial skin). There is moderate evidence for hydroxychloroquine, which is first-line in SLE patients, limited evidence to support other synthetic DMARDs, and moderate evidence supporting thalidomide but with significant risk of toxicity. Of biologic therapies, there are moderate data to support belimumab. Limited evidence exists for other therapies. CONCLUSION Many management options are available for CLE, including topical, systemic and biologic therapies, with a variable balance of efficacy and toxicity. There is a paucity of high-quality clinical trial data. Further trials are required to better understand optimal management of CLE, particularly in specific subgroups.
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Affiliation(s)
- J L Fairley
- School of Public Health and Population Medicine, Monash University, Melbourne, Australia; The Alfred Hospital, Melbourne, Australia
| | - S Oon
- Department of Rheumatology, St Vincent's Hospital, Melbourne, Australia; The University of Melbourne, Australia
| | - A M Saracino
- Centre for Rheumatology and Connective Tissue Diseases, Division of Medicine, University College London, United Kingdom
| | - M Nikpour
- Department of Rheumatology, St Vincent's Hospital, Melbourne, Australia; The University of Melbourne, Australia.
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10
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Blake SC, Daniel BS. Cutaneous lupus erythematosus: A review of the literature. Int J Womens Dermatol 2019; 5:320-329. [PMID: 31909151 PMCID: PMC6938925 DOI: 10.1016/j.ijwd.2019.07.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Revised: 07/04/2019] [Accepted: 07/20/2019] [Indexed: 02/06/2023] Open
Abstract
Knowledge with regard to the pathogenesis of lupus erythematosus has progressed rapidly over the past decade, and with it has come promising new agents for the treatment of cutaneous lupus erythematous (CLE). Classification of CLE is performed using clinical features and histopathologic findings, and is crucial for determining prognosis and choosing therapeutic options. Preventative therapy is critical in achieving optimal disease control, and patients should be counseled on sun-safe behavior and smoking cessation. First-line therapy includes topical corticosteroids and calcineurin inhibitors, with antimalarial therapy. Traditionally, refractory disease was treated with oral retinoids, dapsone, and other oral immunosuppressive drugs, but new therapies are emerging with improved side effect profiles and efficacy. Biologic agents, such as belimumab and ustekinumab, have been promising in case studies but will require larger trials to establish their role in routine therapy. Other novel therapies that have been trialed successfully include spleen tyrosine kinase inhibitors and fumaric acid esters. Finally, new evidence has been published recently that describes safer dosing regimens in thalidomide and lenalidomide, both effective medications for CLE. Given the chronic disease course of CLE, long-term treatment-related side effects must be minimized, and the introduction of new steroid-sparing agents is encouraging in this regard.
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Affiliation(s)
- Stephanie Clare Blake
- University of New South Wales, Sydney, Australia.,St. George Department of Dermatology, Sydney, Australia
| | - Benjamin Silas Daniel
- University of New South Wales, Sydney, Australia.,St. George Department of Dermatology, Sydney, Australia.,St Vincent's Hospital, Melbourne, Australia
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Chasset F, Francès C. Current Concepts and Future Approaches in the Treatment of Cutaneous Lupus Erythematosus: A Comprehensive Review. Drugs 2019; 79:1199-1215. [DOI: 10.1007/s40265-019-01151-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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12
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Tenti S, Fabbroni M, Mancini V, Russo F, Galeazzi M, Fioravanti A. Intravenous Immunoglobulins as a new opportunity to treat discoid lupus erythematosus: A case report and review of the literature. Autoimmun Rev 2018; 17:791-795. [PMID: 29885539 DOI: 10.1016/j.autrev.2018.02.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2018] [Accepted: 02/09/2018] [Indexed: 10/14/2022]
Abstract
Discoid lupus erythematosus (DLE) is a chronic dermatological disease that can lead to scarring, alopecia and dyspigmentation, if not properly treated. Actually, no drugs are specifically approved for the treatment of CLE, although the first-line therapy usually consists of photoprotection associated to topical or oral steroids, topical calcineurin inhibitors and hydroxychloroquine (HCQ). In cases of DLE refractory to these medications, many other agents have been employed, such as dapsone, methotrexate, azathioprine, cyclophosphamide, biologic drugs and Intravenous Immunoglobulin (IVIG). We described the case of a DLE patient resistant to combination therapy with steroid and HCQ who was successfully treated with cyclical IVIG therapy. The treatment with IVIG resulted rapidly effective with persistent efficacy and low rates of relapses, although more cycles of IVIG are needed to achieve a stable clinical remission. We also discussed the beneficial and promising effects of IVIG in patients with Cutaneous Lupus reporting the previously published data.
