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Mulcaire-Jones E, Pugashetti JV, Oldham JM, Khanna D. Novel Therapeutic Approaches in Connective Tissue Disease-Associated Interstitial Lung Disease. Semin Respir Crit Care Med 2024; 45:435-448. [PMID: 38740369 DOI: 10.1055/s-0044-1786155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2024]
Abstract
Connective tissue diseases (CTD) comprise a group of autoimmune diseases that can affect multiple organs in the body including the lungs. The most common form of pulmonary involvement is interstitial lung disease (ILD). CTD-associated ILD (CTD-ILD) can take one of several courses including nonprogressive, chronically progressive, or rapidly progressive. Chronically and rapidly progressive patterns are associated with increased mortality. Limited randomized controlled trial data are available for treatment of CTD-ILD, with most data coming from systemic sclerosis-related ILD. The current first-line treatment for all CTD-ILD is immunosuppression with consideration of antifibrotics, stem cell transplant, and lung transplant in progressive disease. In this article, we review data for ILD treatment options in systemic sclerosis, rheumatoid arthritis, myositis, and primary Sjögren's syndrome-related ILDs.
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Affiliation(s)
- Erica Mulcaire-Jones
- Division of Rheumatology, Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Janelle Vu Pugashetti
- Division of Pulmonary and Critical Care Medicine, Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Justin M Oldham
- Division of Pulmonary and Critical Care Medicine, Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Dinesh Khanna
- Division of Rheumatology, Internal Medicine, University of Michigan, Ann Arbor, Michigan
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2
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Pugashetti JV, Lee JS. Overview of Rheumatoid Arthritis-Associated Interstitial Lung Disease and Its Treatment. Semin Respir Crit Care Med 2024; 45:329-341. [PMID: 38484788 DOI: 10.1055/s-0044-1782218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/24/2024]
Abstract
Interstitial lung disease (ILD) is a common pulmonary complication of rheumatoid arthritis (RA), causing significant morbidity and mortality. Optimal treatment for RA-ILD is not yet well defined. Reliable prognostic indicators are largely byproducts of prior ILD progression, including low or decreasing forced vital capacity and extensive or worsening fibrosis on imaging. In the absence of validated tools to predict treatment response, decisions about whether to initiate or augment treatment are instead based on clinical judgment. In general, treatment should be initiated in patients who are symptomatic, progressing, or at high risk of poor outcomes. Retrospective data suggest that mycophenolate mofetil, azathioprine, and rituximab are likely effective therapies for RA-ILD. Abatacept is also emerging as a potential first-line treatment option for patients with RA-ILD. Further, recent data demonstrate that immunosuppression may be beneficial even in patients with a usual interstitial pneumonia (UIP) pattern on imaging, suggesting that immunosuppression should be considered irrespective of imaging pattern. Recent randomized controlled trials have shown that antifibrotic medications, such as nintedanib and likely pirfenidone, slow forced vital capacity decline in RA-ILD. Consideration can be given to antifibrotic initiation in patients progressing despite immunosuppression, particularly in patients with a UIP pattern. Future research directions include developing tools to predict which patients will remain stable from patients who will progress, discriminating patients who will respond to treatment from nonresponders, and developing algorithms for starting immunosuppression, antifibrotics, or both as first-line therapies.
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Affiliation(s)
- Janelle Vu Pugashetti
- Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, Michigan
| | - Joyce S Lee
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
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3
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Kang HK, Song JW. Progressive Pulmonary Fibrosis: Where Are We Now? Tuberc Respir Dis (Seoul) 2024; 87:123-133. [PMID: 38111100 PMCID: PMC10990610 DOI: 10.4046/trd.2023.0119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Revised: 11/14/2023] [Accepted: 12/04/2023] [Indexed: 12/20/2023] Open
Abstract
Interstitial lung diseases (ILDs) are a diverse collection of lung disorders sharing similar features, such as inflammation and fibrosis. The diagnosis and management of ILD require a multidisciplinary approach using clinical, radiological, and pathological evaluation. Progressive pulmonary fibrosis (PPF) is a distinct form of progressive and fibrotic disease, occurring in ILD cases other than in idiopathic pulmonary fibrosis (IPF). It is defined based on clinical symptoms, lung function, and chest imaging, regardless of the underlying condition. The progression to PPF must be monitored through a combination of pulmonary function tests (forced vital capacity [FVC] and diffusing capacity of the lung for carbon monoxide), an assessment of symptoms, and computed tomography scans, with regular follow-up. Although the precise mechanisms of PPF remain unclear, there is evidence of shared pathogenetic mechanisms with IPF, contributing to similar disease behavior and worse prognosis compared to non-PPF ILD. Pharmacological treatment of PPF includes immunomodulatory agents to reduce inflammation and the use of antifibrotics to target progressive fibrosis. Nintedanib, a known antifibrotic agent, was found to be effective in slowing IPF progression and reducing the annual rate of decline in FVC among patients with PPF compared to placebos. Nonpharmacological treatment, including pulmonary rehabilitation, supplemental oxygen therapy, and vaccination, also play important roles in the management of PPF, leading to comprehensive care for patients with ILD. Although there is currently no cure for PPF, there are treatments that can help slow the progression of the disease and improve quality of life.
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Affiliation(s)
- Hyung Koo Kang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Inje University Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Republic of Korea
| | - Jin Woo Song
- Department of Pulmonology and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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Storrer KM, Müller CDS, Pessoa MCDA, Pereira CADC. Connective tissue disease-associated interstitial lung disease. J Bras Pneumol 2024; 50:e20230132. [PMID: 38536980 PMCID: PMC11095924 DOI: 10.36416/1806-3756/e20230132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 11/22/2023] [Indexed: 05/18/2024] Open
Abstract
Connective tissue disease-associated interstitial lung disease (CTD-ILD) represents a group of systemic autoimmune disorders characterized by immune-mediated organ dysfunction. Systemic sclerosis, rheumatoid arthritis, idiopathic inflammatory myositis, and Sjögren's syndrome are the most common CTDs that present with pulmonary involvement, as well as with interstitial pneumonia with autoimmune features. The frequency of CTD-ILD varies according to the type of CTD, but the overall incidence is 15%, causing an important impact on morbidity and mortality. The decision of which CTD patient should be investigated for ILD is unclear for many CTDs. Besides that, the clinical spectrum can range from asymptomatic findings on imaging to respiratory failure and death. A significant proportion of patients will present with a more severe and progressive disease, and, for those, immunosuppression with corticosteroids and cytotoxic medications are the mainstay of pharmacological treatment. In this review, we summarized the approach to diagnosis and treatment of CTD-ILD, highlighting recent advances in therapeutics for the various forms of CTD.
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Affiliation(s)
| | | | | | - Carlos Alberto de Castro Pereira
- . Disciplina de Pneumologia, Departamento de Medicina, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo (SP) Brasil
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5
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Jeong E, Hong H, Lee YA, Kim KS. Potential Rheumatoid Arthritis-Associated Interstitial Lung Disease Treatment and Computational Approach for Future Drug Development. Int J Mol Sci 2024; 25:2682. [PMID: 38473928 PMCID: PMC11154459 DOI: 10.3390/ijms25052682] [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: 01/22/2024] [Revised: 02/19/2024] [Accepted: 02/20/2024] [Indexed: 03/14/2024] Open
Abstract
Rheumatoid arthritis (RA) is a systemic autoimmune disease characterized by swelling in at least one joint. Owing to an overactive immune response, extra-articular manifestations are observed in certain cases, with interstitial lung disease (ILD) being the most common. Rheumatoid arthritis-associated interstitial lung disease (RA-ILD) is characterized by chronic inflammation of the interstitial space, which causes fibrosis and the scarring of lung tissue. Controlling inflammation and pulmonary fibrosis in RA-ILD is important because they are associated with high morbidity and mortality. Pirfenidone and nintedanib are specific drugs against idiopathic pulmonary fibrosis and showed efficacy against RA-ILD in several clinical trials. Immunosuppressants and disease-modifying antirheumatic drugs (DMARDs) with anti-fibrotic effects have also been used to treat RA-ILD. Immunosuppressants moderate the overexpression of cytokines and immune cells to reduce pulmonary damage and slow the progression of fibrosis. DMARDs with mild anti-fibrotic effects target specific fibrotic pathways to regulate fibrogenic cellular activity, extracellular matrix homeostasis, and oxidative stress levels. Therefore, specific medications are required to effectively treat RA-ILD. In this review, the commonly used RA-ILD treatments are discussed based on their molecular mechanisms and clinical trial results. In addition, a computational approach is proposed to develop specific drugs for RA-ILD.
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Affiliation(s)
- Eunji Jeong
- Department of Medicine, College of Medicine, Kyung Hee University, Seoul 02447, Republic of Korea;
| | - Hyunseok Hong
- Yale College, Yale University, New Haven, CT 06520, USA;
- Department of Clinical Pharmacology and Therapeutics, School of Medicine, Kyung Hee University, Seoul 02447, Republic of Korea
| | - Yeon-Ah Lee
- Division of Rheumatology, Department of Internal Medicine, Kyung Hee University Hospital, Seoul 02447, Republic of Korea;
| | - Kyoung-Soo Kim
- Department of Medicine, College of Medicine, Kyung Hee University, Seoul 02447, Republic of Korea;
- Department of Clinical Pharmacology and Therapeutics, School of Medicine, Kyung Hee University, Seoul 02447, Republic of Korea
- East-West Bone & Joint Disease Research Institute, Kyung Hee University Hospital at Gangdong, Seoul 05278, Republic of Korea
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6
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Akiyama M, Alshehri W, Kaneko Y. Does a window of opportunity for rheumatoid arthritis-associated interstitial lung disease exist? Autoimmun Rev 2024; 23:103501. [PMID: 38086437 DOI: 10.1016/j.autrev.2023.103501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 12/08/2023] [Indexed: 12/17/2023]
Abstract
Rheumatoid arthritis (RA) is an autoimmune disease characterized by chronic inflammatory synovitis, eventually leading to joint destruction. Remarkable advancements in the emergence of molecular targeted therapies and the treatment strategy based on treat-to-target have made it possible for patients to lead their daily lives without disabilities. Specifically, early diagnosis and appropriate treatment without missing a 'window of opportunity' are crucial for improving joint outcomes. On the other hand, interstitial lung disease (ILD) is an extra-articular complication of RA and has an impact on life prognosis. Importantly, it has become evident that achieving remission of arthritis is critical not only for joint outcomes but also to prevent the irreversible progression of pulmonary fibrosis in RA-ILD. Therefore, a 'window of opportunity' may exist not only for joints but also for RA-ILD. However, within RA-ILD, there are cases that progress from an NSIP pattern or airway involvement to a UIP pattern, while there are cases without progression, suggesting that their disease behavior may be diverse. Thus, accumulating evidence is necessary to accurately determine the disease behavior of RA-ILD. This review provides an overview of clinical and radiological features and treatment strategies for RA-ILD, incorporating the latest findings.
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Affiliation(s)
- Mitsuhiro Akiyama
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Waleed Alshehri
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Yuko Kaneko
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan.
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Atienza-Mateo B, Fernández-Díaz C, Vicente-Rabaneda EF, Melero-González RB, Ortiz-Sanjuán F, Casafont-Solé I, Rodríguez-García SC, Ferraz-Amaro I, Castañeda S, Blanco R. Abatacept in usual and in non-specific interstitial pneumonia associated with rheumatoid arthritis. Eur J Intern Med 2024; 119:118-124. [PMID: 37673775 DOI: 10.1016/j.ejim.2023.08.025] [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: 05/07/2023] [Revised: 08/21/2023] [Accepted: 08/26/2023] [Indexed: 09/08/2023]
Abstract
OBJECTIVE To compare the effectiveness of abatacept (ABA) in Rheumatoid Arthritis-associated Interstitial Lung Disease (RA-ILD) according to the radiological patterns of usual (UIP) or non-specific interstitial pneumonia (NSIP). METHODS From an observational longitudinal multicentre study of 263 RA-ILD patients treated with ABA, those with UIP or NSIP were selected. Lung function, chest high resolution computerised tomography (HRCT) and dyspnoea were recorded and compared in both groups from baseline to the end of follow-up (progression definitions: improvement or worsening >10% of FVC or DLCO, changes in HRCT extension and 1-point change in the mMRC scale, respectively). Differences between final and baseline visits were calculated as the average difference (95% CI) through mixed effects models regression. RESULTS We studied 190 patients with UIP (n=106) and NSIP (n=84). General features were similar in both groups except for older age, positive rheumatoid factor, and previous sulfasalazine therapy, which were more frequent in patients with UIP. ILD duration up to ABA initiation was relatively short: median 16 [4-50] and 11 [2-36] months (p=0.36) in UIP and NSIP, respectively. Mean baseline FVC and DLCO were 82% and 63% in UIP and 89% and 65% in NSIP, respectively. Both parameters remained stable during 24 months with ABA. HRCT lesions and dyspnoea improved/stabilized in 73.1% and 90.5% and 72.9% and 94.6% of UIP and NSIP patterns, respectively. CONCLUSION ABA seems equally effective in stabilizing dyspnoea, lung function and radiological impairment in both UIP and NSIP patterns of RA-ILD. Early administration of ABA may prevent RA-ILD progression, regardless of the radiological pattern.
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Affiliation(s)
- Belén Atienza-Mateo
- Rheumatology, Hospital Universitario Marqués de Valdecilla, Immunopathology group, IDIVAL, Santander, Avda.Valdecilla s/n., ES, 39008, Spain
| | | | | | | | | | | | | | - Iván Ferraz-Amaro
- Rheumatology, Hospital Universitario de Canarias, Santa Cruz de Tenerife, Spain
| | - Santos Castañeda
- Rheumatology, Hospital de La Princesa, IIS-Princesa, Madrid, Spain; Cátedra UAM-Roche, EPID-Future, Department of Medicine, Universidad Autónoma de Madrid, Madrid, Spain
| | - Ricardo Blanco
- Rheumatology, Hospital Universitario Marqués de Valdecilla, Immunopathology group, IDIVAL, Santander, Avda.Valdecilla s/n., ES, 39008, Spain.
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Luppi F, Manfredi A, Faverio P, Andersen MB, Bono F, Pagni F, Salvarani C, Bendstrup E, Sebastiani M. The usual Interstitial pneumonia pattern in autoimmune rheumatic diseases. BMC Pulm Med 2023; 23:501. [PMID: 38082233 PMCID: PMC10714466 DOI: 10.1186/s12890-023-02783-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Accepted: 11/23/2023] [Indexed: 12/18/2023] Open
Abstract
Usual Interstitial Pneumonia (UIP) is characterized by progression of lung parenchyma that may be observed in various autoimmune rheumatic diseases (ARDs), including rheumatoid arthritis and connective tissue diseases. From a diagnostic point of view, a UIP pattern related to ARDs may display imaging and pathological features able to distinguish it from that related to IPF, such as the "straight-edge" sign at HRCT and lymphoplasmacytic infiltrates at histologic specimens. Multidisciplinary approach (MDD), involving at least pulmonologist, rheumatologist and radiologist, is fundamental in the differential diagnosis process, but MDD is also required in the evaluation of severity, progression and response to treatment, that is based on the combination of changes in symptoms, pulmonary function trends, and, in selected patients, serial CT evaluation. Differently from IPF, in patients with ARDs both functional evaluation and patient-reported outcomes may be affected by systemic involvement and comorbidities, including musculoskeletal manifestations of disease. Finally, in regards to pharmacological treatment, immunosuppressants have been considered the cornerstone of therapy, despite the lack of solid evidence in most cases; recently, antifibrotic drugs were also proposed for the treatment of progressive fibrosing ILDs other than IPF. In ARD-ILD, the therapeutic choice should balance the need for the control of systemic and lung involvements with the risk of adverse events from multi-morbidities and -therapies. Purpose of this review is to summarize the definition, the radiological and morphological features of the UIP pattern in ARDs, together with risk factors, diagnostic criteria, prognostic evaluation, monitoring and management approaches of the UIP-ARDs.
