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Correia JA, Crespo J, Alves G, Salvador F, Matos-Costa J, Alves JD, Fortuna J, Almeida I, Campar A, Brandão M, Faria R, Marado D, Oliveira S, Santos L, Silva F, Vasconcelos C, Fernandes M, Marinho A. Biologic therapy in large and small vessels vasculitis, and Behçet's disease: Evidence- and practice-based guidance. Autoimmun Rev 2023:103362. [PMID: 37230310 DOI: 10.1016/j.autrev.2023.103362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 05/21/2023] [Indexed: 05/27/2023]
Abstract
OBJECTIVE Vasculitis are a very heterogenous group of systemic autoimmune diseases, affecting large vessels (LVV), small vessels or presenting as a multisystemic variable vessel vasculitis. We aimed to define evidence and practice-based recommendations for the use of biologics in large and small vessels vasculitis, and Behçet's disease (BD). METHODS Recommendations were made by an independent expert panel, following a comprehensive literature review and two consensus rounds. The panel included 17 internal medicine experts with recognized practice on autoimmune diseases management. The literature review was systematic from 2014 until 2019 and later updated by cross-reference checking and experts' input until 2022. Preliminary recommendations were drafted by working groups for each disease and voted in two rounds, in June and September 2021. Recommendations with at least 75% agreement were approved. RESULTS A total of 32 final recommendations (10 for LVV treatment, 7 for small vessels vasculitis and 15 for BD) were approved by the experts and several biologic drugs were considered with different supporting evidence. Among LVV treatment options, tocilizumab presents the higher level of supporting evidence. Rituximab is recommended for treatment of severe/refractory cryoglobulinemic vasculitis. Infliximab and adalimumab are most recommended in treatment of severe/refractory BD manifestations. Other biologic drugs can be considered is specific presentations. CONCLUSION These evidence and practice-based recommendations are a contribute to treatment decision and may, ultimately, improve the outcome of patients living with these conditions.
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Affiliation(s)
- João Araújo Correia
- Serviço de Medicina Interna, Centro Hospitalar Universitário do Porto, Largo Professor Abel Salazar, 4099-001 Porto, Portugal; Unidade de Imunologia Clínica, Departamento de Medicina, Centro Hospitalar Universitário do Porto, Largo Professor Abel Salazar, 4099-001 Porto, Portugal; UMIB - Unidade Multidisciplinar de Investigação Biomédica, ICBAS - Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, Rua Jorge de Viterbo Ferreira 228, 4050-313 Porto, Portugal
| | - Jorge Crespo
- Serviço de Medicina Interna, Departamento de Medicina, Centro Hospitalar e Universitário de Coimbra, Praceta Professor Mota Pinto, 3004-561 Coimbra, Portugal
| | - Glória Alves
- Serviço de Medicina Interna, Hospital da Senhora da Oliveira, Centro Hospitalar Alto Ave, Rua dos Cutileiros 4810-055, Guimarães, Portugal
| | - Fernando Salvador
- Unidade de Doenças Autoimunes, Serviço de Medicina Interna, Centro Hospitalar de Trás-os-Montes e Alto Douro, Avenida da Noruega, 5000-508 Vila Real, Portugal
| | - João Matos-Costa
- Serviço de Medicina Interna, Hospital Distrital de Santarém, Avenida Bernardo Santareno, 2005-177 Santarém,Portugal
| | - José Delgado Alves
- Systemic Autoimmune Diseases Unit, Hospital Prof. Doutor Fernando Fonseca, IC19 - 2720-276, Amadora, Portugal; 4Immune Response and Vascular Disease Unit - iNOVA4Health, NOVA Medical School; R. Câmara Pestana 6, 1150-082 Lisboa, Portugal
| | - Jorge Fortuna
- Serviço de Medicina Interna, Departamento de Medicina, Centro Hospitalar e Universitário de Coimbra, Praceta Professor Mota Pinto, 3004-561 Coimbra, Portugal
| | - Isabel Almeida
- Unidade de Imunologia Clínica, Departamento de Medicina, Centro Hospitalar Universitário do Porto, Largo Professor Abel Salazar, 4099-001 Porto, Portugal; UMIB - Unidade Multidisciplinar de Investigação Biomédica, ICBAS - Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, Rua Jorge de Viterbo Ferreira 228, 4050-313 Porto, Portugal
| | - Ana Campar
- Unidade de Imunologia Clínica, Departamento de Medicina, Centro Hospitalar Universitário do Porto, Largo Professor Abel Salazar, 4099-001 Porto, Portugal; UMIB - Unidade Multidisciplinar de Investigação Biomédica, ICBAS - Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, Rua Jorge de Viterbo Ferreira 228, 4050-313 Porto, Portugal
| | - Mariana Brandão
