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Zamanian RT, Badesch D, Chung L, Domsic RT, Medsger T, Pinckney A, Keyes-Elstein L, D'Aveta C, Spychala M, White RJ, Hassoun PM, Torres F, Sweatt AJ, Molitor JA, Khanna D, Maecker H, Welch B, Goldmuntz E, Nicolls MR. Safety and Efficacy of B-Cell Depletion with Rituximab for the Treatment of Systemic Sclerosis-associated Pulmonary Arterial Hypertension: A Multicenter, Double-Blind, Randomized, Placebo-controlled Trial. Am J Respir Crit Care Med 2021; 204:209-221. [PMID: 33651671 PMCID: PMC8650794 DOI: 10.1164/rccm.202009-3481oc] [Citation(s) in RCA: 60] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Rationale: Systemic sclerosis (SSc)-pulmonary arterial hypertension (PAH) is one of the most prevalent and deadly forms of PAH. B cells may contribute to SSc pathogenesis. Objectives: We investigated the safety and efficacy of B-cell depletion for SSc-PAH. Methods: In an NIH-sponsored, multicenter, double-blinded, randomized, placebo-controlled, proof-of-concept trial, 57 patients with SSc-PAH on stable-dose standard medical therapy received two infusions of 1,000 mg rituximab or placebo administered 2 weeks apart. The primary outcome measure was the change in 6-minute-walk distance (6MWD) at 24 weeks. Secondary endpoints included safety and invasive hemodynamics. We applied a machine learning approach to predict drug responsiveness. Measurements and Main Results: We randomized 57 subjects from 2010 to 2018. In the primary analysis, using data through Week 24, the adjusted mean change in 6MWD at 24 weeks favored the treatment arm but did not reach statistical significance (23.6 ± 11.1 m vs. 0.5 ± 9.7 m; P = 0.12). Although a negative study, when data through Week 48 were also considered, the estimated change in 6MWD at Week 24 was 25.5 ± 8.8 m for rituximab and 0.4 ± 7.4 m for placebo (P = 0.03). Rituximab treatment appeared to be safe and well tolerated. Low levels of RF (rheumatoid factor), IL-12, and IL-17 were sensitive and specific as favorable predictors of a rituximab response as measured by an improved 6MWD (receiver operating characteristic area under the curve, 0.88-0.95). Conclusions: B-cell depletion therapy is a potentially effective and safe adjuvant treatment for SSc-PAH. Future studies in these patients can confirm whether the identified biomarkers predict rituximab responsiveness. Clinical trial registered with www.clinicaltrails.gov (NCT01086540).
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Affiliation(s)
- Roham T Zamanian
- Division of Pulmonary, Allergy, and Critical Care Medicine and.,Vera Moulton Wall Center for Pulmonary Vascular Disease, Stanford, California
| | - David Badesch
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Lorinda Chung
- Division of Pulmonary, Allergy, and Critical Care Medicine and.,Division of Rheumatology and Immunology, Stanford University, Stanford University School of Medicine, Stanford, California
| | - Robyn T Domsic
- Division of Rheumatology and Clinical Immunology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Thomas Medsger
- Division of Rheumatology and Clinical Immunology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | | | | | - Carla D'Aveta
- Rho Federal Systems Division, Durham, North Carolina
| | | | - R James White
- Division of Pulmonary and Critical Care Medicine, University of Rochester, Rochester, New York
| | - Paul M Hassoun
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Fernando Torres
- Division of Pulmonary and Critical Care Medicine, University of Texas Southwestern, Dallas, Texas
| | - Andrew J Sweatt
- Division of Pulmonary, Allergy, and Critical Care Medicine and.,Vera Moulton Wall Center for Pulmonary Vascular Disease, Stanford, California
| | - Jerry A Molitor
- Division of Rheumatic and Autoimmune Diseases, University of Minnesota, Minneapolis, Minnesota
| | - Dinesh Khanna
- Division of Rheumatology, University of Michigan, Ann Arbor, Michigan
| | - Holden Maecker
- Division of Pulmonary, Allergy, and Critical Care Medicine and
| | - Beverly Welch
- National Institute of Allergy and Infectious Diseases, Bethesda, Maryland; and
| | - Ellen Goldmuntz
- National Institute of Allergy and Infectious Diseases, Bethesda, Maryland; and
| | - Mark R Nicolls
- Division of Pulmonary, Allergy, and Critical Care Medicine and.,Vera Moulton Wall Center for Pulmonary Vascular Disease, Stanford, California.,Veterans Affairs Palo Alto Health Care System, Palo Alto, California
