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Surówka A, Żołnierczuk M, Prowans P, Grabowska M, Kupnicka P, Markowska M, Olejnik-Wojciechowska J, Szlosser Z, Wilk A, Szumilas K, Kędzierska-Kapuza K. The Effects of Chronic Immunosuppressive Treatment on Morphological Changes in Cardiac Tissue and the Balance between Matrix Metalloproteinases (MMP-2 and MMP-9) and Their Inhibitors in the Rat Heart. Int J Mol Sci 2024; 25:4468. [PMID: 38674053 PMCID: PMC11049927 DOI: 10.3390/ijms25084468] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Revised: 04/12/2024] [Accepted: 04/16/2024] [Indexed: 04/28/2024] Open
Abstract
Using different three-drug immunosuppressive treatment regimens in a rat model, we aimed to determine the effects of long-term therapy on metalloproteinase-2 and metalloproteinase-9 activity and the expression of their inhibitors, as well as to assess the morphology of the animals' cardiac tissue. Our results suggest that chronic use of immunosuppressive drugs disrupts the balance between the activity of MMPs and TIMPs. Depending on the type of drug regimen used, this leads to abnormalities in the cardiac structure, collagen fiber accumulation, or cardiomyocyte hypertrophy. The information obtained in the present study allows us to conclude that the chronic treatment of rats with the most common clinical immunosuppressive regimens may contribute to abnormalities in the myocardial structure and function. The results presented in this study may serve as a prelude to more in-depth analyses and additional research into the optimal selection of an immunosuppressive treatment with the lowest possible risk of cardiovascular complications for patients receiving organ transplants.
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Affiliation(s)
- Anna Surówka
- Department of Plastic, Endocrine and General Surgery, Pomeranian Medical University, 72-010 Szczecin, Poland
| | - Michał Żołnierczuk
- Department of Vascular Surgery, General Surgery and Angiology, Pomeranian Medical University, 70-111 Szczecin, Poland
| | - Piotr Prowans
- Department of Plastic, Endocrine and General Surgery, Pomeranian Medical University, 72-010 Szczecin, Poland
| | - Marta Grabowska
- Department of Histology and Developmental Biology, Faculty of Health Sciences, Pomeranian Medical University, 70-111 Szczecin, Poland
| | - Patrycja Kupnicka
- Department of Biochemistry and Medical Chemistry, Pomeranian Medical University, Powstańców Wlkp. 72, 70-111 Szczecin, Poland
| | - Marta Markowska
- Department of Plastic, Endocrine and General Surgery, Pomeranian Medical University, 72-010 Szczecin, Poland
- Department of Plastic and Reconstructive Surgery, 109 Military Hospital, 71-422 Szczecin, Poland
| | | | - Zbigniew Szlosser
- Department of Plastic, Endocrine and General Surgery, Pomeranian Medical University, 72-010 Szczecin, Poland
| | - Aleksandra Wilk
- Department of Histology and Embryology, Pomeranian Medical University, 70-111 Szczecin, Poland;
| | - Kamila Szumilas
- Department of Physiology, Pomeranian Medical University, 70-111 Szczecin, Poland
| | - Karolina Kędzierska-Kapuza
- Department of Gastroenterological Surgery and Transplantology, Centre of Postgraduate Medical Education in Warsaw, 137 Woloska St., 02-507 Warsaw, Poland
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2
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Hirschfield GM, Lohse AW. Treating autoimmune hepatitis - More science, more progress, better therapy. J Hepatol 2024; 80:534-536. [PMID: 38309440 DOI: 10.1016/j.jhep.2024.01.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2024] [Accepted: 01/15/2024] [Indexed: 02/05/2024]
Affiliation(s)
- Gideon M Hirschfield
- Toronto Centre for Liver Disease, Division of Gastroenterology and Hepatology, Toronto General Hospital, Toronto, Canada.
| | - Ansgar W Lohse
- Division of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Wilk A, Król M, Kiełbowski K, Bakinowska E, Szumilas K, Surówka A, Kędzierska-Kapuza K. Immunolocalization of Matrix Metalloproteinases 2 and 9 and Their Inhibitors in the Hearts of Rats Treated with Immunosuppressive Drugs-An Artificial Intelligence-Based Digital Analysis. Biomedicines 2024; 12:769. [PMID: 38672125 PMCID: PMC11048150 DOI: 10.3390/biomedicines12040769] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2024] [Revised: 03/26/2024] [Accepted: 03/28/2024] [Indexed: 04/28/2024] Open
Abstract
BACKGROUND Immunosuppressive agents represent a broad group of drugs, such as calcineurin inhibitors, mTOR inhibitors, and glucocorticosteroids, among others. These drugs are widely used in a number of conditions, but lifelong therapy is crucial in the case of organ recipients to prevent rejection. To further increase the safety and efficacy of these agents, their off-target mechanisms of action, as well as processes underlying the pathogenesis of adverse effects, need to be thoroughly investigated. The aim of this study was to examine the impact of various combinations of cyclosporine/tacrolimus/mycophenolate with rapamycin and steroids (CRG, TRG, MRG), on the morphology and morphometry of rats' cardiomyocytes, together with the presence of cardiac collagen and the immunoexpression of MMPs and TIMPs. METHODS Twenty-four rats were divided into four groups receiving different immunosuppressive regiments. After six months of treatment, the hearts were collected and analyzed. RESULTS Cardiomyocytes from the CRG cohorts demonstrated the most pronounced morphological alterations. In addition, chronic immunosuppression reduced the width and length of cardiac cells. However, immunosuppressive therapy did not alter the presence of cardiac collagen fibers. Nevertheless, we observed significant alterations regarding MMP/TIMP homeostasis. CONCLUSIONS Chronic immunosuppression seems to disturb the MMP/TIMP balance in aspects of immunolocalization in the hearts of rats. Further studies are required to analyze other mechanisms and pathways affected by the use of immunosuppressants.
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Affiliation(s)
- Aleksandra Wilk
- Department of Histology and Embryology, Pomeranian Medical University, 70-111 Szczecin, Poland; (A.W.); (M.K.); (E.B.)
| | - Małgorzata Król
- Department of Histology and Embryology, Pomeranian Medical University, 70-111 Szczecin, Poland; (A.W.); (M.K.); (E.B.)
| | - Kajetan Kiełbowski
- Department of Histology and Embryology, Pomeranian Medical University, 70-111 Szczecin, Poland; (A.W.); (M.K.); (E.B.)
| | - Estera Bakinowska
- Department of Histology and Embryology, Pomeranian Medical University, 70-111 Szczecin, Poland; (A.W.); (M.K.); (E.B.)
| | - Kamila Szumilas
- Department of Physiology, Pomeranian Medical University, 70-111 Szczecin, Poland;
| | - Anna Surówka
- Department of Plastic, Endocrine and General Surgery, Pomeranian Medical University, 72-010 Szczecin, Poland;
| | - Karolina Kędzierska-Kapuza
- Department of Gastroenterological Surgery and Transplantology, Center of Postgraduate Medical Education in Warsaw, 137 Wołoska St., 02-507 Warsaw, Poland;
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Herman D, Ghazipura M, Barnes H, Macrea M, Knight SL, Silver RM, Montesi SB, Raghu G, Hossain T. Nintedanib Therapy Alone and Combined with Mycophenolate in Patients with Systemic Sclerosis-associated Interstitial Lung Disease: Systematic Reviews and Meta-analysis. Ann Am Thorac Soc 2024; 21:474-485. [PMID: 37773000 DOI: 10.1513/annalsats.202301-081oc] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Accepted: 07/18/2023] [Indexed: 09/30/2023] Open
Abstract
Background: The American Thoracic Society convened an international multidisciplinary panel to develop clinical practice guidelines for the treatment of systemic sclerosis-associated interstitial lung disease (SSc-ILD). Objective: To conduct a systematic review and evaluate the literature to determine whether patients with SSc-ILD should be treated with nintedanib alone or with the combination of nintedanib plus mycophenolate. Data Sources: Literature searches were conducted across MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials databases through June 2022 for studies using nintedanib or nintedanib plus mycophenolate to treat patients with SSc-ILD. Data Extraction: Mortality, disease progression, quality of life, and adverse event data were extracted, and meta-analysis was performed when possible. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) Working Group method was used to assess the quality of evidence. Synthesis: For nintedanib therapy alone, the systematic review included three total studies and revealed that disease progression was less in the nintedanib arm (the annual rate of decline in forced vital capacity [FVC] was 44.5 ml less, the absolute change from baseline was 46.4 ml less, and FVC% predicted was 1.2% less in the nintedanib arm) compared with placebo. However, gastrointestinal side effects and treatment discontinuation were double in the nintedanib arm compared with placebo. For combination therapy, the systematic review also included three total studies and revealed that changes in the annual rate of decline in FVC favored combination therapy over placebo (mean difference, 79.1 ml). Combination therapy was, however, associated with increased gastrointestinal adverse effects compared with placebo. The quality of evidence for all outcomes was very low as per GRADE. Conclusions: The use of nintedanib alone and in combination with mycophenolate in patients with SSc-ILD is associated with a significant reduction in disease progression compared with placebo but at the cost of increased gastrointestinal side effects and treatment discontinuation. The quality of evidence is very low.
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Affiliation(s)
- Derrick Herman
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, The Ohio State Wexner Medical Center, Columbus, Ohio
| | - Marya Ghazipura
- ZS Associates, Global Health Economics and Outcomes Research, New York, New York
- Division of Epidemiology and
- Division of Biostatistics, Department of Population Health and
| | - Hayley Barnes
- Central Clinical School and
- Centre for Occupational and Environmental Health, Monash University, Melbourne, Australia
- Department of Respiratory Medicine, Alfred Hospital, Melbourne, Australia
| | - Madalina Macrea
- Division of Pulmonary and Sleep Medicine, Salem Veterans Affairs Medical Center, Salem, Virginia
- Department of Medicine, University of Virginia, Charlottesville, Virginia
| | - Shandra L Knight
- Strauss Health Sciences Library, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Richard M Silver
- Division of Rheumatology and Immunology, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Sydney B Montesi
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, Massachusetts; and
| | - Ganesh Raghu
- Center for Interstitial Lung Diseases, Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, and
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington
| | - Tanzib Hossain
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, New York University Grossman School of Medicine, New York University Langone Health, New York, New York
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Chong KM, Jiang H, Lo EAG, Hong WZ, Wong ETY, Chan GC, Cho J. Therapeutic Drug Monitoring in Patients with Systemic Lupus Erythematosus: Utility and Gaps. J Clin Med 2024; 13:451. [PMID: 38256585 PMCID: PMC10816431 DOI: 10.3390/jcm13020451] [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: 11/27/2023] [Revised: 01/09/2024] [Accepted: 01/12/2024] [Indexed: 01/24/2024] Open
Abstract
Despite advances in the treatment of patients with systemic lupus erythematous (SLE), outcomes have remained suboptimal. Persistent disease activity, patient comorbidities and drug toxicities contribute to the accrual of progressive irreversible damage and high rates of morbidity and mortality. Currently, similar drug doses and regimens are promulgated in the treatment guidelines for all SLE patients, despite the vast differences in patient and environmental factors that affect the drugs' metabolism and blood concentrations. This causes a disconnect between drug dosing and drug blood concentrations, which can then result in unpredictability in drug toxicities and therapeutic effects. In this review, we discuss commonly used oral immunosuppressive medications in SLE, their pharmacogenomics, and factors affecting their metabolism and blood concentrations. Further, we highlight the role of therapeutic drug monitoring in SLE, which is the first accessible step to individualising therapy.
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Affiliation(s)
- Kar Mun Chong
- Division of Rheumatology, Department of Medicine, National University Hospital, Singapore 119074, Singapore;
| | - He Jiang
- Department of Pharmacy, National University Hospital, Singapore 119074, Singapore; (H.J.); (E.A.G.L.)
| | - Elaine Ah Gi Lo
- Department of Pharmacy, National University Hospital, Singapore 119074, Singapore; (H.J.); (E.A.G.L.)
| | - Wei-Zhen Hong
- Division of Nephrology, Department of Medicine, National University Hospital, Singapore 119074, Singapore; (W.-Z.H.); (E.T.-Y.W.); (G.C.C.)
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore
| | - Emmett Tsz-Yeung Wong
- Division of Nephrology, Department of Medicine, National University Hospital, Singapore 119074, Singapore; (W.-Z.H.); (E.T.-Y.W.); (G.C.C.)
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore
- National University Centre for Organ Transplantation, National University Hospital, Singapore 119074, Singapore
| | - Gek Cher Chan
- Division of Nephrology, Department of Medicine, National University Hospital, Singapore 119074, Singapore; (W.-Z.H.); (E.T.-Y.W.); (G.C.C.)
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore
| | - Jiacai Cho
- Division of Rheumatology, Department of Medicine, National University Hospital, Singapore 119074, Singapore;
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore
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Finocchietti M, Marino ML, Rosa AC, Bellini A, Masiero L, Cardillo M, Massari M, Spila Alegiani S, Pierobon S, Ferroni E, Zanforlini M, Leoni O, Ledda S, Garau D, Davoli M, Addis A, Belleudi V. Immunosuppression with Generics in Liver and Kidney Transplantation: A Real-World Evidence Study. Drug Des Devel Ther 2024; 18:53-69. [PMID: 38229916 PMCID: PMC10790661 DOI: 10.2147/dddt.s431121] [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] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 12/22/2023] [Indexed: 01/18/2024] Open
Abstract
Purpose This study evaluates the use, benefit-risk profile, and economic impact of generic immunosuppressants (tacrolimus-TAC, cyclosporine-CsA, and mycophenolate-MYC) in kidney and liver transplant recipients compared to brand-name drugs. Patients and Methods A retrospective multicentre observational study, involving four Italian regions, was conducted based on the national transplant Information system and regional healthcare claims data. The analysis focused on incident patients who received kidney and liver transplants between 2013 and 2019 and evaluated the use of generic of CsA, TAC, and MYC during the 30-day period following discharge. For each type of transplant and immunosuppressive agent, the benefit-risk profile of generic vs branded drugs in a two-year window was estimated by multivariate Cox models (HR; 95% CI). Furthermore, the potential cost savings per person associated with one year of treatment using generics were calculated. Results The utilization of generic drugs showed a significant increase; over the study years, the proportion of users among kidney recipients ranged from 14.2% to 40.5% for TAC, from 36.9% to 56.7% for MYC, and from 18.2% to 94.7% for CsA. A great variability in generic uptake for region was found. A comparable risk-benefit profile between generic and branded formulations was shown for all immunosuppressors considered. Choosing generic immunosuppressants during maintenance could result in yearly savings of around 2000 euros per person for each therapy ingredient. Conclusion The study shows an increasing proportion of patients using generic immunosuppressive drugs over time suggesting a growing acceptance of generics within the transplant community and reveals comparable risk-benefit profiles between the generic and branded formulations of TAC, CsA, and MYC. A significant variability in the use of generics immunosuppressive agents was found both at the regional level and among transplant centers and future research should delve into regional prescribing variations.