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Affiliation(s)
- Sara Tenti
- Rheumatology Unit, Department of Medicine, Surgery and Neurosciences, University of Siena, Italy
| | - Marta Fabbroni
- Rheumatology Unit, Department of Medicine, Surgery and Neurosciences, University of Siena, Italy
| | - Virginia Mancini
- Pathology Section, Department of Medical Biotechnology, University of Siena, Siena, Italy
| | - Filomena Russo
- Dermatology Section, Department of Clinical Medicine and Immunological Science, University of Siena, Siena, Italy
| | - Mauro Galeazzi
- Rheumatology Unit, Department of Medicine, Surgery and Neurosciences, University of Siena, Italy
| | - Antonella Fioravanti
- Rheumatology Unit, Department of Medicine, Surgery and Neurosciences, University of Siena, Italy.
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13
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Adrichem ME, Starink MV, van Leeuwen EMM, Kramer C, van Schaik IN, Eftimov F. Drug-induced cutaneous lupus erythematosus after immunoglobulin treatment in chronic inflammatory demyelinating polyneuropathy: a case series. J Peripher Nerv Syst 2018; 22:213-218. [PMID: 28480635 DOI: 10.1111/jns.12218] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Revised: 03/28/2017] [Accepted: 04/29/2017] [Indexed: 01/02/2023]
Abstract
We describe six patients with cutaneous lupus erythematosus (cLE) during immunoglobulin G (IgG) treatment. Five patients were diagnosed with chronic inflammatory demyelinating polyneuropathy (CIDP) and one patient with possible CIDP. Five patients received intravenous immunoglobulin (IVIg) and one patient received subcutaneous immunoglobulin (SCIg). Skin lesions were systematically assessed by a dermatologist including skin biopsies. Patients showed disseminated erythematous plaques on several parts of the body with pre-dominance of the chest and face. Skin biopsies showed perivascular and perifollicular vacuolar inflammation, consistent with the diagnosis of cLE. There were no signs of systemic lupus erythematosus. Anti-SSA (Ro60) antibodies were found in two patients and anti-Ro52 antibodies were detectable in one patient. Symptoms improved in three patients after switching to another brand of IVIg and after use of topical corticosteroids. However, these measures did not lead to a complete resolution of the skin lesions. To achieve complete remission, IgG treatment was ceased in four patients. This led to remission of the skin lesions in two patients and to marked improvement in the other two patients. IVIg had to be restarted in two patients because of a relapse of CIDP which led to worsening of the skin lesions. In one patient with clear IVIg dependency, treatment was continued with addition of topical steroids. In the patient using SCIg, cLE was photosensitive and showed spontaneous remission. The relation of cLE with IgG treatment suggests an immunoglobulin-induced cLE. Only one report previously described the occurrence of IVIg induced cLE in a patient with common variable immunodeficiency.
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Affiliation(s)
- Max E Adrichem
- Department of Neurology, Academic Medical Center, Amsterdam, The Netherlands
| | - Markus V Starink
- Department of Dermatology, Academic Medical Center, Amsterdam, The Netherlands
| | | | | | - Ivo N van Schaik
- Department of Neurology, Academic Medical Center, Amsterdam, The Netherlands
| | - Filip Eftimov
- Department of Neurology, Academic Medical Center, Amsterdam, The Netherlands
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Gordon C, Amissah-Arthur MB, Gayed M, Brown S, Bruce IN, D’Cruz D, Empson B, Griffiths B, Jayne D, Khamashta M, Lightstone L, Norton P, Norton Y, Schreiber K, Isenberg D. The British Society for Rheumatology guideline for the management of systemic lupus erythematosus in adults. Rheumatology (Oxford) 2017; 57:e1-e45. [DOI: 10.1093/rheumatology/kex286] [Citation(s) in RCA: 172] [Impact Index Per Article: 24.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Indexed: 12/15/2022] Open
Affiliation(s)
- Caroline Gordon
- Rheumatology Research Group, Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham,
- Rheumatology Department, City Hospital, Sandwell and West Birmingham Hospitals NHS Trust,
- Rheumatology Department, University Hospitals Birmingham NHS Foundation Trust, Birmingham,
| | - Maame-Boatemaa Amissah-Arthur
- Rheumatology Research Group, Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham,
| | - Mary Gayed
- Rheumatology Research Group, Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham,
- Rheumatology Department, University Hospitals Birmingham NHS Foundation Trust, Birmingham,
| | - Sue Brown
- Royal National Hospital for Rheumatic Diseases, Bath,
| | - Ian N. Bruce
- Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal Research, Institute for Inflammation and Repair, University of Manchester, Manchester Academic Health Sciences Centre,
- The Kellgren Centre for Rheumatology, NIHR Manchester Musculoskeletal Biomedical Research Unit, Central Manchester University Hospitals NHS Foundation Trust, Manchester,
| | - David D’Cruz
- Louise Coote Lupus Unit, Guy’s Hospital, London,
| | - Benjamin Empson
- Laurie Pike Health Centre, Modality Partnership, Birmingham,
| | | | - David Jayne
- Department of Medicine, University of Cambridge,
- Lupus and Vasculitis Unit, Addenbrooke’s Hospital, Cambridge,
| | - Munther Khamashta
- Lupus Research Unit, The Rayne Institute, St Thomas’ Hospital,
