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Kaniecki T, Hughes M, McMahan Z. Managing gastrointestinal manifestations in systemic sclerosis, a mechanistic approach. Expert Rev Clin Immunol 2024; 20:603-622. [PMID: 38406978 PMCID: PMC11098704 DOI: 10.1080/1744666x.2024.2320205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 02/14/2024] [Indexed: 02/27/2024]
Abstract
INTRODUCTION Systemic sclerosis (SSc) is a connective tissue disease with heterogeneous presentation. Gastrointestinal (GI) complications of SSc are characterized by esophageal reflux, abnormal motility, and microbiome dysbiosis, which impact patient quality of life and mortality. Preventative therapeutics are lacking, with management primarily aimed at symptomatic control. AREAS COVERED A broad literature review was conducted through electronic databases and references from key articles. We summarize the physiology of gastric acid production and GI motility to provide context for existing therapies, detail the current understanding of SSc-GI disease, and review GI medications studied in SSc. Finally, we explore new therapeutic options. We propose a management strategy that integrates data on drug efficacy with knowledge of disease pathophysiology, aiming to optimize future therapeutic targets. EXPERT OPINION SSc-GI complications remain a challenge for patients, clinicians, and investigators alike. Management presently focuses on treating symptoms and minimizing mucosal damage. Little evidence exists to suggest immunosuppressive therapy halts progression of GI involvement or reverses damage, leaving many unanswered questions about the optimal clinical approach. Further research focused on identifying patients at risk for GI progression, and the underlying mechanism(s) that drive disease will provide opportunities to prevent long-term damage, and significantly improve patient quality of life.
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Affiliation(s)
- Timothy Kaniecki
- Division of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Michael Hughes
- Department of Rheumatology, Northern Care Alliance NHS Foundation Trust, Salford Care Organisation, Salford, US
- Division of Musculoskeletal and Dermatological Sciences, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Zsuzsanna McMahan
- Division of Rheumatology, UTHealth Houston McGovern Medical School, Houston, TX
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Seelmann D, Poblete MP, Saavedra S, Madrid AM, von Muhlenbrock C, Estay C, Goecke A. Gastric dysrhythmias in patients with early systemic sclerosis: a cross-sectional study. Rheumatol Adv Pract 2024; 8:rkae041. [PMID: 38566833 PMCID: PMC10985681 DOI: 10.1093/rap/rkae041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Accepted: 03/03/2024] [Indexed: 04/04/2024] Open
Abstract
Objectives Gastric involvement in patients with early systemic sclerosis (SSc) has not been previously investigated. We aim to evaluate the association of gastric dysrhythmias with gastrointestinal (GI) symptoms and nailfold video capillaroscopy (NVC). Methods Cross-sectional study. Patients with early SSc, completed the UCLA GIT 2.0 questionnaire, performed an NVC, and a surface Electrogastrography (EGG). Descriptive statistics was used for demographic and clinical characteristics and Fisher and Kendall Tau tests were used for association analysis. Results 75 patients were screened, 30 patients were consecutively enrolled, 29 performed the EGG and 1 patient had a non-interpretable NVC. 29/30 were female with a mean age of 48.7 years (25-72). The mean disease duration from the first non-RP symptom was 22.6 +/-10.8 months and most of the patients had limited disease (76.6%). Total GIT 2.0 score symptoms were moderate-severe in 63% of the participants and 28/29 had an abnormal EGG. Bradygastria was the most common pattern present in 70% of the participants. NVC patterns: 17% early, 34% active, 28% scleroderma-like, 14% non-specific, and 2 patients had a normal NVC. There was no association between severe GI symptoms or NVC patterns and severely abnormal EGG, but the presence of bradygastria was associated with severe impairment in the social functioning area (p 0.018). Conclusions Gastric dysmotility is common in early SSc and there is a lack of correlation between GI symptoms and NVC scleroderma patterns. EGG is a sensitive, cheap, and non-invasive exam, that may be an alternative to early diagnosis of GI involvement.