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Affiliation(s)
- Marco Finocchietti
- Department of Epidemiology, Lazio Regional Health Service-ASL Roma 1, Rome, Italy
| | - Maria Lucia Marino
- Department of Epidemiology, Lazio Regional Health Service-ASL Roma 1, Rome, Italy
| | - Alessandro C Rosa
- Department of Epidemiology, Lazio Regional Health Service-ASL Roma 1, Rome, Italy
| | - Arianna Bellini
- Department of Epidemiology, Lazio Regional Health Service-ASL Roma 1, Rome, Italy
| | - Lucia Masiero
- Italian National Transplant Center, Istituto Superiore di Sanità, Rome, Italy
| | - Massimo Cardillo
- Italian National Transplant Center, Istituto Superiore di Sanità, Rome, Italy
| | - Marco Massari
- National Center for Drug Research and Evaluation, Istituto Superiore Di Sanità, Rome, Italy
| | | | | | | | - Martina Zanforlini
- The innovation and procurement regional company, A.R.I.A. S.p.A.-Lombardy Region, Milan, Italy
| | - Olivia Leoni
- Regional Epidemiological Observatory, Lombardy Region, Milan, Italy
| | - Stefano Ledda
- General Directorate for Health, Sardinia Region, Cagliari, Italy
| | - Donatella Garau
- General Directorate for Health, Sardinia Region, Cagliari, Italy
| | - Marina Davoli
- Department of Epidemiology, Lazio Regional Health Service-ASL Roma 1, Rome, Italy
| | - Antonio Addis
- Department of Epidemiology, Lazio Regional Health Service-ASL Roma 1, Rome, Italy
| | - Valeria Belleudi
- Department of Epidemiology, Lazio Regional Health Service-ASL Roma 1, Rome, Italy
| | - On behalf of CESIT Study Group
- Department of Epidemiology, Lazio Regional Health Service-ASL Roma 1, Rome, Italy
- Italian National Transplant Center, Istituto Superiore di Sanità, Rome, Italy
- National Center for Drug Research and Evaluation, Istituto Superiore Di Sanità, Rome, Italy
- Azienda Zero, Veneto Region, Padua, Italy
- The innovation and procurement regional company, A.R.I.A. S.p.A.-Lombardy Region, Milan, Italy
- Regional Epidemiological Observatory, Lombardy Region, Milan, Italy
- General Directorate for Health, Sardinia Region, Cagliari, Italy
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Gaur S, Paul PP, Motamarri M. Rituximab/ Mycophenolate Combination Therapy in Children with Calcineurin Inhibitor-Resistant FSGS. Indian J Nephrol 2024; 34:45-49. [PMID: 38645919 PMCID: PMC11003586 DOI: 10.4103/ijn.ijn_231_22] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 09/26/2022] [Indexed: 04/23/2024] Open
Abstract
Introduction There is a paucity of data and therapeutic options nationally and internationally on calcineurin inhibitor (CNI)-resistant forms of focal segmental glomerulosclerosis (FSGS) in children. CNI (tacrolimus or cyclosporine) are proven monotherapy in children with FSGS with a steroid-dependent (SD) or steroid-resistant (SR) course. We analyzed a novel therapeutic option in CNI-resistant FSGS by using the dual therapy of rituximab and mycophenolate to maintain remission. Methods This is a retrospective analysis of clinical, therapeutic profile, and treatment outcomes (sustained remission versus no remission) in subjects with CNI-resistant FSGS who received dual rituximab therapy along with mycophenolate as maintenance therapy for a minimum of 1 year. Results The median age of presentation of 13 recruited children was 7.8 years (range: 2.4-17.6 years); nine (69.2%) were males. Ten (76.9%) of them had an SD course and three (23.1%) had an SR course. Four (30.7%) had evidence of acute/chronic CNI toxicity, and the remaining nine (69.3%) showed no response to CNI therapy despite adequate trough levels. Post dual therapy, 11 (84.6%) had sustained remission for at 1 year and two (15.4%) children did not show remission. None reported adverse reactions or infections, and all had preserved renal functions. Conclusion Dual combination therapy with rituximab and mycophenolate among children with CNI-resistant FSGS can emerge as a promising and efficacious treatment strategy to ensure sustained remission in this subset of patients.
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Affiliation(s)
- Saumil Gaur
- Consultant Paediatrician and Transplant Nephrologist, Rainbow Children Hospital, Marathahalli, Bangalore, Karnataka, India
| | - Partha P. Paul
- Department of Paediatric Nephrology, Rainbow Children Hospital, Marathahalli, Bangalore, Karnataka, India
| | - Mounika Motamarri
- Department of Paediatric Nephrology, Rainbow Children Hospital, Marathahalli, Bangalore, Karnataka, India
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Arnalich-Montiel F. Systemic treatment and surgical intervention in inflammatory Terrien disease. Taiwan J Ophthalmol 2024; 14:108-111. [PMID: 38655002 PMCID: PMC11034679 DOI: 10.4103/tjo.tjo-d-23-00176] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 01/10/2024] [Indexed: 04/26/2024] Open
Abstract
This case report presents a unique instance of a 55-year-old male patient exhibiting features of both Terrien marginal degeneration (TMD) and Fuchs' superficial marginal keratitis. Characterized by peripheral corneal thinning vascularization, and a pseudopterygium, the patient experienced recurrent photophobia, redness, and tearing over 15 years. This case challenges the traditional distinction between TMD and Fuchs' superficial marginal keratitis, suggesting a potential common underlying disorder. Mycophenolate mofetil provided a partial response, while pseudopterygium removal led to sustained remission, emphasizing its therapeutic significance. This case highlights the first documented use of mycophenolate in TMD and supports the notion of shared vasculitic origins between TMD and Fuchs' keratitis, raising intriguing questions about targeted therapeutic interventions.
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Herman D, Ghazipura M, Barnes H, Macrea M, Knight SL, Silver RM, Montesi SB, Raghu G, Hossain T. Mycophenolate in Patients with Systemic Sclerosis-associated Interstitial Lung Disease: A Systematic Review and Meta-Analysis. Ann Am Thorac Soc 2024; 21:136-150. [PMID: 37027538 DOI: 10.1513/annalsats.202301-054oc] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Accepted: 04/07/2023] [Indexed: 04/09/2023] Open
Abstract
Rationale: The American Thoracic Society convened an international, multidisciplinary panel to develop clinical practice guidelines for the treatment of systemic sclerosis-associated interstitial lung disease (SSc-ILD). Objective: To conduct a systematic review and evaluate the literature to determine whether patients with SSc-ILD should be treated with mycophenolate. Methods: A literature search was conducted across the MEDLINE, EMBASE, and CENTRAL databases through June 2022 for studies using mycophenolate to treat patients with SSc-ILD. Mortality, disease progression, quality of life, and adverse event data were extracted, and meta-analyses were performed when possible. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) Working Group method was used to assess the quality of evidence. Results: The literature review resulted in seven studies fitting the inclusion criteria. The systematic review and meta-analyses revealed changes in forced vital capacity % predicted (mean difference [MD], 5.4%; 95% confidence interval [95% CI]: 3.3%, 7.5%), diffusing capacity of the lung for carbon monoxide % predicted (MD, 4.64%; 95% CI: 0.54%, 8.74%), and breathlessness score (MD, 1.99; 95% CI: 0.36, 3.62) favored mycophenolate over placebo. The risk of anemia (relative risk [RR], 2.3; 95% CI: 1.2, 71.4) was higher with mycophenolate. There were no significant differences between mycophenolate and cyclophosphamide, except risk of premature discontinuation (RR, 0.6; 95% CI: 0.4, 0.9), and leukopenia (RR, 0.1; 95% CI: 0.05, 0.4) favored mycophenolate. The quality of evidence was moderate to very low per GRADE. Conclusions: Mycophenolate use in patients with SSc-ILD is associated with statistically significant improvements in disease progression and quality-of-life measures compared with placebo. There were no differences in mortality, disease progression, or quality of life compared with cyclophosphamide, but there were fewer adverse events. The quality of evidence is very low.
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Affiliation(s)
- Derrick Herman
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, The Ohio State University, Columbus, Ohio
| | - Marya Ghazipura
- ZS Associates, Global Health Economics and Outcomes Research, New York, New York
- Division of Epidemiology and
- Division of Biostatistics, Department of Population Health, and
| | - Hayley Barnes
- Central Clinical School and
- Centre for Occupational and Environmental Health, Monash University, Melbourne, Australia
- Department of Respiratory Medicine, Alfred Hospital, Melbourne, Australia
| | - Madalina Macrea
- Division of Pulmonary and Sleep Medicine, Salem Veterans Affairs Medical Center, Salem, Virginia
- Department of Medicine, University of Virginia, Charlottesville, Virginia
| | - Shandra L Knight
- Strauss Health Sciences Library, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Richard M Silver
- Division of Rheumatology and Immunology, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Sydney B Montesi
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, Massachusetts; and
| | - Ganesh Raghu
- Center for Interstitial Lung Diseases, Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine and
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington
| | - Tanzib Hossain
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, New York University Grossman School of Medicine, New York University Langone Health, New York, New York
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Padiyar S, Danda D, Goel R, Joseph E, Nair AM, Joseph G, Antonisamy B. Clinical and angiographic outcomes of mycophenolate versus methotrexate in South Asian patients of Takayasu arteritis: Results from an open-label, outcome-assessor blinded randomized controlled trial. Mod Rheumatol 2023; 34:175-181. [PMID: 36542822 DOI: 10.1093/mr/roac157] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 11/30/2022] [Accepted: 12/15/2022] [Indexed: 12/24/2023]
Abstract
OBJECTIVE To compare the clinical and angiographic responses of mycophenolate mofetil (MMF) versus methotrexate (MTX) in Takayasu arteritis (TAK). METHODS This was an open-label, outcome assessor-blinded trial. Adult patients with active TAK were randomized 1:1 to MMF 1 g twice daily or MTX 20 mg once weekly by a computer-generated program. All patients were started on 0.5 mg/kg of steroids with a predetermined tapering protocol. The primary outcome was the treatment response as defined by Indian Takayasu arteritis score at 9 months. The secondary end points included the time to first failure and angiographic progression. RESULTS A total of 52 patients (26 in each arm) were recruited. The rate of responders was 71.43% (15/21) in the MMF arm and 63.64% (14/22) in the MTX arm (P = .58). The median time to the first failure was 9 months (range: 3-9) and 4.5 months (range: 3-9) in the MMF and MTX arms, respectively (P = .052). In both groups, 15% of patients (n = 3) had a progressive disease in angiography. CONCLUSIONS The results showed numerically better outcomes favouring MMF, with a longer time to the first failure than MTX (9 months versus 4.5 months, P = .052). No significant difference was seen in the angiographic outcomes.
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Affiliation(s)
- Shivraj Padiyar
- Department of Clinical Immunology and Rheumatology, Christian Medical College, Vellore, India
| | - Debashish Danda
- Department of Clinical Immunology and Rheumatology, Christian Medical College, Vellore, India
| | - Ruchika Goel
- Department of Clinical Immunology and Rheumatology, Christian Medical College, Vellore, India
| | - Elizabeth Joseph
- Department of Radiology, Christian Medical College, Vellore, India
| | - Aswin M Nair
- Department of Clinical Immunology and Rheumatology, Christian Medical College, Vellore, India
| | - George Joseph
- Department of Cardiology, Christian Medical College, Vellore, India
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11
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Deshpande PV. Minimal Change Nephrotic Syndrome in a Child with Systemic Lupus Erythematosus. Indian J Nephrol 2023; 33:381-383. [PMID: 37881740 PMCID: PMC10593289 DOI: 10.4103/ijn.ijn_113_22] [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: 03/28/2022] [Revised: 05/08/2022] [Accepted: 05/13/2022] [Indexed: 10/27/2023] Open
Abstract
Renal involvement in systemic lupus erythematosus (SLE) is well known. We present a 16-year-old boy, who was in remission on treatment for SLE for the past three years and now presented with nephrotic syndrome. The kidney biopsy was normal with the immunofluorescence revealing no deposits. He went into remission by day 9 of treatment and completed the course of treatment with prednisolone alone with no relapses. The clinical picture along with the histology and autoimmune markers for SLE indicate that he developed minimal change nephrotic syndrome that was responsive to prednisolone. It is important to be aware that minimal change nephrotic syndrome can occur in a patient as part of lupus podocytopathy and heavy immunosuppression may be unwarranted.
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Affiliation(s)
- Pankaj V. Deshpande
- Consultant, Pediatric Nephrology Department, Hinduja Hospital, Mumbai, Maharashtra, India
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12
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Chen HW, Sprow G, Feng R, Werth VP, Chong BF. Cigarette smoking is associated with decreased long-term treatment cessation of mycophenolate mofetil and methotrexate in cutaneous lupus erythematosus. Lupus 2023; 32:1134-1137. [PMID: 37328162 PMCID: PMC10527208 DOI: 10.1177/09612033231183500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Affiliation(s)
- Henry W. Chen
- University of Texas Southwestern Medical Center, Department of Dermatology, Dallas, TX
| | - Grant Sprow
- University of Pennsylvania, Department of Dermatology, Philadelphia, PA
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA
| | - Rui Feng
- University of Pennsylvania, Department of Biostatistics, Philadelphia, PA
| | - Victoria P. Werth
- University of Pennsylvania, Department of Dermatology, Philadelphia, PA
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA
| | - Benjamin F. Chong
- University of Texas Southwestern Medical Center, Department of Dermatology, Dallas, TX
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13
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Rizzi M, Tonello S, Brinno C, Zecca E, Matino E, Cittone M, Rizzi E, Casciaro GF, D’Onghia D, Colangelo D, Minisini R, Bellan M, Castello LM, Chiocchetti A, Pirisi M, Rigamonti C, Lilleri D, Zavaglio F, Bergami F, Sola D, Sainaghi PP. SARS-CoV-2 infection risk is higher in vaccinated patients with inflammatory autoimmune diseases or liver transplantation treated with mycophenolate due to an impaired antiviral immune response: results of the extended follow up of the RIVALSA prospective cohort. Front Immunol 2023; 14:1185278. [PMID: 37545528 PMCID: PMC10398576 DOI: 10.3389/fimmu.2023.1185278] [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] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 07/07/2023] [Indexed: 08/08/2023] Open
Abstract
Background A relevant proportion of immunocompromised patients did not reach a detectable seroconversion after a full primary vaccination cycle against SARS-CoV-2. The effect of different immunosuppressants and the potential risks for SARS-CoV-2 infection in these subjects is largely unknown. Methods Patients from the Rivalsa prospective, observational cohort study with planned anti SARS-CoV-2 third dose mRNA vaccination between October and December 2021 were asked to participate to this follow-up study. Patients were asked about eventual confirmed positivity to SARS-CoV-2 infection within 6 months from the third dose and to undergo a blood draw to evaluate seroconversion status after the additional vaccine shot. Results 19 out of 114 patients taking part in the survey developed a confirmed SARS-CoV-2 infection; we identified mycophenolate treatment as an independent predictor of an increased risk of infection even after the third vaccine dose (OR: 5.20, 95% CI: 1.70-20.00, p=0.0053). This result is in agreement with the in vitro evidence that MMF impairs both B and T lymphocytes driven immune responses (reduction both in memory B cells producing anti-spike antibodies and in proliferating CD4+ and CD8+ T cells). Conclusions Immunocompromised patients need an additional vaccine administration to reach a detectable seroconversion, thus fostering a more personalized approach to their clinical management. Moreover, patients undergoing mycophenolate treatment show a specific increased infection risk, with respect to other immunosuppressants thus supporting a closer monitoring of their health status.
