1
|
Avouac J, Cauvet A, Orvain C, Boulch M, Tilotta F, Tu L, Thuillet R, Ottaviani M, Guignabert C, Bousso P, Allanore Y. Effects of B Cell Depletion by CD19-Targeted Chimeric Antigen Receptor T Cells in a Murine Model of Systemic Sclerosis. Arthritis Rheumatol 2024; 76:268-278. [PMID: 37610259 DOI: 10.1002/art.42677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Revised: 07/22/2023] [Accepted: 08/15/2023] [Indexed: 08/24/2023]
Abstract
OBJECTIVE Our goal was to study the tolerance and efficacy of two B cell depletion strategies, including one with CD19-targeted chimeric antigen receptor (CAR) T cells, in a preclinical model mimicking the severe lung damages observed in systemic sclerosis. METHODS B cell depletion strategies were evaluated in the Fra-2 transgenic (Tg) mouse model. We considered a first group of 16 untreated mice, a second group of 15 mice receiving a single dose of anti-CD20 monoclonal antibody (mAb), and a third group of 8 mice receiving CD19-targeted CAR-T cells in combination with anti-CD20 monoclonal antibody. After six weeks of clinical evaluation, different validated markers of inflammation, lung fibrosis, and pulmonary vascular remodeling were assessed. RESULTS CD19-targeted CAR-T cells infusion in combination with anti-CD20 mAb resulted in a deeper B cell depletion than anti-CD20 mAb alone in the peripheral blood and lesional lungs of Fra-2 Tg mice. CAR-T cell infusion worsened the clinical score and increased mortality in Fra-2 Tg mice. In line with the above findings, CAR-T cell infusion significantly increased lung collagen content, the histological fibrosis score, and right ventricular systolic pressure. CAR-T cells accumulated in lesional lungs and promoted T activation and inflammatory cytokine production. Treatment with anti-CD20 mAb in monotherapy had no impact on lung inflammation-driven fibrosis and pulmonary hypertension. CONCLUSION B cell therapies failed to show efficacy in the Fra2 Tg mice. The exacerbated Fra-2 lung inflammatory burden stimulated accumulation and expansion of activated CD19-targeted CAR-T cells, secondarily inducing T cell activation and systemic inflammation, finally leading to disease worsening.
Collapse
Affiliation(s)
- Jérôme Avouac
- INSERM U1016 and UMR8104, Institut Cochin and Université Paris Cité and Hôpital Cochin, AP-HP, Centre - Université Paris Cité, Paris, France
| | - Anne Cauvet
- INSERM U1016 and UMR8104, Institut Cochin, Paris, France
| | - Cindy Orvain
- INSERM U1016 and UMR8104, Institut Cochin, Paris, France
| | - Morgane Boulch
- Institut Pasteur, INSERM U1223, Université Paris Cité, Paris, France
| | - Françoise Tilotta
- URP 2496 Pathologies, Imagerie et Biothérapies Orofaciales, UFR Odontologie, and Plateforme Imagerie du Vivant, Université Paris Cité, Montrouge, France
| | - Ly Tu
- INSERM UMR_S 999, Le Plessis-Robinson, and Université Paris-Sud, Université Paris-Saclay, Le Kremlin-Bicêtre, France
| | - Raphaël Thuillet
- INSERM UMR_S 999, Le Plessis-Robinson, and Université Paris-Sud, Université Paris-Saclay, Le Kremlin-Bicêtre, France
| | - Mina Ottaviani
- INSERM UMR_S 999, Le Plessis-Robinson, and Université Paris-Sud, Université Paris-Saclay, Le Kremlin-Bicêtre, France
| | - Christophe Guignabert
- INSERM UMR_S 999, Le Plessis-Robinson, and Université Paris-Sud, Université Paris-Saclay, Le Kremlin-Bicêtre, France
| | - Philippe Bousso
- Institut Pasteur, INSERM U1223, Université Paris Cité, Paris, France
| | - Yannick Allanore
- INSERM U1016 and UMR8104, Institut Cochin and Université Paris Cité and Hôpital Cochin, AP-HP, Centre - Université Paris Cité, Paris, France
| |
Collapse
|
2
|
Komura K, Yanaba K, Bouaziz JD, Yoshizaki A, Hasegawa M, Varga J, Takehara K, Matsushita T. Perspective to precision medicine in scleroderma. Front Immunol 2024; 14:1298665. [PMID: 38304250 PMCID: PMC10830793 DOI: 10.3389/fimmu.2023.1298665] [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: 09/22/2023] [Accepted: 12/26/2023] [Indexed: 02/03/2024] Open
Abstract
Systemic sclerosis (SSc) is a rare and heterogeneous disease with no relevant environmental trigger or significant responsible gene. It has been and will continue to be difficult to identify large enough patients to conduct classic population-based epidemiologic exposure/non-exposure studies with adequate power to ascertain environmental and genetic risk factors for these entities. The complexity of pathogenesis and heterogeneity are likely to require personalized/precision medicine for SSc. Since several potential drugs are currently available for specific patients if not whole SSc, classification of SSc seems to form the foundation for a better therapeutic strategy. To date, SSc has been classified based on the extent/severity of the affected area as well as some disease markers, including the autoantibody profile. However, such an analysis should also lead to improvements in the design of appropriately stratified clinical trials to determine the effects and prediction of targeted therapies. An approach based on drug response preclinically conducted using patients' own fibroblasts in vitro, can provide a precise disease marker/therapeutic selection for clinical practice. Because scleroderma dermal fibroblasts have a persistent hyper-productive phenotype occurring not only in person, but also in cell culture conditions. Thus, an accumulating approach based on disease markers ensures progression and de-escalation to re-establish a better life with a personally optimized drug environment after the onset of SSc.
Collapse
Affiliation(s)
- Kazuhiro Komura
- Department of Dermatology, Kanazawa Red Cross Hospital, Japanese Red Cross Society, Kanazawa, Japan
- Northwestern Scleroderma Program, Division of Rheumatology, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Koichi Yanaba
- Department of Dermatology, Jikei University, Tokyo, Japan
| | | | - Ayumi Yoshizaki
- Department of Dermatology, University of Tokyo, Tokyo, Japan
| | | | - John Varga
- Northwestern Scleroderma Program, Division of Rheumatology, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | | | | |
Collapse
|
3
|
Beesley CF, Goldman NR, Taher TE, Denton CP, Abraham DJ, Mageed RA, Ong VH. Dysregulated B cell function and disease pathogenesis in systemic sclerosis. Front Immunol 2023; 13:999008. [PMID: 36726987 PMCID: PMC9885156 DOI: 10.3389/fimmu.2022.999008] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Accepted: 12/22/2022] [Indexed: 01/18/2023] Open
Abstract
Systemic sclerosis (SSc) is a complex, immune-mediated rheumatic disease characterised by excessive extracellular matrix deposition in the skin and internal organs. B cell infiltration into lesional sites such as the alveolar interstitium and small blood vessels, alongside the production of defined clinically relevant autoantibodies indicates that B cells play a fundamental role in the pathogenesis and development of SSc. This is supported by B cell and fibroblast coculture experiments revealing that B cells directly enhance collagen and extracellular matrix synthesis in fibroblasts. In addition, B cells from SSc patients produce large amounts of profibrotic cytokines such as IL-6 and TGF-β, which interact with other immune and endothelial cells, promoting the profibrotic loop. Furthermore, total B cell counts are increased in SSc patients compared with healthy donors and specific differences can be found in the content of naïve, memory, transitional and regulatory B cell compartments. B cells from SSc patients also show differential expression of activation markers such as CD19 which may shape interactions with other immune mediators such as T follicular helper cells and dendritic cells. The key role of B cells in SSc is further supported by the therapeutic benefit of B cell depletion with rituximab in some patients. It is notable also that B cell signaling is impaired in SSc patients, and this could underpin the failure to induce tolerance in B cells as has been shown in murine models of scleroderma.
Collapse
Affiliation(s)
- Claire F. Beesley
- Centre for Rheumatology, Division of Medicine, University College London, London, United Kingdom
| | - Nina R. Goldman
- Centre for Rheumatology, Division of Medicine, University College London, London, United Kingdom
| | - Taher E. Taher
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom
| | - Christopher P. Denton
- Centre for Rheumatology, Division of Medicine, University College London, London, United Kingdom
| | - David J. Abraham
- Centre for Rheumatology, Division of Medicine, University College London, London, United Kingdom
| | - Rizgar A. Mageed
- Centre for Translational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Voon H. Ong
- Centre for Rheumatology, Division of Medicine, University College London, London, United Kingdom
| |
Collapse
|
4
|
Thoreau B, Chaigne B, Mouthon L. Role of B-Cell in the Pathogenesis of Systemic Sclerosis. Front Immunol 2022; 13:933468. [PMID: 35903091 PMCID: PMC9315392 DOI: 10.3389/fimmu.2022.933468] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Accepted: 06/06/2022] [Indexed: 11/29/2022] Open
Abstract
Systemic sclerosis (SSc) is a rare multisystem autoimmune disease, characterized by fibrosis, vasculopathy, and autoimmunity. Recent advances have highlighted the significant implications of B-cells in SSc. B-cells are present in affected organs, their subpopulations are disrupted, and they display an activated phenotype, and the regulatory capacities of B-cells are impaired, as illustrated by the decrease in the IL-10+ producing B-cell subpopulation or the inhibitory membrane co-receptor density. Recent multi-omics evidence highlights the role of B-cells mainly in the early stage of SSc and preferentially during severe organ involvement. This dysregulated homeostasis partly explains the synthesis of anti-endothelial cell autoantibodies (AECAs) or anti-fibroblast autoantibodies (AFAs), proinflammatory or profibrotic cytokines (interleukin-6 and transforming growth factor-β) produced by B and plasma cells. That is associated with cell-to-cell interactions with endothelial cells, fibroblasts, vascular smooth muscle cells, and other immune cells, altogether leading to cell activation and proliferation, cell resistance to apoptosis, the impairment of regulatory mechanisms, and causing fibrosis of several organs encountered in the SSc. Finally, alongside these exploratory data, treatments targeting B-cells, through their depletion by cytotoxicity (anti-CD20 monoclonal antibody), or the cytokines produced by the B-cell, or their costimulation molecules, seem interesting, probably in certain profiles of early patients with severe organic damage.
Collapse
Affiliation(s)
- Benjamin Thoreau
- Department of Internal Medicine, National Referral Center for Rare Systemic Autoimmune Diseases, Cochin Hospital, AP‐HP, CEDEX 14, Paris, France
- Université Paris Cité, Paris, France
- INSERM U1016, Cochin Institute, CNRS UMR 8104, Université Paris Cité, Paris, France
| | - Benjamin Chaigne
- Department of Internal Medicine, National Referral Center for Rare Systemic Autoimmune Diseases, Cochin Hospital, AP‐HP, CEDEX 14, Paris, France
- Université Paris Cité, Paris, France
- INSERM U1016, Cochin Institute, CNRS UMR 8104, Université Paris Cité, Paris, France
| | - Luc Mouthon
- Department of Internal Medicine, National Referral Center for Rare Systemic Autoimmune Diseases, Cochin Hospital, AP‐HP, CEDEX 14, Paris, France
- Université Paris Cité, Paris, France
- INSERM U1016, Cochin Institute, CNRS UMR 8104, Université Paris Cité, Paris, France
- *Correspondence: Luc Mouthon,
| |
Collapse
|
5
|
Du Y, Lei L, Ding H, Chen Y, Pathak S, Hicks J, Tran PT, Wu M, Chang B, Wirtz U, Mohan C. Targeting Multiple End Organs in Lupus and Other Systemic Rheumatic Diseases by Inhibiting Bruton’s Tyrosine Kinase. Front Immunol 2022; 13:893899. [PMID: 35874767 PMCID: PMC9304663 DOI: 10.3389/fimmu.2022.893899] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 06/20/2022] [Indexed: 11/25/2022] Open
Abstract
Bruton tyrosine kinase (Btk) plays a vital role in activating and differentiating B-cells and regulating signaling in myeloid cells. Indeed, the potential use of Btk inhibitors in preventing lupus has been reported. Here, we extend these observations to 4 additional models of end-organ inflammation: (a) BWF1 lupus nephritis mice, (b) anti-GBM nephritis, (c) bleomycin-induced systemic sclerosis like skin disease, and (d) bleomycin-induced lung disease. In agreement with the previous studies, BTK inhibitor (BTKB66) treatment was effective in treating lupus nephritis in terms of reducing renal damage both functionally and histologically, accompanied by significant decrease in proteinuria. Both low-dose and high-dose BTKB66 profoundly blocked renal disease in the anti-GBM nephritis model, with efficacy that was comparable to that seen with dexamethasone. This study provides the first evidence that BTK inhibition has both therapeutic and preventative effects in bleomycin-induced SSc-like disease, in terms of reducing skin thickness, fibrosis, collagen deposition, and inflammation. Likewise, significantly lower lung inflammatory cell infiltration was observed after treatment with BTKB66. Therapeutic benefit was associated with lower numbers of macrophages, proliferating macrophages and activated T-cells in the respective injured organs. The observation that these immune cells play key roles in driving end organ inflammation in multiple systemic rheumatic diseases have broad implications for the use of BTKB66 in managing patients with systemic rheumatic diseases where multiple end organs are afflicted, including lupus and systemic sclerosis.