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Affiliation(s)
- Fabrizio Luppi
- Respiratory Disease, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy.
- School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy.
| | - Andreina Manfredi
- Rheumatology Unit, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria Policlinico di Modena, Modena, Italy
| | - Paola Faverio
- Respiratory Disease, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
- School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Michael Brun Andersen
- Copenhagen University Hospital Gentofte, Copenhagen, Denmark
- Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
| | - Francesca Bono
- Pathology, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | - Fabio Pagni
- School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
- Pathology, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | - Carlo Salvarani
- Rheumatology Unit, Dipartimento Medicina Interna e Specialità Mediche, Azienda Unità Sanitaria Locale di Reggio Emilia-Istituto di Ricerca e Cura a Carattere Scientifico, Reggio Emilia, Italy
| | - Elisabeth Bendstrup
- Center for Rare Lung Disease, Department of Respiratory Diseases and Allergy, Aarhus University Hospital, and Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Marco Sebastiani
- Rheumatology Unit, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria Policlinico di Modena, Modena, Italy
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Koduri G, Solomon JJ. Identification, Monitoring, and Management of Rheumatoid Arthritis-Associated Interstitial Lung Disease. Arthritis Rheumatol 2023; 75:2067-2077. [PMID: 37395725 DOI: 10.1002/art.42640] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 05/23/2023] [Accepted: 06/27/2023] [Indexed: 07/04/2023]
Abstract
Interstitial lung disease (ILD) is a frequent complication of rheumatoid arthritis (RA) that is associated with a significant increase in mortality. Several risk factors for the development of ILD in patients with RA have been identified, but ILD can still develop in the absence of these risk factors. Screening tools for RA-ILD are required to facilitate early detection of RA-ILD. Close monitoring of patients with RA-ILD for progression is crucial to enable timely implementation of treatment strategies to improve outcomes. Patients with RA are commonly treated with immunomodulatory therapies, although their efficacy in slowing the progression of RA-ILD remains the subject of debate. Clinical trials have shown that antifibrotic therapies slow decline in lung function in patients with progressive fibrosing ILDs, including patients with RA-ILD. The management of patients with RA-ILD should be based on multidisciplinary evaluation of the severity and progression of their ILD and the activity of their articular disease. Close collaboration between rheumatologists and pulmonologists is essential to optimize patient care.
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Affiliation(s)
- Gouri Koduri
- Southend University Hospital NHS Foundation Trust, Chelmsford, UK
- Anglia Ruskin University, Chelmsford, UK
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Yuan H, Cui S, Yang L, Cui J, Wang X, Ding M, Jin L, Wang Y, Chang F, Jin H, Ma J, Shi M, Liu A. Efficacy of non-conventional synthetic DMARDs for patients with rheumatoid arthritis-associated interstitial lung disease: a systematic review and meta-analysis. RMD Open 2023; 9:e003487. [PMID: 37899093 PMCID: PMC10619071 DOI: 10.1136/rmdopen-2023-003487] [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: 07/10/2023] [Accepted: 10/09/2023] [Indexed: 10/31/2023] Open
Abstract
OBJECTIVES We conducted a systematic review and meta-analysis to determine the efficacy of non-conventional synthetic disease-modifying antirheumatic drug (ncs-DMARD) strategies on patients with rheumatoid arthritis (RA)-associated interstitial lung disease (ILD). METHODS PubMed, EMBASE, the Cochrane Library and Web of Science were searched for relevant articles from inception to 1 June 2022. The results obtained from the analysis were expressed as mean difference (MD), effect size and 95% CI. RESULTS A total of 17 studies, including 1315 patients with RA-ILD, were eligible. The ncs-DMARDs included abatacept, rituximab, tocilizumab, tumour necrosis factor and Janus kinase inhibitors. Compared with the baseline, there were no significant changes in forced vital capacity (FVC), forced expiratory volume in the first second (FEV1) and diffusion lung capacity for carbon monoxide (DLCO) values in the pooled data after ncs-DMARD treatment (alone or combined with conventional therapy) (p=0.36 for FVC; p=0.96 for FEV1 and p=0.46 for DLCO). Of note, FVC was obviously increased in rituximab subgroup (MD=-4.62, 95% CI -8.90 to -0.33, p=0.03). Also, high-resolution CT non-progression rate and fatality rate due to ILD progression in patients with RA-ILD were 0.792 (95% CI 0.746 to 0.834, p=0.015) and 0.049 (95% CI 0.035 to 0.065, p=0.000), respectively. CONCLUSION ncs-DMARDs alone or combined with conventional therapy might be an optimal and promising treatment for stabilising or improving ILD in patients with RA-ILD. PROSPERO REGISTRATION NUMBER CRD42022356816.
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Affiliation(s)
- Haoming Yuan
- Department of Rheumatology and Immunology, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Shaoxin Cui
- Department of Rheumatology and Immunology, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Lin Yang
- Department of Rheumatology and Immunology, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Jiehan Cui
- Department of Rheumatology and Immunology, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Xiaoping Wang
- Department of Rheumatology and Immunology, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Meng Ding
- Department of Rheumatology and Immunology, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Lu Jin
- Department of Rheumatology and Immunology, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Yanru Wang
- Department of Rheumatology and Immunology, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Fei Chang
- Department of Rheumatology and Immunology, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Hongtao Jin
- Department of Rheumatology and Immunology, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Jun Ma
- Hebei Research Center for Stem Cell Medical Translational Engineering, Shijiazhuang, Hebei, China
- Department of Anatomy, Hebei Medical University, Shijiazhuang City, Hebei, China
| | - Min Shi
- Department of Clinical Laboratory, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
- Hebei Key Laboratory of Laboratory Medicine, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Aijing Liu
- Department of Rheumatology and Immunology, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
- Hebei Research Center for Stem Cell Medical Translational Engineering, Shijiazhuang, Hebei, China
- Hebei Key Laboratory of Laboratory Medicine, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
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11
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Johnston J, Dorrian D, Linden D, Stanel SC, Rivera-Ortega P, Chaudhuri N. Pulmonary Sequelae of COVID-19: Focus on Interstitial Lung Disease. Cells 2023; 12:2238. [PMID: 37759460 PMCID: PMC10527752 DOI: 10.3390/cells12182238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 08/28/2023] [Accepted: 09/06/2023] [Indexed: 09/29/2023] Open
Abstract
As the world transitions from the acute phase of the COVID-19 pandemic, a novel concern has arisen-interstitial lung disease (ILD) as a consequence of SARS-CoV-2 infection. This review discusses what we have learned about its epidemiology, radiological, and pulmonary function findings, risk factors, and possible management strategies. Notably, the prevailing radiological pattern observed is organising pneumonia, with ground-glass opacities and reticulation frequently reported. Longitudinal studies reveal a complex trajectory, with some demonstrating improvement in lung function and radiographic abnormalities over time, whereas others show more static fibrotic changes. Age, disease severity, and male sex are emerging as risk factors for residual lung abnormalities. The intricate relationship between post-COVID ILD and idiopathic pulmonary fibrosis (IPF) genetics underscores the need for further research and elucidation of shared pathways. As this new disease entity unfolds, continued research is vital to guide clinical decision making and improve outcomes for patients with post-COVID ILD.
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Affiliation(s)
- Janet Johnston
- Interstitial Lung Diseases Unit, North West Lung Centre, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester M23 9LT, UK (P.R.-O.)
| | - Delia Dorrian
- Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen’s University Belfast, Belfast BT9 7BL, UK
| | - Dermot Linden
- Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen’s University Belfast, Belfast BT9 7BL, UK
- Mater Hospital, Belfast Health and Social Care Trust, Belfast BT14 6AB, UK
| | - Stefan Cristian Stanel
- Interstitial Lung Diseases Unit, North West Lung Centre, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester M23 9LT, UK (P.R.-O.)
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester M13 9PL, UK
| | - Pilar Rivera-Ortega
- Interstitial Lung Diseases Unit, North West Lung Centre, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester M23 9LT, UK (P.R.-O.)
| | - Nazia Chaudhuri
- School of Medicine, Magee Campus, University of Ulster, Northlands Road, Londonderry BT48 7JL, UK;
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12
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Yang M, Wu YQ, Liu XM, Zhao C, Li T, Li TQ, Zhang XW, Jiang HL, Mao B, Liu W. Efficacy and safety of antifibrotic agents in the treatment of CTD-ILD and RA-ILD: A systematic review and meta-analysis. Respir Med 2023:107329. [PMID: 37315742 DOI: 10.1016/j.rmed.2023.107329] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Revised: 05/23/2023] [Accepted: 06/11/2023] [Indexed: 06/16/2023]
Abstract
OBJECTIVE The clinical spectrum of connective tissue disease-associated interstitial lung disease (CTD-ILD) and rheumatoid arthritis-associated interstitial lung disease (RA-ILD) ranges from asymptomatic findings on radiographic imaging to a rapidly progressive illness leading to respiratory failure and death. The treatment is always challenging due to the paucity of proven effective treatments. Nintedanib and pirfenidone are recently approved antifibrotics in idiopathic pulmonary fibrosis. This study aimed to investigate the efficacy and safety of antifibrotic agents in the treatment of CTD-ILD and RA-ILD. METHODS Relevant databases were searched for randomized controlled trials that compared pirfenidone or nintedanib with placebo in patients with CTD-ILD and RA-ILD. The primary outcome was the change in forced vital capacity (FVC). The odds ratio or risk ratio with 95% confidence interval (CI) was estimated for categorical data, and the mean difference with 95% CI was estimated for continuous data. The I2 statistic was used to assess heterogeneity, and meta-analysis was performed when possible. RESULTS Ten studies with a total of 880 participants met the inclusion criteria. Of these, four studies were included in the meta-analysis. According to the pooled result, the annual decline of FVC was significantly decreased in the antifibrotic agent arm compared to that in the placebo arm (MD 70.58 mL/yr, 95% CI 40.55 to 100.61). CONCLUSION This review suggests a potential benefit and safety of antifibrotic treatment in slowing the decline of FVC in patients with CTD-ILD and RA-ILD. Further large-sample, random-controlled, high-quality trials are needed to provide more evidence in the decision-making regarding the use of antifibrotics in this group of patients. CLINICAL TRIAL REGISTRATION PROSPERO; No.: CRD42022369112; URL: https://www.crd.york.ac.uk/prospero/.
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Affiliation(s)
- Mei Yang
- Division of Pulmonary Medicine, Institute of Integrated Traditional Chinese and Western Medicine, West China Hospital, Sichuan University, Chengdu, PR China
| | - Yan-Qing Wu
- Division of Pulmonary Medicine, Institute of Integrated Traditional Chinese and Western Medicine, West China Hospital, Sichuan University, Chengdu, PR China
| | - Xue-Mei Liu
- Division of Pulmonary Medicine, Institute of Integrated Traditional Chinese and Western Medicine, West China Hospital, Sichuan University, Chengdu, PR China; Department of Pulmonary Diseases, State Key Laboratory of Biotherapy of China, West China Hospital of Sichuan University, Chengdu, PR China
| | - Chen Zhao
- Department of Oral Medicine, Stomatological Hospital and Dental School of Tongji University, Shanghai Engineering Research Center of Tooth Restoration and Regeneration, Shanghai, PR China
| | - Ting Li
- Division of Pulmonary Medicine, Institute of Integrated Traditional Chinese and Western Medicine, West China Hospital, Sichuan University, Chengdu, PR China
| | - Ting-Qian Li
- Division of Pulmonary Medicine, Institute of Integrated Traditional Chinese and Western Medicine, West China Hospital, Sichuan University, Chengdu, PR China
| | - Xia-Wei Zhang
- Respiratory Medicine Unit and National Institute for Health Research (NIHR), Nuffield Department of Medicine Experimental Medicine, Oxford Biomedical Research Centre (BRC), University of Oxford, Oxfordshire, United Kingdom
| | - Hong-Li Jiang
- Division of Pulmonary Medicine, Institute of Integrated Traditional Chinese and Western Medicine, West China Hospital, Sichuan University, Chengdu, PR China
| | - Bing Mao
- Division of Pulmonary Medicine, Institute of Integrated Traditional Chinese and Western Medicine, West China Hospital, Sichuan University, Chengdu, PR China.
| | - Wei Liu
- Division of Pulmonary Medicine, Institute of Integrated Traditional Chinese and Western Medicine, West China Hospital, Sichuan University, Chengdu, PR China.
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13
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Stainer A, Tonutti A, De Santis M, Amati F, Ceribelli A, Bongiovanni G, Torrisi C, Iacopino A, Mangiameli G, Aliberti S, Selmi C. Unmet needs and perspectives in rheumatoid arthritis-associated interstitial lung disease: A critical review. Front Med (Lausanne) 2023; 10:1129939. [PMID: 37007765 PMCID: PMC10062456 DOI: 10.3389/fmed.2023.1129939] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 02/20/2023] [Indexed: 03/18/2023] Open
Abstract
Rheumatoid arthritis (RA) is a chronic systemic autoimmune disease characterized by synovitis as the most common clinical manifestation, and interstitial lung disease (RA-ILD) represents one of the most common and potentially severe extra-articular features. Our current understanding of the mechanisms and predictors of RA-ILD is limited despite the demonstration that an early identification of progressive fibrosing forms is crucial to provide timely treatment with antifibrotic therapies. While high resolution computed tomography is the gold standard technique for the diagnosis and follow-up of RA-ILD, it has been hypothesized that serum biomarkers (including novel and rare autoantibodies), new imaging techniques such as ultrasound of the lung, or the application of innovative radiologic algorithms may help towards predicting and detecting early forms of diseases. Further, while new treatments are becoming available for idiopathic and connective tissue disease-associated forms of lung fibrosis, the treatment of RA-ILD remains anecdotal and largely unexplored. We are convinced that a better understanding of the mechanisms connecting RA with ILD in a subgroup of patients as well as the creation of adequate diagnostic pathways will be mandatory steps for a more effective management of this clinically challenging entity.