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Affiliation(s)
- Manuela Rizzi
- Department of Health Sciences, Università del Piemonte Orientale, Novara, Italy
| | - Stelvio Tonello
- Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy
- CAAD, Center for Autoimmune and Allergic Diseases, and IRCAD (Interdisciplinary Research Center of Autoimmune Diseases), Università del Piemonte Orientale (UPO), Novara, Italy
| | - Cristiana Brinno
- Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy
| | - Erika Zecca
- Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy
- Department of Internal Medicine and COVID-19 Unit, AOU “Maggiore della Carità”, Novara, Italy
- Division of Emergency Medicine and COVID-19 sub-intensive unit, AOU “Maggiore della Carità”, Novara, Italy
| | - Erica Matino
- Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy
- Department of Internal Medicine and COVID-19 Unit, AOU “Maggiore della Carità”, Novara, Italy
- Division of Emergency Medicine and COVID-19 sub-intensive unit, AOU “Maggiore della Carità”, Novara, Italy
| | - Micol Cittone
- Internal Medicine and Rheumatology Unit, AOU “Maggiore della Carità”, Novara, Italy
| | - Eleonora Rizzi
- Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy
- Department of Internal Medicine and COVID-19 Unit, AOU “Maggiore della Carità”, Novara, Italy
- Division of Emergency Medicine and COVID-19 sub-intensive unit, AOU “Maggiore della Carità”, Novara, Italy
| | - Giuseppe Francesco Casciaro
- Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy
- Department of Internal Medicine and COVID-19 Unit, AOU “Maggiore della Carità”, Novara, Italy
- Division of Emergency Medicine and COVID-19 sub-intensive unit, AOU “Maggiore della Carità”, Novara, Italy
| | - Davide D’Onghia
- Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy
| | - Donato Colangelo
- Department of Health Sciences, Università del Piemonte Orientale, Novara, Italy
| | - Rosalba Minisini
- Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy
| | - Mattia Bellan
- Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy
- CAAD, Center for Autoimmune and Allergic Diseases, and IRCAD (Interdisciplinary Research Center of Autoimmune Diseases), Università del Piemonte Orientale (UPO), Novara, Italy
- Department of Internal Medicine and COVID-19 Unit, AOU “Maggiore della Carità”, Novara, Italy
- Division of Emergency Medicine and COVID-19 sub-intensive unit, AOU “Maggiore della Carità”, Novara, Italy
- Internal Medicine and Rheumatology Unit, AOU “Maggiore della Carità”, Novara, Italy
| | - Luigi Mario Castello
- Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy
- Division of Internal Medicine, Azienda Ospedaliera “SS. Antonio e Biagio e Cesare Arrigo”, Alessandria, Italy
| | - Annalisa Chiocchetti
- Department of Health Sciences, Università del Piemonte Orientale, Novara, Italy
- CAAD, Center for Autoimmune and Allergic Diseases, and IRCAD (Interdisciplinary Research Center of Autoimmune Diseases), Università del Piemonte Orientale (UPO), Novara, Italy
| | - Mario Pirisi
- Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy
- CAAD, Center for Autoimmune and Allergic Diseases, and IRCAD (Interdisciplinary Research Center of Autoimmune Diseases), Università del Piemonte Orientale (UPO), Novara, Italy
- Department of Internal Medicine and COVID-19 Unit, AOU “Maggiore della Carità”, Novara, Italy
- Division of Emergency Medicine and COVID-19 sub-intensive unit, AOU “Maggiore della Carità”, Novara, Italy
- Internal Medicine and Rheumatology Unit, AOU “Maggiore della Carità”, Novara, Italy
| | - Cristina Rigamonti
- Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy
- Internal Medicine and Rheumatology Unit, AOU “Maggiore della Carità”, Novara, Italy
| | - Daniele Lilleri
- Unit of Microbiology and Virology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Federica Zavaglio
- Unit of Microbiology and Virology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Federica Bergami
- Unit of Microbiology and Virology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Daniele Sola
- Internal Medicine and Rheumatology Unit, AOU “Maggiore della Carità”, Novara, Italy
| | - Pier Paolo Sainaghi
- Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy
- CAAD, Center for Autoimmune and Allergic Diseases, and IRCAD (Interdisciplinary Research Center of Autoimmune Diseases), Università del Piemonte Orientale (UPO), Novara, Italy
- Department of Internal Medicine and COVID-19 Unit, AOU “Maggiore della Carità”, Novara, Italy
- Division of Emergency Medicine and COVID-19 sub-intensive unit, AOU “Maggiore della Carità”, Novara, Italy
- Internal Medicine and Rheumatology Unit, AOU “Maggiore della Carità”, Novara, Italy
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14
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Williams J, Lacy A, Ranpariya VK, Pichardo RO. Treatment Patterns for Hydroxychloroquine, Methotrexate, and Mycophenolate Mofetil in Lichen Planopilaris: A Retrospective Chart Review. J Cutan Med Surg 2023; 27:403-405. [PMID: 37559372 DOI: 10.1177/12034754231188323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/11/2023]
Affiliation(s)
- Josiah Williams
- Department of Dermatology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Alexa Lacy
- Department of Dermatology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Varun K Ranpariya
- Department of Dermatology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Rita O Pichardo
- Department of Dermatology, Wake Forest School of Medicine, Winston-Salem, NC, USA
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15
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Bordin DS, Livzan MA, Gaus OV, Mozgovoi SI, Lanas A. Drug-Associated Gastropathy: Diagnostic Criteria. Diagnostics (Basel) 2023; 13:2220. [PMID: 37443618 DOI: 10.3390/diagnostics13132220] [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: 02/28/2023] [Revised: 05/30/2023] [Accepted: 06/27/2023] [Indexed: 07/15/2023] Open
Abstract
Drugs are widely used to treat different diseases in modern medicine, but they are often associated with adverse events. Those located in the gastrointestinal tract are common and often mild, but they can be serious or life-threatening and determine the continuation of treatment. The stomach is often affected not only by drugs taken orally but also by those administered parenterally. Here, we review the mechanisms of damage, risk factors and specific endoscopic, histopathological and clinical features of those drugs more often involved in gastric damage, namely NSAIDs, aspirin, anticoagulants, glucocorticosteroids, anticancer drugs, oral iron preparations and proton pump inhibitors. NSAID- and aspirin-associated forms of gastric damage are widely studied and have specific features, although they are often hidden by the coexistence of Helicobacter pylori infection. However, the damaging effect of anticoagulants and corticosteroids or oral iron therapy on the gastric mucosa is controversial. At the same time, the increased use of new antineoplastic drugs, such as checkpoint inhibitors, has opened up a new area of gastrointestinal damage that will be seen more frequently in the near future. We conclude that there is a need to expand and understand drug-induced gastrointestinal damage to prevent and recognize drug-associated gastropathy in a timely manner.
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Affiliation(s)
- Dmitry S Bordin
- A.S. Loginov Moscow Clinical Scientific Center, Department of Pancreatic, Biliary and Upper Digestive Tract Disorders, 111123 Moscow, Russia
- Department of Propaedeutic of Internal Diseases and Gastroenterology, A.I. Yevdokimov Moscow State University of Medicine and Dentistry, 127473 Moscow, Russia
- Department of Outpatient Therapy and Family Medicine, Tver State Medical University, 170100 Tver, Russia
| | - Maria A Livzan
- Department of Faculty Therapy and Gastroenterology, Omsk Sate Medical University, 644099 Omsk, Russia
| | - Olga V Gaus
- Department of Faculty Therapy and Gastroenterology, Omsk Sate Medical University, 644099 Omsk, Russia
| | - Sergei I Mozgovoi
- Department of Pathological Anatomy, Omsk Sate Medical University, 644099 Omsk, Russia
| | - Angel Lanas
- Digestive Diseases Service, Aragón Health Research Institute (IIS Aragón), University Clinic Hospital, University of Zaragoza, 50009 Zaragoza, Spain
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16
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Dobrowolski C, McGinley J, Fazzari M, Su J, Bingham KS, Anderson N, Ruttan L, Beaton DE, Wither JE, Tartaglia MC, Kakvan M, Bonilla D, Choi MY, Fritzler MJ, Diaz Martinez JP, Katz P, Green R, Putterman C, Touma Z. Association of mycophenolate and azathioprine use with cognitive function in systemic lupus. Rheumatology (Oxford) 2023; 62:1860-1869. [PMID: 36135792 PMCID: PMC10152298 DOI: 10.1093/rheumatology/keac540] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 08/26/2022] [Accepted: 09/14/2022] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Cognitive dysfunction (CD) is a common manifestation of SLE that can have detrimental consequences for those affected. To date, no treatments have been approved for SLE-CD. This study aims to assess the association of azathioprine (AZA) and mycophenolate (MMF) use with SLE-CD, given that these medications have demonstrated neuroprotective qualities in prior studies. METHODS Consecutive adult SLE patients presenting to a single healthcare center were considered for participation. The ACR neuropsychological battery for SLE was administered to consenting patients at 0, 6 and 12 months. Scores were compared with age- and sex-matched controls. Primary outcome was CD, defined as a z-score ≤-1.5 in two or more cognitive domains. Mixed-effects logistic regression models were constructed to estimate the odds of CD with respect to AZA and MMF use. RESULTS A total of 300 participants representing 676 patient visits completed the study; 114 (38%) met criteria for CD at baseline. The cumulative AZA dose (g/kg) was associated with reduced odds of CD [odds ratio (OR) 0.76 (95% CI 0.58, 0.98), P = 0.04]. Years of AZA treatment was also associated with reduced odds of CD [OR 0.72 (95% CI 0.54, 0.97), P = 0.03]. MMF use was not associated with CD. CONCLUSION AZA use was associated with significantly lower odds of SLE-CD, while MMF use was not. Additional studies are warranted to further investigate the relationship of AZA and SLE-CD.
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Affiliation(s)
- Chrisanna Dobrowolski
- Division of Rheumatology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - John McGinley
- Department of Neurology, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Melissa Fazzari
- Department of Epidemiology and Population Health and Department of Obstetrics and Gynecology and Women's Health, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Jiandong Su
- University of Toronto Lupus Clinic, Centre for Prognosis Studies in Rheumatic Diseases, Toronto Western Hospital, Toronto, ON, Canada
| | - Kathleen S Bingham
- Centre for Mental Health, University Health Network; Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Nicole Anderson
- University of Toronto Lupus Clinic, Centre for Prognosis Studies in Rheumatic Diseases, Toronto Western Hospital, Toronto, ON, Canada
| | - Lesley Ruttan
- University Health Network-Toronto Rehabilitation Institute, Toronto, ON, Canada
| | - Dorcas E Beaton
- Institute for Work and Health, University of Toronto, Toronto, ON, Canada
| | - Joan E Wither
- University of Toronto Lupus Clinic, Centre for Prognosis Studies in Rheumatic Diseases, Toronto Western Hospital, Toronto, ON, Canada
| | | | - Mahta Kakvan
- University of Toronto Lupus Clinic, Centre for Prognosis Studies in Rheumatic Diseases, Toronto Western Hospital, Toronto, ON, Canada
| | - Dennisse Bonilla
- University of Toronto Lupus Clinic, Centre for Prognosis Studies in Rheumatic Diseases, Toronto Western Hospital, Toronto, ON, Canada
| | - May Y Choi
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Marvin J Fritzler
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Juan Pablo Diaz Martinez
- University of Toronto Lupus Clinic, Centre for Prognosis Studies in Rheumatic Diseases, Toronto Western Hospital, Toronto, ON, Canada
| | - Patricia Katz
- University of California, San Francisco, Novato, CA, USA
| | - Robin Green
- University Health Network-Toronto Rehabilitation Institute, Toronto, ON, Canada
| | - Chaim Putterman
- Department of Microbiology and Immunology, Albert Einstein School of Medicine, Bronx, NY, USA
- Division of Rheumatology, Albert Einstein College of Medicine, Bronx, NY, USA
- Azrieli School of Medicine, Safed, Israel
- Galillee Medical Center, Nahariya, Israel
| | - Zahi Touma
- University of Toronto Lupus Clinic, Centre for Prognosis Studies in Rheumatic Diseases, Toronto Western Hospital, Toronto, ON, Canada
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17
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Weng J, Levy NA, Abbott HY, Mix JA, Wills RW, Mackin AJ, Thomason JM, Cridge H. Retrospective analysis of immunosuppressive and anti-thrombotic protocols in nonassociative immune mediated hemolytic anemia in dogs. J Vet Intern Med 2023; 37:528-536. [PMID: 36809664 PMCID: PMC10061171 DOI: 10.1111/jvim.16652] [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: 04/06/2022] [Accepted: 02/01/2023] [Indexed: 02/24/2023] Open
Abstract
BACKGROUND Evidence supporting the effectiveness of therapeutic protocols for nonassociative immune-mediated hemolytic anemia (na-IMHA) is weak. HYPOTHESIS/OBJECTIVES Investigate the efficacy of various drugs in na-IMHA. ANIMALS Two hundred forty-two dogs. METHODS Multi-institutional retrospective study (2015-2020). Immunosuppressive effectiveness was determined by time to packed cell volume (PCV) stabilization and duration of hospitalization through analysis by mixed model linear regression. Occurrence of disease relapse, death, and antithrombotic effectiveness, were analyzed using mixed model logistic regression. RESULTS Use of corticosteroids vs a multi-agent protocol had no effect on time to PCV stabilization (P = .55), duration of hospitalization (P = .13), or case fatality (P = .06). A higher rate of relapse (P = .04; odds ratio: 3.97; 95% confidence interval [CI]: 1.06-14.8) was detected in dogs receiving corticosteroids (11.3%) during follow-up (median: 28.5 days, range: 0-1631 days) compared to multiple agents (3.1%) during follow up (median: 47.0 days, range: 0-1992 days). When comparing drug protocols, there was no effect on time to PCV stabilization (P = .31), relapse (P = .44), or case fatality (P = .08). Duration of hospitalization was longer, by 1.8 days (95% CI: 0.39-3.28 days), for the corticosteroid with mycophenolate mofetil group (P = .01) compared to corticosteroids alone. Use of clopidogrel vs multiple agents had no effect on development of thromboses (P ≥ .36). CONCLUSIONS AND CLINICAL IMPORTANCE Addition of a second immunosuppressive agent did not alter immediate outcome measures but might be associated with a reduction in relapse. Use of multiple antithrombotic agents did not reduce incidence of thrombosis.
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Affiliation(s)
- Jennifer Weng
- Department of Small Animal Clinical Sciences, College of Veterinary Medicine, Michigan State University, East Lansing, Michigan 48824, USA
| | - Nyssa A Levy
- Department of Small Animal Clinical Sciences, College of Veterinary Medicine, Michigan State University, East Lansing, Michigan 48824, USA
| | - Haley Y Abbott
- Department of Small Animal Clinical Sciences, College of Veterinary Medicine, Michigan State University, East Lansing, Michigan 48824, USA
| | - Jose A Mix
- Department of Small Animal Clinical Sciences, College of Veterinary Medicine, Michigan State University, East Lansing, Michigan 48824, USA
| | - Robert W Wills
- Department of Pathobiology and Population Medicine, College of Veterinary Medicine, Mississippi State University, Mississippi State, Mississippi 39762, USA
| | - Andrew J Mackin
- Department of Clinical Sciences, College of Veterinary Medicine, Mississippi State University, Mississippi State, Mississippi 39762, USA
| | - John M Thomason
- Department of Clinical Sciences, College of Veterinary Medicine, Mississippi State University, Mississippi State, Mississippi 39762, USA
| | - Harry Cridge
- Department of Small Animal Clinical Sciences, College of Veterinary Medicine, Michigan State University, East Lansing, Michigan 48824, USA
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18
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Das S, Sinha D, Ghosal A, Purkayastha S. A case of central nervous system vasculitis secondary to rheumatoid arthritis treated successfully with mycophenolate. Mod Rheumatol Case Rep 2023; 7:130-133. [PMID: 35537857 DOI: 10.1093/mrcr/rxac042] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 04/03/2022] [Accepted: 04/30/2022] [Indexed: 04/30/2023]
Abstract
Here, we report a case of central nervous system vasculitis in rheumatoid arthritis (RA) treated successfully with corticosteroid and mycophenolate. A 53-year-old female with poorly controlled RA presented with unilateral lower motor neurone type seventh cranial nerve palsy. Magnetic resonance imaging (MRI) of the brain revealed bilateral signal intensity changes in posterior fossa, basal ganglia, and periventricular white matter with contrast enhancement. Rheumatoid factor, anti-cyclic citrullinated peptides, and C-reactive protein were high. Cerebrospinal fluid analysis showed pleocytosis with elevated protein. Digital subtraction angiography of the brain revealed a beading pattern in distal branches of anterior, middle, and posterior cerebral arteries bilaterally suggestive of central nervous system vasculitis. We treated the patient with intravenous methylprednisolone followed by oral prednisolone tapered off in 6 months. Mycophenolate mofetil was started at the dose of 2 g per day, along with prednisolone. Sulfasalazine and hydroxychloroquine were also started to treat her arthritis. The patient showed complete neurological improvement, along with a significant resolution of the lesions in MRI.
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Affiliation(s)
- Shyamashis Das
- Department of Rheumatology, Institute of Neurosciences Kolkata, Kolkata, West Bengal, India
| | - Debanjali Sinha
- Department of Rheumatology, Institute of Neurosciences Kolkata, Kolkata, West Bengal, India
| | - Anirban Ghosal
- Department of Neurology, Institute of Neurosciences Kolkata, Kolkata, West Bengal, India
| | - Sukalyan Purkayastha
- Department of Interventional Neuro-Radiology, Institute of Neurosciences Kolkata, Kolkata, West Bengal, India
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19
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Griffin C, Peterson CJ, Parmar K, Nichols J. Disseminated coccidioidomycosis in a patient on mycophenolate. Proc AMIA Symp 2023; 36:261-262. [PMID: 36876268 PMCID: PMC9980540 DOI: 10.1080/08998280.2022.2150494] [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] [Indexed: 12/12/2022] Open
Abstract
Disseminated coccidioidomycosis is a rare but serious complication of fungal illness, with immunocompromised patients more susceptible to severe illness. Here we report a unique case of disseminated coccidioidomycosis in a patient on mycophenolate for treatment of polymyositis.