Collapse
Affiliation(s)
- Yong Du
- The Department of Biomedical Engineering, University of Houston, Houston, TX, United States
- *Correspondence: Chandra Mohan, ; Yong Du,
| | - Ling Lei
- The Department of Biomedical Engineering, University of Houston, Houston, TX, United States
| | - Huihua Ding
- The Department of Biomedical Engineering, University of Houston, Houston, TX, United States
| | - Yanping Chen
- The Department of Biomedical Engineering, University of Houston, Houston, TX, United States
| | - Simanta Pathak
- The Department of Biomedical Engineering, University of Houston, Houston, TX, United States
| | - John Hicks
- Department of Pathology, Texas Children’s Hospital, Houston, TX, United States
| | - Phuongthy T. Tran
- The Department of Biomedical Engineering, University of Houston, Houston, TX, United States
| | - Minghua Wu
- Division of Rheumatology and Clinical Immunogenetics, University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Betty Chang
- Summit Therapeutics, Menlo Park, CA, United States
| | - Uwe Wirtz
- AbbVie, Inc., Precision Medicine, San Francisco, CA, United States
| | - Chandra Mohan
- The Department of Biomedical Engineering, University of Houston, Houston, TX, United States
- *Correspondence: Chandra Mohan, ; Yong Du,
| |
Collapse
|
6
|
Liossis SNC, Bounia CA. Treating Autoimmune-Related Interstitial Lung Disease With B Cell Depletion. Front Med (Lausanne) 2022; 9:937561. [PMID: 35847798 PMCID: PMC9279739 DOI: 10.3389/fmed.2022.937561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 06/08/2022] [Indexed: 11/13/2022] Open
Abstract
Autoimmune rheumatic diseases may affect vital organs with lung involvement being severe and difficult to treat manifestation. Systemic sclerosis (SSc) commonly affects the lung in the form of interstitial lung disease (ILD). ILD may be also seen in patients with rheumatoid arthritis (RA), Sjögren's syndrome (SS), systemic lupus erythematosus (SLE), inflammatory myositis (IM), antisynthetase syndrome (AS), and the ANCA-associated vasculitides (AAV). Rituximab (RTX) is an anti-CD20 B lymphocyte depleting mAb, often administered in the treatment of autoimmune rheumatic diseases. Although RTX is an off-label treatment for CTD–ILD, there are numerous reports providing data that is effective in improving both pulmonary function tests (PFTs) and chest computed tomography findings consistent with ILD. There are retrospective uncontrolled studies that assess RTX as a treatment of ILD in autoimmune diseases. These studies, apart from one, do not include patients with AAV-ILD. In SSc-ILD, in particular, there are both controlled and uncontrolled studies displaying encouraging results following B cell depletion. In addition, a number of retrospective uncontrolled studies and fewer prospective studies evaluate RTX in connective tissue diseases CTD–ILD. Although RTX is an approved treatment for AAV there are scarce only data focusing on patients with AAV-ILD specifically. The results of a handful of studies comparing treatment of CTD-ILD with RTX to treatment with other agents are in favor of RTX. Results from large, still ongoing controlled trials are awaited to ascertain RTX effects in ILD encountered in autoimmune rheumatic diseases. We review herein the results of the different RTX trials in patients with autoimmune disease–associated with ILD. Despite the heterogeneity of these studies, RTX may be considered an alternative and safe but still off-label treatment for patients with refractory CTD–ILD.
Collapse
Affiliation(s)
- Stamatis-Nick C. Liossis
- Division of Rheumatology, Patras University Hospital, Patras, Greece
- Department of Internal Medicine, University of Patras Medical School, Patras, Greece
- *Correspondence: Stamatis-Nick C. Liossis
| | | |
Collapse
|
7
|
Yarkan Tuğsal H, Zengin B, Kenar G, Önen F, Birlik M. Rituximab on lung, skin, and joint involvement in patients with systemic sclerosis: A case series study and review of the literature. Int J Rheum Dis 2022; 25:755-768. [PMID: 35535670 DOI: 10.1111/1756-185x.14333] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 02/15/2022] [Accepted: 04/29/2022] [Indexed: 02/06/2023]
Abstract
OBJECTIVES To evaluate the effectiveness of rituximab (RTX) in systemic sclerosis (SSc) patients. METHODS Data were collected from patient charts before and after RTX administration for 1 year of follow-up time. An updated review of the literature was also done. RESULTS Of 8 patients enrolled (mean age: 62.4 years; mean disease duration: 16.7 years), 2 patients with pulmonary arterial hypertension (PAH) died after the first RTX cycle. The follow-up data of the remaining 6 patients were evaluated. There was a significant improvement in arthritis of Disease Activity Score of 28 joints - C-reactive protein and Clinical Disease Activity Index compared with baseline. The median change in modified Rodnan Skin Score (mRSS), forced vital capacity (FVC), and carbon monoxide diffusing capacity between baseline and 12 months were similar. Lung involvement was detected in 5/6 of survivor patients, FVC was improved in 2/5, worsened in 1/5, and remained stable in 2/5 at the end of 1 year. Among the 5 diffuse cutaneous SSc patients, none of the patients' mRSS deteriorated by more than 5 points, while one patient's mRSS improved by greater than 5 points. CONCLUSION This study suggests that RTX is effective for arthritis in patients with SSc. Also, the effectiveness of RTX in skin and lung involvement of SSc was predominantly toward stable disease or improvement. Despite the long disease duration, the presence of patients who showed improvement in skin and lung involvement after RTX treatment suggests the need to investigate predictors of RTX response.
Collapse
Affiliation(s)
- Handan Yarkan Tuğsal
- Department of Rheumatology, Dokuz Eylul University School of Medicine, Izmir, Turkey
| | - Berrin Zengin
- Department of Rheumatology, Dokuz Eylul University School of Medicine, Izmir, Turkey
| | - Gökçe Kenar
- Department of Rheumatology, Dokuz Eylul University School of Medicine, Izmir, Turkey
| | - Fatoş Önen
- Department of Rheumatology, Dokuz Eylul University School of Medicine, Izmir, Turkey
| | - Merih Birlik
- Department of Rheumatology, Dokuz Eylul University School of Medicine, Izmir, Turkey
| |
Collapse
|
8
|
Vicente-Rabaneda EF, Serra López-Matencio JM, Ancochea J, Blanco R, González-Gay MÁ, Castañeda S. Efficacy and safety of biological drugs in interstitial lung disease associated with connective tissue diseases. Expert Opin Drug Saf 2021; 21:311-333. [PMID: 34433372 DOI: 10.1080/14740338.2021.1973428] [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: 10/20/2022]
Abstract
INTRODUCTION Interstitial lung disease (ILD) is one of the most important manifestations of connective tissue diseases (CTD) due to its association with high morbidity and mortality. AREAS COVERED Literature review focused on the evidence on efficacy and safety of biological therapy. EXPERT OPINION Rituximab (RTX) is the most studied drug, though tocilizumab (TCZ) has methodologically more robust evidence, whereas abatacept (ABA) has only anecdotal reports. RTX studies suggest a clinically relevant effect on lung function and fibrosis in refractory to conventional treatment patients, with a good safety profile. Its multi-level efficacy in systemic sclerosis and the potentially more favorable response of anti-synthetase syndrome, especially when administered early in acute-onset or exacerbated ILD stand out over current standard of care, pending the availability of randomized controlled clinical trials. The significant and clinically meaningful benefit found in lung function and fibrosis with TCZ in faSScinate and focuSSced trials represents a change with respect to the usual practice, reinforcing the importance of treatment in early subclinical or clinical SSc-ILD patients with risk factors for ILD progression. This evidence has led to the inclusion of both RTX and TCZ in the expert-based therapeutic algorithms or recommendations for CTD-ILD management.
Collapse
Affiliation(s)
| | | | - Julio Ancochea
- Pneumology Division, Hospital Universitario de La Princesa, Madrid, Spain.,Cathedra UAM-Roche, EPID-Future, Medicine Department, Universidad Autónoma de Madrid, Spain
| | - Ricardo Blanco
- Rheumatology Division, Hospital Universitario Marqués de Valdecilla, Spain
| | - Miguel Á González-Gay
- Rheumatology Division, Hospital Universitario Marqués de Valdecilla, Spain.,Department of Medicine, University of Cantabria, Santander, Spain.,Faculty of Health Sciences, University of Witwatersrand, Cardiovascular Pathophysiology and Genomics Research Unit, School of Physiology, South Africa
| | - Santos Castañeda
- Rheumatology Division, Hospital Universitario de La Princesa, Madrid, Spain.,Cathedra UAM-Roche, EPID-Future, Medicine Department, Universidad Autónoma de Madrid, Spain
| |
Collapse
|
9
|
Efficacy and safety of rituximab therapy in patients with systemic sclerosis disease (SSc): systematic review and meta-analysis. Clin Rheumatol 2021; 40:3897-3918. [PMID: 33796953 DOI: 10.1007/s10067-021-05698-4] [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] [Received: 01/23/2021] [Revised: 02/22/2021] [Accepted: 03/15/2021] [Indexed: 12/29/2022]
Abstract
The clinical benefits of rituximab in systemic sclerosis (SSc) are still contentious. The present meta-analysis aimed to systematically assess rituximab's safety and efficacy profile in SSc patients. A systematic online query was performed in PubMed, Scopus, Web of Science, and Embase. The studies on the application of rituximab for patients with SSc were reviewed comprehensively for over two years. In terms of efficacy profile, mRSS, MS, LVEF, sPAP, FVC, DLCO, TLC, FEV, DAS, severity activity, HAQ-DI and SF36 were assessed for organ involvement and quality of life. The level of biological and immunological markers was also evaluated in SSc patients treated with RTX. In total, 24 studies met the criteria. Although they did not have a high quality, they were free from heterogeneity and publication bias. The pooled results revealed a long-term improvement in mRSS and MS. HAQ-DI was improved to 0.78 after 12 months, and DAS was significantly reduced to 0.33, 0.23, and 0.24 following 6, 12, and 24 months of treatment, respectively (p = 0.00 for both parameters). The rest of the parameters remained stable over time in patients with SSc. The pooled analysis of these patients demonstrated that the induction of death, cancer, infection, and infusion were 9, 5, 18 and 10%, respectively. Based on the pooled results of this meta-analysis, rituximab improves skin score and disease indices and stabilizes organ involvement in SSc patients. Rituximab seems to possess reasonable safety, similar to previous data from other autoimmune diseases.
Collapse
|
10
|
Xing NS, Fan GZ, Yan F, Liu YP, Zhang R. Safety and efficacy of rituximab in connective tissue disease-associated interstitial lung disease: A systematic review and meta-analysis. Int Immunopharmacol 2021; 95:107524. [PMID: 33721757 DOI: 10.1016/j.intimp.2021.107524] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Revised: 02/19/2021] [Accepted: 02/20/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Rituximab (RTX) is widely used in the treatment of connective tissue disease (CTD) because it can target and eliminate pathogenic B cells. Interstitial lung disease (ILD) is one of the common complications of CTD; however, the clinical benefits of RTX in connective tissue disease-associated interstitial lung disease (CTD-ILD) are still controversial. This meta-analysis was performed to systematically evaluate the efficacy and safety of RTX in CTD-ILD patients. METHODS We performed a systematic online query in PubMed, Cochrane, and Embase up to February 2020. Randomized controlled trials and observational studies on the use of RTX and conventional treatment in CTD-ILD patients were comprehensively reviewed and investigated. RESULTS In total, 6 studies, including 242 participants, were analysed. The pooled results showed that RTX is superior to conventional treatment methods in improving forced vital capacity and modified Rodnan skin scores (MRSS) in patients with systemic sclerosis (P<0. 05), but there was no statistically significant difference between RTX and conventional treatment method in the improvement of lung diffusion function. The risk of adverse effects declined in the RTX therapy groups compared with the conventional therapy groups in terms of infection and the blood system. CONCLUSION The pooled results of this meta-analysis indicated that RTX is well tolerated, and RTX is able to improve or stabilize pulmonary function in CTD-ILD patients.
Collapse
Affiliation(s)
- Nan-Shu Xing
- Department of Rheumatology, The 1st Affiliated Hospital of China Medical University, Shenyang 110001, Liaoning, China
| | - Guan-Zhi Fan
- Department of Rheumatology, The 1st Affiliated Hospital of China Medical University, Shenyang 110001, Liaoning, China
| | - Fei Yan
- Department of Rheumatology, The 1st Affiliated Hospital of China Medical University, Shenyang 110001, Liaoning, China
| | - Yi-Ping Liu
- Department of Rheumatology, The 1st Affiliated Hospital of China Medical University, Shenyang 110001, Liaoning, China
| | - Rong Zhang
- Department of Rheumatology, The 1st Affiliated Hospital of China Medical University, Shenyang 110001, Liaoning, China.
| |
Collapse
|
11
|
Lerman I, Mitchell DC, Richardson CT. Human cutaneous B cells: what do we really know? ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:440. [PMID: 33842661 PMCID: PMC8033329 DOI: 10.21037/atm-20-5185] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
B cells play many critical roles in the systemic immune response, including antibody secretion, antigen presentation, T cell co-stimulation, and pro- and anti-inflammatory cytokine production. However, the contribution of B cells to the local immune response in many non-lymphoid tissues, such as the skin, is incompletely understood. Cutaneous B cells are scarce except in certain malignant and inflammatory conditions, and as such, have been poorly characterized until recently. Emerging evidence now suggests an important role for cutaneous B in both skin homeostasis and pathogenesis of skin disease. Herein, we discuss the potential mechanisms for cutaneous B cell recruitment, localized antibody production, and T cell interaction in human skin infections and primary skin malignancies (i.e., melanoma, squamous cell carcinoma). We further consider the likely contribution of cutaneous B cells to the pathogenesis of inflammatory skin diseases, including pemphigus vulgaris, lupus erythematosus, systemic sclerosis, hidradenitis suppurativa, and atopic dermatitis. Finally, we examine the feasibility of B cell targeted therapy in the dermatologic setting, emphasizing areas that are still open to investigation. Through this review, we hope to highlight what we really know about cutaneous B cells in human skin, which can sometimes be lost in reviews that more broadly incorporate extensive data from animal models.