- Division of Women’s Health, King’s College London,
| | - Liz Lightstone
- Section of Renal Medicine and Vascular Inflammation, Division of Immunology and Inflammation, Department of Medicine, Imperial College London, London,
| | | | | | | | - David Isenberg
- Centre for Rheumatology, University College London, London, UK
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15
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Intravenous immunoglobulins for treatment of connective tissue diseases in dermatology. Wien Med Wochenschr 2017; 168:213-217. [DOI: 10.1007/s10354-017-0595-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Accepted: 08/04/2017] [Indexed: 10/18/2022]
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16
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Kuhn A, Aberer E, Bata-Csörgő Z, Caproni M, Dreher A, Frances C, Gläser R, Klötgen HW, Landmann A, Marinovic B, Nyberg F, Olteanu R, Ranki A, Szepietowski JC, Volc-Platzer B. S2k guideline for treatment of cutaneous lupus erythematosus - guided by the European Dermatology Forum (EDF) in cooperation with the European Academy of Dermatology and Venereology (EADV). J Eur Acad Dermatol Venereol 2016; 31:389-404. [PMID: 27859683 DOI: 10.1111/jdv.14053] [Citation(s) in RCA: 81] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Accepted: 10/26/2016] [Indexed: 12/31/2022]
Abstract
Cutaneous lupus erythematosus (CLE) is a rare inflammatory autoimmune disease with heterogeneous clinical manifestations. To date, no therapeutic agents have been licensed specifically for patients with this disease entity, and topical and systemic drugs are mostly used 'off-label'. The aim of the present guideline was to achieve a broad consensus on treatment strategies for patients with CLE by a European subcommittee, guided by the European Dermatology Forum (EDF) and supported by the European Academy of Dermatology and Venereology (EADV). In total, 16 European participants were included in this project and agreed on all recommendations. Topical corticosteroids remain the mainstay of treatment for localized CLE, and further topical agents, such as calcineurin inhibitors, are listed as alternative first-line or second-line topical therapeutic option. Antimalarials are recommended as first-line and long-term systemic treatment in all CLE patients with severe and/or widespread skin lesions, particularly in patients with a high risk of scarring and/or the development of systemic disease. In addition to antimalarials, systemic corticosteroids are recommended as first-line treatment in highly active and/or severe CLE. Second- and third-line systemic treatments include methotrexate, retinoids, dapsone and mycophenolate mofetil or mycophenolate acid, respectively. Thalidomide should only be used in selected therapy-refractory CLE patients, preferably in addition to antimalarials. Several new therapeutic options, such as B-cell- or interferon α-targeted agents, need to be further evaluated in clinical trials to assess their efficacy and safety in the treatment of patients with CLE.
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Affiliation(s)
- A Kuhn
- Interdisciplinary Center for Clinical Trials (IZKS), University Medical Center Mainz, Mainz, Germany.,Division of Immunogenetics, Tumor Immunology Program, German Cancer Research Center, Heidelberg, Germany
| | - E Aberer
- Department of Dermatology, Medical University of Graz, Graz, Austria
| | - Z Bata-Csörgő
- Department of Dermatology and Allergology, University of Szeged, Szeged, Hungary
| | - M Caproni
- Department of Medical and Surgical Critical Care Section of Dermatology, University of Florence, Florence, Italy
| | - A Dreher
- Evidence-Based Medicine Frankfurt, Institute for General Practice, Goethe-University Frankfurt, Frankfurt, Germany
| | - C Frances
- Department of Dermatology and Allergology, Hôpital Tenon, Paris, France
| | - R Gläser
- Department of Dermatology, Venerology and Allergology, University Hospital of Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - H-W Klötgen
- Department of Dermatology, Inselspital Bern - University Hospital, Bern, Switzerland
| | - A Landmann
- Division of Immunogenetics, Tumor Immunology Program, German Cancer Research Center, Heidelberg, Germany
| | - B Marinovic
- Department of Dermatology and Venereology, University Hospital Center Zagreb and School of Medicine University of Zagreb, Zagreb, Croatia
| | - F Nyberg
- Institution for Clinical Sciences, Unit for Dermatology, Karolinska Institutet at Danderyd Hospital (KIDS), Stockholm, Sweden
| | - R Olteanu
- Department of Dermatology, Colentina Clinical Hospital, Bucharest, Romania
| | - A Ranki
- Department of Skin and allergic diseases, Inflammation Center, Helsinki University Central Hospital, Helsinki, Finland
| | - J C Szepietowski
- Department of Dermatology, Venereology and Allergology, Wroclaw Medical University, Wroclaw, Poland
| | - B Volc-Platzer
- Department of Dermatology, Donauspital, University affiliated Hospital, Vienna, Austria
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17
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Garza-Mayers AC, McClurkin M, Smith GP. Review of treatment for discoid lupus erythematosus. Dermatol Ther 2016; 29:274-83. [DOI: 10.1111/dth.12358] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- Anna Cristina Garza-Mayers
- Harvard Medical School; Boston Massachusetts
- Massachusetts General Hospital, Department of Dermatology; Boston Massachusetts
| | | | - Gideon P. Smith