- Unidade de Imunologia Clínica, Departamento de Medicina, Centro Hospitalar Universitário do Porto, Largo Professor Abel Salazar, 4099-001 Porto, Portugal; UMIB - Unidade Multidisciplinar de Investigação Biomédica, ICBAS - Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, Rua Jorge de Viterbo Ferreira 228, 4050-313 Porto, Portugal
| | - Raquel Faria
- Unidade de Imunologia Clínica, Departamento de Medicina, Centro Hospitalar Universitário do Porto, Largo Professor Abel Salazar, 4099-001 Porto, Portugal; UMIB - Unidade Multidisciplinar de Investigação Biomédica, ICBAS - Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, Rua Jorge de Viterbo Ferreira 228, 4050-313 Porto, Portugal
| | - Daniela Marado
- Serviço de Medicina Interna, Departamento de Medicina, Centro Hospitalar e Universitário de Coimbra, Praceta Professor Mota Pinto, 3004-561 Coimbra, Portugal
| | - Susana Oliveira
- Systemic Autoimmune Diseases Unit, Hospital Prof. Doutor Fernando Fonseca, IC19 - 2720-276, Amadora, Portugal
| | - Lelita Santos
- Serviço de Medicina Interna, Departamento de Medicina, Centro Hospitalar e Universitário de Coimbra, Praceta Professor Mota Pinto, 3004-561 Coimbra, Portugal; Faculdade de Medicina da Universidade de Coimbra, R. Larga 2, 3000-370 Coimbra, Portugal; CIMAGO, Faculdade de Medicina da Universidade de Coimbra, R. Larga 2, 3000-370 Coimbra, Portugal
| | - Fátima Silva
- Serviço de Medicina Interna, Departamento de Medicina, Centro Hospitalar e Universitário de Coimbra, Praceta Professor Mota Pinto, 3004-561 Coimbra, Portugal
| | - Carlos Vasconcelos
- Unidade de Imunologia Clínica, Departamento de Medicina, Centro Hospitalar Universitário do Porto, Largo Professor Abel Salazar, 4099-001 Porto, Portugal; UMIB - Unidade Multidisciplinar de Investigação Biomédica, ICBAS - Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, Rua Jorge de Viterbo Ferreira 228, 4050-313 Porto, Portugal
| | - Milene Fernandes
- RWE & Late Phase, CTI Clinical Trial & Consulting Services Unipessoal Lda, R. Tierno Galvan, 1250-096 Lisboa, Portugal
| | - António Marinho
- Unidade de Imunologia Clínica, Departamento de Medicina, Centro Hospitalar Universitário do Porto, Largo Professor Abel Salazar, 4099-001 Porto, Portugal; UMIB - Unidade Multidisciplinar de Investigação Biomédica, ICBAS - Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, Rua Jorge de Viterbo Ferreira 228, 4050-313 Porto, Portugal.
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Marinho A, Delgado Alves J, Fortuna J, Faria R, Almeida I, Alves G, Araújo Correia J, Campar A, Brandão M, Crespo J, Marado D, Matos-Costa J, Oliveira S, Salvador F, Santos L, Silva F, Fernandes M, Vasconcelos C. Biological therapy in systemic lupus erythematosus, antiphospholipid syndrome, and Sjögren's syndrome: evidence- and practice-based guidance. Front Immunol 2023; 14:1117699. [PMID: 37138867 PMCID: PMC10150407 DOI: 10.3389/fimmu.2023.1117699] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 03/13/2023] [Indexed: 05/05/2023] Open
Abstract
Systemic lupus erythematosus (SLE), antiphospholipid syndrome (APS), and Sjögren's syndrome (SS) are heterogeneous autoimmune diseases. Severe manifestations and refractory/intolerance to conventional immunosuppressants demand other options, namely biological drugs, and small molecules. We aimed to define evidence and practice-based guidance for the off-label use of biologics in SLE, APS, and SS. Recommendations were made by an independent expert panel, following a comprehensive literature review and two consensus rounds. The panel included 17 internal medicine experts with recognized practice in autoimmune disease management. The literature review was systematic from 2014 until 2019 and later updated by cross-reference checking and experts' input until 2021. Preliminary recommendations were drafted by working groups for each disease. A revision meeting with all experts anticipated the consensus meeting held in June 2021. All experts voted (agree, disagree, neither agree nor disagree) during two rounds, and recommendations with at least 75% agreement were approved. A total of 32 final recommendations (20 for SLE treatment, 5 for APS, and 7 for SS) were approved by the experts. These recommendations consider organ involvement, manifestations, severity, and response to previous treatments. In these three autoimmune diseases, most recommendations refer to rituximab, which aligns with the higher number of studies and clinical experience with this biological agent. Belimumab sequential treatment after rituximab may also be used in severe cases of SLE and SS. Second-line therapy with baricitinib, bortezomib, eculizumab, secukinumab, or tocilizumab can be considered in SLE-specific manifestations. These evidence and practice-based recommendations may support treatment decision and, ultimately, improve the outcome of patients living with SLE, APS, or SS.