Collapse
Affiliation(s)
- Irina Lerman
- University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Drew C Mitchell
- University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Christopher T Richardson
- Department of Dermatology, University of Rochester Medical Center, Rochester, NY, USA.,Division of Allergy, Immunology and Rheumatology, University of Rochester Medical Center, Rochester, NY, USA
| |
Collapse
|
12
|
de Figueiredo Caldas MMV, de Azevedo KPM, de França Nunes AC, de Oliveira VH, Pimenta IDSF, de Araújo IDT, Neto FAB, da Silveira Gonçalves de Oliveira AK, Piuvezam G. Is rituximab effective for systemic sclerosis? A systematic review and meta-analysis. Adv Rheumatol 2021; 61:15. [PMID: 33640020 DOI: 10.1186/s42358-021-00170-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Accepted: 02/10/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Systemic sclerosis (SSc) is a clinically complex and challenging disease, that leads to skin fibrosis. Its most frequent complication is interstitial lung disease (ILD), which leads to a worse prognosis. In this situation, cyclophosphamide is considered the gold standard for its treatment, despite the controversies regarding its efficacy and toxicity. However, studies using rituximab (RTX) have shown that this drug may be a promising therapeutic option. OBJECTIVES This paper objective was to analyze the scientific evidence on the RTX effects on SSc. METHODS A systematic review (SR) was performed including clinical trials (CTs) on the use of RTX in SSc, published up to May 2020. The studies were identified through systematic searches in bibliographic databases using a predefined search strategy. The following databases were used: PUBMED, SCOPUS, SCIELO, LILACS, SCIENCE DIRECT, WEB OF SCIENCE, COCHRANE, WHOLIS, PAHO and EMBASE. Also, a manual search was performed. The methodological quality of the studies was determined using Jadad scale, Risk of Bias Tool (RoB 2.0) and Risk of Bias in Non-Randomized Studies - of Interventions tool (ROBINS-I). A meta-analysis of the randomized CTs was performed, using Review Manager. RESULTS Ten CTs were included in this SR. Of these, three were randomized and seven were non-randomized. Five showed a statistically significant improvement in forced vital capacity (FVC) at some time during follow-up. Regarding the skin, eight studies showed statistically significant improvements according toa the modified Rodnan skin score. The meta-analysis found positive effects of RTX in SSc, with a statistical significance for lung disease. CONCLUSION Rituximab is a promising strategy for the SSc-associated ILD and cutaneous fibrosis treatment. PROSPERO registration number: CRD42019132018.
Collapse
Affiliation(s)
| | - Kesley Pablo Morais de Azevedo
- Post-Graduation Program in Public Health (PPGSCol), Federal University of Rio Grande do Norte, Natal, Rio Grande do Norte, Brazil.
| | - Ana Clara de França Nunes
- Post-Graduation Program in Public Health (PPGSCol), Federal University of Rio Grande do Norte, Natal, Rio Grande do Norte, Brazil
| | - Victor Hugo de Oliveira
- Post-Graduation Program in Public Health (PPGSCol), Federal University of Rio Grande do Norte, Natal, Rio Grande do Norte, Brazil
| | | | | | | | | | - Grasiela Piuvezam
- Post-Graduation Program in Public Health (PPGSCol), Federal University of Rio Grande do Norte, Natal, Rio Grande do Norte, Brazil.,Department of Public Health, Post-Graduation Program in Public Health (PPGSCol), Federal University of Rio Grande do Norte, Natal, Rio Grande do Norte, Brazil
| |
Collapse
|
13
|
Rossi D, Sciascia S, Cecchi I, Saracco M, Montabone E, Modena V, Pellerito R, Carignola R, Roccatello D. A 3-Year Observational Study of Patients with Progressive Systemic Sclerosis Treated with an Intensified B Lymphocyte Depletion Protocol: Clinical and Immunological Response. J Clin Med 2021; 10:E292. [PMID: 33466837 PMCID: PMC7830314 DOI: 10.3390/jcm10020292] [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: 12/09/2020] [Revised: 01/03/2021] [Accepted: 01/06/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND B-cells have been suggested to play a role in the pathogenesis of systemic sclerosis (SSc), representing, therefore, a potential therapeutic target. OBJECTIVES We aimed at investigating the 36-month outcomes of 20 SSc patients who underwent an intensified B-depletion therapy (IBCDT) scheme, including both Rituximab (RTX) and cyclophosphamide (CYC). METHODS Data from 20 severe patients (18 females and 2 males, mean age 66.7 ± 11.0 years) with diffuse SSc (anti-topoisomerase I antibody in 95%) patients with multiorgan involvement including interstitial lung disease (ILD) treated with an IBCDT were prospectively collected. IBCDT comprehended: RTX 375 mg/m2 administered for four weekly doses (on days 1, 8, 15, and 22), followed by two additional doses after 30 and 60 days, in addition to two administrations of 10 mg/kg of intravenous CYC plus three methylprednisolone pulses (15 mg/kg) and subsequently followed by oral prednisone rapidly tapered to low minimum dosage of 5 mg daily. In addition, 10 patients with more severe functional respiratory impairment at baseline were also treated with RTX 500 mg every 4 months during the first year and two times a year during the second and the third year. RESULTS After 36 months of follow-up, we recorded significant amelioration in N-terminal-pro-brain natriuretic peptide (NT-proBNP) levels (mean 385.4 ± 517 pg/mL at baseline to 279 ± 543 after 36 months). In addition, a significant radiological improvement of ILD in 20% of patients (4/20) and a radiological stabilization with no sign of progression of interstitial involvement in 13/20 (65%) were documented. A total of 3 out of 20 (15%) patients experienced a worsening of the ILD. No patient showed further decrease in functional respiratory parameters, including forced vital capacity, forced expiratory volume in one second, and mean values of diffusing capacity for carbon monoxide Moreover, no patient showed any change in the ejection fraction and pulmonary artery pressure when comparing values at baseline and after 24 and 36 months of observation. No severe infection, renal flare, RTX-related side effects were observed. No patient died. CONCLUSIONS Our findings support that the IBCDT was well tolerated and might be a promising therapeutic option for the management of SSc, especially in those subjects with multiorgan involvement that includes ILD.
Collapse
Affiliation(s)
- Daniela Rossi
- Center of Research of Rheumatology, Nephrology and Rare Diseases, Coordinating Center of the Interregional Network of Rare Diseases of Piedmont and Aosta Valley, SCDU CMID-Nephrology and Dialysis G. Bosco Hospital and University of Turin, 10154 Turin, Italy; (D.R.); (S.S.); (I.C.); (V.M.)
| | - Savino Sciascia
- Center of Research of Rheumatology, Nephrology and Rare Diseases, Coordinating Center of the Interregional Network of Rare Diseases of Piedmont and Aosta Valley, SCDU CMID-Nephrology and Dialysis G. Bosco Hospital and University of Turin, 10154 Turin, Italy; (D.R.); (S.S.); (I.C.); (V.M.)
| | - Irene Cecchi
- Center of Research of Rheumatology, Nephrology and Rare Diseases, Coordinating Center of the Interregional Network of Rare Diseases of Piedmont and Aosta Valley, SCDU CMID-Nephrology and Dialysis G. Bosco Hospital and University of Turin, 10154 Turin, Italy; (D.R.); (S.S.); (I.C.); (V.M.)
| | - Marta Saracco
- Rheumatology Unit, Mauriziano Umberto I Hospital, 10128 Turin, Italy; (M.S.); (R.P.)
| | - Erika Montabone
- Internal Medicine, San Luigi Gonzaga Hospital Orbassano, 10043 Turin, Italy; (E.M.); (R.C.)
| | - Vittorio Modena
- Center of Research of Rheumatology, Nephrology and Rare Diseases, Coordinating Center of the Interregional Network of Rare Diseases of Piedmont and Aosta Valley, SCDU CMID-Nephrology and Dialysis G. Bosco Hospital and University of Turin, 10154 Turin, Italy; (D.R.); (S.S.); (I.C.); (V.M.)
| | - Raffaele Pellerito
- Rheumatology Unit, Mauriziano Umberto I Hospital, 10128 Turin, Italy; (M.S.); (R.P.)
| | - Renato Carignola
- Internal Medicine, San Luigi Gonzaga Hospital Orbassano, 10043 Turin, Italy; (E.M.); (R.C.)
| | - Dario Roccatello
- Center of Research of Rheumatology, Nephrology and Rare Diseases, Coordinating Center of the Interregional Network of Rare Diseases of Piedmont and Aosta Valley, SCDU CMID-Nephrology and Dialysis G. Bosco Hospital and University of Turin, 10154 Turin, Italy; (D.R.); (S.S.); (I.C.); (V.M.)
| |
Collapse
|
14
|
Borrirukwisitsak S, Tantayakom P, Katchamart W. Efficacy and safety of rituximab on lung and skin involvement in systemic sclerosis: a systematic review and metaanalysis. Clin Rheumatol 2021; 40:2779-2789. [PMID: 33428098 DOI: 10.1007/s10067-020-05542-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 12/08/2020] [Accepted: 12/09/2020] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To evaluate the efficacy and safety of rituximab (RTX), an antiB cell monoclonal antibody, on lung and skin involvement in systemic sclerosis (SSc). METHODS All literature published in Embase and Medline before September 2019 were comprehensively searched. Two independent reviewers selected eligible studies, extracted relevant data, and assessed the quality of the included studies. We only considered randomized, controlled trials (RCTs), cohort studies, and case-control studies that compared RTX with a placebo, other immunosuppressive agents, or corticosteroids. All analyses were performed using RevMan (version 5.3). RESULTS A total of 8 studies (3 RCTs and 5 cohort studies) met our inclusion criteria. The pooled analysis showed a significant improvement of modified Rodnan skin score in the RTX group only in the cohort studies (mean difference [SD] - 3.31 [- 4.95, - 1.68]; I2 = 82%). As to the PFT, the RTX group showed a significant improvement in the forced vital capacity only in 3 RCTs (mean difference [SD] 6.59 [3.51, 9.68]; I2 = 0%). Additionally, the RTX group demonstrated a statistically significant improvement in the diffuse capacity of carbon monoxide only in the cohort studies (mean difference [SD] 7.42 [1.08, 13.76]; I2 = 97%). There were no significant differences in the AEs of the RTX and control groups. CONCLUSIONS RTX may be effective for lung and skin involvement in SSc, with no serious AEs. However, further studies with high quality and a large sample size are necessary to firmly establish the efficacy and safety of the use of RTX with SSc patients. Key Points • RTX may be an alternative treatment for cutaneous and pulmonary manifestations in patients with SSc with a favorable safety profile. • However, further studies with a high quality and large sample size are necessary to firmly establish its efficacy and safety.
Collapse
Affiliation(s)
- Sasimon Borrirukwisitsak
- Division of Rheumatology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, 8th floor, Asadang Building, 2 Wanglang Road, Bangkok Noi, Bangkok, 10700, Thailand
| | - Pongchirat Tantayakom
- Internal Medicine Center, Siriraj Piyamaharajkarun Hospital, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Wanrachada Katchamart
- Division of Rheumatology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, 8th floor, Asadang Building, 2 Wanglang Road, Bangkok Noi, Bangkok, 10700, Thailand.
| |
Collapse
|
15
|
Fallet B, Walker UA. Current immunosuppressive and antifibrotic therapies of systemic sclerosis and emerging therapeutic strategies. Expert Rev Clin Pharmacol 2020; 13:1203-1218. [PMID: 33008265 DOI: 10.1080/17512433.2020.1832466] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Systemic sclerosis (SSc) is a rare, difficult to treat disease with profound effects on quality of life and high mortality. Complex and incompletely understood pathophysiologic processes and greatly heterogeneous clinical presentations and outcomes have hampered drug development. AREAS COVERED This review summarizes the currently available immunosuppressive and antifibrotic therapies and discusses novel approaches for the treatment of SSc. We reviewed the literature using the MEDLINE and ClinicalTrial.gov databases between May and September 2020. EXPERT OPINION Available immunosuppressive and antifibrotic drugs only modestly impact the course of the disease. Most drugs are currently only investigated in the subset of patients with early diffuse cutaneous SSc. In this patient population, hematopoietic stem-cell transplantation is currently the only treatment that has demonstrated reversal of lung involvement, enhanced quality of life and reduced long-term mortality, but carries the risk of short-term treatment-related mortality. A great need to provide better therapeutic options to patients exists also for those patients who have limited cutaneous skin involvement. A better understanding of SSc pathophysiology has enabled the identification of numerous new therapeutic targets. The progress made in the design of clinical trials and outcome parameters will likely result in the improvement of effective management options.
Collapse
Affiliation(s)
- Bénédict Fallet
- Department of Rheumatology, University Hospital Basel , Basel, Switzerland
| | - Ulrich A Walker
- Department of Rheumatology, University Hospital Basel , Basel, Switzerland
| |
Collapse
|
16
|
Tang R, Yu J, Shi Y, Zou P, Zeng Z, Tang B, Wang Y, Ling G, Luo M, Xiao R. Safety and efficacy of Rituximab in systemic sclerosis: A systematic review and meta-analysis. Int Immunopharmacol 2020; 83:106389. [PMID: 32172205 DOI: 10.1016/j.intimp.2020.106389] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Revised: 03/06/2020] [Accepted: 03/07/2020] [Indexed: 02/06/2023]
Abstract
PURPOSE Rituximab is widely prescribed to treat systemic sclerosis (SSc) by the depletion of pathogenic B cells. Nonetheless, the clinical benefit of Rituximab in SSc remains contentious. This meta-analysis was conducted to systematically evaluate the safety and efficacy profile of Rituximab in SSc patients. PATIENTS AND METHODS We performed a systematic online query in PubMed, Cochrane, and Web of Science. The available studies on the use of Rituximab in SSc patients were comprehensively reviewed and investigated. RESULTS In total, 14 studies, including 597 participants, were analyzed. Pooled results showed the long-term improvement in the modified Rodnan skin score (mRSS) for skin function (ΔmRSS: 7.00 at 6 months, 9.70 at 12 months, and 10.93 at 24 months), while forced vital capacity (FVC) (ΔFVC: -0.69 at 6 months, -2.62 at 12 months, and -0.67 at 24 months) and diffusing capacity of the lungs for carbon monoxide (DLCO) (ΔDLCO: -2.39 at 6 months, -3.28 at 12 months, and -0.79 at 24 months) for lung function remained stable in SSc patients after Rituximab treatment. The rate of Rituximab-related adverse events was 12% in the pooled results. CONCLUSION The pooled results of this meta-analysis indicated that Rituximab is well tolerated, and it is able to improve cutaneous function and stabilize pulmonary function in SSc patients.