- Harvard Medical School; Boston Massachusetts
- Massachusetts General Hospital, Department of Dermatology; Boston Massachusetts
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18
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Hansen CB, Callen JP. Current and future treatment options for cutaneous lupus erythematosus. Expert Opin Orphan Drugs 2015. [DOI: 10.1517/21678707.2015.1048224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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19
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Abstract
BACKGROUND Lupus erythematosus is an autoimmune disease with a broad spectrum of cutaneous manifestations. The pathogenesis of lupus is based on a loss of tolerance against self antigens and can be mediated by defects in apoptosis, defects in eliminating cellular remnants and increased activation of the innate as well as the adaptive immune system. The increased activation of the innate immune system can be mediated by sensing of endogenous or exogenous nucleic acids, genetic variants in the components of the receptor cascade or disturbances in restriction of self nucleic acids. The inflammatory milieu is characterized by type I interferon expression and autoantibody production. The main trigger factors of the disease are sun exposure and viral infections. TREATMENT Lupus erythematosus is effectively treated by glucocorticosteroids. Approved alternatives for long-term treatment are antimalarial agents and the B-cell inhibitor belimumab for patients with systemic lupus erythematosus. CONCLUSION Future studies should more intensely analyse the effect of novel therapies on cutaneous manifestations to allow early detection of cutaneous lupus. Furthermore novel therapeutic strategies which specifically target the responsible pathogenetic mechanisms of the individual subtypes of lupus erythematosus are needed to improve the therapeutic success for this heterogeneous patient population.
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20
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Abstract
Systemic lupus erythematosus (SLE) is an autoimmune disease that is characterized by the development of autoantibodies and immunologic attack of different organ systems, including the skin. This review aims to provide an overview of some of the pathogenic processes that may be important in the development of SLE, specifically cutaneous lupus erythematosus, and then illustrates how therapies might be tailored to modify these processes and treat disease.
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Affiliation(s)
- Mark G Kirchhof
- Department of Dermatology and Skin Science, University of British Columbia, 835 West 10th Avenue, Vancouver, British Columbia V5Z 4E8, Canada
| | - Jan P Dutz
- Department of Dermatology and Skin Science, University of British Columbia, 835 West 10th Avenue, Vancouver, British Columbia V5Z 4E8, Canada; Child and Family Research Institute, University of British Columbia, 950 West 28th Avenue, Vancouver, British Columbia V5Z 4H4, Canada.
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21
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Sakthiswary R, D'Cruz D. Intravenous immunoglobulin in the therapeutic armamentarium of systemic lupus erythematosus: a systematic review and meta-analysis. Medicine (Baltimore) 2014; 93:e86. [PMID: 25310743 PMCID: PMC4616295 DOI: 10.1097/md.0000000000000086] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Prepared from the plasma of thousands of blood donors, therapeutic intravenous immunoglobulin (IVIg) mostly consists of human polyspecific immunoglobulin G (IgG). The use of IVIg in systemic lupus erythematosus (SLE) is still considered experimental without any clear indications. The purpose of this systematic review is, therefore, to evaluate the available evidence to determine the therapeutic role of IVIg in SLE. A comprehensive, computerised search was performed in the MEDLINE (Pubmed), Scopus, EMBASE, and Cochrane controlled trials. The study eligibility criteria were randomized controlled trials, and prospective and retrospective observational studies that examined the efficacy of IVIg in adult patients with SLE who were considered the participants.IVIg therapy was the mode of intervention in these patients. Data abstracted included the study design, study population, changes in the disease activity scores (Systemic Lupus Erythematosus Disease Activity Index, Systemic Lupus Activity Measure, and Lupus Activity Index-Pregnancy), steroid dose, complement levels, autoantibodies, and renal function. Thereafter, data analysis established statistical procedures for meta-analysis. Thirteen studies (including 3 controlled and 10 observational) were eligible for inclusion. There was significant reduction in the SLE disease activity scores with IVIg therapy with a standard mean difference of 0.584 (P = 0.002, 95% confidence interval [CI] 0.221-0.947). In terms of rise in complement levels, the response rate was 30.9% (P = 0.001, 95 CI 22.1-41.3). The effects of IVIg on other clinical outcome measures including anti-double-stranded DNA, antinuclear antibody, average steroid dose, and renal function could not be determined because of the limited numbers of trials. The limitations of this review were lack of well-designed controlled trials with adequate sample size on the use of IVIg in SLE. In conclusion, the use of IVIg is associated with significant reduction in SLE disease activity and improvement in complement levels.
