Home infusion program with enzyme replacement therapy for Fabry disease: The experience of a large Italian collaborative group

Fabry disease (FD) [OMIM 301500] is an X-linked lysosomal storage disorder caused by a deficiency of the lysosomal enzyme alpha-galactosidase A, resulting in progressive multisystem accumulation of globotriaosylceramide (Gb3). Although the introduction of Enzyme Replacement Therapy (ERT) resulted in a variety of clinical benefits, life-long intravenous (IV) treatment with ERT with an every other week schedule, may interfere with daily life activities and impact on QoL. We report here a multicentric, observational, longitudinal data analysis on a large cohort of 85 Italian FD patients (45 males, 40 females) from 11 out of 20 Italian regions, who received a cumulative number of 4269 home infusions of agalsidase alfa. For the whole cohort, the average duration of home therapy was 1 year and 11 months (range 3 months–4 years and 6 months), and during this period, compliance to treatment (number of infusions performed vs scheduled) reached 100%. The EQ-5 VAS scale was administered to patients to evaluate the self-reported QoL, 58% of patients showing an increase of EQ-5 VAS score at follow up compared to baseline (home treatment start) or remaining stable. A mild increase of average disease severity, measured through Mainz Severity Score Index (MSSI), was found during hospital treatment (p < 0,007), while it remained stable between the first home therapy infusion and last follow up. Interestingly, 4 out of 7 (57%) patients, showing an improvement in FD-related clinical status after starting home therapy, had previously a sub-optimal compliance to treatment during the period of hospital treatment management. Only 4 adverse non serious reactions (0,093%) were reported totally in 2 patients during home treatment.

We conclude that home infusions in eligible patients with FD are safe, contribute to improve treatment compliance and therapeutic clinical outcomes, and may have a positive impact on self-perceived QoL.

European League Against Rheumatism (EULAR) recommendations for the management of psoriatic arthritis with pharmacological therapies: 2015 update

BACKGROUND

Since the publication of the European League Against Rheumatism recommendations for the pharmacological treatment of psoriatic arthritis (PsA) in 2012, new evidence and new therapeutic agents have emerged. The objective was to update these recommendations.

METHODS

A systematic literature review was performed regarding pharmacological treatment in PsA. Subsequently, recommendations were formulated based on the evidence and the expert opinion of the 34 Task Force members. Levels of evidence and strengths of recommendations were allocated.

RESULTS

The updated recommendations comprise 5 overarching principles and 10 recommendations, covering pharmacological therapies for PsA from non-steroidal anti-inflammatory drugs (NSAIDs), to conventional synthetic (csDMARD) and biological (bDMARD) disease-modifying antirheumatic drugs, whatever their mode of action, taking articular and extra-articular manifestations of PsA into account, but focusing on musculoskeletal involvement. The overarching principles address the need for shared decision-making and treatment objectives. The recommendations address csDMARDs as an initial therapy after failure of NSAIDs and local therapy for active disease, followed, if necessary, by a bDMARD or a targeted synthetic DMARD (tsDMARD). The first bDMARD would usually be a tumour necrosis factor (TNF) inhibitor. bDMARDs targeting interleukin (IL)12/23 (ustekinumab) or IL-17 pathways (secukinumab) may be used in patients for whom TNF inhibitors are inappropriate and a tsDMARD such as a phosphodiesterase 4-inhibitor (apremilast) if bDMARDs are inappropriate. If the first bDMARD strategy fails, any other bDMARD or tsDMARD may be used.

CONCLUSIONS

These recommendations provide stakeholders with an updated consensus on the pharmacological treatment of PsA and strategies to reach optimal outcomes in PsA, based on a combination of evidence and expert opinion.

The natural history of uremic neuropathy

The results obtained by electrophysiological recording allow to discover the constant presence of alterations to the central and/or peripheral nervous system in the uremic syndrome. Thus, it becomes possible to demonstrate the existence of an actual 'uremic neuropathy'. Moreover, the results show the persistence and progression of uremic involvement in the course of dialytic treatment; only after kidney transplantation a return to normal takes place. Methodological and interpretative progress will allow us in the future to broaden our knowledge of uremia by providing a useful guide to therapeutic strategies.