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Affiliation(s)
- Daniela Seelmann
- Rheumatology Section, Medicine Department, Hospital Clínico de la Universidad de Chile, Santiago, Chile
| | - María Paz Poblete
- Rheumatology Section, Medicine Department, Hospital Clínico de la Universidad de Chile, Santiago, Chile
| | - Silvana Saavedra
- Rheumatology Section, Medicine Department, Hospital Clínico de la Fuerza Aérea de Chile, Santiago, Chile
| | - Ana María Madrid
- Gastroenterology Section, Medicine Department, Hospital Clínico de la Universidad de Chile, Santiago, Chile
| | - Christian von Muhlenbrock
- Gastroenterology Section, Medicine Department, Hospital Clínico de la Universidad de Chile, Santiago, Chile
- Digestive Disease Center, Internal Medicine Department, Universidad de los Andes, Santiago, Chile
| | - Camila Estay
- Gastroenterology Section, Medicine Department, Hospital Clínico de la Universidad de Chile, Santiago, Chile
| | - Annelise Goecke
- Rheumatology Section, Medicine Department, Hospital Clínico de la Universidad de Chile, Santiago, Chile
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von Mühlenbrock C, Madrid AM, Defilippi C, Defilippi C, Soto L. Diffuse Gastrointestinal Motor Compromise in Patients with Scleroderma: Utility of Minimally Invasive Techniques. Dig Dis Sci 2024; 69:191-199. [PMID: 37982941 DOI: 10.1007/s10620-023-08151-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 10/09/2023] [Indexed: 11/21/2023]
Abstract
BACKGROUND Scleroderma is a systemic inflammatory disorder that can compromise the gastrointestinal tract in up to 90% of patients. AIM The purpose of this work is to characterize esophageal, gastric, and intestinal compromise in patients with scleroderma by means of minimally invasive methods and its association with symptoms and severity of their rheumatological condition. METHODS Patients with systemic sclerosis were recruited according to the criteria of the American College of Rheumatology. The study of digestive involvement was carried out on four consecutive days: esophageal manometry was performed on the first day, intestinal manometry on the second day, surface electrogastrography on the third, and hydrogen breath test on the fourth. The Mann-Whitney test was used for quantitative variables and the chi-squared test for categorical variables (p < 0.05). RESULTS A total of 30 patients were included, with an average age of 52.7 years and 93% women. Average disease evolution duration was 6.5 years, 70% with limited variety. Rodnan averaged 12 points, being higher in the diffuse variety. The main symptom was heartburn, followed by abdominal distension, with no differences between subtypes except for diffuse nausea; 80% had intestinal manometric compromise, 76% esophageal manometric compromise, and 30% electrogastrographic compromise. Bacterial overgrowth was evidenced in two-thirds (66%) of the patients, and 23% of the patients had simultaneous esophageal, gastric, and intestinal involvement, which correlated with greater skin involvement but not with gastrointestinal symptoms. CONCLUSIONS Gastrointestinal involvement in patients with scleroderma is frequent and is observed regardless of the symptoms and clinical characteristics of the latter, except for skin involvement.
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Affiliation(s)
- Christian von Mühlenbrock
- Functional Digestive Diseases and Motility Laboratory, Gastroenterology Section, Hospital Clinico Universidad de Chile, Dr. Carlos Lorca 999, Independencia, Santiago, Chile.
- Internal Medicine Department, Gastroenterology Section, Universidad de los Andes, Av San Carlos de Apoquindo 2200, Las Condes, Santiago de Chile, Chile.
| | - Ana María Madrid
- Functional Digestive Diseases and Motility Laboratory, Gastroenterology Section, Hospital Clinico Universidad de Chile, Dr. Carlos Lorca 999, Independencia, Santiago, Chile
| | - Claudia Defilippi
- Functional Digestive Diseases and Motility Laboratory, Gastroenterology Section, Hospital Clinico Universidad de Chile, Dr. Carlos Lorca 999, Independencia, Santiago, Chile
| | - Carlos Defilippi
- Functional Digestive Diseases and Motility Laboratory, Gastroenterology Section, Hospital Clinico Universidad de Chile, Dr. Carlos Lorca 999, Independencia, Santiago, Chile
| | - Lilian Soto
- Rheumatology Section, Department of Medicine, Hospital Clinico Universidad de Chile, Santiago, Chile
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Herrán M, Adler BL, Perin J, Morales W, Pimentel M, McMahan ZH. Antivinculin Antibodies in Systemic Sclerosis: Associations With Slow Gastric Transit and Extraintestinal Clinical Phenotype. Arthritis Care Res (Hoboken) 2023; 75:2166-2173. [PMID: 36951252 PMCID: PMC10517080 DOI: 10.1002/acr.25118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 12/19/2022] [Accepted: 03/21/2023] [Indexed: 03/24/2023]
Abstract