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Affiliation(s)
- Chase Griffin
- School of Medicine, Texas Tech University Health Sciences Center, Lubbock, Texas
| | | | - Kanak Parmar
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, Texas
| | - Jacob Nichols
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, Texas
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20
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Anand P, Schneeweiss S, Mostaghimi A, Schneeweiss MC. Longitudinal utilization of systemic immunomodulators before and after dupilumab approval in children with atopic dermatitis. Pediatr Dermatol 2023; 40:132-134. [PMID: 36403606 PMCID: PMC9868069 DOI: 10.1111/pde.15172] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 10/16/2022] [Indexed: 11/22/2022]
Abstract
In our cohort study, we sought to describe the utilization patterns of systemic immunomodulators in children with atopic dermatitis (AD) and how utilization changed after approval of dupilumab, the first systemic drug approved for the treatment of AD. Using US nationwide claims data, we identified children with AD who initiated a systemic therapy (dupilumab, cyclosporine, methotrexate, azathioprine, and mycophenolate mofetil) from March 2015 to February 2021 and used Sankey plots to describe patterns of starting, switching, and discontinuing these drugs. Dupilumab use among children increased from 19.4% before approval in children to 88.3% after approval in 2019-20. Adherence to dupilumab may suggest better tolerance and improved outcomes in children with AD.
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Affiliation(s)
- Priyanka Anand
- Division of Pharmacoepidemiology, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Sebastian Schneeweiss
- Division of Pharmacoepidemiology, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Arash Mostaghimi
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Dermatology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Maria C Schneeweiss
- Division of Pharmacoepidemiology, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Dermatology, Brigham and Women's Hospital, Boston, Massachusetts, USA
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21
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Anand P, Schneeweiss S, Mostaghimi A, Schneeweiss MC. Use patterns of systemic immunomodulators in the United States before and after dupilumab approval in adults with atopic dermatitis. Pharmacoepidemiol Drug Saf 2022; 32:567-576. [PMID: 36527432 PMCID: PMC10073264 DOI: 10.1002/pds.5586] [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: 08/02/2022] [Revised: 11/09/2022] [Accepted: 12/10/2022] [Indexed: 12/23/2022]
Abstract
PURPOSE The patterns of dupilumab use, the first systemic drug approved for the treatment of atopic dermatitis (AD), is not well understood in the context of off-label systemic medications. OBJECTIVE To describe patterns of prescribing, switching and discontinuing systemic AD drugs, before and after the approval of dupilumab and understand variables associated with dupilumab prescription. METHODS Using longitudinal claims data, we identified patients with AD who initiated a systemic therapy (dupilumab, cyclosporine, methotrexate, azathioprine, mycophenolate) from March 2015 to February 2021, with a washout period of 1 year. We used Sankey plots to visualize longitudinal patterns of use at 3, 6, and 12 months and logistic regression to determine associates of dupilumab prescription. RESULTS The number of patients starting systemic treatment increased from 319 before dupilumab approval to 1358 after. Dupilumab use increased from 72% to 84%. In 2019-2020, 36% of patients discontinued systemic treatment within a year compared to 62% in 2015-2016. 92% of patients who started dupilumab in 2020-2021 had received no other systemic treatment before. Patients <60 years and those who used steroid-sparing topical treatments were more likely to receive dupilumab. CONCLUSION Among new users of a systemic treatment for AD, dupilumab was most used treatment by far.
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Affiliation(s)
- Priyanka Anand
- Division of Pharmacoepidemiology, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Sebastian Schneeweiss
- Division of Pharmacoepidemiology, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA.,Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Arash Mostaghimi
- Harvard Medical School, Boston, Massachusetts, USA.,Department of Dermatology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Maria C Schneeweiss
- Division of Pharmacoepidemiology, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA.,Department of Dermatology, Brigham and Women's Hospital, Boston, Massachusetts, USA
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22
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Matson SM, Baqir M, Moua T, Marll M, Kent J, Iannazzo NS, Boente RD, Donatelli JM, Dai J, Diaz FJ, Demoruelle MK, Hamblin MB, Mathai SK, Ryu JH, Pope K, Walker CM, Lee JS. Treatment Outcomes for Rheumatoid Arthritis-Associated Interstitial Lung Disease: A Real-World, Multisite Study of the Impact of Immunosuppression on Pulmonary Function Trajectory. Chest 2022; 163:861-869. [PMID: 36470416 PMCID: PMC10107057 DOI: 10.1016/j.chest.2022.11.035] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 11/04/2022] [Accepted: 11/18/2022] [Indexed: 12/08/2022] Open
Abstract
BACKGROUND Rheumatoid arthritis (RA)-associated interstitial lung disease (ILD) is common in patients with RA and leads to significant morbidity and mortality. No randomized, placebo-controlled data are available that support the role of immunosuppression to treat RA-associated ILD, despite being widely used in clinical practice. RESEARCH QUESTION How does immunosuppression impact pulmonary function trajectory in a multisite retrospective cohort of patients with RA-associated ILD? STUDY DESIGN AND METHODS Patients with RA who started treatment for ILD with mycophenolate, azathioprine, or rituximab were identified retrospectively from five ILD centers. Change in lung function before and after treatment was analyzed using a linear spline mixed-effect model with random intercept. Prespecified secondary analyses examined the impact of radiologic pattern of ILD (ie, usual interstitial pneumonia [UIP] vs non-UIP) on treatment trajectory. RESULTS Two hundred twelve patients were included in the analysis: 92 patients (43.4%) were treated with azathioprine, 77 patients (36.3%) were treated with mycophenolate mofetil, and 43 patients (20.3%) were treated with rituximab. In the combined analysis of all three agents, an improvement in FVC % predicted was found after 12 months of treatment compared with the potential 12-month response without treatment (+3.90%; P ≤ .001; 95% CI, 1.95-5.84). Diffusing capacity of the lungs for carbon monoxide (Dlco) % predicted also improved at 12 months (+4.53%; P ≤ .001; 95% CI, 2.12-6.94). Neither the UIP pattern of ILD nor choice of immunosuppressive agent significantly impacted the pulmonary function trajectory on immunosuppression. INTERPRETATION Immunosuppression was associated with an improved trajectory in FVC and Dlco compared with the pretreatment pulmonary function trajectory. Prospective, randomized trials are required to validate these findings.
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Affiliation(s)
- Scott M Matson
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Kansas Medical Center, Kansas City, KS.
| | - Misbah Baqir
- Division of Pulmonary, Critical Care Medicine, Mayo Clinic, Rochester, MN
| | - Teng Moua
- Division of Pulmonary, Critical Care Medicine, Mayo Clinic, Rochester, MN
| | - Michael Marll
- Department of Medicine, University of Colorado School of Medicine, Aurora, CO
| | - Jessica Kent
- Department of Internal Medicine, Baylor University Medical Center, Dallas, TX
| | - Nicholas S Iannazzo
- Department of Pulmonary, Critical Care, Sleep and Occupational Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Ryan D Boente
- Department of Pulmonary, Critical Care, Sleep and Occupational Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - John M Donatelli
- Department of Radiology and Imaging Sciences, Indiana University School of Medicine, Indianapolis, IN
| | - Junqiang Dai
- Department of Biostatistics and Data Science, University of Kansas Medical Center, Kansas City, KS
| | - Francisco J Diaz
- Department of Biostatistics and Data Science, University of Kansas Medical Center, Kansas City, KS
| | | | - Mark B Hamblin
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Kansas Medical Center, Kansas City, KS
| | - Susan K Mathai
- Center for Advanced Heart and Lung Disease and Baylor Scott & White Research Institute, Baylor University Medical Center, Dallas, TX
| | - Jay H Ryu
- Division of Pulmonary, Critical Care Medicine, Mayo Clinic, Rochester, MN
| | - Kristen Pope
- Department of Radiology, University of Kansas Medical Center, Kansas City, KS
| | | | - Joyce S Lee
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado School of Medicine, Aurora, CO
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23
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Helmstädter M, Schierle S, Isigkeit L, Proschak E, Marschner JA, Merk D. Activity Screening of Fatty Acid Mimetic Drugs Identified Nuclear Receptor Agonists. Int J Mol Sci 2022; 23:ijms231710070. [PMID: 36077469 PMCID: PMC9456086 DOI: 10.3390/ijms231710070] [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] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 08/30/2022] [Accepted: 08/31/2022] [Indexed: 11/16/2022] Open
Abstract
Fatty acid mimetics (FAM) are bioactive molecules acting through the binding sites of endogenous fatty acid metabolites on enzymes, transporters, and receptors. Due to the special characteristics of these binding sites, FAMs share common chemical features. Pharmacological modulation of fatty acid signaling has therapeutic potential in multiple pathologies, and several FAMs have been developed as drugs. We aimed to elucidate the promiscuity of FAM drugs on lipid-activated transcription factors and tested 64 approved compounds for activation of RAR, PPARs, VDR, LXR, FXR, and RXR. The activity screening revealed nuclear receptor agonism of several FAM drugs and considerable promiscuity of NSAIDs, while other compound classes evolved as selective. These screening results were not anticipated by three well-established target prediction tools, suggesting that FAMs are underrepresented in bioactivity data for model development. The screening dataset may therefore valuably contribute to such tools. Oxaprozin (RXR), tianeptine (PPARδ), mycophenolic acid (RAR), and bortezomib (RAR) exhibited selective agonism on one nuclear receptor and emerged as attractive leads for the selective optimization of side activities. Additionally, their nuclear receptor agonism may contribute relevant and valuable polypharmacology.
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Affiliation(s)
- Moritz Helmstädter
- Institute of Pharmaceutical Chemistry, Goethe University Frankfurt, 60438 Frankfurt, Germany
| | - Simone Schierle
- Institute of Pharmaceutical Chemistry, Goethe University Frankfurt, 60438 Frankfurt, Germany
| | - Laura Isigkeit
- Institute of Pharmaceutical Chemistry, Goethe University Frankfurt, 60438 Frankfurt, Germany
| | - Ewgenij Proschak
- Institute of Pharmaceutical Chemistry, Goethe University Frankfurt, 60438 Frankfurt, Germany
| | | | - Daniel Merk
- Institute of Pharmaceutical Chemistry, Goethe University Frankfurt, 60438 Frankfurt, Germany
- Department of Pharmacy, Ludwig-Maximilians-Universität München, 81377 Munich, Germany
- Correspondence:
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24
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Zecca E, Rizzi M, Tonello S, Matino E, Costanzo M, Rizzi E, Casciaro GF, Manfredi GF, Acquaviva A, Gagliardi I, Calzaducca E, Mallela VR, D'Onghia D, Minisini R, Bellan M, Castello LM, Gavelli F, Avanzi GC, Patrucco F, Chiocchetti A, Pirisi M, Rigamonti C, Lilleri D, Sola D, Sainaghi PP. Ongoing Mycophenolate Treatment Impairs Anti-SARS-CoV-2 Vaccination Response in Patients Affected by Chronic Inflammatory Autoimmune Diseases or Liver Transplantation Recipients: Results of the RIVALSA Prospective Cohort. Viruses 2022; 14. [PMID: 36016388 DOI: 10.3390/v14081766] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 07/21/2022] [Accepted: 08/09/2022] [Indexed: 11/16/2022] Open
Abstract
Vaccines are the most effective means to prevent the potentially deadly effects of SARS-CoV-2 infection, but not all vaccinated individuals gain the same degree of protection. Patients undergoing chronic immunosuppressive therapy due to autoimmune diseases or liver transplants, for example, may show impaired anti-SARS-CoV-2 antibody response after vaccination. We performed a prospective observational study with parallel arms, aiming to (a) evaluate seroconversion after anti-SARS-CoV-2 mRNA vaccine administration in different subgroups of patients receiving immunosuppressive treatment for rheumatological or autoimmune diseases or to prevent organ rejection after liver transplantation and (b) identify negative predictors of IgG anti-SARS-CoV-2 development. Out of 437 eligible patients, 183 individuals were enrolled at the Rheumatology and Hepatology Tertiary Units of “Maggiore della Carità” University Hospital in Novara: of those, 52 were healthy subjects, while among the remaining 131 patients, 30 had a diagnosis of spondyloarthritis, 25 had autoimmune hepatitis, 10 were liver transplantation recipients, 23 suffered from connective tissue diseases (including 10 cases that overlapped with other diseases), 40 were treated for rheumatoid arthritis, and 5 had vasculitis. Moreover, all patients were receiving chronic immunosuppressive therapy. The immunogenicity of mRNA COVID-19 vaccines was evaluated by measuring IgG anti-SARS-CoV-2 antibody titers before vaccination and after 10, 30, and 90 days since the first dose administration. Of the selected cohort of patients, 24.0% did not develop any detectable anti-SARS-CoV-2 IgG after a complete mRNA-based two doses primary vaccination cycle. At univariate analysis, independent predictors of an absent antibody response to vaccine were a history of liver transplantation (OR 11.5, 95% CI 2.5−53.7, p = 0.0018), the presence of a comorbid active neoplasia (OR 26.4, 95% CI 2.8−252.4, p = 0.0045), and an ongoing immunosuppressive treatment with mycophenolate (MMF) (OR 14.0, 95% CI 3.6−54.9, p = 0.0002) or with calcineurin inhibitors (OR 17.5, 95% CI 3.1−99.0, p = 0.0012). At multivariate analysis, only treatment with MMF (OR 24.8, 95% CI 5.9−103.2, p < 0.0001) and active neoplasia (OR 33.2, 95% CI 5.4−204.1, p = 0.0002) were independent predictors of seroconversion failure. These findings suggest that MMF dose reduction or suspension may be required to optimize vaccine response in these patients.
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25
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Khan MH, Onyeaghala GC, Rashidi A, Holtan SG, Khoruts A, Israni A, Jacobson PA, Staley C. Fecal β-glucuronidase activity differs between hematopoietic cell and kidney transplantation and a possible mechanism for disparate dose requirements. Gut Microbes 2022; 14:2108279. [PMID: 35921529 PMCID: PMC9351555 DOI: 10.1080/19490976.2022.2108279] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
The intestinal microbiota produces β-glucuronidase that plays an essential role in the metabolism of the immunosuppressant mycophenolate mofetil (MMF). This drug is commonly used in organ and hematopoietic cell transplantation (HCT), with variations in dosing across transplant types. We hypothesized that β-glucuronidase activity differs between transplant types, which may account for differences in dosing requirements. We evaluated fecal β-glucuronidase activity in patients receiving MMF post-allogeneic HCT and post-kidney transplant. Kidney transplant patients had significantly greater β-glucuronidase activity (8.48 ± 6.21 nmol/hr/g) than HCT patients (3.50 ± 3.29 nmol/hr/g; P = .001). Microbially mediated β-glucuronidase activity may be a critical determinant in the amount of mycophenolate entering the systemic circulation and an important factor to consider for precision dosing of MMF.
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Affiliation(s)
- Mohammad Haneef Khan
- Department of Surgery, University of Minnesota Medical School, Minneapolis, MN, United States
| | | | - Armin Rashidi
- Hematology, Oncology, and Transplantation, University of Minnesota Medical School, Minneapolis, MN, United States
| | - Shernan G. Holtan
- Hematology, Oncology, and Transplantation, University of Minnesota Medical School, Minneapolis, MN, United States
| | - Alexander Khoruts
- Gastroenterology, Department of Medicine, University of Minnesota Medical School, Minneapolis, MN, United States
| | - Ajay Israni
- Hennepin Healthcare Research Institute, Minneapolis, MN, United States,Nephrology, Department of Medicine, University of Minnesota Medical School, Minneapolis, MN, United States
| | - Pamala A. Jacobson
- Experimental and Clinical Pharmacology, University of Minnesota College of Pharmacy, Minneapolis, MN, United States
| | - Christopher Staley
- Department of Surgery, University of Minnesota Medical School, Minneapolis, MN, United States,CONTACT Christopher Staley 420 Delaware St, SE, MMC 195, Minneapolis, Minnesota55455, United States
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26
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Chocair PR, Neves PDMDM, Mohrbacher S, Neto MP, Sato VAH, Oliveira ÉS, Barbosa LV, Bales AM, da Silva FP, Cuvello-Neto AL, Duley JA. Case Report: Azathioprine: An Old and Wronged Immunosuppressant. Front Immunol 2022; 13:903012. [PMID: 35757730 PMCID: PMC9226564 DOI: 10.3389/fimmu.2022.903012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 05/12/2022] [Indexed: 12/02/2022] Open
Abstract
Mycophenolate rapidly substituted azathioprine (AZA) in transplant immunosuppression regimens since the 1990s, when early clinical trials indicated better outcomes, although opposite results were also observed. However, none of these trials used the well-established optimization methods for AZA dosing, namely, thiopurine methyltransferase pharmacogenetics combined with monitoring of the thiopurine metabolites 6-thioguanine nucleotides (6-TGN) and 6-methylmercaptopurine (6-MMP). Resistance to optimize AZA therapy remains today in transplant therapy, despite the fact that thiopurine metabolite testing is being used by other medical disciplines with evident improvement in clinical results. In a previous analysis, we found that active 6-TGN metabolites were not detectable in about 30% of kidney transplant patients under continuous use of apparently adequate azathioprine dosage, which demonstrates the need to monitor these metabolites for therapeutic optimization. Two of four case studies presented here exemplifies this fact. On the other hand, some patients have toxic 6-TGN levels with a theoretically appropriate dose, as seen in the other two case studies in this presentation, constituting one more important reason to monitor the AZA dose administered by its metabolites. This analysis is not intended to prove the superiority of one immunosuppressant over another, but to draw attention to a fact: there are thousands of patients around the world receiving an inadequate dose of azathioprine and, therefore, with inappropriate immunosuppression. This report is also intended to draw attention, to clinicians using thiopurines, that allopurinol co-therapy with AZA is a useful therapeutic pathway for those patients who do not adequately form active thioguanine metabolites.