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Affiliation(s)
- Anna Stainer
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Division of Respiratory Medicine, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Antonio Tonutti
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- IRCCS Humanitas Research Hospital, Milan, Italy
| | - Maria De Santis
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Division of Rheumatology and Clinical Immunology, IRCCS Humanitas Research Hospital, Milan, Italy
- *Correspondence: Maria De Santis,
| | - Francesco Amati
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Division of Respiratory Medicine, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Angela Ceribelli
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Division of Rheumatology and Clinical Immunology, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Gabriele Bongiovanni
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- IRCCS Humanitas Research Hospital, Milan, Italy
| | - Chiara Torrisi
- Department of Radiology, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Antonio Iacopino
- Department of Radiology, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Giuseppe Mangiameli
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Division of Thoracic Surgery, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Stefano Aliberti
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Division of Respiratory Medicine, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Carlo Selmi
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Division of Rheumatology and Clinical Immunology, IRCCS Humanitas Research Hospital, Milan, Italy
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14
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Survival of adults with rheumatoid arthritis associated interstitial lung disease - A systematic review and meta-analysis. Semin Arthritis Rheum 2023; 60:152187. [PMID: 36933302 DOI: 10.1016/j.semarthrit.2023.152187] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Revised: 01/16/2023] [Accepted: 03/02/2023] [Indexed: 03/11/2023]
Abstract
BACKGROUND Rheumatoid arthritis associated interstitial lung disease (RA-ILD) is associated with high levels of morbidity and mortality. The primary aim of this systematic review was to determine the duration of survival, from time of diagnosis of RA-ILD. METHODS Medline (Ovid), Embase (OVID), CINAHL (EBSCO), PubMed, and the Cochrane Library were searched for studies that reported duration of survival from time of diagnosis of RA-ILD. Risk of bias of included studies was assessed based upon 4 domains of the Quality In Prognosis Studies tool. Results for median survival were presented by tabulation and discussed qualitatively. Meta-analysis of cumulative mortality at 1 year, >1y to ≤3 years, >3 years to ≤5 years, and >5 years to≤ 10 years was undertaken, for total RA-ILD population, and according to ILD pattern. RESULTS 78 studies were included. Median survival for the total RA-ILD population ranged from 2 to 14 years. Pooled estimates for cumulative percentage mortality up to 1 year were 9.0% (95% CI 6.1, 12.5, I2 88.9%), >1 to ≤3 years 21.4% (17.3, 25.9, I2 85.7%), >3 to ≤ 5 years 30.2% (24.8, 35.9, I2 87.7%), and > 5 to ≤ 10 years 49.1% (40.6, 57.7 I2 85.0%). Heterogeneity was high. Only 15 studies were rated as low risk of bias in all 4 domains assessed. CONCLUSION This review summarises the high mortality of RA-ILD, however the strength of conclusions that can be made is limited by the heterogeneity of the available studies, due to methodological and clinical factors. Further studies are needed to better understand the natural history of this condition.
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15
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Huang H, Chen R, Shao C, Xu Z, Wolters PJ. Diffuse lung involvement in rheumatoid arthritis: a respiratory physician's perspective. Chin Med J (Engl) 2023; 136:280-286. [PMID: 36689640 PMCID: PMC10106218 DOI: 10.1097/cm9.0000000000002577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Indexed: 01/25/2023] Open
Abstract
ABSTRACT The lungs are one of the most common extra-articular organs involved in rheumatoid arthritis (RA), which is reported to occur in up to 60% to 80% of RA patients. Respiratory complications are the second leading cause of death due to RA. Although there is a wide spectrum of RA-associated respiratory diseases, interstitial lung disease is the most common manifestation and it impacts the prognosis of RA. There has been progress in understanding the management and progression of rheumatoid arthritis-associated interstitial lung disease (RA-ILD) and RA-associated respiratory diseases recently, for example, opportunistic pulmonary infectious diseases and toxicity from RA therapies. From a chest physicians' perspective, we will update the diagnosis and treatment of RA-associated ILD, methotrexate-associated lung disease, and the complication of Pneumocystis jiroveci pneumonia in RA in this review.
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Affiliation(s)
- Hui Huang
- Department of Pulmonary and Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100730, China
| | - Ruxuan Chen
- Department of Pulmonary and Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100730, China
| | - Chi Shao
- Department of Pulmonary and Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100730, China
| | - Zuojun Xu
- Department of Pulmonary and Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100730, China
| | - Paul J. Wolters
- Department of Pulmonary and Critical Care Medicine, University of California, San Francisco, CA 94117, USA
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16
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Evolution of Rheumatoid-Arthritis-Associated Interstitial Lung Disease in Patients Treated with JAK Inhibitors: A Retrospective Exploratory Study. J Clin Med 2023; 12:jcm12030957. [PMID: 36769604 PMCID: PMC9917598 DOI: 10.3390/jcm12030957] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 01/16/2023] [Accepted: 01/22/2023] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND The aim of this multicenter retrospective study was to investigate the effectiveness and safety of the available JAK-inhibitors (JAKi) in patients with rheumatoid arthritis (RA) and interstitial lung disease (ILD). METHODS We retrospectively analyzed patients with classified RA and RA-ILD undergoing JAKi in 6 Italian tertiary centers from April 2018 to June 2022. We included patients with at least 6 months of active therapy and one high-resolution chest tomography (HRCT) carried out within 3 months of the start of JAKi treatment. The HRCT was then compared to the most recent one carried out within 3 months before the last available follow-up appointment. We also kept track of the pulmonary function tests. RESULTS We included 43 patients with RA-ILD and 23 males (53.48%) with a median age (interquartile range, IQR) of 68.87 (61.46-75.78) treated with JAKi. The median follow-up was 19.1 months (11.03-34.43). The forced vital capacity remained stable in 22/28 (78.57%) patients, improved in 3/28 (10.71%) and worsened in 3/28 (10.71%). The diffusing capacity of lung for carbon monoxide showed a similar trend, remaining stable in 18/25 (72%) patients, improving in 2/25 (8%) and worsening in 5/25 (20%). The HRCT remained stable in 37/43 (86.05) cases, worsened in 4/43 (9.30%) and improved in the last 2 (4.65%). DISCUSSION This study suggests that JAKi therapy might be a safe therapeutic option for patients with RA-ILD in a short-term follow-up.
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17
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Albrecht K, Strangfeld A, Marschall U, Callhoff J. Interstitial lung disease in rheumatoid arthritis: incidence, prevalence and related drug prescriptions between 2007 and 2020. RMD Open 2023; 9:rmdopen-2022-002777. [PMID: 36669830 PMCID: PMC9872506 DOI: 10.1136/rmdopen-2022-002777] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 01/11/2023] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVE To investigate prevalence, incidence and medication of interstitial lung disease (ILD) among German individuals with rheumatoid arthritis (RA). METHODS Nationwide BARMER claims data from 2007 to 2020 were used. RA-ILD was identified by diagnosis codes, prescription of disease-modifying antirheumatic drugs (DMARDs) and lung diagnostics. ILD was assigned as incident or prevalent relative to the year of the first diagnosis. We identified prescriptions of glucocorticoids, conventional synthetic (cs), biological (b) and targeted synthetic (ts)DMARDs, antifibrotics and rheumatology and/or pulmonology care. RESULTS Among all persons with RA (40 686 in 2007 to 85 175 in 2020), 1.7%-2.2%/year had ILD with a slight decline since 2013. Incident ILD was 0.13%-0.21% per year and remained stable over time. ILD was more common in seropositive RA, in men and in the elderly (mean age 72 years in 2020). Glucocorticoids (84% to 68%), csDMARD (83% to 55%) and non-steroidal anti-inflammatory drug use (62% to 38%) declined, while bDMARDs (16% to 24%) rose. In 2020, 7% received tsDMARDs, 3% antifibrotics, 44% analgesics and 30% opioids. DMARD therapy was more common if a rheumatologist was involved and antifibrotics if a pulmonologist was involved. Opioid use was highest if no specialist was involved (39%) but also common in rheumatology care (32%) and less frequent in pulmonology care (21%). CONCLUSIONS RA-ILD is rare and mainly affects elderly persons. No trend in incidence was observed but treatment strategies have enlarged. Specialist care is necessary to provide disease-specific therapies. The continuing high analgesic and opioid demand shows unmet needs in these patients.
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Affiliation(s)
- Katinka Albrecht
- Epidemiology and Health Services Research, German Rheumatism Research Centre, Berlin, Germany
| | - Anja Strangfeld
- Epidemiology and Health Services Research, German Rheumatism Research Centre, Berlin, Germany,Department of Rheumatology and Clinical Immunology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Ursula Marschall
- Department Medicine and Health Services Research, BARMER Institute for Health System Research, Wuppertal, Germany
| | - Johanna Callhoff
- Epidemiology and Health Services Research, German Rheumatism Research Centre, Berlin, Germany,Institute for Social Medicine, Epidemiology and Health Economics, Charité Universitätsmedizin Berlin, Berlin, Germany
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18
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Venerito V, Manfredi A, Lopalco G, Lavista M, Cassone G, Scardapane A, Sebastiani M, Iannone F. Radiomics to predict the mortality of patients with rheumatoid arthritis-associated interstitial lung disease: A proof-of-concept study. Front Med (Lausanne) 2023; 9:1069486. [PMID: 36698825 PMCID: PMC9870287 DOI: 10.3389/fmed.2022.1069486] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 12/19/2022] [Indexed: 01/11/2023] Open
Abstract
Objectives Patients with rheumatoid arthritis (RA) and interstitial lung disease (ILD) have increased mortality compared to the general population and factors capable of predicting RA-ILD long-term clinical outcomes are lacking. In oncology, radiomics allows the quantification of tumour phenotype by analysing the characteristics of medical images. Using specific software, it is possible to segment organs on high-resolution computed tomography (HRCT) images and extract many features that may uncover disease characteristics that are not detected by the naked eye. We aimed to investigate whether features from whole lung radiomic analysis of HRCT may alone predict mortality in RA-ILD patients. Methods High-resolution computed tomographies of RA patients from January 2012 to March 2022 were analyzed. The time between the first available HRCT and the last follow-up visit or ILD-related death was recorded. We performed a volumetric analysis in 3D Slicer, automatically segmenting the whole lungs and trachea via the Lung CT Analyzer. A LASSO-Cox model was carried out by considering ILD-related death as the outcome variable and extracting radiomic features as exposure variables. Results We retrieved the HRCTs of 30 RA-ILD patients. The median survival time (interquartile range) was 48 months (36-120 months). Thirteen out of 30 (43.33%) patients died during the observation period. Whole line segmentation was fast and reliable. The model included either the median grey level intensity within the whole lung segmentation [high-resolution (HR) 9.35, 95% CI 1.56-55.86] as a positive predictor of death and the 10th percentile of the number of included voxels (HR 0.20, 95% CI 0.05-0.84), the voxel-based pre-processing information (HR 0.23, 95% CI 0.06-0.82) and the flatness (HR 0.42, 95% CI 0.18-0.98), negatively correlating to mortality. The correlation of grey level values to their respective voxels (HR 1.52 95% CI 0.82-2.83) was also retained as a confounder. Conclusion Radiomic analysis may predict RA-ILD patients' mortality and may promote HRCT as a digital biomarker regardless of the clinical characteristics of the disease.
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Affiliation(s)
- Vincenzo Venerito
- Rheumatology Unit, Department of Emergency and Organ Transplantation, University of Bari Aldo Moro, Bari, Italy
| | - Andreina Manfredi
- Rheumatology Unit, Azienda Ospedaliera Policlinico di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Giuseppe Lopalco
- Rheumatology Unit, Department of Emergency and Organ Transplantation, University of Bari Aldo Moro, Bari, Italy
| | - Marlea Lavista
- Rheumatology Unit, Department of Emergency and Organ Transplantation, University of Bari Aldo Moro, Bari, Italy
| | - Giulia Cassone
- Rheumatology Unit, Azienda Ospedaliera Policlinico di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Arnaldo Scardapane
- Radiology Unit, Department of Interdisciplinary Medicine, University of Bari Aldo Moro, Bari, Italy
| | - Marco Sebastiani
- Rheumatology Unit, Azienda Ospedaliera Policlinico di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Florenzo Iannone
- Rheumatology Unit, Department of Emergency and Organ Transplantation, University of Bari Aldo Moro, Bari, Italy,*Correspondence: Florenzo Iannone,
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Yonezawa T, Suzuki A, Fukumitsu K, Katano T, Kako H, Ishii M, Niimi A, Imaizumi K, Sakamoto K, Omote N, Yamaguchi E. Acute exacerbation of rheumatoid arthritis-associated interstitial lung disease triggered by COVID-19: What is the best practice for treatment? Respir Med Case Rep 2023; 43:101857. [PMID: 37124053 PMCID: PMC10125217 DOI: 10.1016/j.rmcr.2023.101857] [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: 11/16/2022] [Accepted: 04/23/2023] [Indexed: 05/02/2023] Open
Abstract
We present a case of 79-year-old female with rheumatoid arthritis-associated interstitial lung disease (RA-ILD) developed an acute exacerbation (AE) triggered by coronavirus disease 2019 (COVID-19). The patient was unresponsive to a combination therapy of remdesivir, dexamethasone, and tocilizumab. Given that a recent multicenter cohort study reported ILD as a poor prognostic contributor in patients with RA and COVID-19, there may be potentially a certain number of patients with AE of RA-ILD triggered by COVID-19. This case highlights the need for a discussion how to treat these patients in a daily clinical practice.
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Affiliation(s)
- Toshiyuki Yonezawa
- Department of Respiratory Medicine and Allergology, Aichi Medical University, Nagakute, Aichi, Japan
- Department of Internal Medicine, Aichi Prefectural Hospital, Okazaki, Aichi, Japan
| | - Atsushi Suzuki
- Department of Internal Medicine, Aichi Prefectural Hospital, Okazaki, Aichi, Japan
- Department of Respiratory Medicine, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Kensuke Fukumitsu
- Department of Internal Medicine, Aichi Prefectural Hospital, Okazaki, Aichi, Japan
- Department of Respiratory Medicine, Allergy and Clinical Immunology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Aichi, Japan
| | - Takuma Katano
- Department of Respiratory Medicine and Allergology, Aichi Medical University, Nagakute, Aichi, Japan
- Department of Internal Medicine, Aichi Prefectural Hospital, Okazaki, Aichi, Japan
| | - Hisashi Kako
- Department of Internal Medicine, Aichi Prefectural Hospital, Okazaki, Aichi, Japan
- Department of Respiratory Medicine, Fujita Health University School of Medicine, Toyoake, Aichi, Japan
| | - Makoto Ishii
- Department of Respiratory Medicine, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Akio Niimi
- Department of Respiratory Medicine, Allergy and Clinical Immunology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Aichi, Japan
| | - Kazuyoshi Imaizumi
- Department of Respiratory Medicine, Fujita Health University School of Medicine, Toyoake, Aichi, Japan
| | - Koji Sakamoto
- Department of Respiratory Medicine, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Norihito Omote
- Department of Respiratory Medicine, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Etsuro Yamaguchi
- Department of Respiratory Medicine and Allergology, Aichi Medical University, Nagakute, Aichi, Japan
- Department of Internal Medicine, Aichi Prefectural Hospital, Okazaki, Aichi, Japan
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20
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Nasonov EL, Ananyeva LP, Avdeev SN. Interstitial lung disease in rheumatoid arthritis: A multidisciplinary problem in rheumatology and pulmonology. RHEUMATOLOGY SCIENCE AND PRACTICE 2022. [DOI: 10.47360/1995-4484-2022-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Rheumatoid arthritis (RA) is an immune-mediated rheumatic disease (IMRDs) characterized by chronic erosive arthritis and systemic damage to internal organs, leading to early disability and reduced life expectancy in patients. A particularly important place among the systemic manifestations of RA is occupied by interstitial lung diseases (ILD) – the most severe form of pulmonary pathology in RA, defined as RA-ILD, which is pathogenetically associated with risk factors (smoking, etc.) and autoimmune mechanisms underlying RA. RA-ILD is a subtype of RA characterized by a severe course and a poor prognosis и неблагоприятным прогнозом. The review presents new data regarding risk factors and biomarkers for RA-ILD; modern diagnostic capabilities based on the use of functional lung tests, high-resolution computed tomography, ultrasound examination of the lungs. Particular attention is paid to the efficacy and safety of pharmacotherapy, including methotrexate, biologics, JAK inhibitors, and antifibrotic therapy. An algorithm for the pharmacotherapy of RA-ILD has been proposed.