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Affiliation(s)
- Rajalingham Sakthiswary
- Department of Medicine (RS), Universiti Kebangsaan Malaysia Medical Centre (UKMMC), Cheras, Malaysia; and Louise Coote Lupus Unit (DD), Gassiot House, St Thomas' Hospital, London, United Kingdom
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22
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23
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Abstract
Cutaneous lupus erythematosus is a heterogeneous autoimmune condition that can significantly impact quality of life. Treatment is focused on reducing clinical inflammation and preventing scarring. The choice of treatment should be guided based on the severity of disease. Mild or localized disease can be treated with sun protection and topical agents. Antimalarials are the initial treatment of choice if systemic therapy is required. Patients with severe or unresponsive disease can also be treated with a number of other immunomodulating or immunosuppressive agents. Clinicians should be aware of their potential adverse effects and appropriate dosing.
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Affiliation(s)
- Christopher B Hansen
- Department of Dermatology, University of Utah, 30 North 1900 East, Salt Lake City, UT 84132, USA.
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24
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Kuhn A, Ruland V, Bonsmann G. Cutaneous lupus erythematosus: Update of therapeutic options. J Am Acad Dermatol 2011; 65:e195-213. [DOI: 10.1016/j.jaad.2010.06.017] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2010] [Revised: 05/28/2010] [Accepted: 06/04/2010] [Indexed: 12/23/2022]
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25
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Fonseca E, Fernández-Torres RM. Managing Acute and Complex Dermatological Situations. Autoimmune Dis 2011. [DOI: 10.1007/978-0-85729-358-9_15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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26
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Abstract
In patients with cutaneous lupus erythematosus (CLE) and mild skin involvement, local therapy consisting of topically applied pharmacological agents, e.g., topical/intralesional steroids, may be sufficient. Recent reports have also shown efficacy of topical calcineurin inhibitors in patients with CLE, particularly on the face. Special attention receives consistent sun protection through photoresistant clothing and application of light-shielding substances with highly potent chemical or physical UVA- and UVB-protective filters. These substances should be applied in sufficient amount (ca. 2 mg/cm(2)) at least 20-30 minutes before sun exposure in order to avoid induction and exacerbation of cutaneous lesions. The mainstay of treatment for disfiguring and widespread skin manifestations in patients with CLE, irrespective of the subtype of the disease, is antimalarial agents. Our understanding of the use of combinations of antimalarials and proper dosing according to the ideal bodyweight limits problems with toxicity. Further therapies, such as methotrexate, or retinoids, dapsone, mycophenolate mofetil, and thalidomide in selected cases, can be helpful for patients with resistant disease; however, side effects need to be taken into consideration. Recent advances in biotechnology resulted in the development of novel systemic agents, but randomized controlled trials are necessary for the approval of new therapeutic strategies in CLE.
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Affiliation(s)
- A Kuhn
- Department of Dermatology, University of Münster, Münster, Germany.
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27
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Kivity S, Katz U, Daniel N, Nussinovitch U, Papageorgiou N, Shoenfeld Y. Evidence for the use of intravenous immunoglobulins--a review of the literature. Clin Rev Allergy Immunol 2010; 38:201-69. [PMID: 19590986 PMCID: PMC7101816 DOI: 10.1007/s12016-009-8155-9] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Intravenous immunoglobulins (IVIg) were first introduced in the middle of the twentieth century for the treatment of primary immunodeficiencies. In 1981, Paul Imbach noticed an improvement of immune-mediated thrombocytopenia, in patients receiving IVIg for immunodeficiencies. This opened a new era for the treatment of autoimmune conditions with IVIg. Since then, IVIg has become an important treatment option in a wide spectrum of diseases, including autoimmune and acute inflammatory conditions, most of them off-label (not included in the US Food and Drug Administration recommendation). A panel of immunologists and internists with experience in IVIg therapy reviewed the medical literature for published data concerning treatment with IVIg. The quality of evidence was assessed, and a summary of the available relevant literature in each disease was given. To our knowledge, this is the first all-inclusive comprehensive review, developed to assist the clinician when considering the use of IVIg in autoimmune diseases, immune deficiencies, and other conditions.