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Affiliation(s)
- Pedro R Chocair
- Internal Medicine and Nephrology Service, Hospital Alemão Oswaldo Cruz, Sao Paulo, Brazil
| | | | - Sara Mohrbacher
- Internal Medicine and Nephrology Service, Hospital Alemão Oswaldo Cruz, Sao Paulo, Brazil
| | | | - Victor A H Sato
- Internal Medicine and Nephrology Service, Hospital Alemão Oswaldo Cruz, Sao Paulo, Brazil
| | - Érico S Oliveira
- Internal Medicine and Nephrology Service, Hospital Alemão Oswaldo Cruz, Sao Paulo, Brazil
| | - Leonardo V Barbosa
- Internal Medicine and Nephrology Service, Hospital Alemão Oswaldo Cruz, Sao Paulo, Brazil
| | - Alessandra M Bales
- Internal Medicine and Nephrology Service, Hospital Alemão Oswaldo Cruz, Sao Paulo, Brazil
| | | | - Américo L Cuvello-Neto
- Internal Medicine and Nephrology Service, Hospital Alemão Oswaldo Cruz, Sao Paulo, Brazil
| | - John A Duley
- School of Pharmacy, The University of Queensland, Woolloongabba, QLD, Australia
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27
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Regele F, Heinzel A, Hu K, Raab L, Eskandary F, Faé I, Zelzer S, Böhmig GA, Bond G, Fischer G, Oberbauer R, Reindl-Schwaighofer R. Stopping of Mycophenolic Acid in Kidney Transplant Recipients for 2 Weeks Peri-Vaccination Does Not Increase Response to SARS-CoV-2 Vaccination-A Non-randomized, Controlled Pilot Study. Front Med (Lausanne) 2022; 9:914424. [PMID: 35755078 PMCID: PMC9226446 DOI: 10.3389/fmed.2022.914424] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 05/19/2022] [Indexed: 12/29/2022] Open
Abstract
Introduction Kidney transplant recipients (KTR) are at high risk of developing severe COVID-19. However, vaccine response in this population is severely impaired with humoral response rates of 36–54 and 55–69% after two or three doses of SARS-COV-2 vaccines, respectively. Triple immunosuppression and specifically the use of anti-proliferative agents such as mycophenolic acid (MPA) or azathioprine (AZA) have been identified as risk factors for vaccine hypo-responsiveness. Methods We hypothesized that in vaccine non-responders to at least three previous vaccine doses, pausing of MPA or AZA for 1 week before and 1 week after an additional vaccination would improve humoral response rates. We conducted an open-label, non-randomized controlled pilot study including 40 KTR with no detectable humoral response after three or four previous vaccine doses. Primary endpoint was seroconversion following SARS-CoV-2 vaccination. MPA and AZA was paused in 18 patients 1 week before until 1 week after an additional vaccine dose while immunosuppression was continued in 22 patients. Results There was no difference in the humoral response rate between the MPA/AZA pause group and the control group (29 vs. 32%, p > 0.99). Absolute antibody levels were also not statistically significantly different between the two groups (p = 0.716).Renal function in the MPA/AZA pause group remained stable and there was no detection of new onset donor-specific antibodies or an increase of donor-derived cell-free DNA serving as a marker of allograft damage throughout the study period. Conclusion Pausing of MPA/AZA for 2 weeks peri-vaccination did not increase the rate of seroconversion in kidney transplant. However, one in three KTR without humoral immune response to at least three previous vaccinations developed antibodies after an additional vaccine dose supporting continued vaccination in non-responders.
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Affiliation(s)
- Florina Regele
- Division of Nephrology and Dialysis, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Andreas Heinzel
- Division of Nephrology and Dialysis, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Karin Hu
- Division of Nephrology and Dialysis, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Lukas Raab
- Division of Nephrology and Dialysis, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Farsad Eskandary
- Division of Nephrology and Dialysis, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Ingrid Faé
- Department of Blood Group Serology and Transfusion Medicine, Medical University of Vienna, Vienna, Austria
| | - Sieglinde Zelzer
- Clinical Institute of Medical and Chemical Laboratory Diagnostics, Medical University of Graz, Graz, Austria
| | - Georg A Böhmig
- Division of Nephrology and Dialysis, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Gregor Bond
- Division of Nephrology and Dialysis, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Gottfried Fischer
- Department of Blood Group Serology and Transfusion Medicine, Medical University of Vienna, Vienna, Austria
| | - Rainer Oberbauer
- Division of Nephrology and Dialysis, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Roman Reindl-Schwaighofer
- Division of Nephrology and Dialysis, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
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28
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Zhang C, Tam TW, Chau MK, García Córdoba CA, Yung S, Chan TM. Effect of Combined Mycophenolate and Rapamycin Treatment on Kidney Fibrosis in Murine Lupus Nephritis. Front Pharmacol 2022; 13:866077. [PMID: 35571122 PMCID: PMC9095843 DOI: 10.3389/fphar.2022.866077] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Accepted: 03/28/2022] [Indexed: 11/29/2022] Open
Abstract
Background: A significant proportion of lupus nephritis patients develop chronic kidney disease (CKD) and progressive kidney fibrosis, for which there is no specific treatment. We previously reported that mycophenolate or rapamycin monotherapy showed comparable efficacy in suppressing kidney fibrosis in a murine model of lupus nephritis through their direct action on mesangial cells. We extended our study to investigate the effect of combined mycophenolate and rapamycin treatment (MR) on kidney fibrosis in NZBWF1/J mice. Methods: Female NZBWF1/J mice with active nephritis were randomized to receive vehicle or treatment with mycophenolate (50 mg/kg/day) and rapamycin (1.5 mg/kg/day) (MR) for up to 12 weeks, and the effect of treatment on clinical parameters, kidney histology, and fibrotic processes was investigated. Results: Progression of nephritis in untreated mice was accompanied by mesangial proliferation, glomerulosclerosis, tubular atrophy, protein cast formation, increased mTOR and ERK phosphorylation, and induction of TGF-β1, IL-6, α-smooth muscle actin, fibronectin, and collagen expression. Combined MR treatment prolonged survival, improved kidney function, decreased anti-dsDNA antibody level, and ameliorated histopathological changes. The effect of combined MR treatment on kidney histology and function was comparable to that of mycophenolate or rapamycin monotherapy. In vitro studies in human mesangial cells showed that exogenous TGF-β1 and IL-6 both induced mTOR and ERK phosphorylation and downstream fibrotic processes. Both mycophenolic acid and rapamycin inhibited inflammatory and fibrotic processes induced by TGF-β1 or IL-6 by downregulating mTOR and ERK phosphorylation. Conclusions: Our findings indicate that combined mycophenolate and rapamycin, at reduced dose, improves kidney fibrosis in murine lupus nephritis through their distinct effect on mTOR and ERK signaling in mesangial cells.
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Affiliation(s)
- Chenzhu Zhang
- Department of Medicine, The University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Tsz Wai Tam
- Department of Medicine, The University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Mel Km Chau
- Department of Medicine, The University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | | | - Susan Yung
- Department of Medicine, The University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Tak Mao Chan
- Department of Medicine, The University of Hong Kong, Hong Kong, Hong Kong SAR, China
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29
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Mandrik O, Fotheringham J, Ren S, Tice JA, Chapman RH, Stevenson MD, Pearson SD, Herron-Smith S, Agboola F, Thokala P. The Cost-Effectiveness of Belimumab and Voclosporin for Patients with Lupus Nephritis in the United States. Clin J Am Soc Nephrol 2022; 17:385-394. [PMID: 35115304 PMCID: PMC8975035 DOI: 10.2215/cjn.13030921] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [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: 09/30/2021] [Accepted: 01/12/2022] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Despite existing therapies, people with lupus nephritis progress to kidney failure and have reduced life expectancy. Belimumab and voclosporin are two new disease-modifying therapies recently approved for the treatment of lupus nephritis. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS A de novo economic model was developed to estimate the cost-effectiveness of these therapies, including the following health states: "complete response," "partial response," and "active disease" defined by eGFR and proteinuria changes, kidney failure, and death. Short-term data and mean cohort characteristics were sourced from pivotal clinical trials of belimumab (the Belimumab International Study in Lupus Nephritis) and voclosporin (the Aurinia Urinary Protection Reduction Active-Lupus with Voclosporin trial and Aurinia Renal Response in Active Lupus With Voclosporin). Risk of mortality and kidney failure were on the basis of survival modeling using published Kaplan-Meier data. Each drug was compared with the standard of care as represented by the comparator arm in its respective pivotal trial(s) using US health care sector perspective, with a societal perspective also explored. RESULTS In the health care perspective probabilistic analysis, the incremental cost-effectiveness ratio for belimumab compared with its control arm was estimated to be approximately $95,000 per quality-adjusted life year. The corresponding incremental ratio for voclosporin compared with its control arm was approximately $150,000 per quality-adjusted life year. Compared with their respective standard care arms, the probabilities of belimumab and voclosporin being cost effective at a threshold of $150,000 per quality-adjusted life year were 69% and 49%, respectively. Cost-effectiveness was dependent on assumptions made regarding survival in response states, costs and utilities in active disease, and the utilities in response states. In the analysis from a societal perspective, the incremental ratio for belimumab was estimated to be approximately $66,000 per quality-adjusted life year, and the incremental ratio for voclosporin was estimated to be approximately $133,000 per quality-adjusted life year. CONCLUSIONS Compared with their respective standard care arms, belimumab but not voclosporin met willingness-to-pay thresholds of $100,000 per quality-adjusted life year. Despite potential clinical superiority in the informing trials, there remains high uncertainty around the cost-effectiveness of voclosporin.
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Affiliation(s)
- Olena Mandrik
- Health Economic and Decision Science, School of Health and Related Research, The University of Sheffield, Sheffield, United Kingdom
| | - James Fotheringham
- Health Economic and Decision Science, School of Health and Related Research, The University of Sheffield, Sheffield, United Kingdom
| | - Shijie Ren
- Health Economic and Decision Science, School of Health and Related Research, The University of Sheffield, Sheffield, United Kingdom
| | - Jeffrey A. Tice
- Department of Medicine, University of California, San Francisco, California
| | | | - Matthew D. Stevenson
- Health Economic and Decision Science, School of Health and Related Research, The University of Sheffield, Sheffield, United Kingdom
| | | | | | - Foluso Agboola
- Institute for Clinical and Economic Review, Boston, Massachusetts
| | - Praveen Thokala
- Health Economic and Decision Science, School of Health and Related Research, The University of Sheffield, Sheffield, United Kingdom
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Sarayani A, Albogami Y, Thai TN, Smolinski NE, Patel P, Wang Y, Nduaguba S, Rasmussen SA, Winterstein AG. Prenatal exposure to teratogenic medications in the era of Risk Evaluation and Mitigation Strategies. Am J Obstet Gynecol 2022; 227:263.e1-263.e38. [PMID: 35032444 DOI: 10.1016/j.ajog.2022.01.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 01/09/2022] [Accepted: 01/10/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND Prevention of prenatal exposures to teratogenic drugs is a significant clinical and public health concern. With the enactment of the US Food and Drug Administration Amendments Act in 2007, the US Food and Drug Administration has begun to require manufacturers to implement Risk Evaluation and Mitigation Strategies to prevent prenatal exposures. Among 12 risk evaluation and mitigation strategy drugs, several had predecessor risk mitigation plans (eg, isotretinoin) and some were newly required (eg, mycophenolate). Only a small proportion of teratogenic drugs are currently subject to Risk Evaluation and Mitigation Strategies, and the extent of prenatal exposure to the universe of teratogenic drugs compared with drugs subject to Risk Evaluation and Mitigation Strategies is unknown. Moreover, the effectiveness of such advanced risk mitigation programs in preventing prenatal exposure is not clear. OBJECTIVE This study aimed to characterize the epidemiology of prenatal exposures to definite and potential teratogens during the risk evaluation and mitigation strategy era. STUDY DESIGN We constructed a time-series of pregnancies identified from a national private insurance claims database (IBM MarketScan) to estimate prenatal exposures to teratogenic drugs (2006-2017). Pregnancy outcomes, gestational age, and the onset of pregnancy were determined with previously validated algorithms. The Teratology Information Service and Clinical Pharmacology databases were used to identify drugs with definite (n=141) or potential (n=65) teratogenic effects, and drugs with debatable risks such as benzodiazepines, statins, tetracyclines, sex hormones, infertility treatments, and gonadotropin-releasing hormone analogs were excluded. We defined prenatal exposure as ≥1 prescription fill or medical encounter involving administration of drugs with a definite teratogenic risk (including 12 for which there is a "current or discontinued" risk evaluation and mitigation strategy) or a potential teratogenic risk. We evaluated secular trends and modeled the effects of age, preconception exposure, and state healthcare quality rankings on prenatal exposure, adjusting for demographic factors and clinical conditions. RESULTS The cohort included 3,445,612 pregnancies (2,532,444 live deliveries). Prenatal exposures to definite teratogens decreased slightly during the study years from 1.86 to 1.24 per 100 pregnancies between 2006 and 2017, whereas exposure increased for potential teratogens from 3.40% to 5.33%. Prenatal exposure prevalences were higher during the first trimester and for pregnancies that ended in nonlive outcomes. Drugs subject to Risk Evaluation and Mitigation Strategies had low background utilization and contributed to a small proportion of prenatal exposures (15.1 per 100,000 pregnancies). We also observed fewer prenatal exposures to risk evaluation and mitigation strategy drugs among women of childbearing age who used these treatments (0.14% vs 0.36% for any definite teratogen). Age extremes and low state-level healthcare quality rankings were independent predictors of prenatal exposure. CONCLUSION Fetuses in more than 1 in 16 pregnancies continued to be exposed to teratogenic drugs during the past decade. Drugs with Risk Evaluation and Mitigation Strategies imposed a small burden of prenatal exposure because of the low background utilization rates and lower pregnancy prevalence among women of childbearing age who used these drugs. Although the declining exposure rates to teratogenic drugs with definite risk are encouraging, the rising prenatal exposure to drugs with potential risk calls for more assessments. Future research is needed to elucidate the health outcomes of fetuses exposed to potential risk drugs, understand the effectiveness of risk evaluation and mitigation strategy programs, and prioritize teratogenic drugs for advanced risk mitigation.