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Affiliation(s)
- E. L. Nasonov
- V.A. Nasonova Research Institute of Rheumatology; I.M. Sechenov First Moscow State Medical University of the Ministry of Health Care of Russian Federation (Sechenov University)
| | | | - S. N. Avdeev
- I.M. Sechenov First Moscow State Medical University of the Ministry of Health Care of Russian Federation (Sechenov University)
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21
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Wu D, Luo Y, Li T, Zhao X, Lv T, Fang G, Ou P, Li H, Luo X, Huang A, Pang Y. Systemic complications of rheumatoid arthritis: Focus on pathogenesis and treatment. Front Immunol 2022; 13:1051082. [PMID: 36618407 PMCID: PMC9817137 DOI: 10.3389/fimmu.2022.1051082] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 12/09/2022] [Indexed: 12/24/2022] Open
Abstract
As a systemic autoimmune disease, rheumatoid arthritis (RA) usually causes damage not only to joints, but also to other tissues and organs including the heart, kidneys, lungs, digestive system, eyes, skin, and nervous system. Excessive complications are closely related to the prognosis of RA patients and even lead to increased mortality. This article summarizes the serious complications of RA, focusing on its incidence, pathogenesis, clinical features, and treatment methods, aiming to provide a reference for clinicians to better manage the complications of RA.
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Affiliation(s)
- Di Wu
- Zhuang Medical College, Guangxi University of Chinese Medicine, Nanning, Guangxi, China
| | - Yehao Luo
- School of Second Clinical Medicine, Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China
| | - Tong Li
- Zhuang Medical College, Guangxi University of Chinese Medicine, Nanning, Guangxi, China
| | - Xinyi Zhao
- Zhuang Medical College, Guangxi University of Chinese Medicine, Nanning, Guangxi, China
| | - Ting Lv
- Zhuang Medical College, Guangxi University of Chinese Medicine, Nanning, Guangxi, China
| | - Gang Fang
- Zhuang Medical College, Guangxi University of Chinese Medicine, Nanning, Guangxi, China
| | - Peiqi Ou
- Zhuang Medical College, Guangxi University of Chinese Medicine, Nanning, Guangxi, China
| | - Hongyi Li
- Zhuang Medical College, Guangxi University of Chinese Medicine, Nanning, Guangxi, China
| | - Xiaofan Luo
- Zhuang Medical College, Guangxi University of Chinese Medicine, Nanning, Guangxi, China
| | - An Huang
- Zhuang Medical College, Guangxi University of Chinese Medicine, Nanning, Guangxi, China,*Correspondence: An Huang, ; Yuzhou Pang,
| | - Yuzhou Pang
- Zhuang Medical College, Guangxi University of Chinese Medicine, Nanning, Guangxi, China,*Correspondence: An Huang, ; Yuzhou Pang,
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22
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Kim YE, Ahn SM, Oh JS, Kim YG, Lee CK, Yoo B, Hong S. Clinical significance of tocilizumab-related neutropenia in patients with rheumatoid arthritis. Joint Bone Spine 2022; 90:105510. [PMID: 36526232 DOI: 10.1016/j.jbspin.2022.105510] [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: 08/25/2022] [Revised: 11/21/2022] [Accepted: 12/01/2022] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To determine the risks and clinical significance of tocilizumab (TCZ)-related neutropenia, in real-world settings, for patients with rheumatoid arthritis (RA). METHODS Medical records of RA patients treated with TCZ at a tertiary referral hospital in South Korea were collected. Infectious complications were defined as cases confirmed by clinical diagnosis and treated with antibiotics. RESULTS A total of 277 RA patients with TCZ treatment (intravenous: 152 [54.9%], subcutaneous: 125 [45.1%]) were included in our study. During the observational period, 22 (7%) patients experienced grade 3 neutropenia. No patients discontinued TCZ due to neutropenia, while the dosage of conventional synthetic DMARD (csDMARD) was either reduced or discontinued for 8 patients. Patients, who experienced neutropenia while using csDMARD, had a higher risk for grade 3/4 neutropenia during TCZ treatment (hazard ratio [HR]: 3.120, 95% CI: 1.189-8.189, P=0.021). Among infections, pulmonary infections were the most common (10.35 per 100 patient-years). Age over 60 years (HR: 2.133, 95% CI: 1.118-4.071, P=0.022) and the presence of extra-articular manifestations (adjusted HR: 11.096, 95% CI: 5.353-22.999, P<0.001), but not neutropenia (adjusted HR: 1.263, 95% CI: 0.269-5.945, P=0.77), were risk factors for infections during TCZ treatment. CONCLUSION Approximately 7% of RA patients treated with TCZ developed grade 3 neutropenia. The previous history of neutropenia during csDMARD was a risk factor for TCZ-related neutropenia. Age and extra-articular manifestations, but not neutropenia, were risk factors for infection during TCZ treatment, suggesting that TCZ treatment can be maintained in the presence of neutropenia unless infection occurs.
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Affiliation(s)
- Young-Eun Kim
- Department of Rheumatology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, 05505 Seoul, Republic of Korea
| | - Soo Min Ahn
- Department of Rheumatology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, 05505 Seoul, Republic of Korea
| | - Ji Seon Oh
- Information Medicine, Big Data Research Center, Asan Medical Center, Seoul, Republic of Korea
| | - Yong-Gil Kim
- Department of Rheumatology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, 05505 Seoul, Republic of Korea
| | - Chang-Keun Lee
- Department of Rheumatology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, 05505 Seoul, Republic of Korea
| | - Bin Yoo
- Department of Rheumatology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, 05505 Seoul, Republic of Korea
| | - Seokchan Hong
- Department of Rheumatology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, 05505 Seoul, Republic of Korea.
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Narváez J, Díaz Del Campo Fontecha P, Brito García N, Bonilla G, Aburto M, Castellví I, Cano-Jiménez E, Mena-Vázquez N, Nieto MA, Ortiz AM, Valenzuela C, Abad Hernández MÁ, Castrejón I, Correyero Plaza M, Francisco Hernández FM, Hernández Hernández MV, Rodríquez Portal JA. SER-SEPAR recommendations for the management of rheumatoid arthritis-related interstitial lung disease. Part 2: Treatment. REUMATOLOGIA CLINICA 2022; 18:501-512. [PMID: 36064885 DOI: 10.1016/j.reumae.2022.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 03/15/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVE To develop multidisciplinary recommendations to improve the management of rheumatoid arthritis-related interstitial lung disease (RA-ILD). METHODS Clinical research questions relevant to the objective of the document were identified by a panel of rheumatologists and pneumologists selected based on their experience in the field. Systematic reviews of the available evidence were conducted, and evidence was graded according to the Scottish Intercollegiate Guidelines Network (SIGN) criteria. Specific recommendations were made. RESULTS Six PICO questions were selected, three of which analysed the safety and effectiveness of glucocorticoids, classical synthetic disease-modifying anti-rheumatic drugs (DMARDs) and other immunosuppressants, biological agents, targeted synthetic DMARDs, and antifibrotic therapies in the treatment of this complication. A total of 12 recommendations were formulated based on the evidence found and/or expert consensus. CONCLUSIONS We present the first official SER-SEPAR document with specific recommendations for RA-ILD management developed to resolve some common clinical questions, reduce clinical healthcare variability, and facilitate decision-making for patients.
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Affiliation(s)
- Javier Narváez
- Servicio de Reumatología, Hospital Universitario de Bellvitge, Hospitalet de Llobregat, Barcelona, Spain.
| | | | - Noé Brito García
- Unidad de Investigación, Sociedad Española de Reumatología, Madrid, Spain
| | - Gema Bonilla
- Servicio de Reumatología, Hospital Universitario La Paz, Madrid, Spain
| | - Myriam Aburto
- Servicio de Neumología, Hospital Universitario Galdakao-Usansolo, Bilbao, Spain
| | - Iván Castellví
- Servicio de Reumatología, Hospital Universitario de la Santa Creu i Sant Pau, Barcelona, Spain
| | | | - Natalia Mena-Vázquez
- Servicio de Reumatología, Hospital Regional Universitario de Málaga, Málaga, Spain
| | - M Asunción Nieto
- Servicio de Neumología, Hospital Clínico San Carlos, Madrid, Spain
| | - Ana María Ortiz
- Servicio de Reumatología, Hospital Universitario de La Princesa, Madrid, Spain
| | - Claudia Valenzuela
- Servicio de Neumología, Hospital Universitario de La Princesa, Madrid, Spain
| | | | - Isabel Castrejón
- Servicio de Reumatología, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - María Correyero Plaza
- Servicio de Reumatología, Hospital Universitario Quironsalud de Pozuelo, Pozuelo de Alarcón, Madrid, Spain
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Diesler R, Cottin V. Pulmonary fibrosis associated with rheumatoid arthritis: from pathophysiology to treatment strategies. Expert Rev Respir Med 2022; 16:541-553. [PMID: 35695895 DOI: 10.1080/17476348.2022.2089116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Rheumatoid arthritis (RA) is the most common inflammatory autoimmune disease, characterised by symmetric destructive arthritis and synovitis. Lung involvement is frequent, including in the form of interstitial lung disease (ILD). RA-ILD often presents with a radiologic and pathologic pattern of usual interstitial pneumonia, similar to idiopathic pulmonary fibrosis, highlighting the similarities between the two diseases, but other patterns and pathological associations are described. AREAS COVERED This article reviews the pathogenesis of pulmonary fibrosis in the setting of rheumatoid arthritis as well as the current and future therapeutic options. EXPERT OPINION Pulmonary fibrosis in the setting of RA-ILD is an example of genotype-environment interaction and involves multiple mechanisms including autoimmunity, inflammation and fibrogenesis. Despite that ILD conveys most of the exceeding mortality in RA patients, there are no official guidelines for the management of RA-ILD. Attention should be paid to potential lung toxicity of RA treatment even though some of them might help stabilise the ILD. Current standard of care is often composed of glucocorticoids that may be associated with immunosuppressive therapy. Following the approval of antifibrotic therapy for ILDs with a progressive fibrosing phenotype, current works are evaluating the benefit of such treatment in RA-ILD.
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Affiliation(s)
- Rémi Diesler
- National Reference Center for Rare Pulmonary Diseases, Louis Pradel Hospital, Hospices Civils de Lyon, University of Lyon, INRAE, Lyon, France
| | - Vincent Cottin
- National Reference Center for Rare Pulmonary Diseases, Louis Pradel Hospital, Hospices Civils de Lyon, University of Lyon, INRAE, Lyon, France
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25
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Laria A, Lurati AM, Zizzo G, Zaccara E, Mazzocchi D, Re KA, Marrazza M, Faggioli P, Mazzone A. Interstitial Lung Disease in Rheumatoid Arthritis: A Practical Review. Front Med (Lausanne) 2022; 9:837133. [PMID: 35646974 PMCID: PMC9136053 DOI: 10.3389/fmed.2022.837133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 02/07/2022] [Indexed: 11/25/2022] Open
Abstract
Rheumatoid arthritis (RA) is a systemic inflammatory disease, which primarily causes symmetric polyarthritis. An extrarticolar involvement is common, and the commonly involved organ is lungs. Although cardiac disease is responsible for most RA-related deaths, pulmonary disease is also a major contributor, accounting for ~10-20% of all mortality. Pulmonary disease is a common (60-80% of patients with RA) extra-articular complication of RA. Optimal screening, diagnostic, and treatment strategies of pulmonary disease remain uncertain, which have been the focus of an ongoing investigation. Clinicians should regularly assess patients with RA for the signs and symptoms of pulmonary disease and, reciprocally, consider RA and other connective tissue diseases when evaluating a patient with pulmonary disease of an unknown etiology. RA directly affects all anatomic compartments of the thorax, including the lung parenchyma, large and small airways, pleura, and less commonly vessels. In addition, pulmonary infection and drug-induced lung disease associated with immunosuppressive agents used for the treatment of RA may occur.
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Affiliation(s)
- Antonella Laria
- Asst Ovest Milanese–Rheumatology Unit, Magenta Hospital, Milan, Italy
| | | | - Gaetano Zizzo
- Asst Ovest Milanese–Internal Medicine Department, Cuggiono Hospital, Milan, Italy
| | - Eleonora Zaccara
- Asst Ovest Milanese–Internal Medicine Unit, Legnano Hospital, Milan, Italy
| | - Daniela Mazzocchi
- Asst Ovest Milanese–Rheumatology Unit, Magenta Hospital, Milan, Italy
| | - Katia Angela Re
- Asst Ovest Milanese–Rheumatology Unit, Magenta Hospital, Milan, Italy
| | | | - Paola Faggioli
- Asst Ovest Milanese–Internal Medicine Unit, Legnano Hospital, Milan, Italy
| | - Antonino Mazzone
- Asst Ovest Milanese–Internal Medicine Unit, Legnano Hospital, Milan, Italy
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A retrospective study of the efficacy of JAK inhibitors or abatacept on rheumatoid arthritis-interstitial lung disease. Inflammopharmacology 2022; 30:705-712. [PMID: 35462572 PMCID: PMC9135879 DOI: 10.1007/s10787-022-00936-w] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 02/05/2022] [Indexed: 12/15/2022]
Abstract
Objectives To examine the effectiveness of Janus-kinase inhibitors (JAKis) or abatacept (ABA) in patients with rheumatoid arthritis-interstitial lung disease (RA-ILD). Methods Patients with RA-ILD receiving JAKis or ABA were retrospectively evaluated at baseline and after 18 months of treatment. A computer-aided method (CaM) was used to assess the extent of high-resolution computed tomography (HRCT) fibrosis percentage. According to HRCT fibrosis changes, patients were classified as “worsened” (progression of 15% or more), “stable” (changes within 15%) or “improved” (reduction of 15% or more). Correlations between RA characteristics and JAKis or ABA responses were studied using a multivariate regression model. Results Seventy-five patients (69.3% women) were evaluated, 31 received a JAKi while 44 received ABA. In the JAKis group, five patients (16.1%) showed RA-ILD progression, 20 patients (64.5%) were considered stable, and six patients (19.4%) demonstrated RA-ILD improvement. In the ABA group, five patients (11.3%) showed RA-ILD progression, 32 patients (72.7%) were stable, and seven patients (16.0%) demonstrated RA-ILD improvement. In both groups, the percentage of current smokers was different between those classified as "worsened" and those classified as "improved/stable" (p = 0.01). In multivariate regression analysis, current smoking habit (p = 0.0051) and concomitant methotrexate treatment (p = 0.0078) were the two variables related to RA-ILD progression in ABA-treated patients, whereas in JAKis-treated patients, the only RA-ILD progression-related variable was disease duration of RA (p < 0.001). Conclusions Treatment with JAKis or ABA was related to stability or improvement of RA-ILD in 83.9% and 88.6% of patients, respectively. RA duration is the only variable associated with worsening RA-ILD in JAKis-treated patients.
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Case AH. Clinical Overview of Progressive Fibrotic Interstitial Lung Disease. Front Med (Lausanne) 2022; 9:858339. [PMID: 35372405 PMCID: PMC8965041 DOI: 10.3389/fmed.2022.858339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 01/31/2022] [Indexed: 11/13/2022] Open
Abstract
Interstitial lung diseases (ILD) on the whole have variable prognoses, but there are those which manifest with fibrosis and are characterized by disease progression. Chief among these is idiopathic pulmonary fibrosis, but other ILDs, including autoimmune ILD and chronic hypersensitivity pneumonitis, may have a progressive fibrotic phenotype also. A usual interstitial pneumonia pattern of lung involvement is a prominent risk factor for such a course, suggesting shared fibrotic pathways that may be targeted by antifibrotic therapies. This brief review describes ILDs that are most commonly fibrotic, shared risk factors for development of PF-ILD, and evidence for antifibrotic use in their management.