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Connolly MK. Systemic sclerosis (scleroderma): remaining challenges. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:438. [PMID: 33842659 PMCID: PMC8033370 DOI: 10.21037/atm-20-5449] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Despite progress in treating internal organ involvement in systemic sclerosis (scleroderma) (SSc), such as pulmonary disease, effective treatments for the hallmark of the disease, cutaneous fibrosis, remain elusive. None of the disease-modifying antirheumatic drugs (DMARDS) have shown proven efficacy for SSc skin fibrosis, and there remain no FDA-approved medications, all of which are off-label, for cutaneous fibrosis in SSc. This review article will briefly summarize conventional therapies, biologics and hematopoietic stem cell transplants and select ongoing clinical trials in SSc. The gold standard for measuring skin fibrosis in SSc is the modified Rodnan skin score (MRSSS). This is a validated test that measures skin thickness (0 to 3) at 17 locations for a total score of 51. Improvements in skin score over time are used in clinical trials to quantitate skin fibrosis. Although recording the Rodnan skin score is technically straightforward, requiring no special equipment, and noninvasive, the fluctuating natural history of the disease includes improvement over time without interventions, rendering meaningful trials difficult to assess. Understanding of the basic molecular mechanisms driving pathologic fibrosis in SSc remains lacking, and underpins the often empiric nature and likely the lack of efficacy of many therapeutics that have been tried. Although repeated skin biopsies might be a more precise way to follow disease progression and regression, this is necessarily invasive and requires special tools. Here, this review will look at conventional therapies, biologics, autologous hematopoietic stem cell transplantation, and catalog some of the ongoing clinical trials in SSc with a focus on cutaneous fibrosis.
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Affiliation(s)
- Mary Karin Connolly
- Department of Dermatology, University of California, San Francisco, San Francisco, CA 94115, USA
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de Figueiredo Caldas MMV, de Azevedo KPM, de França Nunes AC, de Oliveira VH, Pimenta IDSF, de Araújo IDT, Neto FAB, da Silveira Gonçalves de Oliveira AK, Piuvezam G. Is rituximab effective for systemic sclerosis? A systematic review and meta-analysis. Adv Rheumatol 2021; 61:15. [PMID: 33640020 DOI: 10.1186/s42358-021-00170-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Accepted: 02/10/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Systemic sclerosis (SSc) is a clinically complex and challenging disease, that leads to skin fibrosis. Its most frequent complication is interstitial lung disease (ILD), which leads to a worse prognosis. In this situation, cyclophosphamide is considered the gold standard for its treatment, despite the controversies regarding its efficacy and toxicity. However, studies using rituximab (RTX) have shown that this drug may be a promising therapeutic option. OBJECTIVES This paper objective was to analyze the scientific evidence on the RTX effects on SSc. METHODS A systematic review (SR) was performed including clinical trials (CTs) on the use of RTX in SSc, published up to May 2020. The studies were identified through systematic searches in bibliographic databases using a predefined search strategy. The following databases were used: PUBMED, SCOPUS, SCIELO, LILACS, SCIENCE DIRECT, WEB OF SCIENCE, COCHRANE, WHOLIS, PAHO and EMBASE. Also, a manual search was performed. The methodological quality of the studies was determined using Jadad scale, Risk of Bias Tool (RoB 2.0) and Risk of Bias in Non-Randomized Studies - of Interventions tool (ROBINS-I). A meta-analysis of the randomized CTs was performed, using Review Manager. RESULTS Ten CTs were included in this SR. Of these, three were randomized and seven were non-randomized. Five showed a statistically significant improvement in forced vital capacity (FVC) at some time during follow-up. Regarding the skin, eight studies showed statistically significant improvements according toa the modified Rodnan skin score. The meta-analysis found positive effects of RTX in SSc, with a statistical significance for lung disease. CONCLUSION Rituximab is a promising strategy for the SSc-associated ILD and cutaneous fibrosis treatment. PROSPERO registration number: CRD42019132018.
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Affiliation(s)
| | - Kesley Pablo Morais de Azevedo
- Post-Graduation Program in Public Health (PPGSCol), Federal University of Rio Grande do Norte, Natal, Rio Grande do Norte, Brazil.