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Li H, Yang L, Song Y, Zhao X, Sun C, Zhang L, Zhao H, Pan Y. Comparative effectiveness of different treatment modalities for active, moderate-to-severe Graves' orbitopathy: a systematic review and network meta-analysis. Acta Ophthalmol 2021; 100:e1189-e1198. [PMID: 34918472 DOI: 10.1111/aos.15074] [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: 04/16/2021] [Revised: 11/01/2021] [Accepted: 11/19/2021] [Indexed: 10/19/2022]
Abstract
To compare the effects of different treatment modalities on active, moderate-to-severe Graves' orbitopathy (GO). We searched PubMed and Embase for randomized controlled trials published up to 30 Nov 2020, of different modalities for the treatment of active, moderate-to-severe GO. We performed Bayesian network meta-analyses. This study is registered with PROSPERO (CRD42020166287). Fifteen RCTs were identified. Network meta-analysis showed that in comparison with placebo, teprotumumab, mycophenolate plus intravenous glucocorticoids (IVGCs), mycophenolate, rituximab, azathioprine, IVGCs, orbital radiotherapy, oral glucocorticoids (OGCs) were effective treatments (ordered from most effective to least effective). Teprotumumab was more efficacious in reducing proptosis than IVGCs. No significant difference in changes in diplopia grade was recorded between teprotumumab, rituximab, orbital radiotherapy and IVGCs. Low (4.5-5 g), middle (6 g) and high (7-8 g) cumulative doses of IVGCs were shown to be more effective than OGC in improving the overall response rate, but the very low-group (<3 g) seemed to have a lower risk of adverse events. We found that teprotumumab offered the highest level of efficacy in terms of the overall response rate and was more efficacious in reducing proptosis than IVGCs. With regard to different dosages of IVGCs, the cumulative dose of 4.5-5 g of IVGCs seems to be the most appropriate schedule in terms of efficacy and safety outcomes. Due to the limited number of patients treated with teprotumumab and the lack of comparison with other effective therapeutics, teprotumumab might not become the standard first-line therapy for active, moderate-to-severe GO.
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Affiliation(s)
- Hongxun Li
- Tianjin Key Lab of Ophthalmology and Visual Science Tianjin Eye Institute Tianjin Eye Hospital Tianjin China
| | - Lihong Yang
- Tianjin Key Lab of Ophthalmology and Visual Science Tianjin Eye Institute Tianjin Eye Hospital Tianjin China
| | - Yi Song
- Tianjin Key Lab of Ophthalmology and Visual Science Tianjin Eye Institute Tianjin Eye Hospital Tianjin China
- Clinical College of Ophthalmology Tianjin Medical University Tianjin China
| | - Xinheng Zhao
- Tianjin Key Lab of Ophthalmology and Visual Science Tianjin Eye Institute Tianjin Eye Hospital Tianjin China
- Clinical College of Ophthalmology Tianjin Medical University Tianjin China
| | - Chunhua Sun
- Tianjin Key Lab of Ophthalmology and Visual Science Tianjin Eye Institute Tianjin Eye Hospital Tianjin China
| | - Lei Zhang
- Tianjin Key Lab of Ophthalmology and Visual Science Tianjin Eye Institute Tianjin Eye Hospital Tianjin China
| | - Hong Zhao
- Tianjin Key Lab of Ophthalmology and Visual Science Tianjin Eye Institute Tianjin Eye Hospital Tianjin China
| | - Ye Pan
- Tianjin Key Lab of Ophthalmology and Visual Science Tianjin Eye Institute Tianjin Eye Hospital Tianjin China
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Sampaio-Barros PD, Medeiros-Ribeiro AC, Luppino-Assad AP, Miossi R, Carriço da Silva H, Yuki EFVN, Pasoto SG, Saad CGS, Silva CA, Kupa LVK, Deveza GBH, Pedrosa TN, Aikawa NE, Bonfá E. SARS-CoV-2 vaccine in patients with systemic sclerosis: Impact of disease subtype and therapy. Rheumatology (Oxford) 2021; 61:SI169-SI174. [PMID: 34894235 PMCID: PMC8689834 DOI: 10.1093/rheumatology/keab886] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Revised: 11/18/2021] [Indexed: 01/07/2023] Open
Abstract
OBJECTIVE To analyse the safety, immunogenicity and factors affecting antibody response to Severe Acute Respiratory Syndrome-Coronavirus-2(SARS-CoV-2) vaccination in patients with systemic sclerosis (SSc). METHODS This is a phase 4 prospective study within a larger trial of two doses of inactivated SARS-CoV-2 vaccine (CoronaVac) in 51 SSc patients compared with 153 controls. Anti-SARS-CoV-2-IgG and neutralizing antibodies (NAb) were assessed at each vaccine shot (D0/D28) and 6 weeks after the 2nd dose(D69), only in individuals with negative baseline IgG/NAb and those who did not have coronavirus-19(COVID19) during follow-up. Vaccine safety was also assessed in all participants. RESULTS Patients and controls had comparable median ages [48(38.5-57) vs 48(38-57) years, p= 0.945]. Patients had mostly diffuse SSc (68.6%) and the majority (74.5%) had interstitial lung disease. Most patients were under immunosuppressive therapy (72.5%), mainly mycophenolate mofetil (MMF) (52.9%). After full vaccination (D69), anti-SARS-CoV-2-IgG frequency (64.1% vs 94.2%, p< 0.001) and NAb positivity (53.8% vs 76.9%; p= 0.006) were moderate, although lower than controls. The first dose response (D28) was low and comparable for both SC (p= 0.958) and NAb positivity (p= 0.537). SSc patients under MMF monotherapy vs other (no therapy/other DMARDs) had lower immunogenicity (SC : 31.3% vs 90%, p< 0.001) and NAb : 18.8% vs 85%, p< 0.001). Multiple regression analysis confirmed that MMF use, but not disease subtype, is associated with insufficient seroconversion [odds ratio (OR)=0.056(95%CI 0.009-0.034), p= 0.002] and NAb positivity [OR = 0.047(95%CI 0.007-0.036), p= 0.002]. No moderate/severe side-effects were observed. CONCLUSION CoronaVac has an excellent safety profile and moderate response to anti-SARS-CoV-2 vaccine in SSc. Vaccine antibody response is not influenced by disease subtype and is greatly affected by MMF, reinforcing the need for additional strategies to up-modulate vaccine response in this subgroup of patients. TRIAL REGISTRATION ClinicalTrials.gov, https://clinicaltrials.gov, NCT04754698.
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Affiliation(s)
| | - Ana Cristina Medeiros-Ribeiro
- Division of Rheumatology, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, SP, Brazil
| | - Ana Paula Luppino-Assad
- Division of Rheumatology, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, SP, Brazil
| | - Renata Miossi
- Division of Rheumatology, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, SP, Brazil
| | - Henrique Carriço da Silva
- Division of Rheumatology, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, SP, Brazil
| | - Emily F V N Yuki
- Division of Rheumatology, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, SP, Brazil
| | - Sandra G Pasoto
- Division of Rheumatology, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, SP, Brazil
| | - Carla G S Saad
- Division of Rheumatology, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, SP, Brazil
| | - Clóvis A Silva
- Division of Rheumatology, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, SP, Brazil.,Pediatric Rheumatology Unit, Childrens' Institute, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, SP, Brazil
| | - Léonard V K Kupa
- Division of Rheumatology, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, SP, Brazil
| | - Giordano B H Deveza
- Division of Rheumatology, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, SP, Brazil
| | - Tatiana N Pedrosa
- Division of Rheumatology, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, SP, Brazil
| | - Nádia E Aikawa
- Division of Rheumatology, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, SP, Brazil.,Pediatric Rheumatology Unit, Childrens' Institute, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, SP, Brazil
| | - Eloisa Bonfá
- Division of Rheumatology, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, SP, Brazil
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Schmitt MM, Ferré EMN, Sampaio De Melo M, Cooper MA, Quezado MM, Heller T, Lionakis MS. Mycophenolate-Induced Colitis in Autoimmune Polyendocrinopathy-Candidiasis-Ectodermal Dystrophy Patients. JPGN Rep 2021; 2:e131. [PMID: 35425944 PMCID: PMC9004485 DOI: 10.1097/pg9.0000000000000131] [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] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Accepted: 09/10/2021] [Indexed: 06/14/2023]
Abstract
INTRODUCTION Autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy (APECED) is a prototypic monogenic autoimmune disorder caused by AIRE deficiency-mediated impaired central immune tolerance. Although multiple endocrine and non-endocrine tissues are affected in APECED, the colon is an uncommon target of autoimmune attack. Mycophenolate is a potent immunomodulatory medication that is used to treat autoimmune manifestations in patients with APECED and other autoimmune diseases. METHODS We reviewed the clinical, laboratory, genetic, histological, and treatment data of mycophenolate-induced colitis in our cohort of 104 APECED patients. DISCUSSION Among 10 mycophenolate-treated APECED patients, four (40%) developed reversible biopsy-proven mycophenolate-induced colitis characterized by an inflammatory bowel disease-like and/or graft-versus-host disease-like histological pattern. Mycophenolate-induced colitis appears to be a common complication in patients with APECED for which clinicians should maintain a high index of suspicion.
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Affiliation(s)
- Monica M. Schmitt
- From the Fungal Pathogenesis Section, Laboratory of Clinical Immunology and Microbiology (LCIM), National Institute of Allergy & Infectious Diseases (NIAID), NIH, Bethesda, Maryland
| | - Elise M. N. Ferré
- From the Fungal Pathogenesis Section, Laboratory of Clinical Immunology and Microbiology (LCIM), National Institute of Allergy & Infectious Diseases (NIAID), NIH, Bethesda, Maryland
| | - Michelly Sampaio De Melo
- Laboratory of Pathology, Center for Cancer Research, National Cancer Institute (NCI), NIH, Bethesda, Maryland
| | - Megan A. Cooper
- Department of Pediatrics, Division of Rheumatology/Immunology, Washington University School of Medicine, St. Louis, Missouri
| | - Martha M. Quezado
- Laboratory of Pathology, Center for Cancer Research, National Cancer Institute (NCI), NIH, Bethesda, Maryland
| | - Theo Heller
- Translational Hepatology Section, Liver Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), NIH, Bethesda, Maryland
| | - Michail S. Lionakis
- From the Fungal Pathogenesis Section, Laboratory of Clinical Immunology and Microbiology (LCIM), National Institute of Allergy & Infectious Diseases (NIAID), NIH, Bethesda, Maryland
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Bani Fawwaz BA, Aldwairy A, Farooq A. Mycophenolate-Induced Colitis: A Rare Side Effect. Cureus 2021; 13:e18250. [PMID: 34712529 PMCID: PMC8542390 DOI: 10.7759/cureus.18250] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/24/2021] [Indexed: 11/09/2022] Open
Abstract
Mycophenolic acid (MPA) is a well-known immunosuppressive medication that is widely used in solid organ transplant recipients. This medication is known to have various gastrointestinal (GI) side effects. Some of those side effects are simple and temporary like nausea; on the other hand, it can also lead to more serious side effects like colitis. We herein report a case of MPA-induced colitis that presented with severe diarrhea. Unexpectedly, the endoscopic appearance of the colon was normal. Moreover, pathology findings were nonspecific. Symptoms had resolved after discontinuation of the medication. MPA-induced colitis is a rare side effect with no established guidelines for management or treatment. Furthermore, the nonspecific endoscopic and microscopic findings make it a diagnostic dilemma.
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Affiliation(s)
| | - Ahmad Aldwairy
- Internal Medicine, MedStar Washington Hospital Center, Washington, USA
| | - Aimen Farooq
- Internal Medicine, AdventHealth Orlando, Orlando, USA
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Janardana R, Irodi A, Chebbi PP, Goel R, Vimala LR, Padiyar S, Peediyakal A, Mathew J, Nair A, Christopher DJ, Danda D. Mycophenolate in scleroderma-associated interstitial lung disease: Real-world data from rheumatology and pulmonology clinics in South Asia. J Scleroderma Relat Disord 2021; 6:271-276. [PMID: 35387216 PMCID: PMC8922665 DOI: 10.1177/23971983211024410] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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: 04/06/2021] [Accepted: 05/15/2021] [Indexed: 11/10/2023]
Abstract
INTRODUCTION There is a paucity of real-world data on mycophenolate mofetil/mycophenolate sodium in systemic sclerosis-related interstitial lung disease. AIM To study the efficacy of mycophenolate mofetil/ mycophenolate sodium in systemic sclerosis-related interstitial lung disease. METHODS In this single-centre study, clinical, laboratory and imaging details of consecutive patients with systemic sclerosis-related interstitial lung disease receiving mycophenolate mofetil/mycophenolate sodium from rheumatology and pulmonology clinics between January 2008 and March 2017 were retrospectively retrieved. The change in percentage of predicted normal forced vital capacity at last follow-up visit as compared with baseline was studied. In addition, high-resolution computed tomography scans at baseline and 2-year follow-up visit were scored as either stable/improved or worsened by experienced thoracic radiologists blinded to the clinical details of patients. RESULTS Altogether, 88 patients (85.2% females) with mean age (SD) of 33.8 years (± 11.3) and median (interquartile range) duration of disease since non-Raynaud's symptoms of 36 months (13.5-60) were studied. Diffuse systemic sclerosis comprised 85.2% of them. The mean baseline forced vital capacity was 61.2 ± 17.9% and median scores for ground glass opacities and fibrosis in high-resolution computed tomography were 0.5 (0-1.3) and 1 (0-1.3), respectively. At a median follow-up duration of 30 months (interquartile range = 16.5-49), the percentage of forced vital capacity improved by 1.8% (-3.82 to 9.07) as compared with baseline visit (p = 0.02). In the 2-year follow-up, the ground glass opacity and fibrosis scores in high-resolution computed tomography improved in 17.3% and 7.7% of patients and stabilized in 63.5% and 78.8% patients, respectively. CONCLUSION Mycophenolate mofetil/mycophenolate sodium was efficacious in improving /stabilizing forced vital capacity irrespective of the baseline high-resolution computed tomography lung scores in our patients with systemic sclerosis-related interstitial lung disease during the ⩾ 2-year follow-up period.
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Affiliation(s)
- Ramya Janardana
- Department of Clinical Immunology and
Rheumatology, Christian Medical College, Vellore, India
- Clinical Immunology & Rheumatology,
St. John’s Medical College, Bengaluru, India
| | - Aparna Irodi
- Department of Radiology, Christian
Medical College, Vellore, India
| | - Pramod P Chebbi
- Department of Clinical Immunology and
Rheumatology, Christian Medical College, Vellore, India
- SDM College of Medical Sciences and
Hospital, Dharwad, India
| | - Ruchika Goel
- Department of Clinical Immunology and
Rheumatology, Christian Medical College, Vellore, India
| | - Leena R Vimala
- Department of Radiology, Christian
Medical College, Vellore, India
| | - Shivraj Padiyar
- Department of Clinical Immunology and
Rheumatology, Christian Medical College, Vellore, India
| | - Anoof Peediyakal
- Department of Clinical Immunology and
Rheumatology, Christian Medical College, Vellore, India
- Dr Anoof’s RheumaCare, Calicut,
India
| | - John Mathew
- Department of Clinical Immunology and
Rheumatology, Christian Medical College, Vellore, India
| | - Aswin Nair
- Department of Clinical Immunology and
Rheumatology, Christian Medical College, Vellore, India
| | | | - Debashish Danda
- Department of Clinical Immunology and
Rheumatology, Christian Medical College, Vellore, India
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He X, Li S, Zhang J, Cao L, Yang C, Rong P, Yi S, Ghimire K, Ma X, Wang W. Benefit of Belatacept in Cord Blood-Derived Regulatory T Cell-Mediated Suppression of Alloimmune Response. Cell Transplant 2021; 30:9636897211046556. [PMID: 34570631 PMCID: PMC8718163 DOI: 10.1177/09636897211046556] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
The role of Regulatory T cells (Tregs) in tolerance induction post-transplantation is well-established, but Tregs adoptive transfer alone without combined immunosuppressants have failed so far in achieving clinical outcomes. Here we applied a set of well-designed criteria to test the influence of commonly used immunosuppressants (belatacept, tacrolimus, and mycophenolate) on cord blood-derived Tregs (CB-Tregs). Our study shows that while none of these immunosuppressants modulated the stability and expression of homing molecules by CB-Tregs, belatacept met all other selective criteria, shown by its ability to enhance CB-Tregs-mediated in vitro suppression of the allogeneic response without affecting their viability, proliferation, mitochondrial metabolism and expression of functional markers. In contrast, treatment with tacrolimus or mycophenolate led to reduced expression of functional molecule GITR in CB-Tregs, impaired their viability, proliferation and mitochondrial metabolism. These findings indicate that belatacept could be considered as a candidate in Tregs-based clinical immunomodulation regimens to induce transplant tolerance.