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Lee H, Lee SI, Kim HO. Recent Advances in Basic and Clinical Aspects of Rheumatoid Arthritis-associated Interstitial Lung Diseases. JOURNAL OF RHEUMATIC DISEASES 2022; 29:61-70. [PMID: 37475899 PMCID: PMC10327618 DOI: 10.4078/jrd.2022.29.2.61] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 01/17/2022] [Accepted: 01/17/2022] [Indexed: 07/22/2023]
Abstract
Rheumatoid arthritis (RA) is a common autoimmune disease that mainly affects the joints and systemic organs, such as the skin, eyes, heart, gastrointestinal tract, and lungs. In particular, among various pulmonary involvements, interstitial lung disease (ILD) is closely related to the selection of anti-rheumatic drugs and the long-term prognosis of patients with RA. Although the exact pathogenesis of RA-ILD is not well defined, several mechanistic pathways, similar to those of idiopathic pulmonary fibrosis, have been elucidated recently. Conversely, RA-related autoantibodies, including anti-cyclic citrullinated peptide antibody, are detectable in circulation and in the lungs, even in the absence of articular symptoms. RA-ILD can also predate years before the occurrence of joint symptoms. This evidence supports the fact that local dysregulated mucosal immunity in the lung causes systemic autoimmunity, resulting in clinically evident polyarthritis of RA. Because the early diagnosis of RA-ILD is important, imaging tests, such as computed tomography and pulmonary function tests, are being used for early diagnosis, but there is no clear guideline for the early diagnosis of RA-ILD and selection of optimal disease-modifying anti-rheumatic drugs for the treatment of patients with RA with ILD. In addition, the efficacy of nintedanib, a new anti-fibrotic agent, for RA-ILD treatment, has been investigated recently. This review collectively discusses the basic and clinical aspects, such as pathogenesis, animal models, diagnosis, and treatment, of RA-ILD.
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Affiliation(s)
- Hanna Lee
- Division of Rheumatology, Department of Internal Medicine, Gyeongsang National University Hospital, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Sang-Il Lee
- Division of Rheumatology, Department of Internal Medicine, Gyeongsang National University Hospital, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Hyun-Ok Kim
- Division of Rheumatology, Department of Internal Medicine, Gyeongsang National University Changwon Hospital, Gyeongsang National University School of Medicine, Changwon, Korea
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Venerito V, Angelini O, Fornaro M, Cacciapaglia F, Lopalco G, Iannone F. A Machine Learning Approach for Predicting Sustained Remission in Rheumatoid Arthritis Patients on Biologic Agents. J Clin Rheumatol 2022; 28:e334-e339. [PMID: 34542990 DOI: 10.1097/rhu.0000000000001720] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
METHODS In this longitudinal study, patients with RA who started a biological disease-modifying antirheumatic drug (bDMARD) in a tertiary care center were analyzed. Demographic and clinical characteristics were collected at treatment baseline, 12-month, and 24-month follow-up. A wrapper feature selection algorithm was used to determine an attribute core set. Four different ML algorithms, namely, LR, random forest, K-nearest neighbors, and extreme gradient boosting, were then trained and validated with 10-fold cross-validation to predict 24-month sustained DAS28 (Disease Activity Score on 28 joints) remission. The performances of the algorithms were then compared assessing accuracy, precision, and recall. RESULTS Our analysis included 367 patients (female 323/367, 88%) with mean age ± SD of 53.7 ± 12.5 years at bDMARD baseline. Sustained DAS28 remission was achieved by 175 (47.2%) of 367 patients. The attribute core set used to train algorithms included acute phase reactant levels, Clinical Disease Activity Index, Health Assessment Questionnaire-Disability Index, as well as several clinical characteristics. Extreme gradient boosting showed the best performance (accuracy, 72.7%; precision, 73.2%; recall, 68.1%), outperforming random forest (accuracy, 65.9%; precision, 65.6%; recall, 59.3%), LR (accuracy, 64.9%; precision, 62.6%; recall, 61.9%), and K-nearest neighbors (accuracy, 63%; precision, 61.5%; recall, 54.8%). CONCLUSIONS We showed that ML models can be used to predict sustained remission in RA patients on bDMARDs. Furthermore, our method only relies on a few easy-to-collect patient attributes. Our results are promising but need to be tested on longitudinal cohort studies.
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Affiliation(s)
- Vincenzo Venerito
- From the Rheumatology Unit, Department of Emergency and Organ Transplantations, University of Bari "Aldo Moro," Bari, Italy
| | | | - Marco Fornaro
- From the Rheumatology Unit, Department of Emergency and Organ Transplantations, University of Bari "Aldo Moro," Bari, Italy
| | - Fabio Cacciapaglia
- From the Rheumatology Unit, Department of Emergency and Organ Transplantations, University of Bari "Aldo Moro," Bari, Italy
| | - Giuseppe Lopalco
- From the Rheumatology Unit, Department of Emergency and Organ Transplantations, University of Bari "Aldo Moro," Bari, Italy
| | - Florenzo Iannone
- From the Rheumatology Unit, Department of Emergency and Organ Transplantations, University of Bari "Aldo Moro," Bari, Italy
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Efficacy and Safety of Rituximab in Autoimmune Disease-Associated Interstitial Lung Disease: A Prospective Cohort Study. J Clin Med 2022; 11:jcm11040927. [PMID: 35207203 PMCID: PMC8879100 DOI: 10.3390/jcm11040927] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Revised: 02/04/2022] [Accepted: 02/08/2022] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVES To analyze the efficacy and safety of rituximab (RTX) in connective tissue disease associated with interstitial lung disease (CTD-ILD). METHODS We performed a multicenter, prospective, observational study of patients with CTD-ILD receiving rituximab between 2015 and 2020. The patients were assessed using high-resolution computed tomography and pulmonary function tests at baseline, at 12 months, and at the end of follow-up. The main outcome measure at the end of follow-up was forced vital capacity (FVC) > 10% or diffusing capacity of the lungs for carbon monoxide (DLCO) > 15% and radiological progression or death. We recorded clinical characteristics, time to initiation of RTX, concomitant treatment, infections, and hospitalization. A Cox regression analysis was performed to identify factors associated with worsening ILD. RESULTS We included 37 patients with CTD-ILD treated with RTX for a median (IQR) of 38.2 (17.7-69.0) months. At the end of the follow-up, disease had improved or stabilized in 23 patients (62.1%) and worsened in seven (18.9%); seven patients (18.9%) died. No significant decline was observed in median FVC (72.2 vs. 70.8; p = 0.530) or DLCO (55.9 vs. 52.2; p = 0.100). The multivariate analysis showed the independent predictors for worsening of CTD-ILD to be baseline DLCO (OR (95% CI), 0.904 (0.8-0.9); p = 0.015), time to initiation of RTX (1.01 (1.001-1.02); p = 0.029), and mycophenolate (0.202 (0.04-0.8); p = 0.034). Only 28 of the 37 patients (75.6%) were still undergoing treatment with RTX: two patients (5.4%) stopped treatment due to adverse events and seven patients (18.9%) died owing to progression of ILD and superinfection. CONCLUSION Lung function improved or stabilized in more than half of patients with CTD-ILD treated with RTX. Early treatment and combination with mycophenolate could reduce the risk of progression of ILD.
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Conway R, Nikiphorou E. Efficacy and safety of conventional synthetic, biologic and targeted synthetic DMARDs in RA-ILD: A narrative review. INDIAN JOURNAL OF RHEUMATOLOGY 2022. [DOI: 10.4103/injr.injr_157_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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van den Bosch L, Luppi F, Ferrara G, Mura M. Immunomodulatory treatment of interstitial lung disease. Ther Adv Respir Dis 2022; 16:17534666221117002. [PMID: 35938712 PMCID: PMC9364223 DOI: 10.1177/17534666221117002] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Interstitial lung diseases (ILDs) other than idiopathic pulmonary fibrosis (IPF) have an array of immunomodulatory treatment options compared with IPF, due to their inflammatory component. However, there is a relative paucity of guidance on the management of this heterogeneous group of diseases. In ILDs other than IPF, immunosuppression is the cornerstone of therapy, with varying levels of evidence for different immunomodulatory agents and for each specific ILD. Classification of ILDs is important for guiding treatment decisions. Immunomodulatory agents mainly include corticosteroids, mycophenolate mofetil (MMF), azathioprine, methotrexate, cyclophosphamide and rituximab. In this review, the available evidence for single agents in the most common ILDs is first discussed. We then reviewed practical therapeutic approaches in connective tissue disease-related ILD and interstitial pneumonia with autoimmune features, scleroderma-related ILD, vasculitis and dermatomyositis with hypoxemic respiratory failure, idiopathic non-specific interstitial pneumonia, hypersensitivity pneumonitis sarcoidosis, fibrosing organizing pneumonia and eosinophilic pneumonia. The treatment of acute exacerbations of ILD is also discussed. Therapy augmentation in ILD is dictated by the recognition of progression of disease. Criteria for the evaluation of progression of disease are then discussed. Finally, specific protocol and measures to increase patients' safety are reviewed as well, including general monitoring and serologic surveillance, Pneumocystis jirovecii prophylaxis, patients' education, genetic testing for azathioprine, MMF serum levels and cyclophosphamide administration protocols. Immunomodulatory therapies are largely successful in the management of ILDs and can be safely managed with the application of specific protocols, precautions and monitoring.
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Affiliation(s)
| | - Fabrizio Luppi
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy.,Respiratory Unit, San Gerardo Hospital, ASST Monza, Monza, Italy
| | - Giovanni Ferrara
- Division of Pulmonary Medicine, University of Alberta, Edmonton, AB, Canada
| | - Marco Mura
- London Health Sciences Centre, Victoria Hospital, 800 Commissioners Road East, Room E6-203, London, ON N6A 5W9, Canada
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Mori Y, Izumiyama T, Mori N, Aizawa T. Interstitial Lung Disease in a Woman with Rheumatoid Arthritis Treated with Denosumab: A Case Report. Mod Rheumatol Case Rep 2021; 6:155-159. [PMID: 34791403 DOI: 10.1093/mrcr/rxab046] [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: 07/08/2021] [Revised: 09/30/2021] [Accepted: 10/21/2021] [Indexed: 11/12/2022]
Abstract
The present report describes the case of an 84-year-old female Japanese patient with rheumatoid arthritis (RA) who experienced exacerbation of interstitial lung disease (ILD) after denosumab (Dmab) treatment. The onset of RA occurred in 2008, and the patient had been treated with intravenous or subcutaneous injection of tocilizumab (TCZ) since 2009. In July 2013, she experienced a lumbar vertebral fracture and began treatment with 60-mg Dmab injection every 6 months in January 2014. The patient had a history of mild ILD and was evaluated for ILD by chest computed tomography (CT) imaging prior to the start of Dmab use. The vertebral fracture did not recur after the initiation of Dmab treatment, and her osteoporosis was successfully treated. However, she expressed a concern of exacerbations of cough and respiratory discomfort that had occurred since September 2019. The chest CT image in November 2015 showed minor ILD progression, whereas the image in September 2019 showed severe exacerbation of ILD. To treat this exacerbation, 10 mg of methylprednisolone (mPSL) and 2.5 mg of tacrolimus (TAC) were administered, and Dmab was discontinued. The patient was subsequently switched to oral bisphosphonate. The patient's respiratory discomfort and the finding of interstitial lung lesion in CT imaging improved after Dmab discontinuation. This case showed that exacerbation of ILD may occur after Dmab treatment, and physicians should consider the risks of Dmab-related ILD in patients with RA complicated by ILD.
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Affiliation(s)
- Yu Mori
- Department of Orthopedic Surgery, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
| | - Takuya Izumiyama
- Department of Orthopedic Surgery, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
| | - Naoko Mori
- Department of Diagnostic Radiology, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
| | - Toshimi Aizawa
- Department of Orthopedic Surgery, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
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Mena-Vázquez N, Rojas-Gimenez M, Romero-Barco CM, Manrique-Arija S, Hidalgo Conde A, Arnedo Díez de los Ríos R, Cabrera César E, Ortega-Castro R, Espildora F, Aguilar-Hurtado MC, Añón-Oñate I, Pérez-Albaladejo L, Abarca-Costalago M, Ureña-Garnica I, Velloso-Feijoo ML, Redondo-Rodriguez R, Fernández-Nebro A. Characteristics and Predictors of Progression Interstitial Lung Disease in Rheumatoid Arthritis Compared with Other Autoimmune Disease: A Retrospective Cohort Study. Diagnostics (Basel) 2021; 11:diagnostics11101794. [PMID: 34679492 PMCID: PMC8534825 DOI: 10.3390/diagnostics11101794] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 09/14/2021] [Accepted: 09/27/2021] [Indexed: 12/22/2022] Open
Abstract
Objectives: To describe the characteristics and progression of interstitial lung disease in patients with associated systemic autoimmune disease (ILD-SAI) and to identify factors associated with progression and mortality. Patients and methods: We performed a multicenter, retrospective, observational study of patients with ILD-SAI followed between 2015 and 2020. We collected clinical data and performed pulmonary function testing and high-resolution computed tomography at diagnosis and at the final visit. The main outcome measure at the end of follow-up was forced vital capacity (FVC) >10% or diffusing capacity of the lungs for carbon monoxide >15% and radiological progression or death. Cox regression analysis was performed to identify factors associated with worsening of ILD. Results: We included 204 patients with ILD-SAI: 123 (60.3%) had rheumatoid arthritis (RA), 58 had (28.4%) systemic sclerosis, and 23 (11.3%) had inflammatory myopathy. After a median (IQR) period of 56 (29.8–93.3) months, lung disease had stabilized in 98 patients (48%), improved in 33 (16.1%), and worsened in 44 (21.5%). A total of 29 patients (14.2%) died. Progression and hospitalization were more frequent in patients with RA (p = 0.010). The multivariate analysis showed the independent predictors for worsening of ILD-SAI to be RA (HR, 1.9 [95% CI, 1.3–2.7]), usual interstitial pneumonia pattern (HR, 1.7 [95% CI, 1.0–2.9]), FVC (%) (HR, 2.3 [95% CI, 1.4–3.9]), and smoking (HR, 2.7 [95%CI, 1.6–4.7]). Conclusion: Disease stabilizes or improves after a median of 5 years in more than half of patients with ILD-SAI, although more than one-third die. Data on subgroups and risk factors could help us to predict poorer outcomes.
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Affiliation(s)
- Natalia Mena-Vázquez
- Instituto de Investigación Biomédica de Málaga (IBIMA), 29010 Málaga, Spain; (C.M.R.-B.); (S.M.-A.); (I.U.-G.); (R.R.-R.); (A.F.-N.)
- UGC de Reumatología, Hospital Regional Universitario de Málaga, 29009 Málaga, Spain
- Correspondence: ; Tel.: +34-952290360
| | - Marta Rojas-Gimenez
- Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), 14004 Córdoba, Spain; (M.R.-G.); (R.O.-C.)
- UGC de Reumatología, Hospital Universitario Reina Sofía de Córdoba, 14004 Córdoba, Spain
| | - Carmen María Romero-Barco
- Instituto de Investigación Biomédica de Málaga (IBIMA), 29010 Málaga, Spain; (C.M.R.-B.); (S.M.-A.); (I.U.-G.); (R.R.-R.); (A.F.-N.)
- UGC de Reumatología, Hospital Clínico Universitario Virgen de la Victoria, 29010 Málaga, Spain
| | - Sara Manrique-Arija
- Instituto de Investigación Biomédica de Málaga (IBIMA), 29010 Málaga, Spain; (C.M.R.-B.); (S.M.-A.); (I.U.-G.); (R.R.-R.); (A.F.-N.)