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Affiliation(s)
- Shaye Kivity
- Center for Autoimmune Diseases, Sheba Medical Center, Tel Hashomer, Israel
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28
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Abstract
Cutaneous lupus erythematosus (LE) may present in a variety of clinical forms. Three recognized subtypes of cutaneous LE are acute cutaneous LE (ACLE), subacute cutaneous LE (SCLE), and chronic cutaneous LE (CCLE). ACLE may be localized (most often as a malar or 'butterfly' rash) or generalized. Multisystem involvement as a component of systemic LE (SLE) is common, with prominent musculoskeletal symptoms. SCLE is highly photosensitive, with predominant distribution on the upper back, shoulders, neck, and anterior chest. SCLE is frequently associated with positive anti-Ro antibodies and may be induced by a variety of medications. Classic discoid LE is the most common form of CCLE, with indurated scaly plaques on the scalp, face, and ears, with characteristic scarring and pigmentary change. Less common forms of CCLE include hyperkeratotic LE, lupus tumidus, lupus profundus, and chilblain lupus. Common cutaneous disease associated with, but not specific for, LE includes vasculitis, livedo reticularis, alopecia, digital manifestations such as periungual telangiectasia and Raynaud phenomenon, photosensitivity, and bullous lesions. The clinical presentation of each of these forms, their diagnosis, and the inter-relationships between cutaneous LE and SLE are discussed. Common systemic findings in SLE are reviewed, as are diagnostic strategies, including histopathology, immunopathology, serology, and other laboratory findings. Treatments for cutaneous LE initially include preventive (e.g. photoprotective) strategies and topical therapies (corticosteroids and topical calcineurin inhibitors). For skin disease not controlled with these interventions, oral antimalarial agents (most commonly hydroxychloroquine) are often beneficial. Additional systemic therapies may be subdivided into conventional treatments (including corticosteroids, methotrexate, thalidomide, retinoids, dapsone, and azathioprine) and newer immunomodulatory therapies (including efalizumab, anti-tumor necrosis factor agents, intravenous immunoglobulin, and rituximab). We review evidence for the use of these medications in the treatment of cutaneous LE.
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Affiliation(s)
- Hobart W Walling
- Department of Dermatology, University of Utah School of Medicine, Salt Lake City, Utah 84132, USA
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29
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Arnson Y, Shoenfeld Y, Amital H. Intravenous immunoglobulin therapy for autoimmune diseases. Autoimmunity 2009; 42:553-60. [DOI: 10.1080/08916930902785363] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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30
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Abstract
Systemic lupus erythematosus (SLE) is a complex autoimmune disease with variable clinical manifestations that is characterized by flares and periods of relative quiescence. The disease occurs approximately 10 times more frequently in women and is more prevalent among certain ethnic groups. The etiology is complex and dependent upon an interaction of genetic, hormonal, and environmental factors. Corticosteroids and immunosuppressive agents have transformed the outlook for patients with lupus. Unfortunately, the increased lifespan unmasked an accelerated process of atherosclerosis and cardiovascular disease. Early mortality is usually attributable to active lupus, but deaths late in the disease process are often secondary to thrombotic events. Advancements in the understanding of molecular and cellular mechanisms involved in the pathogenesis have resulted in development of novel therapies. Immunomodulatory drugs developed for other diseases are being investigated for use in specific manifestations of lupus. Individualization of treatment and lifelong monitoring are required in most patients.
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31
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32
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Pelle MT. Issues and advances in the management and pathogenesis of cutaneous lupus erythematosus. ACTA ACUST UNITED AC 2007; 22:55-65. [PMID: 17249295 DOI: 10.1016/j.yadr.2006.09.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Evidence-based therapy for cutaneous lupus is lacking. A new clinical assessment tool for cutaneous lupus, the CLASI score, will enable more standardized assessments of response to therapy. Anti-Ro autoantibodies are associated with photosensitive SLE and SCLE, and they play a role in cell survival following ultraviolet exposure. Ro also functions in quality control of small RNAs, important in the prevention of autoimmune disease. Drug-induced lupus erythematosus can be anti-Ro- or anti-dsDNA-associated; SCLE and photosensitivity are characteristic of Ro-positive drug-induced lupus. Biologic therapies and IVIg are being studied for the treatment of SLE and cutaneous lupus. Large, controlled trials are needed, not only to evaluate newer therapies, but also to substantiate and define the usage of traditional therapies for cutaneous lupus erythematosus.
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Affiliation(s)
- Michelle T Pelle
- University of California San Diego, 200 West Arbor Drive, MC 8420, San Diego, CA 92103, USA.