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Affiliation(s)
- António Marinho
- Unidade de Imunologia Clínica, Centro Hospitalar Universitário do Porto, Porto, Portugal
- UMIB - Unidade Multidisciplinar de Investigação Biomédica, ICBAS - Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, Porto, Portugal
- *Correspondence: António Marinho,
| | - José Delgado Alves
- Systemic Autoimmune Diseases Unit, Hospital Prof. Doutor Fernando Fonseca, Amadora, Portugal
- Immune Response and Vascular Disease Unit - iNOVA4Health, NOVA Medical School, Lisboa, Portugal
| | - Jorge Fortuna
- Serviço de Medicina Interna, Departamento de Medicina, Centro Hospitalar Universitário de Coimbra, Coimbra, Portugal
| | - Raquel Faria
- Unidade de Imunologia Clínica, Centro Hospitalar Universitário do Porto, Porto, Portugal
- UMIB - Unidade Multidisciplinar de Investigação Biomédica, ICBAS - Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, Porto, Portugal
| | - Isabel Almeida
- Unidade de Imunologia Clínica, Centro Hospitalar Universitário do Porto, Porto, Portugal
- UMIB - Unidade Multidisciplinar de Investigação Biomédica, ICBAS - Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, Porto, Portugal
| | - Glória Alves
- Serviço de Medicina Interna, Hospital da Senhora da Oliveira - Centro Hospitalar Alto Ave, Guimarães, Portugal
| | - João Araújo Correia
- Unidade de Imunologia Clínica, Centro Hospitalar Universitário do Porto, Porto, Portugal
- UMIB - Unidade Multidisciplinar de Investigação Biomédica, ICBAS - Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, Porto, Portugal
- Serviço de Medicina Interna, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Ana Campar
- Unidade de Imunologia Clínica, Centro Hospitalar Universitário do Porto, Porto, Portugal
- UMIB - Unidade Multidisciplinar de Investigação Biomédica, ICBAS - Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, Porto, Portugal
| | - Mariana Brandão
- Unidade de Imunologia Clínica, Centro Hospitalar Universitário do Porto, Porto, Portugal
- UMIB - Unidade Multidisciplinar de Investigação Biomédica, ICBAS - Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, Porto, Portugal
| | - Jorge Crespo
- Serviço de Medicina Interna, Departamento de Medicina, Centro Hospitalar Universitário de Coimbra, Coimbra, Portugal
| | - Daniela Marado
- Serviço de Medicina Interna, Departamento de Medicina, Centro Hospitalar Universitário de Coimbra, Coimbra, Portugal
| | - João Matos-Costa
- Serviço de Medicina Interna, Hospital Distrital de Santarém, Santarém, Portugal
| | - Susana Oliveira
- Systemic Autoimmune Diseases Unit, Hospital Prof. Doutor Fernando Fonseca, Amadora, Portugal
| | - Fernando Salvador
- Unidade de Doenças Autoimunes, Serviço de Medicina Interna, Centro Hospitalar de Trás-os-Montes e Alto Douro, Vila Real, Portugal
| | - Lelita Santos
- Serviço de Medicina Interna, Departamento de Medicina, Centro Hospitalar Universitário de Coimbra, Coimbra, Portugal
- Faculdade de Medicina, Universidade de Coimbra, Coimbra, Portugal
- Linha de Investigação Clínica e Interdisciplinar em Meio Ambiente, Genética e Oncobiologia (CIMAGO), Faculdade de Medicina da Universidade de Coimbra, Coimbra, Portugal
| | - Fátima Silva
- Serviço de Medicina Interna, Departamento de Medicina, Centro Hospitalar Universitário de Coimbra, Coimbra, Portugal
| | - Milene Fernandes
- Real-World Evidence & Late Phase, CTI Clinical Trial & Consulting Services Unipessoal Lda, Lisboa, Portugal
| | - Carlos Vasconcelos
- Unidade de Imunologia Clínica, Centro Hospitalar Universitário do Porto, Porto, Portugal
- UMIB - Unidade Multidisciplinar de Investigação Biomédica, ICBAS - Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, Porto, Portugal
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Abuowda Y, Almeida RS, Oliveira AA, Pego P, Santos C, Matos-Costa J. Treatment of digital ulcers in systemic sclerosis: Case series study of thirteen patients and discussion on outcome. Rev Assoc Med Bras (1992) 2017; 63:422-426. [PMID: 28724039 DOI: 10.1590/1806-9282.63.05.422] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2016] [Accepted: 11/07/2016] [Indexed: 12/19/2022] Open