- UGC de Reumatología, Hospital Regional Universitario de Málaga, 29009 Málaga, Spain
| | - Ana Hidalgo Conde
- Servicio de Medicina Interna, Hospital Universitario Virgen de la Victoria, 29010 Málaga, Spain; (A.H.C.); (R.A.D.d.l.R.); (M.A.-C.)
| | - Rocío Arnedo Díez de los Ríos
- Servicio de Medicina Interna, Hospital Universitario Virgen de la Victoria, 29010 Málaga, Spain; (A.H.C.); (R.A.D.d.l.R.); (M.A.-C.)
| | - Eva Cabrera César
- UGC Neumología, Hospital Universitario Virgen de la Victoria, 29010 Málaga, Spain;
| | - Rafaela Ortega-Castro
- Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), 14004 Córdoba, Spain; (M.R.-G.); (R.O.-C.)
- UGC de Reumatología, Hospital Universitario Reina Sofía de Córdoba, 14004 Córdoba, Spain
| | - Francisco Espildora
- UGC de Neumología, Hospital Regional Universitario de Málaga, 29009 Málaga, Spain;
| | | | | | | | - Manuel Abarca-Costalago
- Servicio de Medicina Interna, Hospital Universitario Virgen de la Victoria, 29010 Málaga, Spain; (A.H.C.); (R.A.D.d.l.R.); (M.A.-C.)
| | - Inmaculada Ureña-Garnica
- Instituto de Investigación Biomédica de Málaga (IBIMA), 29010 Málaga, Spain; (C.M.R.-B.); (S.M.-A.); (I.U.-G.); (R.R.-R.); (A.F.-N.)
- UGC de Reumatología, Hospital Regional Universitario de Málaga, 29009 Málaga, Spain
| | | | - Rocio Redondo-Rodriguez
- Instituto de Investigación Biomédica de Málaga (IBIMA), 29010 Málaga, Spain; (C.M.R.-B.); (S.M.-A.); (I.U.-G.); (R.R.-R.); (A.F.-N.)
- UGC de Reumatología, Hospital Regional Universitario de Málaga, 29009 Málaga, Spain
| | - Antonio Fernández-Nebro
- Instituto de Investigación Biomédica de Málaga (IBIMA), 29010 Málaga, Spain; (C.M.R.-B.); (S.M.-A.); (I.U.-G.); (R.R.-R.); (A.F.-N.)
- UGC de Reumatología, Hospital Regional Universitario de Málaga, 29009 Málaga, Spain
- Departamento de Medicina, Universidad de Málaga, 29010 Málaga, Spain
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Decision-Making Strategy for the Treatment of Rheumatoid Arthritis-Associated Interstitial Lung Disease (RA-ILD). J Clin Med 2021; 10:jcm10173806. [PMID: 34501253 PMCID: PMC8432201 DOI: 10.3390/jcm10173806] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 08/23/2021] [Indexed: 02/07/2023] Open
Abstract
Rheumatoid arthritis (RA) is a common type of autoimmune arthritis. Patient clinical outcomes might be influenced by numerous respiratory diseases, but interstitial lung disease (ILD) is the most important comorbidity. RA-associated ILD (RA-ILD) is divided into acute/subacute and chronic forms. In the acute/subacute course, if the disease is severe as indicated by a diffuse alveolar damage pattern, high-dose corticosteroids combined with antimicrobial agents should be promptly initiated while considering the differential diagnoses, primarily acute exacerbation (AE) of RA-ILD, drug-induced pneumonitis, and Pneumocystis pneumonia. As initial therapeutic management in the chronic course, the RA itself should be stabilized without delay; thereafter, the activity of ILD itself can be stabilized, considering the safety of each anti-rheumatic drug. The formation of the usual interstitial pneumonia (UIP) pattern is the most important determinant because lung function can worsen more quickly with this pattern. However, because clinicians can fail to identify specific radiological patterns, it is important to determine whether each patient with RA-ILD has UIP-like lesions such as subpleural reticulation, traction bronchiectasis, and honeycombing especially progressively enlarged cysts. In patients with progressive RA-ILD and high risk for infection or AE of ILD in whom fibrosis is dominant, clinicians should consider starting an anti-fibrotic agent.
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The Extent and Diverse Trajectories of Longitudinal Changes in Rheumatoid Arthritis Interstitial Lung Diseases Using Quantitative HRCT Scores. J Clin Med 2021; 10:jcm10173812. [PMID: 34501260 PMCID: PMC8432030 DOI: 10.3390/jcm10173812] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 08/17/2021] [Indexed: 02/08/2023] Open
Abstract
We aimed to validate quantitative high-resolution computed tomography (HRCT) imaging analyses of interstitial lung disease (ILD) in rheumatoid arthritis (RA) patients, and to delineate a broad spectrum of annual longitudinal changes of ILD severity in the RA-ILD cohorts. Retrospective cohort 1 (n = 26) had matched PFT results and prospective cohort 2 (n = 34) were followed for over two years with baseline serum specimen. Automated quantitative analysis of HRCT was expressed as the extent of ground-glass opacity, lung fibrosis, honeycombing, and their summation-the total extent of quantitative ILD (QILD). Higher QILD score was associated with lower pulmonary function especially for DLCO% (ρ = -0.433, p = 0.027). Higher serum level of Krebs von den Lungen 6 were significantly associated with high QILD scores (ρ = 0.400, p = 0.026). Regarding QILD score changes in whole lung, even a single point increase was significantly associated with interval progression detected by the radiologist. Four distinct patterns (improvement, worsening, convex-like, and concave-like) during the 24 months were described by QILD scores. Prolonged disease duration of ILD at baseline was significantly associated with worsening of QILD scores. QILD has the potential to reliably evaluate the dynamic severity changes in patients with RA-ILD.
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Morel J, Tournadre A, Sellam J, Bouhnik Y, Cornec D, Devauchelle-Pensec V, Dieudé P, Goupille P, Kluger N, Lazaro E, Le Goff B, de Lédinghen V, Lequerré T, Nocturne G, Seror R, Truchetet ME, Verhoeven F, Pham T, Richez C. Practical Management of patients on anti-IL6R therapy: Practical guidelines drawn up by the Club Rhumatismes et Inflammation (CRI). Joint Bone Spine 2021; 88:105221. [PMID: 34183155 DOI: 10.1016/j.jbspin.2021.105221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Jacques Morel
- Service de Rhumatologie, CHU Montpellier, Montpellier, France
| | - Anne Tournadre
- Service de Rhumatologie, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Jérémie Sellam
- Service de Rhumatologie, CHU Saint-Antoine, Paris, France
| | - Yoram Bouhnik
- Service de Gastro-entérologie, CHU Hôpital Beaujon, Clichy, France
| | - Divi Cornec
- Service de Rhumatologie, CHRU La Cavale Blanche, Brest, France
| | | | - Philippe Dieudé
- Service de Rhumatologie, CHU Bichat-Claude Bernard, Paris, France
| | | | - Nicolas Kluger
- Dpt Dermatology, Helsinki, Finland & Service de Dermatologie, CHU Bichat-Claude Bernard, Paris, France
| | - Estibaliz Lazaro
- Service de Médecine interne, Hôpital Haut-Lévêque, CHU Bordeaux, Pessac, France
| | | | - Victor de Lédinghen
- Unité d'Hépatologie et transplantation hépatique, Hôpital Haut-Lévêque, CHU Bordeaux, Pessac, France
| | | | | | - Raphaèle Seror
- Service de Rhumatologie, Bicêtre, Le Kremlin-Bicêtre, France
| | | | | | - Thao Pham
- Service de Rhumatologie, CHU Sainte-Marguerite, Marseille, France
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Abatacept in rheumatoid arthritis-associated interstitial lung disease: short-term outcomes and predictors of progression. Clin Rheumatol 2021; 40:4861-4867. [PMID: 34313866 PMCID: PMC8599404 DOI: 10.1007/s10067-021-05854-w] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Revised: 06/27/2021] [Accepted: 06/30/2021] [Indexed: 10/25/2022]
Abstract
INTRODUCTION Interstitial lung disease in rheumatoid arthritis (RA-ILD) is an extra-articular involvement that impairs the prognosis and for which there is still no well-coded treatment. The aim of this study was to evaluate abatacept (ABA) effectiveness and safety in patients with RA-ILD. METHODS RA-ILD patients who started ABA treatment were consecutively enrolled. Chest high-resolution computed tomography (HRCT), clinical, laboratory and respiratory function variables were collected at baseline and after 18 months of ABA treatment. HRCT abnormalities were evaluated using a computer-aided method (CaM). ABA response was established based on the change in the percentage of fibrosis evaluated at HRCT-CaM, dividing patients into "worsened" (progression ≥ 15%), "improved" (reduction ≥ 15%), and "stable" (changes within the 15% range). The multivariate regression model was used to assess the associations between RA characteristics and ABA response. RESULTS Forty-four patients (81% women, mean age 59.1 ± 8.0, mean disease duration of 7.5 ± 3.1 years) were studied. Five patients (11.4%) showed RA-ILD progression, 32 patients (72.6%) were considered stable, and 7 patients (16.0%) showed an RA-ILD improvement. The proportion of current smokers was significantly different between "worsened" patients, respect to those defined as "improved/stable" (p = 0.01). Current smoking habit (p = 0.005) and concomitant methotrexate treatment (p = 0.0078) were the two variables related to RA-ILD progression in multivariate regression analysis. CONCLUSION Treatment with ABA is associated with a RA-ILD stability or improvement in the 88.6% of patients. Current smoking habit and concomitant treatment with methotrexate are the modifiable factors associated with RA-ILD worsening. Key Points • Abatacept plays a favourable role in the control of RA-ILD, with a significant worsening in only 11.4% of patients during a 18-month follow-up period. • The predictive variables related to RA-ILD progression during abatacept therapy are the concomitant treatment with methotrexate and current smoking habit.
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Selvaraj V, Khan MS, Bavishi C, Dapaah-Afriyie K, Finn A, Lal A, Mylonakis E. Tocilizumab in Hospitalized Patients with COVID-19: A Meta Analysis of Randomized Controlled Trials. Lung 2021; 199:239-248. [PMID: 34050796 PMCID: PMC8164079 DOI: 10.1007/s00408-021-00451-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 05/11/2021] [Indexed: 12/21/2022]
Abstract
Background To date, only dexamethasone has been shown to reduce mortality in coronavirus disease-19 (COVID-19) patients. Tocilizumab has been recently added to the treatment guidelines for hospitalized COVID-19 patients, but data remain conflicting. Study Design and Methods Electronic databases such as MEDLINE, EMBASE, and Cochrane central were searched from March 1, 2020, until March 10, 2021, for randomized controlled trials evaluating the efficacy of tocilizumab in hospitalized COVID-19 patients. The outcomes assessed were all-cause mortality, mechanical ventilation, and time to discharge. Results Nine studies (with 6490 patients) were included in the analysis. In total, 3358 patients received tocilizumab, and 3132 received standard care/placebo. Pooled analysis showed a significantly decreased risk of all-cause mortality (RR 0.89, 95% CI 0.80–0.98, p = 0.02) and progression to mechanical ventilation (RR 0.80, 95% CI 0.71–0.89, p < 0.0001) in the tocilizumab arm compared to standard therapy or placebo. In addition, there was a trend towards improved median time to hospital discharge (RR 1.28, 95% CI 1.12–1.45, p = 0.0002). Conclusions Tocilizumab therapy improves outcomes of mortality and need for mechanical ventilation, in hospitalized patients with COVID-19 infection compared with standard therapy or placebo. Our findings suggest the efficacy of tocilizumab therapy in hospitalized COVID-19 patients and strengthen the concept that tocilizumab is a promising therapeutic intervention to improve mortality and morbidity in COVID-19 patients. Supplementary Information The online version contains supplementary material available at 10.1007/s00408-021-00451-9.
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Affiliation(s)
- Vijairam Selvaraj
- Division of Medicine, The Miriam Hospital, 164 Summit Ave, Providence, RI, 02906, USA. .,Division of Medicine Aff2, Warren Alpert Medical School of Brown University, Providence, RI, USA.
| | - Mohammad Saud Khan
- Division of Medicine, The Miriam Hospital, 164 Summit Ave, Providence, RI, 02906, USA.,Division of Medicine Aff2, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Chirag Bavishi
- Division of Medicine Aff2, Warren Alpert Medical School of Brown University, Providence, RI, USA.,Division of Cardiology, Cardiovascular Institute, Rhode Island Hospital, Providence, RI, USA
| | - Kwame Dapaah-Afriyie
- Division of Medicine, The Miriam Hospital, 164 Summit Ave, Providence, RI, 02906, USA.,Division of Medicine Aff2, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Arkadiy Finn
- Division of Medicine, The Miriam Hospital, 164 Summit Ave, Providence, RI, 02906, USA.,Division of Medicine Aff2, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Amos Lal
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Eleftherios Mylonakis
- Division of Medicine Aff2, Warren Alpert Medical School of Brown University, Providence, RI, USA.,Division of Infectious Diseases, Rhode Island Hospital, Providence, RI, USA
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Manfredi A, Cassone G, Luppi F, Atienza-Mateo B, Cavazza A, Sverzellati N, González-Gay MA, Salvarani C, Sebastiani M. Rheumatoid arthritis related interstitial lung disease. Expert Rev Clin Immunol 2021; 17:485-497. [PMID: 33779447 DOI: 10.1080/1744666x.2021.1905524] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Interstitial lung disease (ILD) represents a frequent extra-articular manifestation of rheumatoid arthritis (RA) deeply impacting both quality of life and overall prognosis. Areas covered: A literature search was performed including PubMed, Embase, Scopus, and Web of Science. Many retrospective studies investigated the possible risk factors for RA-related ILD (RA-ILD), aiming to identify patients at risk. Among them, males, smokers, positivity of anti-citrullinated peptide antibodies have been associated with RA-ILD, such as some genetic haplotypes. Usual interstitial pneumonia is the histologic and radiologic pattern most frequently observed, followed by nonspecific interstitial pneumonia. Since lung involvement can represent the RA onset, an early differential diagnosis with idiopathic interstitial pneumonia can be difficult or sometimes impossible. High-resolution computed tomography represents the gold standard for ILD diagnosis, while multidisciplinary discussion should be required to assess disease staging, severity and progression. Expert opinion: Management of RA-ILD patients is challenging due to the lack of evidence-based data regarding both assessment and treatment. Moreover, the high variability of clinical presentation and evolution makes it difficult to establish the correct therapeutic strategy. Currently, multidisciplinary approach, including at least rheumatologists, pulmonologists, and radiologists, is desirable to define therapy and follow-up strategies.