Collapse
Affiliation(s)
- Rui Tang
- Department of Rheumatology and Immunology, The Second Xiangya Hospital, Central South University, Changsha 410011, Hunan, China; Department of Dermatology, The Second Xiangya Hospital, Central South University, Changsha 410011, Hunan, China
| | - Jiangfan Yu
- Department of Dermatology, The Second Xiangya Hospital, Central South University, Changsha 410011, Hunan, China
| | - Yaqian Shi
- Department of Dermatology, The Second Xiangya Hospital, Central South University, Changsha 410011, Hunan, China
| | - Puyu Zou
- Department of Dermatology, The Second Xiangya Hospital, Central South University, Changsha 410011, Hunan, China
| | - Zhuotong Zeng
- Department of Dermatology, The Second Xiangya Hospital, Central South University, Changsha 410011, Hunan, China
| | - Bingsi Tang
- Department of Dermatology, The Second Xiangya Hospital, Central South University, Changsha 410011, Hunan, China
| | - Yaoyao Wang
- Department of Dermatology, Sir Run Run Shaw Hospital, Zhejiang University, Hangzhou 310020, Zhejiang, China
| | - Guanghui Ling
- Department of Rheumatology and Immunology, The Second Xiangya Hospital, Central South University, Changsha 410011, Hunan, China
| | - Mei Luo
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha 410008, Hunan, China.
| | - Rong Xiao
- Department of Dermatology, The Second Xiangya Hospital, Central South University, Changsha 410011, Hunan, China.
| |
Collapse
|
17
|
Misra DP, Ahmed S, Agarwal V. Is biological therapy in systemic sclerosis the answer? Rheumatol Int 2020; 40:679-694. [PMID: 31960079 DOI: 10.1007/s00296-020-04515-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Accepted: 01/07/2020] [Indexed: 12/19/2022]
Abstract
Systemic sclerosis is a systemic fibrosing disorder associated with significant morbidity and mortality, with no universally accepted disease-modifying therapy. Significant advances in the understanding of systemic sclerosis in recent years have guided the exploration of biological drugs in systemic sclerosis. In this narrative review, we summarize the published literature on biologic therapies in systemic sclerosis. A double-blind randomized trial, and an open label trial of tocilizumab (which antagonizes the interleukin 6 receptor), identified potential benefits in skin and lung fibrosis in systemic sclerosis; however, these differences failed to attain statistical significance. Two open-label trials compared rituximab (which depletes B lymphocytes) to conventional treatment/ cyclophosphamide in systemic sclerosis-associated interstitial lung disease (ILD), and revealed significant improvements in lung functions and skin disease with rituximab. Significant observational data also support the use of rituximab in skin, lung, muscle and joint manifestations of systemic sclerosis. Abatacept (which blocks T lymphocyte activation) has demonstrated utility for skin and joint disease in systemic sclerosis; a recent clinical trial failed to demonstrate benefits in improving skin thickness compared to placebo. Agents targeting type I interferons, interleukin 17 pathway, CD19 and plasma cells hold promise in systemic sclerosis; however, high-quality evidence is lacking. The results of different ongoing clinical trials targeting B lymphocytes, T lymphocytes, various cytokines (interleukins 6, 17, 4, 13, IL-1α), platelet-derived growth factor receptor, proteasome, integrins or oncostatin M may help guide future therapeutic regimens with biological agents in systemic sclerosis.
Collapse
Affiliation(s)
- Durga Prasanna Misra
- Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), Lucknow, 226014, India.
| | - Sakir Ahmed
- Department of Clinical Immunology and Rheumatology, Kalinga Institute of Medical Sciences, Bhubaneswar, India
| | - Vikas Agarwal
- Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), Lucknow, 226014, India
| |
Collapse
|
18
|
Nasonov EL, Beketova TV, Ananyeva LP, Vasilyev VI, Solovyev SK, Avdeeva AS. PROSPECTS FOR ANTI-B-CELL THERAPY IN IMMUNO-INFLAMMATORY RHEUMATIC DISEASES. RHEUMATOLOGY SCIENCE AND PRACTICE 2019. [DOI: 10.14412/1995-4484-2019-3-40] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- E L. Nasonov
- V.A. Nasonova Research Institute of Rheumatology; I.M. Sechenov First Moscow State Medical University (Sechenov University), Ministry of Health of Russia
| | | | | | | | | | | |
Collapse
|
19
|
Ebata S, Yoshizaki A, Fukasawa T, Miura S, Takahashi T, Sumida H, Asano Y, Sato S. Rituximab therapy is more effective than cyclophosphamide therapy for Japanese patients with anti-topoisomerase I-positive systemic sclerosis-associated interstitial lung disease. J Dermatol 2019; 46:1006-1013. [PMID: 31502326 DOI: 10.1111/1346-8138.15079] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2019] [Accepted: 08/15/2019] [Indexed: 11/30/2022]
Abstract
Systemic sclerosis-associated interstitial lung disease (SSc-ILD) is the most frequent cause of death for SSc but there is still no sufficient treatment available. Although cyclophosphamide (CYC) therapy is a common treatment which has shown statistical efficacy against SSc-ILD to date, its effects are temporary and not enough. Rituximab (RTX), the anti-CD20 monoclonal antibody, has recently shown efficacy in many autoimmune diseases. In SSc-ILD, RTX is also considered to be one of the novel treatment candidates. However, studies of SSc-ILD in Japanese treated with RTX have only a few case reports. Therefore, in this study, we retrospectively compared nine patients treated with RTX and 30 patients treated with CYC to investigate the efficacy of RTX treatment for Japanese anti-topoisomerase I-positive SSc-ILD patients. At the 24-month evaluation, the improvement rates of percent predicted of forced vital capacity and percent predicted of diffusing capacity of the lung carbon monoxide in the RTX-treated group were significantly higher than those in the CYC-treated group (20.6 ± 8.8% vs 1.1 ± 3.9%; P < 0.05 and 34.0 ± 6.0% vs -1.5 ± 2.8%; P < 0.01, respectively). In addition, skin thickness scores also showed a marked improvement from 13.5 points before the start of treatment to 5.8 points after 24 months by RTX therapy (P < 0.05). These results suggest that RTX treatment is more effective for Japanese SSc-ILD patients than CYC treatment. In the future, it is expected that large-scale clinical trials will show the usefulness of RTX treatment for SSc-ILD.
Collapse
Affiliation(s)
- Satoshi Ebata
- Department of Dermatology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Ayumi Yoshizaki
- Department of Dermatology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Takemichi Fukasawa
- Department of Dermatology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Shunsuke Miura
- Department of Dermatology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Takehiro Takahashi
- Department of Dermatology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hayakazu Sumida
- Department of Dermatology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yoshihide Asano
- Department of Dermatology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Shinichi Sato
- Department of Dermatology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| |
Collapse
|
20
|
Caldas MMVDF, Neto FAB, de Azevedo KPM, Pimenta IDSF, Oliveira AKDSGD, Piuvezam G. Rituximab in systemic sclerosis: A protocol for systematic review. Medicine (Baltimore) 2019; 98:e17110. [PMID: 31567948 PMCID: PMC6756608 DOI: 10.1097/md.0000000000017110] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Accepted: 08/19/2019] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Systemic sclerosis (SSc) is a clinically complex and challenging disease, the most frequent complication of which is interstitial lung disease, which leads to a worse prognosis. In this situation, cyclophosphamide is considered the criterion standard for treatment, despite the controversies regarding its efficacy and toxicity. However, studies using rituximab (RTX) have shown that this drug may be a promising therapeutic option. The objective is to describe a protocol of a systematic review (SR) that analyzes the scientific evidence on the effects of RTX on SSc. METHODS This protocol is guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols. The databases to be searched are PubMed, Scopus, SciELO, LILACS, ScienceDirect, Web of Science, COCHRANE, WHOLIS, PAHO, and EMBASE. The studies that would be included in SR are clinical trials that evaluate the use of RTX in patients with SSc who meet the classification criteria for the disease according to American College of Rheumatology and European League Against Rheumatism (2013) and/or LeRoy criteria will be included in the SR. The data to be extracted are related to the characteristics of the studies: authors, year of publication, study location, type of study, sample size and age, patient characteristics, duration of intervention, therapeutic scheme, follow-up time, main variables, and main results. RESULTS In our study, we hope to find articles presenting new evidence supporting treatment of SSc with RTX. CONCLUSIONS The SR will present results of scientific evidence for the effects of RTX in SSc. We hope that the results could strengthen clinical decisions for the best treatment of SSc and guide future researches. PROSPERO REGISTRATION NUMBER CRD42019132018.
Collapse
Affiliation(s)
| | | | | | | | | | - Grasiela Piuvezam
- Department of Public Health, Post-Graduation Program in Public Health (PPGSCol), Federal University of Rio Grande do Norte, Rio Grande do Norte, Brazil
| |
Collapse
|
21
|
Berghen N, Vulsteke JB, Westhovens R, Lenaerts J, De Langhe E. Rituximab in systemic autoimmune rheumatic diseases: indications and practical use. Acta Clin Belg 2019; 74:272-279. [PMID: 30253707 DOI: 10.1080/17843286.2018.1521904] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Objectives: To review the therapeutic option of Rituximab, a chimeric anti-CD20 antibody, in systemic autoimmune rheumatic diseases (SARDs) such as systemic lupus erythematosus, systemic sclerosis, primary Sjögren syndrome and idiopathic inflammatory myopathy. Methods: A non-systematic review was conducted. Results: The specific role and indication of rituximab in SARDs has been the subject of multiple trials in recent years. Evidence supports the use of rituximab in moderate-to-severe refractory systemic lupus erythematosus, diffuse skin involvement in systemic sclerosis and systemic involvement in primary Sjögren syndrome. Several guidelines have adopted these indications. In addition, there is a consensus about the use of rituximab in refractory myositis. The role of rituximab in interstitial lung disease associated with these SARDs needs to be further explored. Conclusion: Rituximab is a treatment option in several SARDs. Upcoming trials, use in daily practice and the safety profile are elaborated on.
Collapse
Affiliation(s)
- Nathalie Berghen
- Department of Rheumatology, University Hospitals Leuven, Leuven, Belgium
- Department of Development and Regeneration, Skeletal Biology and Engineering Research Center, KU Leuven, Belgium
| | | | - Rene Westhovens
- Department of Rheumatology, University Hospitals Leuven, Leuven, Belgium
- Department of Development and Regeneration, Skeletal Biology and Engineering Research Center, KU Leuven, Belgium
| | - Jan Lenaerts
- Department of Rheumatology, University Hospitals Leuven, Leuven, Belgium
| | - Ellen De Langhe
- Department of Rheumatology, University Hospitals Leuven, Leuven, Belgium
- Department of Development and Regeneration, Skeletal Biology and Engineering Research Center, KU Leuven, Belgium
| |
Collapse
|
22
|
Melissaropoulos K, Kraniotis P, Bogdanos D, Dimitroulas T, Sakkas L, Daoussis D. Targeting very early systemic sclerosis: a case-based review. Rheumatol Int 2019; 39:1961-1970. [PMID: 31254002 DOI: 10.1007/s00296-019-04357-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Accepted: 06/21/2019] [Indexed: 12/18/2022]
Abstract
It is unknown whether treatment in very early/early systemic sclerosis (SSc) can affect long-term outcomes. A case-based review was conducted (i) to assess the effect of rituximab (RTX) in very early SSc and (ii) to explore how many clinical trials in SSc targeted early disease and whether treatment of these patients led to better clinical outcomes. We identified cases of very early SSc from our department and performed a search in MEDLINE and Scopus databases for clinical trials in SSc during 2005-2018. Two cases are reported where RTX was administered within 24 months from the appearance of Raynaud's. In the first case, there was an improvement in interstitial lung disease as indicated by the improvement in pulmonary function tests and the regression of changes in high-resolution chest computed tomography. In the second case, a good clinical response in skin fibrosis was observed. The review revealed the following: (i) only one-third of the studies were specifically designed to target early disease, (ii) there is confusion related to disease duration definition across SSc clinical trials but an obvious trend towards improvement was evident during the past years, (iii) the question of whether early implementation of therapy may lead to better clinical outcomes cannot be definitely answered based on existing data and (iv) there is still a very low level of incorporation of the new classification criteria in SSc trials. This review suggests that there may be a window of opportunity in SSc and highlights the need for clinical trials targeting very early/early disease.