OBJECTIVE The gastrointestinal (GI) tract is commonly affected in systemic sclerosis (SSc). A positive association between antivinculin antibody levels and GI symptom severity is reported in SSc. We sought to examine whether antivinculin antibodies associate with measures of GI dysmotility and extraintestinal clinical phenotype in SSc. METHODS A total of 88 well-characterized patients with SSc and GI disease were assayed for antivinculin antibodies by enzyme-linked immunosorbent assay. Whole-gut scintigraphy, GI symptom scores, and clinical features of SSc were compared between patients with and without antibodies. RESULTS Twenty of 88 (23%) patients had antivinculin antibodies, which were more prevalent in patients with slow gastric transit (35% versus 22%). In the univariate analyses, patients who were positive for antivinculin antibodies were more likely to have limited cutaneous disease (odds ratio [OR] 9.60 [95% confidence interval (95% CI) 1.19, 77.23]) and thyroid disease (OR 4.09 [95% CI 1.27, 13.21]). Such patients were also less likely to have lung involvement based on a Medsger Severity Score of ≥2 (OR 0.25 [95% CI 0.07, 0.92]). Higher levels of antivinculin autoantibodies were associated with less gastric emptying (β coefficient -3.41 [95% CI -6.72, -0.09]). The association between antivinculin antibodies and each of these clinical features remained significant in the multivariable model. In particular, the presence of antivinculin antibodies (β coefficient -6.20 [95% CI -12.33, -0.063]) and higher levels of antivinculin antibodies (β coefficient -3.64 [95% CI -7.05, -0.23]) were each significantly associated with slower gastric transit. CONCLUSION Antivinculin antibodies associate with slower gastric transit in SSc and may provide insight into GI complications of SSc.
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Affiliation(s)
| | | | - Jamie Perin
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | | | - Mark Pimentel
- Cedars-Sinai Medical Center, Los Angeles, California
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McMahan ZH, Kulkarni S, Chen J, Chen JZ, Xavier RJ, Pasricha PJ, Khanna D. Systemic sclerosis gastrointestinal dysmotility: risk factors, pathophysiology, diagnosis and management. Nat Rev Rheumatol 2023; 19:166-181. [PMID: 36747090 DOI: 10.1038/s41584-022-00900-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/20/2022] [Indexed: 02/08/2023]
Abstract
Nearly all patients with systemic sclerosis (SSc) are negatively affected by dysfunction in the gastrointestinal tract, and the severity of gastrointestinal disease in SSc correlates with high mortality. The clinical complications of this dysfunction are heterogeneous and include gastro-oesophageal reflux disease, gastroparesis, small intestinal bacterial overgrowth, intestinal pseudo-obstruction, malabsorption and the requirement for total parenteral nutrition. The abnormal gastrointestinal physiology that promotes the clinical manifestations of SSc gastrointestinal disease throughout the gastrointestinal tract are diverse and present a range of therapeutic targets. Furthermore, the armamentarium of medications and non-pharmacological interventions that can benefit affected patients has substantially expanded in the past 10 years, and research is increasingly focused in this area. Here, we review the details of the gastrointestinal complications in SSc, tie physiological abnormalities to clinical manifestations, detail the roles of standard and novel therapies and lay a foundation for future investigative work.
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Affiliation(s)
| | - Subhash Kulkarni
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Joan Chen
- Division of Gastroenterology, University of Michigan, Ann Arbor, MI, USA
| | - Jiande Z Chen
- Division of Gastroenterology, University of Michigan, Ann Arbor, MI, USA
| | - Ramnik J Xavier
- Division of Gastroenterology, Massachusetts General Hospital, Boston, MA, USA.,Center for Microbiome Informatics and Therapeutics, Massachusetts Institute of Technology, Cambridge, MA, USA.,Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - P Jay Pasricha
- Division of Gastroenterology, Johns Hopkins University, Baltimore, MD, USA.,Department of Medicine, Mayo Clinic, Scottsdale, AZ, USA
| | - Dinesh Khanna
- Division of Rheumatology, University of Michigan, Ann Arbor, MI, USA. .,University of Michigan Scleroderma Program, Ann Arbor, MI, USA.
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Abstract
The upper gastrointestinal (GI) tract is frequently involved in systemic sclerosis (SSc) and may impact quality of life, physical function and survival. Although we are currently very proactive in terms of screening for heart and lung involvement, patients with SSc are not routinely screened for GI involvement. This review details the available investigations for common upper GI symptoms in SSc, including dysphagia, reflux and bloating and provides advice as to how to integrate these investigations into current clinical care.