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Affiliation(s)
- Andreina Manfredi
- Rheumatology Unit, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria Policlinico Di , Modena, Italy
| | - Giulia Cassone
- Rheumatology Unit, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria Policlinico Di , Modena, Italy.,Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy
| | - Fabrizio Luppi
- Department of Medicine and Surgery, University of Milan Bicocca, Milan, Italy.,Department of Medicine and Surgery, Respiratory Unit, San Gerardo Hospital, ASST Monza, Monza, Italy
| | - Belen Atienza-Mateo
- Department of Rheumatology, Hospital Universitario Marques De Valdecilla, IDIVAL, University of Cantabria Santander, Santander, Spain
| | - Alberto Cavazza
- Pathology Unit, IRCCS Arcispedale Santa Maria Nuova, Azienda Unità Sanitaria Locale-IRCCS Di Reggio Emilia, Reggio Emilia, Italy
| | - Nicola Sverzellati
- Section of Radiology, Unit of Surgical Sciences, Department of Medicine and Surgery (Dimec), University of Parma, Parma, Italy
| | - Miguel A González-Gay
- Department of Rheumatology, Hospital Universitario Marques De Valdecilla, IDIVAL, University of Cantabria Santander, Santander, Spain
| | - Carlo Salvarani
- Rheumatology Unit, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria Policlinico Di , Modena, Italy.,Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy.,Rheumatology Unit, IRCCS Arcispedale Santa Maria Nuova, Azienda Unità Sanitaria Locale-IRCCS Di Reggio Emilia, Reggio Emilia, Italy
| | - Marco Sebastiani
- Rheumatology Unit, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria Policlinico Di , Modena, Italy
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Vicente-Rabaneda EF, Atienza-Mateo B, Blanco R, Cavagna L, Ancochea J, Castañeda S, González-Gay MÁ. Efficacy and safety of abatacept in interstitial lung disease of rheumatoid arthritis: A systematic literature review. Autoimmun Rev 2021; 20:102830. [PMID: 33887489 DOI: 10.1016/j.autrev.2021.102830] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 02/11/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Interstitial lung disease (ILD) is a serious complication that represents the second leading cause of death in patients with rheumatoid arthritis (RA). Treatment of RA-ILD remains controversial. The absence of randomized clinical trials and specific ACR or EULAR therapeutic guidelines makes it difficult to establish solid therapeutic recommendations on this issue. In this scenario, real-world data is especially valuable. OBJECTIVE To review the literature evidence on the efficacy and safety of abatacept (ABA) for the treatment of rheumatoid arthritis (RA) with associated interstitial lung disease (ILD), given its clinical relevance and the lack of consensus on its therapeutic management. METHODS PUBMED and EMBASE were searched from the date of approval of ABA to the end of 2020 using a combination of RA, ILD and ABA terms following PRISMA guidelines. Identified studies were evaluated by two independent investigators. RESULTS Nine original studies (1 case series and 8 observational studies) were selected for inclusion in the systematic review. No randomized trial or meta-analysis were identified. The mean age of patients ranged from 61.2 to 75 years and the mean RA duration varied from 7.4 to 18 years. Subcutaneous ABA (74.5%-91%) predominated in combination with conventional synthetic DMARDs (csDMARDs) (58%-75%), and it was used as first-line biologic agent in 22.8%-64.9% of the patients. The mean course of ILD ranged from 1 to 6.7 years, being usual and nonspecific interstitial pneumonia the most frequent patterns. Improvement or stabilization of ILD imaging (76.6%-92.7%) and FVC or DLCO (>85%) was described after a mean follow-up of 17.4-47.8 months, regardless of the pattern of lung involvement, being more remarkable in patients with shorter evolution of ILD. ABA led to significantly lower ILD worsening rates than TNF inhibitors (TNFi) and was associated with a 90% reduction in the relative risk of deterioration of ILD at 24 months of follow-up compared to TNFi and csDMARDs. Combination with methotrexate may have a corticoid-sparing effect. No unexpected adverse events were identified. CONCLUSIONS Current evidence suggests that ABA may be a plausible alternative to treat RA patients with ILD. It would be highly desirable to develop prospective randomized controlled studies to confirm these findings.
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Affiliation(s)
- Esther F Vicente-Rabaneda
- Rheumatology Division, Hospital Universitario de la Princesa, IIS-Princesa, C/Diego de León 62, 28006 Madrid, Spain.
| | - Belén Atienza-Mateo
- Rheumatology Division, Hospital Universitario Marqués de Valdecilla, Av. de Valdecilla 25, 39008 Santander, Cantabria, Spain.
| | - Ricardo Blanco
- Rheumatology Division, Hospital Universitario Marqués de Valdecilla, Av. de Valdecilla 25, 39008 Santander, Cantabria, Spain.
| | - Lorenzo Cavagna
- University and IRCCS Policlinico S. Matteo Foundation, Viale Camillo Golgi 19, 27100 Pavia, Italy.
| | - Julio Ancochea
- Pneumology Division, Hospital Universitario de la Princesa, IIS-Princesa, C/Diego de León 62, 28006 Madrid, Spain; Cátedra UAM-Roche, EPID-Future, Medicine Department, Universidad Autónoma de Madrid, C/Arzobispo Morcillo 4, 28029 Madrid, Spain.
| | - Santos Castañeda
- Rheumatology Division, Hospital Universitario de la Princesa, IIS-Princesa, C/Diego de León 62, 28006 Madrid, Spain; Cátedra UAM-Roche, EPID-Future, Medicine Department, Universidad Autónoma de Madrid, C/Arzobispo Morcillo 4, 28029 Madrid, Spain.
| | - Miguel Á González-Gay
- Rheumatology Division, Hospital Universitario Marqués de Valdecilla, Av. de Valdecilla 25, 39008 Santander, Cantabria, Spain; University of Cantabria, Santander, Spain; University of Witwatersrand, Cardiovascular Pathophysiology and Genomics Research Unit, School of Physiology, Faculty of Health Sciences, South Africa.
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Favalli EG, Maioli G, Biggioggero M, Caporali R. Clinical management of patients with rheumatoid arthritis during the COVID-19 pandemic. Expert Rev Clin Immunol 2021; 17:561-571. [PMID: 33787418 DOI: 10.1080/1744666x.2021.1908887] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Introduction: Coronavirus disease 2019 (COVID-19) pandemic raises a great challenge in the management of patients with rheumatoid arthritis (RA), which are generally more susceptible to infection events because of the autoimmune condition itself and the treatment with immunomodulatory drugs. The use of disease-modifying anti-rheumatic drugs (DMARDs), including biologics and targeted-synthetic DMARDs, has aroused particular interest because of both their immunosuppressive effects and their hypothetical potential in COVID-19 treatment.Areas covered: For this narrative review, a literature search was conducted between December 2019 and February 2021 on PubMed including epidemiological studies, gathering the main evidence available to date about the impact of COVID-19 on RA patients and the influence of anti-rheumatic drugs on patients' susceptibility to this infection. We also summarize the recommendations from the international guidelines on the management of rheumatic diseases and treatments in this pandemic context, especially focused on RA.Expert opinion: About a year after the outbreak of the pandemic, we are able to answer some of the most relevant questions regarding patients with RA and their management in this pandemic context. Our efforts must now be directed toward consolidating the currently available data with more rigorous studies and facing new issues and challenges including, foremost, vaccination.
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Affiliation(s)
- Ennio Giulio Favalli
- Division of Clinical Rheumatology, ASST Gaetano Pini-CTO Institute, Milano, Italy
| | - Gabriella Maioli
- Division of Clinical Rheumatology, ASST Gaetano Pini-CTO Institute, Milano, Italy
| | - Martina Biggioggero
- Division of Clinical Rheumatology, ASST Gaetano Pini-CTO Institute, Milano, Italy
| | - Roberto Caporali
- Division of Clinical Rheumatology, ASST Gaetano Pini-CTO Institute, Milano, Italy.,Department of Clinical Sciences & Community Health, Research Center for Adult and Pediatric Rheumatic Diseases, Università Degli Studi Di Milano, Milano, Italy
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Predictors of Progression and Mortality in Patients with Prevalent Rheumatoid Arthritis and Interstitial Lung Disease: A Prospective Cohort Study. J Clin Med 2021; 10:jcm10040874. [PMID: 33672699 PMCID: PMC7924396 DOI: 10.3390/jcm10040874] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 02/12/2021] [Accepted: 02/16/2021] [Indexed: 12/13/2022] Open
Abstract
Objectives: To describe a prospective cohort of patients with rheumatoid arthritis associated with interstitial lung disease (RA-ILD) and identify risk factors associated with disease progression and mortality in this cohort. Patients and methods: We performed a multicenter, prospective, observational study of patients with RA-ILD receiving disease-modifying antirheumatic drugs (DMARDs) between 2015 and 2020. The patients were assessed using high-resolution computed tomography and pulmonary function tests at baseline and at 60 months. The main endpoint was “Progression to ILD at the end of follow-up” in terms of the following outcomes: (1) improvement (i.e., improvement in forced vital capacity (FVC) ≥10% or diffusing capacity of the lungs for carbon monoxide (DLCO) ≥15% and absence of radiological progression); (2) nonprogression (stabilization or improvement in FVC ≤10% or diffusing capacity of the lungs for carbon monoxide (DLCO) <15% and absence of radiological progression); (3) progression (worsening of FVC >10% or DLCO >15% and radiological progression); or (4) death. We recorded demographic and clinical characteristics, lung function, and the incidence of adverse events. A Cox regression analysis was performed to identify factors associated with the worsening of ILD. Results: After 60 months, lung disease had stabilized in 66 patients (56.9%), improved in 9 (7.8%), and worsened in 23 (19.8%). Eighteen patients (15.5%) died, with a mean survival of 71.8 (1.9) months after diagnosis of ILD. The Cox multivariate analysis revealed the independent predictors of worsening of RA-ILD to be usual interstitial pneumonia (hazard ratio (HR), 2.6 (95%CI, 1.0–6.7)), FVC <80% (HR, 3.8 (95%CI, 1.5–6.7)), anticitrullinated protein antibody titers (HR, 2.8 (95%CI, 1.1–6.8)), smoking (HR, 2.5 (95%CI, 1.1–6.2)), and treatment with abatacept, tocilizumab, or rituximab (HR, 0.4 (95%CI, 0.2–0.8)). During follow-up, 79 patients (68%) experienced an adverse event, mostly infection (61%). Infection was fatal in 10/18 patients (55.5%) during follow-up. Conclusions: Lung function is stable in most patients with RA-ILD receiving treatment with disease-modifying anti-rheumatic drugs (DMARDs), although one-third worsened or died. Identifying factors associated with worsening in RA-ILD is important for clinical management.
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Williamson J, Black L, Black A, Koduri G, Kelly C. There are similarities between rheumatic disease with lung involvement and COVID-19 pneumonia. Ir J Med Sci 2021; 191:1-5. [PMID: 33564974 PMCID: PMC7872822 DOI: 10.1007/s11845-021-02545-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 02/02/2021] [Indexed: 01/08/2023]
Abstract
Introduction There is considerable overlap between the clinical manifestations of covid-19 pneumonia and the acute interstitial lung disease seen in certain rheumatic disorders. In addition, pulmonary fibrosis is increasingly recognised as a potentially serious consequence of both. Methods This review explores this overlap of clinical features, risk factors and causation, offering insights into the immune mechanisms that contribute to both sets of disorders. Results The therapeutic role of immunosuppression and biologic agents in the treatment of covid-19 is explained in the light of this. Discussion We propose how lessons learned from the insights recently gained into each disorder can improve our insight into immunological mechanisms and application of therapeutic interventions in the other.
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Affiliation(s)
| | | | | | | | - Clive Kelly
- University of Newcastle Upon Tyne, Newcastle upon Tyne, UK.
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Bonek K, Roszkowski L, Massalska M, Maslinski W, Ciechomska M. Biologic Drugs for Rheumatoid Arthritis in the Context of Biosimilars, Genetics, Epigenetics and COVID-19 Treatment. Cells 2021; 10:323. [PMID: 33557301 PMCID: PMC7914976 DOI: 10.3390/cells10020323] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 01/24/2021] [Accepted: 01/30/2021] [Indexed: 01/08/2023] Open
Abstract
Rheumatoid arthritis (RA) affects around 1.2% of the adult population. RA is one of the main reasons for work disability and premature retirement, thus substantially increasing social and economic burden. Biological disease-modifying antirheumatic drugs (bDMARDs) were shown to be an effective therapy especially in those rheumatoid arthritis (RA) patients, who did not adequately respond to conventional synthetic DMARD therapy. However, despite the proven efficacy, the high cost of the therapy resulted in limitation of the widespread use and unequal access to the care. The introduction of biosimilars, which are much cheaper relative to original drugs, may facilitate the achievement of the therapy by a much broader spectrum of patients. In this review we present the properties of original biologic agents based on cytokine-targeted (blockers of TNF, IL-6, IL-1, GM-CSF) and cell-targeted therapies (aimed to inhibit T cells and B cells properties) as well as biosimilars used in rheumatology. We also analyze the latest update of bDMARDs' possible influence on DNA methylation, miRNA expression and histone modification in RA patients, what might be the important factors toward precise and personalized RA treatment. In addition, during the COVID-19 outbreak, we discuss the usage of biologicals in context of effective and safe COVID-19 treatment. Therefore, early diagnosing along with therapeutic intervention based on personalized drugs targeting disease-specific genes is still needed to relieve symptoms and to improve the quality of life of RA patients.
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Affiliation(s)
- Krzysztof Bonek
- Department of Rheumatology, National Institute of Geriatrics Rheumatology and Rehabilitation, 02-635 Warsaw, Poland; (K.B.); (L.R.)
| | - Leszek Roszkowski
- Department of Rheumatology, National Institute of Geriatrics Rheumatology and Rehabilitation, 02-635 Warsaw, Poland; (K.B.); (L.R.)
| | - Magdalena Massalska
- Department of Pathophysiology and Immunology, National Institute of Geriatrics Rheumatology and Rehabilitation, 02-635 Warsaw, Poland; (M.M.); (W.M.)
| | - Wlodzimierz Maslinski
- Department of Pathophysiology and Immunology, National Institute of Geriatrics Rheumatology and Rehabilitation, 02-635 Warsaw, Poland; (M.M.); (W.M.)
| | - Marzena Ciechomska
- Department of Pathophysiology and Immunology, National Institute of Geriatrics Rheumatology and Rehabilitation, 02-635 Warsaw, Poland; (M.M.); (W.M.)
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Cassone G, Sebastiani M, Vacchi C, Erre GL, Salvarani C, Manfredi A. Efficacy and safety of mycophenolate mofetil in the treatment of rheumatic disease-related interstitial lung disease: a narrative review. Drugs Context 2021; 10:dic-2020-8-8. [PMID: 33505480 PMCID: PMC7813435 DOI: 10.7573/dic.2020-8-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 11/26/2020] [Indexed: 12/13/2022] Open
Abstract
Mycophenolate mofetil (MMF) is an antimetabolite with a potent inhibitory effect on proliferation of T and B lymphocytes used since the early 1990s for the prevention of acute allograft rejection after organ transplant. MMF is also widely used for the treatment of a variety of rheumatic diseases (RDs) and their pulmonary involvement. Interstitial lung disease (ILD) is a heterogeneous group of progressive fibrotic diseases of the lung, which is often secondary to RD and represents a major cause of morbidity and mortality. MMF is considered the main alternative to cyclophosphamide as a first-line agent to treat RD-related ILD or as possible maintenance therapy after cyclophosphamide, with a lower rate of side-effects. However, as for other immunosuppressive agents, the use of MMF in RD-ILD is supported by poor scientific evidence. In this narrative review, we describe the available data and recent advances on the effectiveness and safety of MMF for the treatment of ILD related to RD, including rheumatoid arthritis, systemic sclerosis, primary Sjögren syndrome, systemic lupus erythematosus, idiopathic inflammatory myopathies, undifferentiated connective tissue disease, interstitial pneumonia with autoimmune features and antineutrophil cytoplasmic antibody-associated vasculitis.