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Affiliation(s)
- Xing He
- Institute for Cell Transplantation and Gene Therapy, the 3rd Xiangya Hospital of Central South University, Changsha, People's Republic of China
| | - Sang Li
- Institute for Cell Transplantation and Gene Therapy, the 3rd Xiangya Hospital of Central South University, Changsha, People's Republic of China
| | - Juan Zhang
- Institute for Cell Transplantation and Gene Therapy, the 3rd Xiangya Hospital of Central South University, Changsha, People's Republic of China
| | - Lu Cao
- Institute for Cell Transplantation and Gene Therapy, the 3rd Xiangya Hospital of Central South University, Changsha, People's Republic of China
| | - Cejun Yang
- Institute for Cell Transplantation and Gene Therapy, the 3rd Xiangya Hospital of Central South University, Changsha, People's Republic of China
| | - Pengfei Rong
- Institute for Cell Transplantation and Gene Therapy, the 3rd Xiangya Hospital of Central South University, Changsha, People's Republic of China
| | - Shounan Yi
- Institute for Cell Transplantation and Gene Therapy, the 3rd Xiangya Hospital of Central South University, Changsha, People's Republic of China.,Centre for Transplant and Renal Research (CTRR), Westmead Institute for Medical Research, The University of Sydney, Sydney, NSW, Australia
| | - Kedar Ghimire
- Centre for Transplant and Renal Research (CTRR), Westmead Institute for Medical Research, The University of Sydney, Sydney, NSW, Australia
| | - Xiaoqian Ma
- Institute for Cell Transplantation and Gene Therapy, the 3rd Xiangya Hospital of Central South University, Changsha, People's Republic of China
| | - Wei Wang
- Institute for Cell Transplantation and Gene Therapy, the 3rd Xiangya Hospital of Central South University, Changsha, People's Republic of China
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Waldman RA, Grant-Kels JM. Dermatology patients on biologics and certain other systemic therapies should receive a "booster" messenger RNA COVID-19 vaccine dose: A critical appraisal of recent Food and Drug Administration and Advisory Committee on Immunization Practices recommendations. J Am Acad Dermatol 2021; 85:1113-6. [PMID: 34437985 DOI: 10.1016/j.jaad.2021.08.031] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 08/18/2021] [Indexed: 12/15/2022]
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Barber KF, Loughin CA, Marino DJ, Lesser M. The Effects of Mycophenolate on the Formation of Granulation Tissue Post-operatively in Canine Tracheal Stent Patients (2014-2020). Front Vet Sci 2021; 8:697513. [PMID: 34414226 PMCID: PMC8370251 DOI: 10.3389/fvets.2021.697513] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 07/02/2021] [Indexed: 11/13/2022] Open
Abstract
Objectives: To determine if mycophenolate mofetil reduces the incidence and severity of granulation tissue in-growth in canine tracheal stent patients. Study design: Randomized clinical trial. Animals: 111 dogs from the hospital population. Methods: Client-owned dogs that received an endoluminal self-expanding tracheal stent for canine tracheal collapse between 2014 and 2020 were randomly assigned into one of two treatment groups. Control group medication protocol consisted of prednisone 0.5 mg/kg PO BID/SID/EOD × 30 days, hydrocodone 0.25 mg/kg PO TID × 30 days, and cefovecin 8 mg/kg SQ post-placement. Mycophenolate group medication protocol was identical to the control group medication protocol with the addition of mycophenolate mofetil 10 mg/kg PO BID × 30 days, SID for life. Recheck tracheoscopy was performed at 1, 3, and 6 months post-stent placement. Presence and severity of granulation tissue were determined by tracheoscopy and were recorded as a percentage of tracheal lumen obstruction by blinded evaluators (none present, <25%, >25-50%, and >50%). Results: At none of the three time points was there a statistically significant difference in grade between controls and those receiving mycophenolate (p = 0.467, p = 0.330, and p = 0.410). Conclusions and Clinical Significance: Our results suggest that mycophenolate can be safely given to these patients but do not support that its administration will reduce the incidence and severity of granulation tissue. Although a difference was observed in the severity of granulation tissue between the two groups, loss to follow-up may have influenced conclusions. A larger study would be warranted to further evaluate the effect of mycophenolate on the development of granulation tissue.
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Affiliation(s)
- Kevin F Barber
- Department of Surgery, Long Island Veterinary Specialists, Plainview, NY, United States
| | - Catherine A Loughin
- Department of Surgery, Long Island Veterinary Specialists, Plainview, NY, United States
| | - Dominic J Marino
- Department of Surgery, Long Island Veterinary Specialists, Plainview, NY, United States
| | - Martin Lesser
- Biostatistics Unit, Feinstein Institute for Medical Research, Northwell Healthy, Great Neck, NY, United States
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Thishya K, Sreenu B, Raju SB, Kutala VK. Impact of Pharmacogenetic Determinants of Tacrolimus and Mycophenolate on Adverse Events in Renal Transplant Patients. Curr Drug Metab 2021; 22:342-352. [PMID: 33459227 DOI: 10.2174/1389200222666210114123349] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 10/14/2020] [Accepted: 11/28/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Graft acceptance against immunity is one of the major challenges in solid organ transplant. Immunosuppressive medications have effectively improved the post-transplantation outcome however, it has its own limitations. Genetic polymorphisms in drug-metabolizing enzymes have been identified as the potential targets in developing a pharmacogenetic strategy, to individualize drug dose and also in preventing the adverse events. OBJECTIVE The rationale of the study was to explore polymorphisms in tacrolimus and mycophenolate metabolic pathways that influence the adverse clinical outcomes in renal transplant recipients. METHODS A total of 255 renal transplant recipients were analyzed for the pharmacogenetic determinants of tacrolimus (CYP3A5*3 ABCB1 1236 T>C ABCB1 2677 G>A/T ABCB1 3435 T>C) and mycophenolate (UGT1A8*3 UGT1A9 IMPDH I IMPDH II c.787C>T ABCC2 -24 C>T and c.3972C>T) using Sanger sequencing. RESULTS Acute rejection (AR) was observed in 5.88% of the transplant recipients whereas acute tubular necrosis (ATNs) was observed in 7.45% of the patients within early stage of the maintenance phase. Infections such as urinary tract infection (UTI) and cytomegalovirus (CMV) infection were observed in 11.37% and 12.16% of the patients. The AUC of mycophenolate was significantly higher in patients with increased risk for infections. ABCC2 -24 C>T c.3972C>T polymorphisms and ABCB1 3435 C-allele were associated with reduced risk for infections. ABCC2 rs3740066 was associated with 2.06-fold all-cause mortality risk. CYP3A5 AG- and UGT1A9-440 CC-genotypes showed increased risk and ABCC 3972C>T CC-genotype showed protection against adverse events. CONCLUSION Genetic variants in tacrolimus and mycophenolate metabolic pathways were found to influence the morbidity and mortality in renal transplant recipients.
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Affiliation(s)
- Kalluri Thishya
- Department of Clinical Pharmacology and Therapeutics, Nizam's Institute of Medical Sciences (NIMS), Hyderabad, Telangana, India
| | - Boddupally Sreenu
- Department of Clinical Pharmacology and Therapeutics, Nizam's Institute of Medical Sciences (NIMS), Hyderabad, Telangana, India
| | - Sree B Raju
- Department of Nephrology, Nizam's Institute of Medical Sciences (NIMS), Hyderabad, Telangana, India
| | - Vijay Kumar Kutala
- Department of Clinical Pharmacology and Therapeutics, Nizam's Institute of Medical Sciences (NIMS), Hyderabad, Telangana, India
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Rodríguez-Perálvarez M, Colmenero J, Salcedo M. Reply to: "Age and comorbidity are central to the risk of death from COVID-19 in liver transplant recipients". J Hepatol 2021; 75:228-229. [PMID: 33862040 PMCID: PMC8056821 DOI: 10.1016/j.jhep.2021.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 03/25/2021] [Accepted: 04/03/2021] [Indexed: 01/08/2023]
Affiliation(s)
- Manuel Rodríguez-Perálvarez
- Department of Hepatology and Liver Transplantation, Hospital Universitario Reina Sofía, IMIBIC, University of Córdoba, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Spain.
| | - Jordi Colmenero
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Spain,Liver Transplant Unit, Hospital Clínic, IDIBAPS, University of Barcelona, Spain
| | - Magdalena Salcedo
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Spain,Hepatology and Liver Transplantation Unit, Hospital General Universitario Gregorio Marañón, Universidad Complutense, Madrid, Spain
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Collinge M, Schneider P, Li D, Parish S, Dumont C, Freebern W, Ghanime J, Guimont-Derochers F, Langenkamp A, Lebron J, Li N, Marban C, Plitnick L, Wheeler J. Cross-company evaluation of the human lymphocyte activation assay. J Immunotoxicol 2021; 17:51-58. [PMID: 32124652 DOI: 10.1080/1547691x.2020.1725694] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
Nonclinical immunotoxicity evaluation is an important component of safety assessment for pharmaceuticals. One in vitro assay that can be applied in a weight of evidence assessment is the human lymphocyte activation (HuLA) assay, an antigen recall assay, similar in many respects to the in vivo T-cell-dependent antibody response (TDAR) in that cooperation of multiple immune cell types are needed to produce responses. This assay uses human cells and is more amenable than the TDAR to compound ranking and mechanistic studies. The HuLA assay requires less time and drug than TDAR assays, uses a relevant antigen (influenza), reflects a human immune response, and applies principles of the 3Rs to non-clinical safety assessment. Peripheral blood mononuclear cells (PBMC) from flu-immunized donors are re-stimulated with flu-vaccine in the presence of test articles, and proliferation is measured. Published data demonstrate the applicability of the HuLA assay, but it has not been evaluated for reproducibility across testing sites. To evaluate assay reproducibility, scientists from a consortium of institutions conducted the assay in parallel, using a common pool of donor PBMC, influenza vaccine, and known immunosuppressant compounds (cyclosporine A and mycophenolic acid). The HuLA assay was highly reproducible in identification of inhibition of antigen-specific responses, and there was significant agreement across testing sites in the half maximal inhibitory concentration (IC50) values. Intra-site variability was the largest contributor to the variability observed within the assay. The HuLA assay was demonstrated to be ideally suited to comparing multiple compounds (i.e. compound ranking or benchmarking) within the same assay. Overall, the data reported herein support the HuLA assay as a useful tool in mechanistic evaluations of antigen-specific immune responses.
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Affiliation(s)
| | | | | | - Stanley Parish
- Health and Environmental Sciences Institute, Washington, DC, USA
| | | | | | | | | | - Anja Langenkamp
- Roche Pharmaceutical Research and Development, Basel, Switzerland
| | | | | | - Celine Marban
- Roche Pharmaceutical Research and Development, Basel, Switzerland
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Oreschak K, Saba LM, Rafaels N, Ambardekar AV, Deininger KM, PageII R, Lindenfeld J, Aquilante CL. Variants in mycophenolate and CMV antiviral drug pharmacokinetic and pharmacodynamic genes and leukopenia in heart transplant recipients. J Heart Lung Transplant 2021; 40:917-925. [PMID: 34253456 DOI: 10.1016/j.healun.2021.05.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 10/20/2020] [Revised: 05/06/2021] [Accepted: 05/11/2021] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND The objective was to assess the relationship between single nucleotide polymorphisms in mycophenolate and cytomegalovirus antiviral drug pharmacokinetic and pharmacodynamic genes and drug-induced leukopenia in adult heart transplant recipients. METHODS This retrospective analysis included n = 148 patients receiving mycophenolate and a cytomegalovirus antiviral drug. In total, 81 single nucleotide polymorphisms in 21 pharmacokinetic and 23 pharmacodynamic genes were selected for investigation. The primary and secondary outcomes were mycophenolate and/or cytomegalovirus antiviral drug-induced leukopenia, defined as a white blood cell count <3.0 × 109/L, in the first six and 12 months post-heart transplant, respectively. RESULTS Mycophenolate and/or cytomegalovirus antiviral drug-induced leukopenia occurred in 20.3% of patients. HNF1A rs1169288 A>C (p.I27L) was associated with drug-induced leukopenia (unadjusted p = 0.002; false discovery rate <20%) in the first six months post-transplant. After adjusting for covariates, HNF1A rs1169288 variant C allele carriers had significantly higher odds of leukopenia compared to A/A homozygotes (odds ratio 6.19; 95% CI 1.97-19.43; p = 0.002). Single nucleotide polymorphisms in HNF1A, SLC13A1, and MBOAT1 were suggestively associated (p < 0.05) with the secondary outcome but were not significant after adjusting for multiple comparisons. CONCLUSION Our data suggest genetic variation may play a role in the development of leukopenia in patients receiving mycophenolate and cytomegalovirus antiviral drugs after heart transplantation. Following replication, pharmacogenetic markers, such as HNF1A rs1169288, could help identify patients at higher risk of drug-induced leukopenia, allowing for more personalized immunosuppressant therapy and cytomegalovirus prophylaxis following heart transplantation.
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Affiliation(s)
- Kris Oreschak
- Department of Pharmaceutical Sciences, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado, USA
| | - Laura M Saba
- Department of Pharmaceutical Sciences, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado, USA
| | - Nicholas Rafaels
- Division of Biomedical Informatics and Personalized Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Amrut V Ambardekar
- Division of Cardiology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Kimberly M Deininger
- Department of Pharmaceutical Sciences, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado, USA
| | - RobertL PageII
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado, USA
| | - JoAnn Lindenfeld
- Division of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Christina L Aquilante
- Department of Pharmaceutical Sciences, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado, USA.
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Mori F, Nardini I, Caricasole A, Amega NS, Farina C. Characterization of a plasma-derived double-viral-inactivated factor VIII concentrate (antihaemophilic factor [human]): Focus on TTP treatment. Haemophilia 2021; 27:e409-e411. [PMID: 33529361 DOI: 10.1111/hae.14260] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 12/07/2020] [Accepted: 01/11/2021] [Indexed: 01/25/2023]
Affiliation(s)
- Filippo Mori
- Department of Research & Innovation, Kedrion S.p.A, Loc. Bolognana, Italy
| | - Ilaria Nardini
- Department of Research & Innovation, Kedrion S.p.A, Loc. Bolognana, Italy
| | - Andrea Caricasole
- Department of Research & Innovation, Kedrion S.p.A, Loc. Bolognana, Italy
| | - Novinyo Serge Amega
- Department of Medical Affairs, Kedrion Biopharma Inc, Fort Lee, New Jersey, USA
| | - Claudio Farina
- Department of Research & Innovation, Kedrion S.p.A, Loc. Bolognana, Italy
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Rong Y, Jun H, Kiang TKL. Population pharmacokinetics of mycophenolic acid in paediatric patients. Br J Clin Pharmacol 2021; 87:1730-1757. [PMID: 33118201 DOI: 10.1111/bcp.14590] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [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: 05/27/2020] [Revised: 09/07/2020] [Accepted: 09/22/2020] [Indexed: 12/14/2022] Open
Abstract
Mycophenolic acid (MPA) is widely used in paediatric kidney transplant patients and sometimes prescribed for additional indications. Population pharmacokinetic or pharmacodynamic modelling has been frequently used to characterize the fixed, random and covariate effects of MPA in adult patients. However, MPA population pharmacokinetic data in the paediatric population have not been systematically summarized. The objective of this narrative review was to provide an up-to-date critique of currently available paediatric MPA population pharmacokinetic models, with emphases on modelling techniques, pharmacological findings and clinical relevance. PubMed and EMBASE were searched from inception of database to May 2020, where a total of 11 studies have been identified representing kidney transplant (n = 4), liver transplant (n = 1), haematopoietic stem cell transplant (n = 1), idiopathic nephrotic syndrome (n = 2), systemic lupus erythematosus (n = 2), and a combined population consisted of kidney, liver and haematopoietic stem cell transplant patients (n = 1). Critical analyses were provided in the context of MPA absorption, distribution, metabolism, excretion and bioavailability in this paediatric database. Comparisons to adult patients were also provided. With respect to clinical utility, Bayesian estimation models (n = 6) with acceptable accuracy and precision for MPA exposure determination have also been identified and systematically evaluated. Overall, our analyses have identified unique features of MPA clinical pharmacology in the paediatric population, while recognizing several gaps that still warrant further investigations. This review can be used by pharmacologists and clinicians for improving MPA pharmacokinetic-pharmacodynamic modelling and patient care.