Collapse
Affiliation(s)
| | | | - Dimitrios Bogdanos
- Department of Rheumatology, Faculty of Medicine, School of Health Sciences, University of Thessaly, 41110, Larissa, Greece
| | - Theodoros Dimitroulas
- 4th Department of Internal Medicine Hippokration Hospital, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Lazaros Sakkas
- Department of Rheumatology, Faculty of Medicine, School of Health Sciences, University of Thessaly, 41110, Larissa, Greece
| | - Dimitrios Daoussis
- Department of Rheumatology, Patras University Hospital, University of Patras Medical School, Patras, Greece.
| |
Collapse
|
23
|
Antonopoulos I, Daoussis D, Lalioti ME, Markatseli TE, Drosos AA, Taraviras S, Andonopoulos AP, Liossis SNC. B cell depletion treatment decreases CD4+IL4+ and CD4+CD40L+ T cells in patients with systemic sclerosis. Rheumatol Int 2019; 39:1889-1898. [PMID: 31227855 DOI: 10.1007/s00296-019-04350-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2019] [Accepted: 06/15/2019] [Indexed: 01/29/2023]
Abstract
Recent data suggests that rituximab may favorably affect skin fibrosis and lung function in patients with systemic sclerosis. Based on experimental data suggesting a key role of B and T cells in scleroderma we aimed to explore the effect(s) of rituximab treatment on T cell subpopulations. Fifteen patients with scleroderma who received rituximab treatment and six who received standard treatment alone were recruited. Peripheral CD4+IL4+, CD4+INFγ+, CD4+IL17+ and CD4+CD40L+ T cells were assessed using flow cytometry. Using ELISA, serum levels of IL4 were assessed. Skin CD4+IL4+ T cells were assessed with confocal microscopy from skin biopsies. Following rituximab treatment skin CD4+IL4+ T cells obviously decreased as seen with confocal microscopy. Moreover, peripheral CD4+IL4+ T cells decreased significantly compared to those from patients who received standard treatment alone: median (IQR): 14.9 (22.63-12.88) vs 7.87 (12.81-4.9)%, p = 0.005 and 9.43 (19.53-7.50)% vs 14.86 (21.96-6.75)%, p = NS at baseline and 6 months later respectively, whereas there was no difference in serum IL4 levels. Peripheral CD4+CD40L+ T cells also decreased significantly following rituximab treatment compared to those from patients who received standard treatment alone: median (IQR): 17.78 (25.64-14.44)% vs 8.15 (22.85-3.08)%, p = 0.04 and 22.13 (58.77-8.20)% vs 72.11 (73.05-20.45)%, p = NS at baseline and 6 months later respectively. Furthermore, peripheral CD4+INFγ+ and CD4+IL17+ T cells revealed no differences following rituximab treatment. Our study demonstrates a link between rituximab treatment and CD4+IL4+ T cell decrease both in the skin and peripheral blood of patients with SSc.
Collapse
Affiliation(s)
- Ioannis Antonopoulos
- Division of Rheumatology, Department of Internal Medicine, Patras University Hospital, University of Patras Medical School, Rion, 26504, Patras, Greece
| | - Dimitrios Daoussis
- Division of Rheumatology, Department of Internal Medicine, Patras University Hospital, University of Patras Medical School, Rion, 26504, Patras, Greece
| | - Maria-Eleni Lalioti
- Department of Physiology, School of Medicine, University of Patras, Rion, 26504, Patras, Greece
| | - Theodora E Markatseli
- Department of Rheumatology, Ioannina University Hospital, University of Ioannina Medical School, Ioannina, Greece
| | - Alexandros A Drosos
- Department of Rheumatology, Ioannina University Hospital, University of Ioannina Medical School, Ioannina, Greece
| | - Stavros Taraviras
- Department of Physiology, School of Medicine, University of Patras, Rion, 26504, Patras, Greece
| | - Andrew P Andonopoulos
- Division of Rheumatology, Department of Internal Medicine, Patras University Hospital, University of Patras Medical School, Rion, 26504, Patras, Greece
| | - Stamatis-Nick C Liossis
- Division of Rheumatology, Department of Internal Medicine, Patras University Hospital, University of Patras Medical School, Rion, 26504, Patras, Greece.
| |
Collapse
|
24
|
Cutolo M, Soldano S, Smith V. Pathophysiology of systemic sclerosis: current understanding and new insights. Expert Rev Clin Immunol 2019; 15:753-764. [PMID: 31046487 DOI: 10.1080/1744666x.2019.1614915] [Citation(s) in RCA: 191] [Impact Index Per Article: 38.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Introduction: Systemic sclerosis (SSc) is a complex autoimmune connective tissue disease characterized by chronic and progressive tissue and organ fibrosis with broad patient-to-patient variability. Some risk factors are known and include combination of persistent Raynaud's phenomenon, steroid hormone imbalance, selected chemicals, thermal, or other injuries. Endogenous and/or exogenous environmental trigger/risk factors promote epigenetic mechanisms in genetically primed subjects. Disease pathogenesis presents early microvascular changes with endothelial cell dysfunction, followed by the activation of mechanisms promoting their transition into myofibroblasts. A complex autoimmune response, involving innate and adaptive immunity with specific/functional autoantibody production, characterizes the disease. Progressive fibrosis and ischemia involve skin and visceral organs resulting in their irreversible damage/failure. Progenitor circulating cells (monocytes, fibrocytes), together with growth factors and cytokines participate in disease diffusion and evolution. Epigenetic, vascular and immunologic mechanisms implicated in systemic fibrosis, represent major targets for incoming disease modifying therapeutic approaches. Areas covered: This review discusses current understanding and new insights of SSc pathogenesis, through an overview of the most relevant advancements to present aspects and mechanisms involved in disease pathogenesis. Expert opinion: Considering SSc intricacy/heterogeneity, early combination therapy with vasodilators, immunosuppressive and antifibrotic drugs should successfully downregulate the disease progression, especially if started from the beginning.
Collapse
Affiliation(s)
- Maurizio Cutolo
- a Research Laboratory and Academic Unit of Clinical Rheumatology, Department of Internal Medicine , University of Genova, IRCCS San Martino Polyclinic Hospital Genova , Genova , Italy
| | - Stefano Soldano
- a Research Laboratory and Academic Unit of Clinical Rheumatology, Department of Internal Medicine , University of Genova, IRCCS San Martino Polyclinic Hospital Genova , Genova , Italy
| | - Vanessa Smith
- b Department of Internal Medicine , Ghent University , Ghent , Belgium.,c Department of Rheumatology , Ghent University Hospital , Ghent , Belgium.,d Unit for Molecular Immunology and Inflammation , VIB Inflammation Research Center (IRC) , Ghent , Belgium
| |
Collapse
|
25
|
Elhai M, Boubaya M, Distler O, Smith V, Matucci-Cerinic M, Alegre Sancho JJ, Truchetet ME, Braun-Moscovici Y, Iannone F, Novikov PI, Lescoat A, Siegert E, Castellví I, Airó P, Vettori S, De Langhe E, Hachulla E, Erler A, Ananieva L, Krusche M, López-Longo FJ, Distler JHW, Hunzelmann N, Hoffmann-Vold AM, Riccieri V, Hsu VM, Pozzi MR, Ancuta C, Rosato E, Mihai C, Kuwana M, Saketkoo LA, Chizzolini C, Hesselstrand R, Ullman S, Yavuz S, Rednic S, Caimmi C, Bloch-Queyrat C, Allanore Y. Outcomes of patients with systemic sclerosis treated with rituximab in contemporary practice: a prospective cohort study. Ann Rheum Dis 2019; 78:979-987. [PMID: 30967395 DOI: 10.1136/annrheumdis-2018-214816] [Citation(s) in RCA: 116] [Impact Index Per Article: 23.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2018] [Revised: 02/07/2019] [Accepted: 02/28/2019] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To assess the safety and efficacy of rituximab in systemic sclerosis (SSc) in clinical practice. METHODS We performed a prospective study including patients with SSc from the European Scleroderma Trials and Research (EUSTAR) network treated with rituximab and matched with untreated patients with SSc. The main outcomes measures were adverse events, skin fibrosis improvement, lung fibrosis worsening and steroids use among propensity score-matched patients treated or not with rituximab. RESULTS 254 patients were treated with rituximab, in 58% for lung and in 32% for skin involvement. After a median follow-up of 2 years, about 70% of the patients had no side effect. Comparison of treated patients with 9575 propensity-score matched patients showed that patients treated with rituximab were more likely to have skin fibrosis improvement (22.7 vs 14.03 events per 100 person-years; OR: 2.79 [1.47-5.32]; p=0.002). Treated patients did not have significantly different rates of decrease in forced vital capacity (FVC)>10% (OR: 1.03 [0.55-1.94]; p=0.93) nor in carbon monoxide diffusing capacity (DLCO) decrease. Patients having received rituximab were more prone to stop or decrease steroids (OR: 2.34 [1.56-3.53], p<0.0001). Patients treated concomitantly with mycophenolate mofetil had a trend for better outcomes as compared with patients receiving rituximab alone (delta FVC: 5.22 [0.83-9.62]; p=0.019 as compared with controls vs 3 [0.66-5.35]; p=0.012). CONCLUSION Rituximab use was associated with a good safety profile in this large SSc-cohort. Significant change was observed on skin fibrosis, but not on lung. However, the limitation is the observational design. The potential stabilisation of lung fibrosis by rituximab has to be addressed by a randomised trial.
Collapse
Affiliation(s)
- Muriel Elhai
- Rheumatology A Department, Paris Descartes University, Cochin Hospital, Paris, France
| | - Marouane Boubaya
- Unit of Clinical Research, Paris Seine Saint Denis University, Bobigny, France
| | - Oliver Distler
- Center of Experimental Rheumatology, Zurich, Switzerland
| | - Vanessa Smith
- Rheumatology and Internal Medicine, Ghent University Hospital, Ghent, Belgium.,Unit for Molecular Immunology and Inflammation, VIB Inflammation Research Center (IRC), Ghent, Belgium
| | | | | | | | | | - Florenzo Iannone
- Interdisciplinary Department of Medicine-Rheumatology Unit, Policlinico, University of Bari, bari, Italy
| | - Pavel I Novikov
- Clinic of Nephrology, Internal and Occupational Diseases, Sechenov First Moscow State Medical University, Moscow, Russian Federation
| | - Alain Lescoat
- Internal Medicine, CHU south hospital, RENNES, France
| | - Elise Siegert
- Rheumatology, Charit University Hospital, Berlin, Germany
| | - Ivan Castellví
- Hospital de la Santa Creu i Sant Pau, Barcelona, Spain, Barcelona, Spain
| | - Paolo Airó
- Rheumatology and Clinical Immunology Service, Spedali Civili di Brescia, Brescia, Italy
| | - Serena Vettori
- Rheumatology Department, Second University of Naples, Naples, Italy
| | - Ellen De Langhe
- Laboratory of Tissue Homeostasis and Disease, Skeletal Biology and Engineering Research Center, Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - Eric Hachulla
- Univ. Lille, Inserm, CHU Lille, U995 - LIRIC - Lille Inflammation Research International Center, Service de Médecine Interne, Hôpital Claude Huriez, Centre de Référence pour la Sclérodermie Systémique, FHU IMMInENT, F-59000, Lille, France
| | - Anne Erler
- Division of Rheumatology Department of Medicine III, Technical University of Dresden, Dresden, Germany
| | - Lidia Ananieva
- Institute of Rheumatology, Russian Academy of Medical Science, Moscow, Russian Federation
| | - Martin Krusche
- Internal Medicine, Rheumatology, Immunology and Nephrology, Asklepios Clinic Altona, Hamburg, Germany
| | - F J López-Longo
- Rheumatology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Jörg H W Distler
- Department of Internal Medicine III, University of Erlangen, Erlangen, Germany
| | | | | | - Valeria Riccieri
- Clinical Medicine and Therapy, Sapienza University of Rome, Rome, Italy
| | - Vivien M Hsu
- Rutgers-Robert Wood Johnson Medical School Scleroderma Program, New Brunswick, New Jersey,USA
| | - Maria R Pozzi
- Dipartimento di Medicina, Ospedale San Gerardo, Monza, Italy
| | - Codrina Ancuta
- Rheumatology 2 Department, Universitatea de Medicina si Farmacie Gr T Popa Iasi Facultatea de Medicina, Iasi, Romania
| | - Edoardo Rosato
- Centroper la Sclerosi Sistemica -Dipartimento di Medicina Clinica, Università LaSapienza, Rome, Italy
| | - Carina Mihai
- Internal Medicine and Rheumatology Department, Cantacuzino Hospital, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Masataka Kuwana
- Allergy and Rheumatology, Nippon Medical School Graduate School of Medicine, Tokyo, Japan
| | - Lesley Ann Saketkoo
- University Medical Center Comprehensive Pulmonary Hypertension Center (UMC-CPHC); Tulane University Lung Center Tulane, New Orleans Scleroderma and Sarcoidosis Patient Care and Research Center New Orleans, New Orleans, Louisiana, USA
| | | | | | - Susanne Ullman
- University Hospital of Copenhagen, Department of Dermatology, Hospital Bispebjerg, Copenhagen, Denmark
| | - Sule Yavuz
- Department of Rheumatology, University of Marmara, Istanbul, Turkey
| | | | | | | | - Yannick Allanore
- Rheumatology A Department, Cochin Hospital, APHP, Paris Descartes University, Paris, France
| | | |
Collapse
|
26
|
Daoussis D, Liossis SN. Treatment of systemic sclerosis associated fibrotic manifestations: Current options and future directions. Mediterr J Rheumatol 2019; 30:33-37. [PMID: 32185340 PMCID: PMC7045920 DOI: 10.31138/mjr.30.1.33] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 01/25/2019] [Accepted: 02/01/2019] [Indexed: 01/17/2023] Open
Abstract
Systemic sclerosis (SSc) is a complicated multisystem disease which is characterized by the highest standardized mortality ratio among all systemic rheumatic diseases with no approved therapies so far. From a pathogenetic point of view it is generally considered that autoimmunity, vasculopathy and fibrosis are the main pathophysiologic processes. In this opinion article/minireview we will discuss current and future options for SSc-related fibrotic manifestations (skin thickening and lung fibrosis). Based on the results of SLS II the best treatment option for skin involvement in SSc is mycophenolate mofetil (MMF). Methotrexate (MTX) is another option which is safe and of low cost but evidence supporting its use is weak. The standard of care for SSc-ILD nowadays is MMF. Patients not responding to MMF could be treated with rituximab (RTX) or cyclophosphamide (CYC) (tocilizumab [TCZ] could be an option as well but only for patients with increased inflammatory markers). Hematopoietic stem cell transplantation (HSCT) could be considered in patients with severe/life-threatening disease who have failed conventional treatment. The most promising therapeutic approach currently been evaluated in phase 3 trials is probably the combination of MMF plus pirfenidone.