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Affiliation(s)
- Giulia Cassone
- Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy.,Chair and Rheumatology Unit, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria Policlinico di Modena, Modena, Italy.,Rheumatology Unit, IRCCS Arcispedale Santa Maria Nuova, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Marco Sebastiani
- Chair and Rheumatology Unit, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria Policlinico di Modena, Modena, Italy
| | - Caterina Vacchi
- Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy.,Chair and Rheumatology Unit, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria Policlinico di Modena, Modena, Italy
| | - Gian Luca Erre
- Rheumatology Unit, Azienda Ospedaliero-Universitaria di Sassari, Sassari, Italy
| | - Carlo Salvarani
- Chair and Rheumatology Unit, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria Policlinico di Modena, Modena, Italy.,Rheumatology Unit, IRCCS Arcispedale Santa Maria Nuova, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Andreina Manfredi
- Chair and Rheumatology Unit, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria Policlinico di Modena, Modena, Italy
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Villar-Fincheira P, Sanhueza-Olivares F, Norambuena-Soto I, Cancino-Arenas N, Hernandez-Vargas F, Troncoso R, Gabrielli L, Chiong M. Role of Interleukin-6 in Vascular Health and Disease. Front Mol Biosci 2021; 8:641734. [PMID: 33786327 PMCID: PMC8004548 DOI: 10.3389/fmolb.2021.641734] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 02/01/2021] [Indexed: 01/08/2023] Open
Abstract
IL-6 is usually described as a pleiotropic cytokine produced in response to tissue injury or infection. As a pro-inflammatory cytokine, IL-6 activates innate and adaptative immune responses. IL-6 is released in the innate immune response by leukocytes as well as stromal cells upon pattern recognition receptor activation. IL-6 then recruits immune cells and triggers B and T cell response. Dysregulated IL-6 activity is associated with pathologies involving chronic inflammation and autoimmunity, including atherosclerosis. However, IL-6 is also produced and released under beneficial conditions, such as exercise, where IL-6 is associated with the anti-inflammatory and metabolic effects coupled with physical adaptation to intense training. Exercise-associated IL-6 acts on adipose tissue to induce lipogenesis and on arteries to induce adaptative vascular remodeling. These divergent actions could be explained by complex signaling networks. Classical IL-6 signaling involves a membrane-bound IL-6 receptor and glycoprotein 130 (gp130), while trans-signaling relies on a soluble version of IL-6R (sIL-6R) and membrane-bound gp130. Trans-signaling, but not the classical pathway, is regulated by soluble gp130. In this review, we discuss the similarities and differences in IL-6 cytokine and myokine signaling to explain the differential and opposite effects of this protein during inflammation and exercise, with a special focus on the vascular system.
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Affiliation(s)
- Paulina Villar-Fincheira
- Advanced Center for Chronic Diseases & CEMC, Faculty of Chemical and Pharmaceutical Sciences, Universidad de Chile, Santiago, Chile
| | - Fernanda Sanhueza-Olivares
- Advanced Center for Chronic Diseases & CEMC, Faculty of Chemical and Pharmaceutical Sciences, Universidad de Chile, Santiago, Chile
| | - Ignacio Norambuena-Soto
- Advanced Center for Chronic Diseases & CEMC, Faculty of Chemical and Pharmaceutical Sciences, Universidad de Chile, Santiago, Chile
| | - Nicole Cancino-Arenas
- Advanced Center for Chronic Diseases & CEMC, Faculty of Chemical and Pharmaceutical Sciences, Universidad de Chile, Santiago, Chile
| | - Felipe Hernandez-Vargas
- Advanced Center for Chronic Diseases & CEMC, Faculty of Chemical and Pharmaceutical Sciences, Universidad de Chile, Santiago, Chile
| | - Rodrigo Troncoso
- Laboratorio de Investigación en Nutrición y Actividad Física (LABINAF), Instituto de Nutrición y Tecnología de los Alimentos, Universidad de Chile, Santiago, Chile
| | - Luigi Gabrielli
- Advanced Center for Chronic Diseases, Faculty of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
- *Correspondence: Luigi Gabrielli, ; Mario Chiong,
| | - Mario Chiong
- Advanced Center for Chronic Diseases & CEMC, Faculty of Chemical and Pharmaceutical Sciences, Universidad de Chile, Santiago, Chile
- *Correspondence: Luigi Gabrielli, ; Mario Chiong,
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Salvarani C, Dolci G, Massari M, Merlo DF, Cavuto S, Savoldi L, Bruzzi P, Boni F, Braglia L, Turrà C, Ballerini PF, Sciascia R, Zammarchi L, Para O, Scotton PG, Inojosa WO, Ravagnani V, Salerno ND, Sainaghi PP, Brignone A, Codeluppi M, Teopompi E, Milesi M, Bertomoro P, Claudio N, Salio M, Falcone M, Cenderello G, Donghi L, Del Bono V, Colombelli PL, Angheben A, Passaro A, Secondo G, Pascale R, Piazza I, Facciolongo N, Costantini M. Effect of Tocilizumab vs Standard Care on Clinical Worsening in Patients Hospitalized With COVID-19 Pneumonia: A Randomized Clinical Trial. JAMA Intern Med 2021; 181:24-31. [PMID: 33080005 PMCID: PMC7577199 DOI: 10.1001/jamainternmed.2020.6615] [Citation(s) in RCA: 489] [Impact Index Per Article: 163.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
IMPORTANCE The coronavirus disease 2019 (COVID-19) pandemic is threatening billions of people worldwide. Tocilizumab has shown promising results in retrospective studies in patients with COVID-19 pneumonia with a good safety profile. OBJECTIVE To evaluate the effect of early tocilizumab administration vs standard therapy in preventing clinical worsening in patients hospitalized with COVID-19 pneumonia. DESIGN, SETTING, AND PARTICIPANTS Prospective, open-label, randomized clinical trial that randomized patients hospitalized between March 31 and June 11, 2020, with COVID-19 pneumonia to receive tocilizumab or standard of care in 24 hospitals in Italy. Cases of COVID-19 were confirmed by polymerase chain reaction method with nasopharyngeal swab. Eligibility criteria included COVID-19 pneumonia documented by radiologic imaging, partial pressure of arterial oxygen to fraction of inspired oxygen (Pao2/Fio2) ratio between 200 and 300 mm Hg, and an inflammatory phenotype defined by fever and elevated C-reactive protein. INTERVENTIONS Patients in the experimental arm received intravenous tocilizumab within 8 hours from randomization (8 mg/kg up to a maximum of 800 mg), followed by a second dose after 12 hours. Patients in the control arm received supportive care following the protocols of each clinical center until clinical worsening and then could receive tocilizumab as a rescue therapy. MAIN OUTCOME AND MEASURES The primary composite outcome was defined as entry into the intensive care unit with invasive mechanical ventilation, death from all causes, or clinical aggravation documented by the finding of a Pao2/Fio2 ratio less than 150 mm Hg, whichever came first. RESULTS A total of 126 patients were randomized (60 to the tocilizumab group; 66 to the control group). The median (interquartile range) age was 60.0 (53.0-72.0) years, and the majority of patients were male (77 of 126, 61.1%). Three patients withdrew from the study, leaving 123 patients available for the intention-to-treat analyses. Seventeen patients of 60 (28.3%) in the tocilizumab arm and 17 of 63 (27.0%) in the standard care group showed clinical worsening within 14 days since randomization (rate ratio, 1.05; 95% CI, 0.59-1.86). Two patients in the experimental group and 1 in the control group died before 30 days from randomization, and 6 and 5 patients were intubated in the 2 groups, respectively. The trial was prematurely interrupted after an interim analysis for futility. CONCLUSIONS AND RELEVANCE In this randomized clinical trial of hospitalized adult patients with COVID-19 pneumonia and Pao2/Fio2 ratio between 200 and 300 mm Hg who received tocilizumab, no benefit on disease progression was observed compared with standard care. Further blinded, placebo-controlled randomized clinical trials are needed to confirm the results and to evaluate possible applications of tocilizumab in different stages of the disease. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04346355; EudraCT Identifier: 2020-001386-37.
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Affiliation(s)
- Carlo Salvarani
- SOC Reumatologia, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy.,Unità di Reumatologia, Università degli Studi di Modena e Reggio Emilia, Reggio Emilia, Italy
| | - Giovanni Dolci
- Unità di Malattie Infettive, Università degli Studi di Modena e Reggio Emilia, Reggio Emilia, Italy
| | - Marco Massari
- SOC Malattie Infettive, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Domenico Franco Merlo
- SC Infrastruttura Ricerca e Statistica, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Silvio Cavuto
- SC Infrastruttura Ricerca e Statistica, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Luisa Savoldi
- SC Infrastruttura Ricerca e Statistica, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Paolo Bruzzi
- SC Epidemiologia Clinica, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Fabrizio Boni
- SOC Internistica Multidisciplinare, Ospedale Civile Guastalla, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Luca Braglia
- SC Infrastruttura Ricerca e Statistica, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Caterina Turrà
- SOC Farmacia, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | | | - Roberto Sciascia
- UOC Medicina Generale Ospedale di Vittorio Veneto, Treviso, Italy
| | - Lorenzo Zammarchi
- Dipartimento di Medicina Sperimentale e Clinica, Università degli Studi di Firenze, SOD Malattie infettive e tropicali, AOU Careggi, Firenze, Italy
| | - Ombretta Para
- Medicina Interna 1, Dipartimento Emergenza ed Accettazione, AOU Careggi, Firenze, Italy
| | - Pier Giorgio Scotton
- UO di Malattie Infettive, Ospedale Regionale Ca' Foncello di Treviso, Treviso, Italy
| | - Walter Omar Inojosa
- UO di Malattie Infettive, Ospedale Regionale Ca' Foncello di Treviso, Treviso, Italy
| | - Viviana Ravagnani
- SSD Centro DH Allergologia e Immunologia Clinica, ASST-Mantova, Mantva, Italy
| | | | - Pier Paolo Sainaghi
- SS Reumatologia, SC Medicina Interna, DIMET, Università del Piemonte Orientale e AOU Maggiore della Carità di Novara
| | | | | | - Elisabetta Teopompi
- SOC Internistica Multidisciplinare, Ospedale Civile Guastalla, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Maurizio Milesi
- Unità di malattie Infettive, ASST di Cremona, Cremona, Italy
| | - Perla Bertomoro
- UOC Medicina Generale, ULSS6 Euganea Ospedali Riuniti Padova Sud, Padova, Italy
| | | | - Mario Salio
- SC Malattie dell'Apparato Respiratorio, AO SS. Antonio e Biagio e C. Arrigo, Alessandria, Italy
| | - Marco Falcone
- Unità di Malattie Infettive, Dipartimento di Medicina Clinica e Sperimentale, Università di Pisa, Pisa, Italy
| | | | - Lorenzo Donghi
- UO Malattie Infettive ed Epatologia, AOU Parma, Parma, Italy
| | - Valerio Del Bono
- Malattie Infettive e Tropicali, AO S. Croce e Carle, Cuneo, Italy
| | | | - Andrea Angheben
- Dipartimento di Malattie Infettive, Tropicali e Microbiologia, IRCCS Ospedale Sacro Cuore-Don Calabria, Negrar di Valpolicella, Verona, Italy
| | | | | | - Renato Pascale
- UO Malattie Infettive, Dipartimento di scienze mediche e chirurgiche, Università di Bologna, Bologna, Italy
| | - Ilaria Piazza
- UOC Medicina Interna, AUSSS3 Serenissima, Dolo, Venezia, Italy
| | - Nicola Facciolongo
- SOC Pneumologia, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
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Seeliger B, Prasse A. Immunomodulation in Autoimmune Interstitial Lung Disease. Respiration 2020; 99:819-829. [PMID: 33271551 DOI: 10.1159/000511200] [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: 04/13/2020] [Accepted: 08/28/2020] [Indexed: 11/19/2022] Open
Abstract
Interstitial lung diseases (ILDs) associated with autoimmune or systemic disease are increasingly recognized and our pathophysiological understanding rapidly expanding. Treatment modalities, however, are still mainly driven by established disease-modifying antirheumatic drugs (DMARDs) where, despite decades of experience of their use in the underlying diseases such as rheumatoid arthritis, mostly ret-rospective data exist informing their effect on the course of interstitial lung disease (ILD). In recent years, randomized trials investigating the effects of biological DMARDs (bDMARDs) have been completed or are currently running, generating new treatment options for often relentlessly progressive diseases. Herein, we summarize the evidence and current use of both synthetic DMARDs and bDMARDs in the context of ILDs associated with autoimmune/systemic disease.
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Affiliation(s)
- Benjamin Seeliger
- Department of Respiratory Medicine, Hannover Medical School and Biomedical Research in End-stage and Obstructive Lung Disease (BREATH), German Center for Lung Research (DZL), Hannover, Germany,
| | - Antje Prasse
- Department of Respiratory Medicine, Hannover Medical School and Biomedical Research in End-stage and Obstructive Lung Disease (BREATH), German Center for Lung Research (DZL), Hannover, Germany.,Fraunhofer Institute for Toxicology and Experimental Medicine, Hannover, Germany
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50
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Piccirillo MC, Ascierto P, Atripaldi L, Cascella M, Costantini M, Dolci G, Facciolongo N, Fraganza F, Marata A, Massari M, Montesarchio V, Mussini C, Negri EA, Parrella R, Popoli P, Botti G, Arenare L, Chiodini P, Gallo C, Salvarani C, Perrone F. TOCIVID-19 - A multicenter study on the efficacy and tolerability of tocilizumab in the treatment of patients with COVID-19 pneumonia. Study protocol. Contemp Clin Trials 2020; 98:106165. [PMID: 33031955 PMCID: PMC7536129 DOI: 10.1016/j.cct.2020.106165] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 09/30/2020] [Accepted: 10/01/2020] [Indexed: 01/08/2023]
Abstract
BACKGROUND Pneumonia is the most frequent complication of COVID-19, due to an aberrant host immune response that is associated with an acute respiratory distress syndrome, and, in most critical patients, with a "cytokine storm". IL-6 might play a key role in the cytokine storm and might be a potential target to treat severe and critical COVID-19. Tocilizumab is a recombinant humanized monoclonal antibody, directed against IL-6 receptor. METHODS This multicentre study project includes a single-arm phase 2 study and a further parallel cohort, enrolling hospitalized patients with COVID-19 pneumonia and oxygen saturation at rest in ambient air ≤93% or requiring respiratory support. Patients receive tocilizumab 8 mg/kg (up to 800 mg) as one intravenous administration. A second administration (same dose) after 12 h is optional. Two-week and one-month lethality rates are the co-primary endpoints. Sample size planned for the phase 2 study is 330 patients. The parallel cohort will include patients who cannot enter the phase 2 study because being intubated from more than 24 h, or having already received tocilizumab, or the phase 2 study has reached sample size. Primary analysis will include patients enrolled in the phase 2 study. Results of the primary analysis will be validated in the prospective cohort of patients consecutively registered after phase 2 closure from March 20 to March 24, who were potentially eligible for the phase 2 study. CONCLUSION This trial aims to verify the safety and efficacy of tocilizumab in the Italian population with COVID-19 pneumonia and respiratory impairment. EudraCT Number: 2020-001110-38; Clinicaltrials.gov ID NCT04317092.
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Affiliation(s)
| | - Paolo Ascierto
- Istituto Nazionale Tumori, IRCCS, Fondazione G. Pascale, Napoli, Italy
| | - Luigi Atripaldi
- AORN Ospedali dei Colli -Monaldi -Cotugno- CTO, Napoli, Italy
| | - Marco Cascella
- Istituto Nazionale Tumori, IRCCS, Fondazione G. Pascale, Napoli, Italy
| | | | - Giovanni Dolci
- Azienda USL-IRCCS di Reggio Emilia, Italy; Università degli Studi di Modena e Reggio Emilia, Italy
| | | | | | | | | | | | | | | | | | | | - Gerardo Botti
- Istituto Nazionale Tumori, IRCCS, Fondazione G. Pascale, Napoli, Italy
| | - Laura Arenare
- Istituto Nazionale Tumori, IRCCS, Fondazione G. Pascale, Napoli, Italy
| | - Paolo Chiodini
- Università degli Studi della Campania Luigi Vanvitelli, Italy
| | - Ciro Gallo
- Università degli Studi della Campania Luigi Vanvitelli, Italy
| | - Carlo Salvarani
- Azienda USL-IRCCS di Reggio Emilia, Italy; Università degli Studi di Modena e Reggio Emilia, Italy
| | - Francesco Perrone
- Istituto Nazionale Tumori, IRCCS, Fondazione G. Pascale, Napoli, Italy.
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