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Affiliation(s)
- Yan Rong
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, AB, Canada
| | - Heajin Jun
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, AB, Canada.,College of Pharmacy, Seoul National University, Seoul, Republic of Korea
| | - Tony K L Kiang
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, AB, Canada
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Li Y, Lou Y, Chen Y, Yang J, Li D, Jiang B, Lan J, Wen J, Fu Y, Zhang Y, Tao J, Zhu J. Polysaccharide mycophenolate-based nanoparticles for enhanced immunosuppression and treatment of immune-mediated inflammatory diseases. Am J Cancer Res 2021; 11:3694-3709. [PMID: 33664856 PMCID: PMC7914372 DOI: 10.7150/thno.52891] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2020] [Accepted: 12/22/2020] [Indexed: 11/14/2022] Open
Abstract
Immune-mediated inflammatory diseases (IMIDs) are characterized by immune dysregulation and severe inflammation caused by the aberrant and overactive host immunological response. Mycophenolic acid (MPA)-based immunosuppressive drugs are potential treatments for IMIDs because of their mild side-effect profile; however, their therapeutic effects are limited by the high albumin binding rate, unsatisfactory pharmacokinetics, and undefined cellular uptake selectivity. Methods: Polysaccharide mycophenolate was synthesized by conjugating MPA molecules to dextran (a typical polysaccharide widely used in drug delivery) and encapsulated extra free MPA molecules to fabricate MPA@Dex-MPA nanoparticles (NPs). The efficacy of these NPs for mediating immunosuppression and treatment of IMIDs was evaluated in imiquimod-induced psoriasis-like skin inflammation in Balb/c mice, a representative IMID model. Results: The MPA@Dex-MPA NPs exhibited high MPA loading efficiency, low albumin binding rates, and sustained MPA release, resulting in improved pharmacokinetics in vivo. Compared to free MPA, MPA@Dex-MPA NPs induced more robust therapeutic effects on IMIDs. Mechanistic studies indicated that MPA@Dex-MPA NPs were primarily distributed in dendritic cells (DCs) and significantly suppressed the overactivated DCs in vivo and in vitro. Furthermore, the recovered DCs rehabilitated the IL-23/Th17 axis function and significantly ameliorated imiquimod-induced psoriasis-like skin inflammation. Importantly, MPA@Dex-MPA NPs showed favorable safety and biocompatibility in vivo. Conclusion: Our results indicated the polysaccharide mycophenolate-based NPs to be highly promising for IMID treatment.
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Erre GL, Mangoni AA. Current therapeutic strategies in connective tissue disease-related interstitial lung disease: introduction to the special issue. Drugs Context 2021; 10:2020-12-1. [PMID: 33505479 PMCID: PMC7813434 DOI: 10.7573/dic.2020-12-1] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 12/04/2020] [Indexed: 11/21/2022] Open
Abstract
This Editorial introduces the Special Issue on the efficacy and safety of current treatment strategies for patients with connective tissue disease-related interstitial lung disease, including the use of immunosuppressants, such as cyclophosphamide, mycophenolate mofetil and rituximab, and antifibrotic drugs.
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Affiliation(s)
- Gian Luca Erre
- Dipartimento di Scienze Mediche, Chirurgiche e sperimentali, Università degli Studi di Sassari, Sassari, Italy
- Dipartimento di Specialità Mediche, Azienda Ospedaliero-Universitaria di Sassari, Sassari, Italy
| | - Arduino Aleksander Mangoni
- Discipline of Clinical Pharmacology, College of Medicine and Public Health, Flinders University and Flinders Medical Centre, Adelaide, Australia
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Avello A, Fernandez-Prado R, Santos-Sanchez-Rey B, Rojas-Rivera J, Ortiz A. Slo-Mo anti-neutrophil cytoplasmic antibody-associated renal vasculitis. Clin Kidney J 2021; 14:18-22. [PMID: 33564403 PMCID: PMC7857803 DOI: 10.1093/ckj/sfaa181] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 07/14/2020] [Indexed: 11/14/2022] Open
Abstract
Nephrologists are familiar with severe cases of anti-neutrophil cytoplasmic antibodies-associated vasculitis (AAV) presenting as rapidly progressive glomerulonephritis. However, less is known about AAV with slowly progressive renal involvement. While its existence is acknowledged in textbooks, much remains unknown regarding its relative frequency versus more aggressive cases as well as about the optimal therapeutic approach and response to therapy. Moreover, this uncommon presentation may be underdiagnosed, given the scarce familiarity of physicians. In this issue of Clinical Kidney Journal, Trivioli et al. report the largest series to date and first systematic assessment of patients with AAV and slowly progressive renal involvement, defined as a reduction in estimated glomerular filtration rate (eGFR) of 25-50% in the 6 months prior to diagnosis after excluding secondary causes. Key findings are that slowly progressive AAV may be less common than previously thought, although it still represents the second most common presentation of renal AAV, it usually has a microscopic polyangiitis, anti-myeloperoxidase, mainly renal phenotype in elderly individuals, diagnosis may be late (over one-third of patients had end-stage kidney disease at diagnosis), clearly identifying an unmet need for physician awareness about this presentation, but those not needing renal replacement therapy at diagnosis still responded to immunosuppression.
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Affiliation(s)
- Alejandro Avello
- Department of Medicine, School of Medicine, IIS-Fundación Jiménez Diaz, Division of Nephrology and Hypertension, Universidad Autónoma de Madrid, Madrid, Spain
- Red de Investigación Renal (REDINREN), Instituto Carlos III-FEDER, Madrid, Spain
| | - Raul Fernandez-Prado
- Department of Medicine, School of Medicine, IIS-Fundación Jiménez Diaz, Division of Nephrology and Hypertension, Universidad Autónoma de Madrid, Madrid, Spain
- Red de Investigación Renal (REDINREN), Instituto Carlos III-FEDER, Madrid, Spain
| | - Begoña Santos-Sanchez-Rey
- Department of Medicine, School of Medicine, IIS-Fundación Jiménez Diaz, Division of Nephrology and Hypertension, Universidad Autónoma de Madrid, Madrid, Spain
- Red de Investigación Renal (REDINREN), Instituto Carlos III-FEDER, Madrid, Spain
| | - Jorge Rojas-Rivera
- Department of Medicine, School of Medicine, IIS-Fundación Jiménez Diaz, Division of Nephrology and Hypertension, Universidad Autónoma de Madrid, Madrid, Spain
- Red de Investigación Renal (REDINREN), Instituto Carlos III-FEDER, Madrid, Spain
| | - Alberto Ortiz
- Department of Medicine, School of Medicine, IIS-Fundación Jiménez Diaz, Division of Nephrology and Hypertension, Universidad Autónoma de Madrid, Madrid, Spain
- Red de Investigación Renal (REDINREN), Instituto Carlos III-FEDER, Madrid, Spain
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Karabayas M, Dospinescu P, Fluck N, Kidder D, Fordyce G, Hollick RJ, De Bari C, Basu N. Evaluation of adjunctive mycophenolate for large vessel giant cell arteritis. Rheumatol Adv Pract 2020; 4:rkaa069. [PMID: 33381680 PMCID: PMC7756006 DOI: 10.1093/rap/rkaa069] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 10/11/2020] [Indexed: 12/25/2022] Open
Abstract
Objectives GCA patients with large vessel involvement (LV-GCA) experience greater CS requirements and higher relapse rates compared with classical cranial GCA. Despite the distinct disease course, interventions in LV-GCA have yet to be investigated specifically. This study aimed to evaluate the CS-sparing effect and tolerability of first-line mycophenolate in LV-GCA. Methods A retrospective cohort study was conducted in patients with LV-GCA identified from a regional clinical database between 2005 and 2019. All cases were prescribed mycophenolate derivatives (MYC; MMF or mycophenolic acid) at diagnosis and were followed up for ≥2 years. The primary outcome was the cumulative CS dose at 1 year. Secondary outcomes included MYC tolerance, relapse rates and CRP levels at 1 and 2 years. Results A total of 37 patients (65% female; mean age 69.4 years, SD 7.9 years) were identified. All cases demonstrated large vessel involvement via CT/PET (n = 34), CT angiography (n = 5) or magnetic resonance angiography (n = 2). After 2 years, 31 patients remained on MYC, whereas 6 had switched to MTX or tocilizumab owing to significant disease relapse. The mean (±SD) cumulative prednisolone dose at 1 year was 4960 (±1621) mg. Relapse rates at 1 and 2 years were 16.2 and 27%, respectively, and CRP levels at 1 and 2 years were 4 [interquartile range (IQR) 4–6] and 4 (IQR 4–4) mg/l, respectively. Conclusion To our knowledge, this is the first attempt to assess the effectiveness of any specific agent in LV-GCA. MYC might be both effective in reducing CS exposure and well tolerated in this subpopulation. A future randomized controlled trial is warranted.
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Affiliation(s)
- Maira Karabayas
- Aberdeen Centre for Arthritis & Musculoskeletal Health, University of Aberdeen.,Rheumatology Service, NHS Grampian
| | | | - Nick Fluck
- Renal Unit, Aberdeen Royal Infirmary, NHS Grampian, Aberdeen
| | - Dana Kidder
- Renal Unit, Aberdeen Royal Infirmary, NHS Grampian, Aberdeen
| | | | - Rosemary J Hollick
- Aberdeen Centre for Arthritis & Musculoskeletal Health, University of Aberdeen.,Rheumatology Service, NHS Grampian
| | - Cosimo De Bari
- Aberdeen Centre for Arthritis & Musculoskeletal Health, University of Aberdeen.,Rheumatology Service, NHS Grampian
| | - Neil Basu
- Institute of Infection, Immunity & Inflammation, University of Glasgow, Glasgow, UK
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Robles-Vera I, de la Visitación N, Sánchez M, Gómez-Guzmán M, Jiménez R, Moleón J, González-Correa C, Romero M, Yang T, Raizada MK, Toral M, Duarte J. Mycophenolate Improves Brain-Gut Axis Inducing Remodeling of Gut Microbiota in DOCA-Salt Hypertensive Rats. Antioxidants (Basel) 2020; 9:E1199. [PMID: 33260593 DOI: 10.3390/antiox9121199] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 11/26/2020] [Accepted: 11/27/2020] [Indexed: 12/17/2022] Open
Abstract
Microbiota is involved in the host blood pressure (BP) regulation. The immunosuppressive drug mofetil mycophenolate (MMF) ameliorates hypertension. The present study analyzed whether MMF improves dysbiosis in mineralocorticoid-induced hypertension. Male Wistar rats were assigned to three groups: untreated (CTR), deoxycorticosterone acetate (DOCA)-salt, and DOCA treated with MMF for 4 weeks. MMF treatment reduced systolic BP, improved endothelial dysfunction, and reduced oxidative stress and inflammation in aorta. A clear separation in the gut bacterial community between CTR and DOCA groups was found, whereas the cluster belonging to DOCA-MMF group was found to be intermixed. No changes were found at the phylum level among all experimental groups. MMF restored the elevation in lactate-producing bacteria found in DOCA-salt joined to an increase in the acetate-producing bacteria. MMF restored the percentage of anaerobic bacteria in the DOCA-salt group to values similar to control rats. The improvement of gut dysbiosis was associated with an enhanced colonic integrity and a decreased sympathetic drive in the gut. MMF inhibited neuroinflammation in the paraventricular nuclei in the hypothalamus. This study demonstrates for the first time that MMF reduces gut dysbiosis in DOCA-salt hypertension models. This effect seems to be related to its capacity to improve gut integrity due to reduced sympathetic drive in the gut associated with reduced brain neuroinflammation.
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Sunderland A, Russ G, Sallustio B, Cervelli M, Joyce D, Ooi E, Jeffrey G, Boudville N, Chakera A, Dogra G, Chan D, Wong G, Lim WH. Effect of the proton-pump Inhibitor pantoprazole on MycoPhenolic ACid exposure in kidney and liver transplant recipienTs (IMPACT study): a randomized trial. Nephrol Dial Transplant 2020; 35:1060-1070. [PMID: 32516810 DOI: 10.1093/ndt/gfaa111] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [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: 01/30/2020] [Accepted: 03/31/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Mycophenolic acid (MPA) is widely utilized as an immunosuppressant in kidney and liver transplantation, with reports suggesting an independent relationship between MPA concentrations and adverse allograft outcome. Proton-pump inhibitors (PPIs) may have variable effects on the absorption of different MPA formulations leading to differences in MPA exposure. METHODS A multicentre, randomized, prospective, double-blind placebo-controlled cross-over study was conducted to determine the effect of the PPI pantoprazole on the MPA and its metabolite MPA-glucuronide (MPA-G) area under the curve (AUC) >12 h (MPA-AUC12 h) in recipients maintained on mycophenolate mofetil (MMF) or enteric-coated mycophenolate sodium (EC-MPS). We planned a priori to examine separately recipients maintained on MMF and EC-MPS for each pharmacokinetic parameter. The trial (and protocol) was registered with the Australian New Zealand Clinical Trials Registry on 24 March 2011, with the registration number of ACTRN12611000316909 ('IMPACT' study). RESULTS Of the 45 recipients screened, 40 (19 MMF and 21 EC-MPS) were randomized. The mean (standard deviation) recipient age was 58 (11) years with a median (interquartile range) time post-transplant of 43 (20-132) months. For recipients on MMF, there was a significant reduction in the MPA-AUC12 h [geometric mean (95% confidence interval) placebo: 53.9 (44.0-65.9) mg*h/L versus pantoprazole: 43.8 (35.6-53.4) mg*h/L; P = 0.004] when pantoprazole was co-administered compared with placebo. In contrast, co-administration with pantoprazole significantly increased MPA-AUC12 h [placebo: 36.1 (26.5-49.2) mg*h/L versus pantoprazole: 45.9 (35.5-59.3) mg*h/L; P = 0.023] in those receiving EC-MPS. Pantoprazole had no effect on the pharmacokinetic profiles of MPA-G for either group. CONCLUSIONS The co-administration of pantoprazole substantially reduced the bioavailability of MPA in patients maintained on MMF and had the opposite effect in patients maintained on EC-MPS, and therefore, clinicians should be cognizant of this drug interaction when prescribing the different MPA formulations.
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Affiliation(s)
- Andrew Sunderland
- Department of Renal Medicine, Sir Charles Gairdner Hospital, Perth, Australia
| | - Graeme Russ
- Department of Nephrology & Transplantation Services, Royal Adelaide Hospital, and University of Adelaide, Adelaide, Australia
| | - Benedetta Sallustio
- Discipline of Pharmacology, Adelaide Medical School, The University of Adelaide, Adelaide, Australia.,Department of Clinical Pharmacology, The Queen Elizabeth Hospital, Adelaide, Australia
| | - Matthew Cervelli
- Department of Pharmacy, Royal Adelaide Hospital, Adelaide, Australia
| | - David Joyce
- School of Biomedical Sciences, University of Western Australia, Perth, Australia.,Biochemistry and Toxicology, PathWest, Perth, Australia.,Faculty of Health and Medical Sciences, Medical School, University of Western Australia, Perth, Australia
| | - Esther Ooi
- School of Biomedical Sciences, University of Western Australia, Perth, Australia.,Faculty of Health and Medical Sciences, Medical School, University of Western Australia, Perth, Australia
| | - Gary Jeffrey
- Faculty of Health and Medical Sciences, Medical School, University of Western Australia, Perth, Australia.,Department of Hepatology Unit, Sir Charles Gairdner Hospital, Perth, Australia
| | - Neil Boudville
- Department of Renal Medicine, Sir Charles Gairdner Hospital, Perth, Australia.,Faculty of Health and Medical Sciences, Medical School, University of Western Australia, Perth, Australia
| | - Aron Chakera
- Department of Renal Medicine, Sir Charles Gairdner Hospital, Perth, Australia
| | - Gursharan Dogra
- Department of Renal Medicine, Sir Charles Gairdner Hospital, Perth, Australia
| | - Doris Chan
- Department of Renal Medicine, Sir Charles Gairdner Hospital, Perth, Australia
| | - Germaine Wong
- Sydney School of Public Health, University of Sydney, Sydney, Australia.,Centre for Transplant and Renal Research, Westmead Hospital, Sydney, Australia.,Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, Australia
| | - Wai H Lim
- Department of Renal Medicine, Sir Charles Gairdner Hospital, Perth, Australia.,Faculty of Health and Medical Sciences, Medical School, University of Western Australia, Perth, Australia
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