Collapse
Affiliation(s)
- Dimitrios Daoussis
- Department of Rheumatology, University of Patras Medical School, Patras University Hospital, Patras, Greece
| | - Stamatis-Nick Liossis
- Department of Rheumatology, University of Patras Medical School, Patras University Hospital, Patras, Greece
| |
Collapse
|
27
|
Treatment of Diffuse Cutaneous Systemic Sclerosis with Biologics, Small Molecules and Stem Cell Transplantation: What Is the Evidence to Date? CURRENT TREATMENT OPTIONS IN RHEUMATOLOGY 2019. [DOI: 10.1007/s40674-019-00119-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
|
28
|
Kubo S, Smith V, Cutolo M, Tanaka Y. The role of nailfold videocapillaroscopy in patients with systemic sclerosis. Immunol Med 2018; 41:113-119. [PMID: 30938276 DOI: 10.1080/25785826.2018.1531189] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
Systemic sclerosis (SSc) is a complex disease which consists of autoimmunity, fibrosis and vasculopathy. Most organ involvement in SSc patients is related to progressive fibrosis. Once fibrosis progresses, it becomes impossible to maintain a normal structure histologically. Therefore, treatment in cases with advanced fibrosis is quite difficult. On the other hand, the role of vasculopathy is clear in the pathogenesis of SSc. Lethal organ disorders of SSc, such as pulmonary arterial hypertension and scleroderma renal crisis, include severe signs of advanced vasculopathy. Nailfold videocapillaroscopy (NVC) is a safe and crucial method for evaluating microvasculopathy. The morphological changes and their progressions can be detected and scored by NVC. Indeed, the microvascular damage and dysfunction represent early markers of systemic sclerosis. Systemic sclerosis has clinical heterogeneity and the use of NVC has been validated to help with early diagnosis and even treatment. Finally, NVC may be useful in evaluating the pathogenesis of systemic sclerosis and its progression in connection with other early biomarkers and functional tools.
Collapse
Affiliation(s)
- Satoshi Kubo
- a The First Department of Internal Medicine , University of Occupational and Environmental Health , Fukuoka , Japan
| | - Vanessa Smith
- b Department of Internal Medicine , Ghent University , Gent , Belgium
| | - Maurizio Cutolo
- c Research Laboratories and Academic Division of Rheumatology, Department of Internal Medicine , University of Genova , Genova , Italy
| | - Yoshiya Tanaka
- a The First Department of Internal Medicine , University of Occupational and Environmental Health , Fukuoka , Japan
| |
Collapse
|
29
|
Abstract
INTRODUCTION Systemic sclerosis (SSc) is a rare autoimmune connective tissue disease characterized by vascular dysfunction, fibrosis, inflammation and autoantibodies. The pathophysiology of SSc is not completely understood, and many patients acquire organ or tissue damage despite advances in treatment. Current treatments target affected organs with modest improvements. Areas covered: This review evaluates several treatment strategies for SSc based on involved organs including skin, pulmonary, cardiac, renal, musculoskeletal, and gastrointestinal. Currently, pulmonary hypertension and interstitial lung disease are the primary causes of increased mortality. We will outline an approach to treatment of SSc based on disease manifestations and current evidence. Expert commentary: This complex disease is currently treated with therapies developed for similar indications such as for vascular manifestations of SSc using idiopathic pulmonary arterial hypertension treatments. Future directions in this field may include combination and maintenance therapy that is currently used in other autoimmune diseases, and tailoring these treatments according to the patients' phenotype. This will hopefully increase the efficacy of available treatments and decrease mortality from SSc.
Collapse
Affiliation(s)
- Maysoon Eldoma
- a Division of Rheumatology, St. Joseph's Health Care, Department of Medicine , University of Western Ontario , Ontario , Canada.,b Rheumatologist, Connective Tissue Disease Fellow , University of Western Ontario , Ontario , Canada.,c Division of Rheumatology, Department of Medicine , University of Calgary , Calgary , Alberta , Canada
| | - Janet Pope
- a Division of Rheumatology, St. Joseph's Health Care, Department of Medicine , University of Western Ontario , Ontario , Canada.,d Division Head Rheumatology and Professor of Medicine , University of Western Ontario , Ontario , Canada
| |
Collapse
|
30
|
Efficacy and safety of rituximab in systemic sclerosis: French retrospective study and literature review. Autoimmun Rev 2018; 17:582-587. [DOI: 10.1016/j.autrev.2017.12.010] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Accepted: 12/28/2017] [Indexed: 12/15/2022]
|
31
|
Aringer M, Denton CP. Systemic sclerosis phase III clinical trials: Hope on the horizon? JOURNAL OF SCLERODERMA AND RELATED DISORDERS 2018; 3:193-200. [DOI: 10.1177/2397198318775353] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Accepted: 04/15/2018] [Indexed: 12/19/2022]
Abstract
While significant progress has been made in treating systemic sclerosis, many patients still have an outcome that is far from satisfactory. For the first time in history, several drugs are now in phase III randomized controlled trials. Approaches tested include the anti-B cell antibody rituximab, the anti-interleukin-6 receptor antibody tocilizumab, the antifibrotic drugs nintedanib and pirfenidone, and the cannabinoid receptor mimetic lenabasum. That all these drugs are in advanced clinical trials despite the relatively low incidence of the disease therefore is good news. Not only is there realistic hope that at least some of the approaches will work, this also indicates growing industry interest, for most of the trials are company-sponsored. This review attempts to delineate the ongoing trials and to summarize the underlying evidence of these candidate systemic sclerosis drugs.
Collapse
Affiliation(s)
- Martin Aringer
- Division of Rheumatology, Department of Medicine III, University Medical Center and Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Christopher P Denton
- Royal Free Hospital and Centre for Rheumatology and Connective Tissue Diseases, University College London, London, UK
| |
Collapse
|
32
|
Melsens K, Vandecasteele E, Deschepper E, Badot V, Blockmans D, Brusselle G, De Langhe E, De Pauw M, Debusschere C, Decuman S, Deroo L, Houssiau F, Lenaerts J, Piette Y, Thevissen K, Vanthuyne M, Westhovens R, Wijnant S, De Keyser F, Smith V. Two years follow-up of an open-label pilot study of treatment with rituximab in patients with early diffuse cutaneous systemic sclerosis. Acta Clin Belg 2018; 73:119-125. [PMID: 28891418 DOI: 10.1080/17843286.2017.1372244] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
OBJECTIVES Following results in open-label studies of rituximab in patients with systemic sclerosis, a Belgian three-centre initiative was launched to explore safety and efficacy of rituximab in early, diffuse cutaneous systemic sclerosis (dcSSc). METHODS Open-label study of 17 patients with early dcSSc, treated with two courses of rituximab, at month 0 and 6. Clinical examination, lung function testing, echocardiography, disease activity score (DAS) and functional status were performed at baseline and over 24 months of follow-up. RESULTS Modified Rodnan skin score (MRSS) changed significantly over time, with a mean of 25.5 (standard deviation [SD] 6.0) at baseline to 12.6 (SD 5.1) at month 24 (Mixed Model Analysis [MMA] p < 0.0001), which is a decrease of 51% at month 24 vs. baseline. DAS showed significant decrease over the total study period, with a score of 4.1 (SD 1.7) at baseline to 1.5 (SD 1.8) at month 24 (MMA p < 0.0001). Additionally, this was significant at all time points vs. baseline, both for MRSS and DAS. Internal organ status remained clinically stable throughout the study period. No statistically significant differences compared to baseline were found at the follow-up time points. Seven serious adverse events took place, all except for one, considered unrelated to study medication. CONCLUSIONS This is the first multicentre Belgian collaboration investigating potential efficacy of rituximab in early dcSSc. Rituximab appears to be safe and tolerable and it may have beneficial effects on skin involvement, on overall disease activity and on stabilization of internal organ status in early dcSSc.
Collapse
Affiliation(s)
- Karin Melsens
- Department of Rheumatology, Universitair Ziekenhuis Gent, Ghent, Belgium
- Faculty of Medicine and Health Sciences, Department of Internal Medicine, Universiteit Gent, Ghent, Belgium
| | - Els Vandecasteele
- Department of Cardiology, Universitair Ziekenhuis Gent, Ghent, Belgium
| | - Ellen Deschepper
- Department of Public Health, Biostatistics Unit, Universiteit Gent, Ghent, Belgium
| | - Valérie Badot
- Department of Rheumatology, Hopital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Daniel Blockmans
- Department of General Internal Medicine, universitaire ziekenhuizen leuven, Leuven, Belgium
| | - Guy Brusselle
- Department of Respiratory Medicine, Universitair Ziekenhuis Gent, Ghent, Belgium
| | - Ellen De Langhe
- Department of Rheumatology, universitaire ziekenhuizen leuven, Leuven, Belgium
| | - Michel De Pauw
- Department of Cardiology, Universitair Ziekenhuis Gent, Ghent, Belgium
| | - Claire Debusschere
- Department of Rheumatology, Universitair Ziekenhuis Gent, Ghent, Belgium
- Faculty of Medicine and Health Sciences, Department of Internal Medicine, Universiteit Gent, Ghent, Belgium
| | - Saskia Decuman
- Faculty of Medicine and Health Sciences, Department of Internal Medicine, Universiteit Gent, Ghent, Belgium
| | - Liselotte Deroo
- Faculty of Medicine and Health Sciences, Universiteit Gent, Ghent, Belgium
| | - Frédéric Houssiau
- Department of Rheumatology, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Jan Lenaerts
- Department of Rheumatology, universitaire ziekenhuizen leuven, Leuven, Belgium
| | - Yves Piette
- Department of Rheumatology, Universitair Ziekenhuis Gent, Ghent, Belgium
| | - Kristof Thevissen
- Department of Rheumatology, Universitair Ziekenhuis Gent, Ghent, Belgium
| | - Marie Vanthuyne
- Department of Rheumatology, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - René Westhovens
- Department of Rheumatology, universitaire ziekenhuizen leuven, Leuven, Belgium
| | - Sara Wijnant
- Faculty of Medicine and Health Sciences, Universiteit Gent, Ghent, Belgium
| | - Filip De Keyser
- Department of Rheumatology, Universitair Ziekenhuis Gent, Ghent, Belgium
- Faculty of Medicine and Health Sciences, Department of Internal Medicine, Universiteit Gent, Ghent, Belgium
| | - Vanessa Smith
- Department of Rheumatology, Universitair Ziekenhuis Gent, Ghent, Belgium
- Faculty of Medicine and Health Sciences, Department of Internal Medicine, Universiteit Gent, Ghent, Belgium
| |
Collapse
|
33
|
Schioppo T, Ingegnoli F. Current perspective on rituximab in rheumatic diseases. DRUG DESIGN DEVELOPMENT AND THERAPY 2017; 11:2891-2904. [PMID: 29042750 PMCID: PMC5633295 DOI: 10.2147/dddt.s139248] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
The steadily increasing knowledge regarding pathogenetic mechanisms in autoimmune rheumatic diseases has paved the way to different therapeutic approaches. In particular, the market entry of biologics has dramatically modified the natural history of rheumatic chronic inflammatory diseases with a meaningful impact on patients’ quality of life. Among the wide spectrum of available biological treatments, rituximab (RTX), first used in the treatment of non-Hodgkin’s lymphoma, was later approved for rheumatoid arthritis and anti-neutrophil cytoplasmic antibodies-associated vasculitis. Nowadays, in rheumatology, RTX is also used with off-label indications in patients with systemic sclerosis, Sjögren’s syndrome and systemic lupus erythematosus. RTX is a monoclonal antibody directed to CD20 molecules expressed on the surfaces of pre-B and mature B lymphocytes. It acts by causing apoptosis of these cells with antibody- and complement-dependent cytotoxicity. As inflammatory responses to cell-associated immune complexes are key elements in the pathogenesis of several autoimmune rheumatic diseases, such an approach might be effective in these patients. In fact, RTX, by promoting the rapid and long-term depletion of circulating and lymphoid tissue-associated B cells, leads to a lower recruitment of these effector cells at sites of immune complex deposition, thus reducing inflammation and tissue damage. RTX is of the most interest to rheumatologists as it represents an important additional therapeutic approach. Thus, the advent in clinical practice of approved RTX biosimilars, such as CT-P10, may be of help in improving treatment access as well as in reducing costs.
Collapse
Affiliation(s)
- Tommaso Schioppo
- Department of Clinical Sciences and Community Health, Division of Rheumatology, ASST Pini, Università degli Studi di Milano, Milano, Italy
| | - Francesca Ingegnoli
- Department of Clinical Sciences and Community Health, Division of Rheumatology, ASST Pini, Università degli Studi di Milano, Milano, Italy
| |
Collapse
|
34
|
Zulian F. Scleroderma in children. Best Pract Res Clin Rheumatol 2017; 31:576-595. [DOI: 10.1016/j.berh.2018.02.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Revised: 11/27/2017] [Accepted: 12/06/2017] [Indexed: 12/15/2022]
|
35
|
Boonstra M, Meijs J, Dorjée AL, Marsan NA, Schouffoer A, Ninaber MK, Quint KD, Bonte-Mineur F, Huizinga TWJ, Scherer HU, de Vries-Bouwstra JK. Rituximab in early systemic sclerosis. RMD Open 2017; 3:e000384. [PMID: 28879049 PMCID: PMC5574444 DOI: 10.1136/rmdopen-2016-000384] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Revised: 05/19/2017] [Accepted: 06/09/2017] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES (1) Hypothesis testing of the potency of rituximab (RTX) in preventing fibrotic complications and (2) assessing acceptability and feasibility of RTX in early systemic sclerosis (SSc). METHODS A small, 24-month, randomised, double-blind, placebo-controlled, single-centre trial in patients with SSc diagnosed <2 years was conducted. Patients received RTX or placebo infusions at t=0, t=15 days and t=6 months. Patients were clinically evaluated every 3 months, with lung function tests and high-resolution CT every other visit. Skin biopsies were taken at baseline and month 3. Immunophenotyping of peripheral blood mononuclear cells was performed at every visit, except at months 9 and 18. Adverse events, course of skin and pulmonary involvement and B cell populations in skin and peripheral blood were evaluated. RESULTS In total 16, patients (rituximab n=8, placebo n=8) were included. Twelve patients had diffuse cutaneous SSc. Eighty-eight adverse events (RTX n=53, placebo n=35, p=0.22) and 11 serious adverse events (RTX n=7, placebo n=4, p=0.36) occurred. No unexpected RTX-related events were observed. Mean skin score over time did not differ between the groups. Over time, forced vital capacity and extent of lung involvement slightly improved with RTX, but this difference was insignificant. In peripheral blood B cells depletion was demonstrated. CONCLUSIONS No unexpected safety issues were observed with RTX in early SSc. Although this small trial could not confirm or reject potential efficacy of RTX in these patients, future placebo-controlled trials are warranted, specifically in the subgroup of patients with pulmonary involvement. TRIAL REGISTRATION NUMBER EudraCT 2008-07180-16; Results.