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Volkmann ER, McMahan Z. Gastrointestinal involvement in systemic sclerosis: pathogenesis, assessment and treatment. Curr Opin Rheumatol 2022; 34:328-336. [PMID: 35993874 PMCID: PMC9547962 DOI: 10.1097/bor.0000000000000899] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The majority of patients with systemic sclerosis (SSc) will experience involvement of their gastrointestinal over the course of their disease. Despite the high prevalence of gastrointestinal involvement in SSc, the strategies pertaining to the assessment and treatment for this clinical dimension of SSc have historically been limited. However, the present review highlights recent research contributions that enhance our understanding of SSc-GI patient subsets and provides updates on pathogenic mechanisms of disease, assessment and symptom-directed management. RECENT FINDINGS In the past few years, several studies have identified risk factors for more severe gastrointestinal disease in SSc and have provided insight to optimize diagnosis and management of SSc-GI symptoms. This article also provides a review of currently available investigations and therapies for individual SSc-GI disease manifestations and reflects on actively evolving areas of research, including our understanding the role of the gut microbiome in SSc. SUMMARY Here, we provide important updates pertaining to the risk stratification, assessment, diagnosis and management of SSc patients with gastrointestinal symptoms. These findings provide opportunities to enhance patient care and highlight exciting opportunities for future research.
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Affiliation(s)
- Elizabeth R. Volkmann
- Division of Rheumatology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Zsuzsanna McMahan
- Division of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Aliyu M, Zohora FT, Anka AU, Ali K, Maleknia S, Saffarioun M, Azizi G. Interleukin-6 cytokine: An overview of the immune regulation, immune dysregulation, and therapeutic approach. Int Immunopharmacol 2022; 111:109130. [PMID: 35969896 DOI: 10.1016/j.intimp.2022.109130] [Citation(s) in RCA: 47] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 07/26/2022] [Accepted: 08/03/2022] [Indexed: 12/19/2022]
Abstract
Several studies have shown that interleukin 6 (IL-6) is a multifunctional cytokine with both pro-inflammatory and anti-inflammatory activity, depending on the immune response context. Macrophages are among several cells that secrete IL-6, which they express upon activation by antigens, subsequently inducing fever and production of acute-phase proteins from the liver. Moreover, IL-6 induces the final maturation of B cells into memory B cells and plasma cells as well as an adaptive role for short-term energy allocation. Activation of IL-6 receptors results in the intracellular activation of the JAK/STAT pathway with resultant production of inflammatory cytokines. Several mechanisms-controlled IL-6 expression, but aberrant production was shown to be crucial in the pathogenesis of many diseases, which include autoimmune and chronic inflammatory diseases. IL-6 in combination with transforming growth factor β (TGF-β) induced differentiation of naïve T cells to Th17 cells, which is the cornerstone in autoimmune diseases. Recently, IL-6 secretion was shown to form the backbone of hypercytokinemia seen in the Coronavirus disease 2019 (COVID-19)-associated hyperinflammation and multiorgan failure. There are two classes of approved IL-6 inhibitors: anti-IL-6 receptor monoclonal antibodies (e.g., tocilizumab) and anti-IL-6 monoclonal antibodies (i.e., siltuximab). These drugs have been evaluated in patients with rheumatoid arthritis, juvenile idiopathic arthritis, cytokine release syndrome, and COVID-19 who have systemic inflammation. JAK/STAT pathway blockers were also successfully used in dampening IL-6 signal transduction. A better understanding of different mechanisms that modulate IL-6 expression will provide the much-needed solution with excellent safety and efficacy profiles for the treatment of autoimmune and inflammatory diseases in which IL-6 derives their pathogenesis.
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Affiliation(s)
- Mansur Aliyu
- Department of Immunology, School of Public Health, Tehran University of Medical Sciences, International Campus, TUMS-IC, Tehran, Iran; Department of Medical Microbiology, Faculty of Clinical Science, College of Health Sciences, Bayero University, Kano, Nigeria
| | - Fatema Tuz Zohora
- Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, Malaysia
| | - Abubakar Umar Anka
- Department of Medical Laboratory Science, College of Medical Sciences, Ahmadu Bello University, Zaria, Nigeria
| | - Kashif Ali
- Department of Pharmacy Abdul Wali, Khan University Mardan, Pakistan
| | - Shayan Maleknia
- Biopharmaceutical Research Center, AryoGen Pharmed Inc., Alborz University of Medical Sciences, Karaj, Iran
| | - Mohammad Saffarioun
- Biopharmaceutical Research Center, AryoGen Pharmed Inc., Alborz University of Medical Sciences, Karaj, Iran
| | - Gholamreza Azizi
- Non-communicable Diseases Research Center, Alborz University of Medical Sciences, Karaj, Iran.
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