| | - Ana Clara de França Nunes
- Post-Graduation Program in Public Health (PPGSCol), Federal University of Rio Grande do Norte, Natal, Rio Grande do Norte, Brazil
| | - Victor Hugo de Oliveira
- Post-Graduation Program in Public Health (PPGSCol), Federal University of Rio Grande do Norte, Natal, Rio Grande do Norte, Brazil
| | | | | | | | | | - Grasiela Piuvezam
- Post-Graduation Program in Public Health (PPGSCol), Federal University of Rio Grande do Norte, Natal, Rio Grande do Norte, Brazil.,Department of Public Health, Post-Graduation Program in Public Health (PPGSCol), Federal University of Rio Grande do Norte, Natal, Rio Grande do Norte, Brazil
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Zhang S, Lv J, Ren X, Hao X, Zhou P, Wang Y. The efficacy and safety of fecal microbiota transplantation in the treatment of systemic sclerosis: A protocol for systematic review and meta analysis. Medicine (Baltimore) 2020; 99:e21267. [PMID: 32664182 PMCID: PMC7360200 DOI: 10.1097/md.0000000000021267] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Systemic sclerosis (SSc) is 1 of the most complex systemic autoimmune diseases.Accumulating evidence suggests that gut microbiota affect the development and function of the immune system and may play a role in the pathogenesis of autoimmune diseases. This new paradigm raises the possibility that many diseases result, at least partially, from microbiota-related dysfunction. This understanding invites the investigation of fecal microbiota transplantation (FMT) in the treatment of SSc. However, no study has specifically and systematically investigated the efficacy and safety of FMT in the treatment of SSc. Thus, this study will systematically and comprehensively appraise the efficacy and safety of FMT in the treatment of SSc. METHODS We will search the following sources without restrictions for date, language, or publication status: PubMed, Web of Science,Cochrane Central Register of Controlled Trials (CENTRAL) Cochrane Library, EMBASE and China National Knowledge Infrastructure. We will apply a combination of Medical Subject Heading (MeSH) and free-text terms incorporating database-specific controlled vocabularies and text words to implement search strategies. We will also search the ongoing trials registered in the World Health Organization's International Clinical Trials Registry Platform. Besides, the previous relevant reviews conducted on FMT for SSc and reference lists of included studies will also be searched. RESULTS This study will provide a reliable basis for the treatment of SSc with FMT. CONCLUSIONS The findings will be an available reference to evaluate the efficacy and safety of FMT in the treatment of SSc. REGISTRATION NUMBER INPLASY202060019.
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Affiliation(s)
| | - Jingjing Lv
- Hebei Province Hospital of Chinese Medicine, Shijiazhuang City, Hebei
| | | | - Xinyu Hao
- Hebei University of Chinese Medicine
| | | | - Yangang Wang
- Hebei Province Hospital of Chinese Medicine, Shijiazhuang City, Hebei
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Ebata S, Yoshizaki A, Fukasawa T, Asano Y, Oba K, Sato S. Rapid decrease of serum surfactant protein-D levels predicts the reactivity of rituximab therapy in systemic sclerosis-associated interstitial lung disease. J Dermatol 2020; 47:796-800. [PMID: 32383266 DOI: 10.1111/1346-8138.15379] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Accepted: 04/09/2020] [Indexed: 01/10/2023]
Abstract
Systemic sclerosis (SSc) is an autoimmune disorder characterized by vascular damage and excessive fibrosis. SSc-associated interstitial lung disease (ILD) is a leading cause of death in SSc. Several studies have shown the efficacy of rituximab (RTX) in SSc-ILD, but no study has examined the relation between RTX reactivity and change of serum marker levels. In this study we examined the relation between change of serum surfactant protein-D (SP-D) levels and change of percentage forced vital capacity (FVC) in 11 SSc-ILD patients with anti-topoisomerase I antibody treated by RTX. Serum SP-D levels were significantly decreased compared with baseline at 2 weeks after first RTX infusion in good responders (P = 0.04), while not in poor responders (P = 0.77). Moreover, ΔSP-D at 2 weeks negatively correlated with Δ%FVC at 24 weeks (P = 0.001). In conclusion, we suggested that the rapid decrease of SP-D levels may be a predictive marker of RTX effect against SSc-ILD.
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Affiliation(s)
- Satoshi Ebata
- Department of Dermatology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Ayumi Yoshizaki
- Department of Dermatology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Takemichi Fukasawa
- Department of Dermatology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yoshihide Asano
- Department of Dermatology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Koji Oba
- Department of Biostatistics, School of Public Health, Graduate School of Medicine, and Interfaculty Initiative in Information Studies, The University of Tokyo, Tokyo, Japan
| | - Shinichi Sato
- Department of Dermatology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
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Autoantibodies to stratify systemic sclerosis patients into clinically actionable subsets. Autoimmun Rev 2020; 19:102583. [PMID: 32553611 DOI: 10.1016/j.autrev.2020.102583] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Accepted: 05/27/2020] [Indexed: 01/29/2023]
Abstract
Systemic sclerosis (SSc) is a rare chronic disease of unknown etiology characterized by vascular abnormalities and fibrosis involving the skin and internal organs, especially the gastrointestinal tract, lung, heart and kidneys. Although the disease was historically stratified according to the extent of skin involvement, more recent approaches place more emphasis on patterns and extent of internal organ involvement. Despite numerous clinical trials, disease-modifying treatment options are still limited resulting in persistent poor quality of life and high mortality. This review provides an overview of autoantibodies in SSc and novel approaches to stratify the disease into clinically actionable subsets.
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