Collapse
Affiliation(s)
- Maaike Boonstra
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Jessica Meijs
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Annemarie L Dorjée
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Nina Ajmone Marsan
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Anne Schouffoer
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands.,Department of Rheumatology, Haga Hospital, The Hague, The Netherlands
| | - Maarten K Ninaber
- Department of Pulmonology, Leiden University Medical Center, Leiden, The Netherlands
| | - Koen D Quint
- Department of Dermatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Femke Bonte-Mineur
- Department of Rheumatology, Maasstad Hospital, Rotterdam, The Netherlands
| | - Tom W J Huizinga
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Hans U Scherer
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | | |
Collapse
|
36
|
Matsushita T, Takehara K. An update on biomarker discovery and use in systemic sclerosis. Expert Rev Mol Diagn 2017; 17:823-833. [DOI: 10.1080/14737159.2017.1356722] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Takashi Matsushita
- Department of Dermatology, Faculty of Medicine, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Kanazawa, Japan
| | - Kazuhiko Takehara
- Department of Dermatology, Faculty of Medicine, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Kanazawa, Japan
| |
Collapse
|
37
|
Yanaba K. Strategy for treatment of fibrosis in systemic sclerosis: Present and future. J Dermatol 2017; 43:46-55. [PMID: 26782006 DOI: 10.1111/1346-8138.13026] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2015] [Accepted: 06/06/2015] [Indexed: 11/30/2022]
Abstract
Systemic sclerosis (SSc) is a generalized connective tissue disorder characterized by microvascular damage, autoimmunity, and excessive fibrosis of the skin and various internal organs. Regardless of the recent progress in medicine, no radical therapy for SSc has been developed, and the risk of mortality remains high. Therefore, diagnosis in the early disease stage, risk stratification for the development of serious organ involvement and therapeutic intervention with disease-modifying drugs can reduce the maximum degree of fibrosis, leading to improved long-term survival. Recently, new criteria for very early diagnosis of SSc have been proposed, which are expected to be useful for regularly following up patients with very early SSc, regardless of the absence of skin sclerosis, and for detecting the development of internal organ involvement as early as possible. At present, several immunosuppressants, including methotrexate, corticosteroids and cyclophosphamide, are being used for the treatment of fibrosis. Furthermore, mycophenolate mofetil, i.v. immunoglobulins, B-cell depletion, anti-interleukin-6 receptor antibody, autologous hematopoietic stem cell transplantation, rapamycin, pirfenidone and imatinib mesylate are potential candidates for the treatment of SSc, although their efficacy has not been validated. Moreover, targeting transforming growth factor-1 and its signaling pathway or modulating the imbalance between T-helper 1 and 2 immune responses are also attractive therapeutic options. This review describes recent advances in the strategy for treatment of fibrosis in SSc and future perspectives.
Collapse
Affiliation(s)
- Koichi Yanaba
- Department of Dermatology, The Jikei University School of Medicine, Tokyo, Japan
| |
Collapse
|
38
|
Bruni C, Praino E, Allanore Y, Distler O, Gabrielli A, Iannone F, Matucci-Cerinic M. Use of biologics and other novel therapies for the treatment of systemic sclerosis. Expert Rev Clin Immunol 2016; 13:469-482. [PMID: 27899043 DOI: 10.1080/1744666x.2017.1263153] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
INTRODUCTION Systemic sclerosis (SSc) is a systemic autoimmune disease characterized by vasculopathy, inflammation and fibrosis. These three main disease-determining pathways are the target of the currently available treatments used to possibly modify the progression of disease-related manifestations, although this synergy has not been fully applied on SSc joint, skin or lung involvement yet. Areas covered: we describe the current status of SSc treatment/therapy performing a literature search in MEDLINE/Pubmed and Thomson Reuter's Web of Science for articles published until March 2016. Moreover, ongoing registered clinical trials (RCTs) on SSc were searched through clinicaltrials.gov website. Expert commentary: presently, promising drugs are under evaluation to target the different pathogenic pathways of systemic sclerosis: Tocilizumab and Abatacept for skin and lung fibrosis; Riociguat and Selexipag are approved for pulmonary arterial hypertension but promising anti-fibrotic effects are now being studied. Finally, several anti-fibrotic molecules are currently involved in RCTs, such as Nintedanib, IVA-337, Terguride.
Collapse
Affiliation(s)
- Cosimo Bruni
- a Department of Experimental and Clinical Medicine, Division of Rheumatology AOUC , University of Firenze , Firenze , Italy
| | - Emanuela Praino
- a Department of Experimental and Clinical Medicine, Division of Rheumatology AOUC , University of Firenze , Firenze , Italy.,b Interdisciplinary Dept of Medicine, division of Rheumatology , University of Bari , Bari , Italy
| | - Yannick Allanore
- c Department of Rheumatology A and INSERM U1016 , Paris Descartes University, Cochin Hospital , Paris , France
| | - Oliver Distler
- d Department of Rheumatology , University Hospital Zurich , Zurich , Switzerland
| | - Armando Gabrielli
- e Department Of Clinical and Molecular Sciences, Clinica Medica , University 'Politecnica delle Marche' , Ancona , Italy
| | - Florenzo Iannone
- b Interdisciplinary Dept of Medicine, division of Rheumatology , University of Bari , Bari , Italy
| | - Marco Matucci-Cerinic
- a Department of Experimental and Clinical Medicine, Division of Rheumatology AOUC , University of Firenze , Firenze , Italy
| |
Collapse
|
39
|
Daoussis D, Melissaropoulos K, Sakellaropoulos G, Antonopoulos I, Markatseli TE, Simopoulou T, Georgiou P, Andonopoulos AP, Drosos AA, Sakkas L, Liossis SN. A multicenter, open-label, comparative study of B-cell depletion therapy with Rituximab for systemic sclerosis-associated interstitial lung disease. Semin Arthritis Rheum 2016; 46:625-631. [PMID: 27839742 DOI: 10.1016/j.semarthrit.2016.10.003] [Citation(s) in RCA: 135] [Impact Index Per Article: 16.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Revised: 10/05/2016] [Accepted: 10/07/2016] [Indexed: 12/22/2022]
Abstract
OBJECTIVES Rituximab (RTX) may favorably affect lung function and skin fibrosis in patients with systemic sclerosis (SSc). We aimed to assess long-term efficacy and safety of RTX in SSc compared to standard treatment. METHODS A total of 51 patients with SSc-associated interstitial lung disease were recruited and treated with RTX (n = 33) or conventional treatment (n = 18). Median follow-up was 4 years (range: 1-7). Conventional treatment consisted of azathioprine (n = 2), methotrexate (n = 6), and mycophenolate mofetil (n = 10). RESULTS Patients in the RTX group showed an increase in FVC at 2 years (mean ± SD of FVC: 80.60 ± 21.21 vs 86.90 ± 20.56 at baseline vs 2 years, respectively, p = 0.041 compared to baseline). In sharp contrast, patients in the control group had no change in FVC during the first 2 years of follow-up. At the 7 year time point the remaining patients in the RTX group (n = 5) had higher FVC compared to baseline (mean ± SD of FVC: 91.60 ± 14.81, p = 0.158 compared to baseline) in contrast to patients in the control group (n = 9) where FVC deteriorated (p < 0.01, compared to baseline). Direct comparison between the 2 groups showed a significant benefit for the RTX group in FVC (p = 0.013). Improvement of skin thickening was found in both the RTX and the standard treatment group; however, direct comparison between groups strongly favored RTX at all-time points. Adverse events were comparable between groups. CONCLUSIONS Our data indicate that RTX has a beneficial effect on lung function and skin fibrosis in patients with SSc. Randomized controlled studies are highly needed.
Collapse
Affiliation(s)
- Dimitrios Daoussis
- Division of Rheumatology, Department of Internal Medicine, Patras University Hospital, University of Patras Medical School, 26504 Rion, Patras, Greece.
| | - Konstantinos Melissaropoulos
- Division of Rheumatology, Department of Internal Medicine, Patras University Hospital, University of Patras Medical School, 26504 Rion, Patras, Greece
| | | | - Ioannis Antonopoulos
- Division of Rheumatology, Department of Internal Medicine, Patras University Hospital, University of Patras Medical School, 26504 Rion, Patras, Greece
| | - Theodora E Markatseli
- Department of Rheumatology, Ioannina University Hospital, University of Ioannina Medical School, Ioannina, Greece
| | - Theodora Simopoulou
- Department of Rheumatology, Larissa University Hospital, University of Thessaly Medical School, Larissa, Greece
| | | | - Andrew P Andonopoulos
- Division of Rheumatology, Department of Internal Medicine, Patras University Hospital, University of Patras Medical School, 26504 Rion, Patras, Greece
| | - Alexandros A Drosos
- Department of Rheumatology, Ioannina University Hospital, University of Ioannina Medical School, Ioannina, Greece
| | - Lazaros Sakkas
- Department of Rheumatology, Larissa University Hospital, University of Thessaly Medical School, Larissa, Greece
| | - Stamatis-Nick Liossis
- Division of Rheumatology, Department of Internal Medicine, Patras University Hospital, University of Patras Medical School, 26504 Rion, Patras, Greece
| |
Collapse
|
40
|
Zulian F, Balzarin M, Birolo C. Recent advances in the management of juvenile systemic sclerosis. Expert Rev Clin Immunol 2016; 13:361-369. [DOI: 10.1080/1744666x.2017.1243467] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Francesco Zulian
- Pediatric Rheumatology Unit, Department for Woman and Child Health, University of Padua, Padua, Italy
| | - Marta Balzarin
- Pediatric Rheumatology Unit, Department for Woman and Child Health, University of Padua, Padua, Italy
| | - Carolina Birolo
- Pediatric Rheumatology Unit, Department for Woman and Child Health, University of Padua, Padua, Italy
| |
Collapse
|
41
|
Cutolo M, Damjanov N, Ruaro B, Zekovic A, Smith V. Imaging of connective tissue diseases: Beyond visceral organ imaging? Best Pract Res Clin Rheumatol 2016; 30:670-687. [DOI: 10.1016/j.berh.2016.10.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2016] [Revised: 10/10/2016] [Accepted: 10/11/2016] [Indexed: 10/20/2022]
|
42
|
Daoussis D, Tsamandas A, Antonopoulos I, Filippopoulou A, Papachristou DJ, Papachristou NI, Andonopoulos AP, Liossis SN. B cell depletion therapy upregulates Dkk-1 skin expression in patients with systemic sclerosis: association with enhanced resolution of skin fibrosis. Arthritis Res Ther 2016; 18:118. [PMID: 27208972 PMCID: PMC4875588 DOI: 10.1186/s13075-016-1017-y] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2015] [Accepted: 05/11/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Rituximab (RTX) may favorably affect skin and lung fibrosis in patients with systemic sclerosis (SSc); however, the underlying molecular mechanisms remain unknown. We aimed to explore the hypothesis that RTX may mediate its antifibrotic effects by regulating the expression of Dickkopf-1 (Dkk-1), an inhibitor of the Wnt pathway. METHODS Fourteen patients with SSc and five healthy subjects were recruited. Dkk-1 expression was immunohistochemically assessed in skin biopsies obtained from 11 patients with SSc (8 treated with RTX and 3 with standard treatment), whereas DKK1 gene expression was assessed in 3 patients prior to and following RTX administration. RESULTS In baseline biopsies obtained from all patients with SSc but not in healthy subjects, Dkk-1 was undetectable in skin fibroblasts. Following RTX treatment, four out of eight patients had obvious upregulation of Dkk-1 skin expression. Similarly, RTX treatment correlated with a significant 4.8-fold upregulation of DKK1 gene expression (p = 0.030). In contrast, TGFβ expression in the upper dermis was significantly attenuated following treatment. Moreover, this decreased expression of TGFβ in the skin was significantly more pronounced in the subgroup of patients with Dkk-1 upregulation. In this subgroup TGFβ was downregulated by 50.88 % in contrast to only 15.98 % in patients who did not have Dkk-1 upregulation (p = 0.022). CONCLUSIONS This is the first study demonstrating a link between B cell depletion and skin Dkk-1 upregulation in patients with SSc. RTX-mediated B cell depletion may mechanistically function via the recently established TGFβ-Dkk-1 axis in improving skin fibrosis.