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33
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Smith DI, Swamy PM, Heffernan MP. Off-label uses of biologics in dermatology: Interferon and intravenous immunoglobulin (Part 1 of 2). J Am Acad Dermatol 2007; 56:e1-54. [PMID: 17190617 DOI: 10.1016/j.jaad.2006.06.016] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2005] [Revised: 05/04/2006] [Accepted: 06/19/2006] [Indexed: 11/29/2022]
Abstract
The introduction of a number of biologic therapies into the market has revolutionized the practice of dermatology. These therapies include interferons, intravenous immunoglobulin, infliximab, adalimumab, etanercept, efalizumab, alefacept, and rituximab. Most dermatologists are familiar with the Food and Drug Administration-approved indications of these medications. However, numerous off-label uses have evolved. As part 1 of a 2-part series, this article will review the literature regarding the off-label uses of the interferons and intravenous immunoglobulin in dermatology.
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34
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Steinbrecher A, Berlit P. Intravenous immunoglobulin treatment in vasculitis and connective tissue disorders. J Neurol 2006; 253 Suppl 5:V39-49. [PMID: 16998753 DOI: 10.1007/s00415-006-5006-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Vasculitis syndromes and connective tissue disorders are heterogeneous and mostly rare multisystem disorders with various autoimmune mechanisms driving tissue inflammation and remodeling, ischemic and hemorrhagic tissue damage. While the nervous system can be affected by most of these diseases, the pathogenesis for neural involvement is often ambiguous and elusive for the clinician. Intravenous immunoglobulins (IVIG) have been used for the treatment of most of these disorders. However, a thorough review of the literature indicates that the role for IVIG has to be discussed for individual entities, has often only anecdotal evidence, and is particularly hard to define with respect to neurological manifestations. This review gathers the available evidence on the efficacy of IVIG in neurologically relevant rheumatic diseases, leading to recommendations for their clinical use.
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Affiliation(s)
- Andreas Steinbrecher
- Department of Neurology, University of Regensburg, Universitaetsstr. 84, 93053, Regensburg, Germany.
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35
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Maeshima E, Kida Y, Goda M, Minami Y. A case of systemic lupus erythematosus expressing intractable thrombocytopenia remedied effectively by intermittent and continuous administrations of a small amount of immune globulin. Mod Rheumatol 2006; 16:239-42. [PMID: 16906375 DOI: 10.1007/s10165-006-0482-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2006] [Accepted: 04/05/2006] [Indexed: 10/24/2022]
Abstract
We describe a case where intermittent and continuous administrations of a small amount of immune globulin were effective in the treatment of refractory chronic immune thrombocytopenic purpura by systemic lupus erythematosus (SLE). Steroid pulse therapy and cyclophosphamide pulse therapy were considered for thrombopenia. However, the patient had compressed fracture of the lumbar vertebrae due to osteoporosis and right external malleolus ulcer with complications of infection. Therefore, high-dose intravenous immune globulin (IVIG) therapy (400 mg/kg daily for 5 consecutive days) was administered. Then, as a maintenance therapy, a small amount of 400 mg/kg for 1 day (400 mg/kg monthly) was given in an intermittent and continuous manner, which resulted in improvement of thrombocytopenia and reduction of the amount of steroid administered.
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MESH Headings
- Chronic Disease
- Female
- Fractures, Compression/etiology
- Humans
- Immunoglobulins, Intravenous/administration & dosage
- Lupus Erythematosus, Systemic/complications
- Lupus Erythematosus, Systemic/immunology
- Middle Aged
- Osteoporosis/complications
- Purpura, Thrombocytopenic, Idiopathic/etiology
- Purpura, Thrombocytopenic, Idiopathic/immunology
- Purpura, Thrombocytopenic, Idiopathic/therapy
- Remission Induction
- Steroids/administration & dosage
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Affiliation(s)
- Etsuko Maeshima
- Department of Health and Sport Management, Osaka University of Health and Sport Sciences, 1-1 Asashirodai, Kumatoricho, Sennan, Osaka, 590-0496, Japan.