Abstract
Introduction: In systemic sclerosis (SSc), digital ulcers (DU) are debilitating and recurrent. They are markers of prognosis and are associated with disability and mortality. Treatment strategies have been developed to block the proposed mechanisms of this complication. Objective: Clinical description of a population of SSc patients with DU, treatment, complications and outcome. Method: Analysis of 48 SSc patients meeting 2013 ACR-EULAR criteria, followed between 1999-2015; 13 patients had DU. Treatment protocol applied included cycles of 21 days of alprostadil, which can be repeated in the absence of DU healing. After DU healing, bosentan was initiated. Results: DU healing was achieved with intravenous prostanoid in 12 patients; seven patients required repeated treatment for DU healing. Twelve patients were later treated with bosentan; three of them experienced recurrence of DU, while one was anti-B2-GPI positive. Four patients had soft tissue loss and three other suffered digital amputation, these being late diagnosis. Conclusion: Younger patients and early referrals had better outcomes. Endothelin receptor antagonist toxicity should be monitored, particularly in patients previously exposed to hepatotoxic drugs.
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Affiliation(s)
- Yahia Abuowda
- Clinic of autoimmune diseases, Department of Internal Medicine - III, Hospital Distrital de Santarém, Santarém, Portugal.,NEDAI - Group of Systemic Autoimmune Diseases of the SPMI - Sociedade Portuguesa de Medicina Interna, Lisboa, Portugal
| | - Raquel Sousa Almeida
- Clinic of autoimmune diseases, Department of Internal Medicine - III, Hospital Distrital de Santarém, Santarém, Portugal.,NEDAI - Group of Systemic Autoimmune Diseases of the SPMI - Sociedade Portuguesa de Medicina Interna, Lisboa, Portugal
| | - Ana Alves Oliveira
- Clinic of autoimmune diseases, Department of Internal Medicine - III, Hospital Distrital de Santarém, Santarém, Portugal.,NEDAI - Group of Systemic Autoimmune Diseases of the SPMI - Sociedade Portuguesa de Medicina Interna, Lisboa, Portugal
| | - Petra Pego
- Clinic of autoimmune diseases, Department of Internal Medicine - III, Hospital Distrital de Santarém, Santarém, Portugal.,NEDAI - Group of Systemic Autoimmune Diseases of the SPMI - Sociedade Portuguesa de Medicina Interna, Lisboa, Portugal
| | - Cristina Santos
- Clinic of autoimmune diseases, Department of Internal Medicine - III, Hospital Distrital de Santarém, Santarém, Portugal.,NEDAI - Group of Systemic Autoimmune Diseases of the SPMI - Sociedade Portuguesa de Medicina Interna, Lisboa, Portugal.,DUO Registry Center - The Digital Ulcers Outcome Registry Center D0489, Santarém, Portugal
| | - João Matos-Costa
- Clinic of autoimmune diseases, Department of Internal Medicine - III, Hospital Distrital de Santarém, Santarém, Portugal.,NEDAI - Group of Systemic Autoimmune Diseases of the SPMI - Sociedade Portuguesa de Medicina Interna, Lisboa, Portugal.,DUO Registry Center - The Digital Ulcers Outcome Registry Center D0489, Santarém, Portugal
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Matos-Costa J, Almeida I, Santos L, Delgado Alves J, Pinheiro S, Santos M, Dias C, Serradeiro E, Alves G, Vedes J, Brito H, Ferreira P, Oliveira N, Garcia J, Pinelo E, Ferreira A, Marinho A. AB0605 ridai.org/ssc: The Portuguese National Systemic Sclerosis Registry – Focus on Quality of Life and Data Conformity. Ann Rheum Dis 2016. [DOI: 10.1136/annrheumdis-2016-eular.5783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Matos-Costa J, Pego P, Abuowda Y, Alves Oliveira A, Aguiar-Câmara I, Santos C. AB0500 Treatment of digital ulcers in systemic sclerosis: a review of ten patients from a single center and discussion on outcome. Ann Rheum Dis 2013. [DOI: 10.1136/annrheumdis-2013-eular.2822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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