Collapse
Affiliation(s)
- Dimitrios Daoussis
- Division of Rheumatology, Department of Internal Medicine, Patras University Hospital, University of Patras Medical School, Rion, Patras, 26504, Greece.
| | - Athanassios Tsamandas
- Department of Patholology, Patras University Hospital, University of Patras Medical School, Patras, Greece
| | - Ioannis Antonopoulos
- Division of Rheumatology, Department of Internal Medicine, Patras University Hospital, University of Patras Medical School, Rion, Patras, 26504, Greece
| | - Alexandra Filippopoulou
- Division of Rheumatology, Department of Internal Medicine, Patras University Hospital, University of Patras Medical School, Rion, Patras, 26504, Greece
| | - Dionysios J Papachristou
- Department of Anatomy-Histology-Embryology, Laboratory of Bone and Soft Tissue Studies, University of Patras Medical School, Patras, Greece
| | - Nicholaos I Papachristou
- Department of Anatomy-Histology-Embryology, Laboratory of Bone and Soft Tissue Studies, University of Patras Medical School, Patras, Greece
| | - Andrew P Andonopoulos
- Division of Rheumatology, Department of Internal Medicine, Patras University Hospital, University of Patras Medical School, Rion, Patras, 26504, Greece
| | - Stamatis-Nick Liossis
- Division of Rheumatology, Department of Internal Medicine, Patras University Hospital, University of Patras Medical School, Rion, Patras, 26504, Greece
| |
Collapse
|
43
|
SMITH VANESSA, PIZZORNI CARMEN, RICCIERI VALERIA, DECUMAN SASKIA, BRUSSELLE GUY, DE PAUW MICHEL, DESCHEPPER ELLEN, PIETTE YVES, RUARO BARBARA, SULLI ALBERTO, VANDECASTEELE ELS, MELSENS KARIN, DE KEYSER FILIP, CUTOLO MAURIZIO. Stabilization of Microcirculation in Patients with Early Systemic Sclerosis with Diffuse Skin Involvement following Rituximab Treatment: An Open-label Study. J Rheumatol 2016; 43:995-6. [DOI: 10.3899/jrheum.151018] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
|
44
|
Brady SM, Shapiro L, Mousa SA. Current and future direction in the management of scleroderma. Arch Dermatol Res 2016; 308:461-71. [PMID: 27139430 DOI: 10.1007/s00403-016-1647-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Revised: 02/23/2016] [Accepted: 04/08/2016] [Indexed: 12/19/2022]
Abstract
Scleroderma is a heterogeneous disease with a complex etiology. As more information is gained about the underlying mechanisms and the improved classifications of scleroderma subtypes, treatments can be better personalized. Improving scleroderma patients' early diagnosis before end organ manifestations occur should improve clinical trial design and outcomes. Two recently FDA-approved antifibrotics for idiopathic pulmonary fibrosis may be effective treatments in patients with pulmonary fibrosis secondary to scleroderma after further investigation. The potential impact of Nanobiotechnology in improving the efficacy and safety of existing antifibrotics and immunomodulators might present an exciting new approach in the management of scleroderma.
Collapse
Affiliation(s)
- Sean M Brady
- The Pharmaceutical Research Institute, Albany College of Pharmacy and Health Sciences, 1 Discovery Drive (Room 238), Rensselaer, NY, 12144, USA
| | - Lee Shapiro
- Division of Rheumatology, Steffens Scleroderma Center, Albany Medical College, Albany, NY, USA
| | - Shaker A Mousa
- The Pharmaceutical Research Institute, Albany College of Pharmacy and Health Sciences, 1 Discovery Drive (Room 238), Rensselaer, NY, 12144, USA.
| |
Collapse
|
45
|
Del Papa N, Zaccara E. From mechanisms of action to therapeutic application: A review on current therapeutic approaches and future directions in systemic sclerosis. Best Pract Res Clin Rheumatol 2016; 29:756-69. [PMID: 27107511 DOI: 10.1016/j.berh.2016.02.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2015] [Revised: 02/01/2016] [Indexed: 01/08/2023]
Abstract
Systemic sclerosis (SSc) is one of the most complex connective tissue diseases. Although the pathogenesis of SSc still remains elusive, it is generally accepted that initial vascular injury due to autoimmunity might result in the constitutive activation of fibroblasts and fibrosis. All of these three processes interact and affect one another resulting in a polymorphous spectrum of clinical and pathologic manifestations of SSc. The disease pleomorphism poses numerous difficulties in defining the ideal outcomes to be used in clinical trials. Despite significant progress over the past decades, the clinical management of patients with SSc remains a challenge. Novel therapies are currently being tested in the treatment of SSc and have the potential for modifying the disease process and improving the clinical outcomes. However, the evaluation of the studies is still difficult, due to either the small size of included patients or the different types and phases of the scleroderma disease under scrutiny.
Collapse
Affiliation(s)
- Nicoletta Del Papa
- U.O.C. Day Hospital Reumatologia, Dip. Reumatologia, Ospedale G. Pini, Milan, Italy.
| | - Eleonora Zaccara
- U.O.C. Day Hospital Reumatologia, Dip. Reumatologia, Ospedale G. Pini, Milan, Italy
| |
Collapse
|
46
|
Sanges S, Guerrier T, Launay D, Lefèvre G, Labalette M, Forestier A, Sobanski V, Corli J, Hauspie C, Jendoubi M, Yakoub-Agha I, Hatron PY, Hachulla E, Dubucquoi S. Role of B cells in the pathogenesis of systemic sclerosis. Rev Med Interne 2016; 38:113-124. [PMID: 27020403 DOI: 10.1016/j.revmed.2016.02.016] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Revised: 02/17/2016] [Accepted: 02/27/2016] [Indexed: 12/28/2022]
Abstract
Systemic sclerosis (SSc) is an orphan disease characterized by progressive fibrosis of the skin and internal organs. Aside from vasculopathy and fibrotic processes, its pathogenesis involves an aberrant activation of immune cells, among which B cells seem to play a significant role. Indeed, B cell homeostasis is disturbed during SSc: the memory subset is activated and displays an increased susceptibility to apoptosis, which is responsible for their decreased number. This chronic loss of B cells enhances bone marrow production of the naïve subset that accounts for their increased number in peripheral blood. This permanent activation state can be explained mainly by two mechanisms: a dysregulation of B cell receptor (BCR) signaling, and an overproduction of B cell survival signals, B cell activating factor (BAFF) and a proliferation-inducing ligand (APRIL). These disturbances of B cell homeostasis induce several functional anomalies that participate in the inflammatory and fibrotic events observed during SSc: autoantibody production (some being directly pathogenic); secretion of pro-inflammatory and pro-fibrotic cytokines (interleukin-6); direct cooperation with other SSc-involved cells [fibroblasts, through transforming growth factor-β (TGF-β) signaling, and T cells]. These data justify the evaluation of anti-B cell strategies as therapeutic options for SSc, such as B cell depletion or blockage of B cell survival signaling.
Collapse
Affiliation(s)
- S Sanges
- Université de Lille, U995, Lille Inflammation Research International Center (LIRIC), 59000 Lille, France; Inserm, U995, 59000 Lille, France; CHU de Lille, département de médecine interne et immunologie clinique, 59000 Lille, France; Centre national de référence maladies systémiques et auto-immunes rares (sclérodermie systémique), 59000 Lille, France; FHU Immune-Mediated Inflammatory Diseases and Targeted Therapies, 59000 Lille, France
| | - T Guerrier
- Université de Lille, U995, Lille Inflammation Research International Center (LIRIC), 59000 Lille, France; Inserm, U995, 59000 Lille, France; CHU de Lille, Centre de biologie-pathologie-génétique, institut d'Immunologie, 59000 Lille, France
| | - D Launay
- Université de Lille, U995, Lille Inflammation Research International Center (LIRIC), 59000 Lille, France; Inserm, U995, 59000 Lille, France; CHU de Lille, département de médecine interne et immunologie clinique, 59000 Lille, France; Centre national de référence maladies systémiques et auto-immunes rares (sclérodermie systémique), 59000 Lille, France; FHU Immune-Mediated Inflammatory Diseases and Targeted Therapies, 59000 Lille, France.
| | - G Lefèvre
- Université de Lille, U995, Lille Inflammation Research International Center (LIRIC), 59000 Lille, France; Inserm, U995, 59000 Lille, France; CHU de Lille, département de médecine interne et immunologie clinique, 59000 Lille, France; Centre national de référence maladies systémiques et auto-immunes rares (sclérodermie systémique), 59000 Lille, France; FHU Immune-Mediated Inflammatory Diseases and Targeted Therapies, 59000 Lille, France; CHU de Lille, Centre de biologie-pathologie-génétique, institut d'Immunologie, 59000 Lille, France
| | - M Labalette
- Université de Lille, U995, Lille Inflammation Research International Center (LIRIC), 59000 Lille, France; Inserm, U995, 59000 Lille, France; FHU Immune-Mediated Inflammatory Diseases and Targeted Therapies, 59000 Lille, France; CHU de Lille, Centre de biologie-pathologie-génétique, institut d'Immunologie, 59000 Lille, France
| | - A Forestier
- Université de Lille, U995, Lille Inflammation Research International Center (LIRIC), 59000 Lille, France; Inserm, U995, 59000 Lille, France; CHU de Lille, département de médecine interne et immunologie clinique, 59000 Lille, France; Centre national de référence maladies systémiques et auto-immunes rares (sclérodermie systémique), 59000 Lille, France; FHU Immune-Mediated Inflammatory Diseases and Targeted Therapies, 59000 Lille, France
| | - V Sobanski
- Université de Lille, U995, Lille Inflammation Research International Center (LIRIC), 59000 Lille, France; Inserm, U995, 59000 Lille, France; CHU de Lille, département de médecine interne et immunologie clinique, 59000 Lille, France; Centre national de référence maladies systémiques et auto-immunes rares (sclérodermie systémique), 59000 Lille, France; FHU Immune-Mediated Inflammatory Diseases and Targeted Therapies, 59000 Lille, France
| | - J Corli
- Université de Lille, U995, Lille Inflammation Research International Center (LIRIC), 59000 Lille, France; Inserm, U995, 59000 Lille, France; FHU Immune-Mediated Inflammatory Diseases and Targeted Therapies, 59000 Lille, France; CHU de Lille, département de rhumatologie, 59000 Lille, France
| | - C Hauspie
- Université de Lille, U995, Lille Inflammation Research International Center (LIRIC), 59000 Lille, France; Inserm, U995, 59000 Lille, France; CHU de Lille, Centre de biologie-pathologie-génétique, institut d'Immunologie, 59000 Lille, France
| | - M Jendoubi
- Université de Lille, U995, Lille Inflammation Research International Center (LIRIC), 59000 Lille, France; Inserm, U995, 59000 Lille, France
| | - I Yakoub-Agha
- Université de Lille, U995, Lille Inflammation Research International Center (LIRIC), 59000 Lille, France; Inserm, U995, 59000 Lille, France; FHU Immune-Mediated Inflammatory Diseases and Targeted Therapies, 59000 Lille, France; CHU de Lille, département des maladies du sang, 59000 Lille, France
| | - P-Y Hatron
- Université de Lille, U995, Lille Inflammation Research International Center (LIRIC), 59000 Lille, France; CHU de Lille, département de médecine interne et immunologie clinique, 59000 Lille, France; Centre national de référence maladies systémiques et auto-immunes rares (sclérodermie systémique), 59000 Lille, France; FHU Immune-Mediated Inflammatory Diseases and Targeted Therapies, 59000 Lille, France
| | - E Hachulla
- Université de Lille, U995, Lille Inflammation Research International Center (LIRIC), 59000 Lille, France; Inserm, U995, 59000 Lille, France; CHU de Lille, département de médecine interne et immunologie clinique, 59000 Lille, France; Centre national de référence maladies systémiques et auto-immunes rares (sclérodermie systémique), 59000 Lille, France; FHU Immune-Mediated Inflammatory Diseases and Targeted Therapies, 59000 Lille, France
| | - S Dubucquoi
- Université de Lille, U995, Lille Inflammation Research International Center (LIRIC), 59000 Lille, France; Inserm, U995, 59000 Lille, France; FHU Immune-Mediated Inflammatory Diseases and Targeted Therapies, 59000 Lille, France; CHU de Lille, Centre de biologie-pathologie-génétique, institut d'Immunologie, 59000 Lille, France
| |
Collapse
|
47
|
BONROY CAROLIEN, SMITH VANESSA, DESCHEPPER ELLEN, DE KEYSER FILIP, DEVREESE KATRIEN. Specific Antinuclear Antibody Level Changes after B Cell Depletion Therapy in Systemic Sclerosis Are Associated with Improvement of Skin Thickening. J Rheumatol 2016; 43:247-9. [DOI: 10.3899/jrheum.150105] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
|
48
|
Abstract
The treatment of immune-mediated inflammatory diseases (IMIDs) has dramatically improved over the last two decades by the development of a series of targeted biological therapies. This paper focuses on new developments in the treatment of IMIDs. In particular, we discuss how different ways of targeting the same mediators can lead to different efficacy and safety profiles, using B cell targeting as example. In addition, we discuss the emerging field of 'small molecules' that target specifically intracellular processes related to cytokine signaling, cell activation, cell migration, and other processes relevant to tissue inflammation.
Collapse
|
49
|
Rituximab in the treatment of patients with systemic sclerosis. Our experience and review of the literature. Autoimmun Rev 2015. [DOI: 10.1016/j.autrev.2015.07.008] [Citation(s) in RCA: 114] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
|
50
|
Abstract
Systemic sclerosis (SSc) is a rare autoimmune disease characterized by autoantibody production, small-vessel vasculopathy, and skin and other organ fibrosis. The disease is clinically heterogeneous with most patients having some degree of skin sclerosis with varying organ system involvement. Early disease can be difficult to diagnose, especially with minimal skin sclerosis and absence of anti-nuclear antibody (ANA) positivity; however, studies have demonstrated early diagnosis is important as early treatment could potentially lead to better outcomes. New classification criteria have recently been published that have higher sensitivity for detecting early disease thus allowing for a broader spectrum of patients to be represented in clinical trials. Treatment guidelines have been published based on a limited number of randomized-controlled clinical trials; however, there are ongoing phase II and III clinical trials with novel agents that are promising and will change the treatment landscape over the next decade.
Collapse
Affiliation(s)
- Courtney J McCray
- Division of Rheumatology and Clinical Immunogenetics, Department of Internal Medicine, University of Texas Health Science Center-Houston (UTHSC-H), 6431 Fannin St. MSB 5.278, Houston, TX, 77030, USA
| | | |
Collapse
|