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36
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Toubi E, Kessel A, Shoenfeld Y. High-dose intravenous immunoglobulins: an option in the treatment of systemic lupus erythematosus. Hum Immunol 2006; 66:395-402. [PMID: 15866703 DOI: 10.1016/j.humimm.2005.01.022] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2004] [Accepted: 01/19/2005] [Indexed: 02/07/2023]
Abstract
Despite encouraging reports on the efficacy of intravenous immunoglobulin (IVIG) therapy in systemic lupus erythematosus (SLE), the clinical value of this treatment is not well established, and most of the data are based on case reports and small series of patients. IVIG has been used successfully to treat SLE patients with a broad spectrum of clinical manifestations, such as refractory thrombocytopenia, pancytopenia, central nervous system (CNS) involvement, secondary antiphospholipid syndrome, and lupus nephritis. The beneficial effects of IVIG on overall disease activity are usually prompt, with marked improvement within a few days, but they are often of limited duration. Improvement lasts for several weeks after the last infusion, although clinical response could be maintained by continuous monthly IVIG infusions. IVIG therapy immunomodulates autoimmune diseases by interacting with various Fcgamma receptors in such a way that it downregulates activating FcRIIA and FcRIIC and/or upregulates inhibitory FcRIIB. However, in SLE, additional mechanisms include inhibition of complement-mediated damage, modulation of production of cytokines and cytokine antagonists, modulation of T- and B-lymphocyte function, induction of apoptosis in lymphocytes and monocytes, downregulation of autoantibody production, manipulation of the idiotypic network, and neutralization of pathogenic autoantibodies. At present, IVIG in SLE is indicated either in severe cases that are nonresponsive to other therapeutic modalities, or when SLE can be controlled only with high-dose steroids; in such patients, IVIG thus becomes a useful steroid-sparing agent. However, this needs to be confirmed in double-blind, placebo-controlled studies.
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Affiliation(s)
- E Toubi
- Division of Allergy and Clinical Immunology, Bnai Zion Medical Center, Haifa, Israel.
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37
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Dooley MA, Ginzler EM. Newer therapeutic approaches for systemic lupus erythematosus: immunosuppressive agents. Rheum Dis Clin North Am 2006; 32:91-102, ix. [PMID: 16504823 DOI: 10.1016/j.rdc.2005.11.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
There has been unprecedented growth in new therapeutic approaches for the treatment of systemic lupus erythematosus (SLE). These approaches include re-evaluation of the doses and duration of therapy with traditional agents, including intravenous cyclophosphamide and azathioprine. Drugs that were developed for other uses are being applied to specific SLE manifestations, and have spurred larger scale trials for overall disease activity. In addition, several new agents show promise in clinical trials; many have safer toxicity profiles than do traditional therapies. Some of these agents have multiple immunomodulatory effects, whereas others interfere with a specific immunologic process in one of the pathogenetic pathways of SLE activity.
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38
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Callen JP. Management of ‘refractory’ skin disease in patients with lupus erythematosus. Best Pract Res Clin Rheumatol 2005; 19:767-84. [PMID: 16150402 DOI: 10.1016/j.berh.2005.05.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Skin disease in patients with lupus erythematosus can be subdivided into two broad categories-those lesions that, when biopsied, demonstrate an interface dermatitis and those that do not demonstrate an interface dermatitis. The skin lesions that are represented by the interface dermatitis include discoid lupus erythematosus (DLE), subacute cutaneous lupus erythematosus (SCLE), and acute cutaneous lupus erythematosus. Many patients with these cutaneous lesions can be managed with "standard" therapies, including sunscreens, protective clothing and behavioral alteration, and topical corticosteroids with or without an oral antimalarial agent. These standard therapies are often not used appropriately, resulting in a situation in which the patient is felt to have refractory disease. This chapter discusses these therapies and defines what is meant by refractory disease and how the author approaches these patients.
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Affiliation(s)
- Jeffrey P Callen
- Division of Dermatology, School of Medicine, University of Louisville, 310 East Broadway, Louisville, KY 40202, USA.
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Sherer Y, Shoenfeld Y. Intravenous immunoglobulin for immunomodulation of systemic lupus erythematosus. Autoimmun Rev 2005; 5:153-5. [PMID: 16431350 DOI: 10.1016/j.autrev.2005.09.002] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Intravenous immunoglobulin (IVIg) is used for replacement therapy in immunodeficiency states and for immunomodulation of various autoimmune diseases. Several case reports and series support a beneficial role of IVIg in systemic lupus erythematosus (SLE), both as salvage immunotherapy and in control of disease activity in general and amelioration of classical disease manifestations. Further, lupus nephritis can also be treated usually successfully with IVIg. A few questions remain unanswered as to the appropriate therapeutic dosage and the clinical manifestations that can be best treated with IVIg.
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Affiliation(s)
- Yaniv Sherer
- Department of Medicine 'B' & Center for Autoimmune Diseases, Sheba Medical Center Tel-Hashomer, Israel
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Abstract
This paper reviews the latest treatments for cutaneous lupus erythematosus. It focuses on evidence-based guidance for the management of cutaneous lupus erythematosus, with identification of the strength of evidence available at this time. In addition, I have briefly reviewed the epidemiological aspects, diagnosis and evaluation of patients with cutaneous lupus erythematosus. This review reflects data available from the Cochrane Library, Medline, literature searches, and the experience of the author managing patients with cutaneous lupus erythematosus for over 25 years.
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Affiliation(s)
- J P Callen
- Division of Dermatology, University of Louisville School of Medicine, Louisville, KY 40292, USA.
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