[Effects of dose of erythropoiesis stimulating agents on cardiovascular outcomes, quality of life and costs of haemodialysis. the clinical evaluation of the DOSe of erythropoietins (C.E. DOSE) Trial]

BACKGROUND

Anaemia is a risk factor for death, adverse cardiovascular outcomes and poor quality of life in patients with chronic kidney disease (CKD). Erythropoietin Stimulating Agents (ESA) are the most used treatment option. In observational studies, higher haemoglobin (Hb) levels (around 11-13 g/dL) are associated with improved survival and quality of life compared to Hb levels around 9-10 g/dL. Randomized studies found that targeting higher Hb levels with ESA causes an increased risk of death, mainly due to adverse cardiovascular outcomes. It is possible that this is mediated by ESA dose rather than haemoglobin concentration, although this hypothesis has never been formally tested.

METHODS

We present the protocol of the Clinical Evaluation of the Dose of Erythropoietins (C.E. DOSE) trial, which will assess the benefits and harms of a high versus a low ESA dose therapeutic strategy for the management of anaemia of end stage kidney disease (ESKD). This is a randomized, prospective open label blinded end-point (PROBE) design trial due to enroll 900 haemodialysis patients. Patients will be randomized 1:1 to 4000 UI/week i. v. versus 18000 UI/week i. v. of epoetin alfa, beta or any other epoetin in equivalent doses. The primary outcome of the trial is a composite of cardiovascular events. In addition, quality of life and costs of these two strategies will be assessed. The study has been approved and funded by the Italian Agency of Drugs (Agenzia Italiana del Farmaco (AIFA)) within the 2006 funding plan for independent research on drugs (registered at www.clinicaltrials.gov (NCT00827021)).

Metabolic abnormalities associated with initiation of systemic treatment for psoriasis: evidence from the Italian Psocare Registry

OBJECTIVE

To evaluate variations in laboratory parameters and diagnoses of selected clinical conditions up to 16 weeks after starting a new systemic psoriasis treatment for Psocare Registry enrollees.

DESIGN

Prospective cohort study.

SETTING

Italian public referral centres for psoriasis treatment.

PATIENTS

First-time recipients (n = 10,539) of continuous systemic psoriasis treatment for at least 16 weeks.

MAIN OUTCOME MEASURE

Mean variations in (weeks 8 and 16) and proportions of patients reaching a clinically meaningful increase in serum levels (week 16) of total and low-density lipoprotein cholesterol, triglycerides, aspartate amino transferase, alanine amino transferase and creatinine, as well as week-16 cumulative incidences of new diagnoses of diabetes mellitus and arterial hypertension.

RESULTS

Mean cholesterol and triglyceride levels significantly increased in patients treated with acitretin or cyclosporine. Mean triglyceride levels also increased in efalizumab- and etanercept-treated patients. Mean transaminase values increased in methotrexate-treated patients, and mean aspartate amino transferase levels increased in infliximab-treated patients. The average serum creatinine value increased in cyclosporine-treated patients. Acitretin and cyclosporine were associated with risk of hypercholesterolaemia (odds ratios 1.51 and 1.34) and acitretin with risk of hypertriglyceridaemia (odds ratio 1.43). Methotrexate and infliximab were associated with risk of more than doubling the upper normal aspartate amino transferase (odds ratios 2.06 and 1.87) and alanine amino transferase (odds ratios 2.38 and 1.74) values. The relative risk of developing arterial hypertension and diabetes was increased for patients receiving cyclosporine (odds ratios 3.31 and 2.88).

CONCLUSION

Systemic treatments for psoriasis resulted in heterogeneous effects on the parameters analysed.

European League Against Rheumatism recommendations for the management of psoriatic arthritis with pharmacological therapies

BACKGROUND

Psoriatic arthritis (PsA) is a clinically heterogeneous disease. Clear consensual treatment guidance focused on the musculoskeletal manifestations of PsA would be advantageous. The authors present European League Against Rheumatism (EULAR) recommendations for the treatment of PsA with systemic or local (non-topical) symptomatic and disease-modifying antirheumatic drugs (DMARD).

METHODS

The recommendations are based on evidence from systematic literature reviews performed for non-steroidal anti-inflammatory drugs (NSAID), glucocorticoids, synthetic DMARD and biological DMARD. This evidence was discussed, summarised and recommendations were formulated by a task force comprising 35 representatives, and providing levels of evidence, strength of recommendations and levels of agreement.

RESULTS

Ten recommendations were developed for treatment from NSAID through synthetic DMARD to biological agents, accounting for articular and extra-articular manifestations of PsA. Five overarching principles and a research agenda were defined.

CONCLUSION

These recommendations are intended to provide rheumatologists, patients and other stakeholders with a consensus on the pharmacological treatment of PsA and strategies to reach optimal outcomes, based on combining evidence and expert opinion. The research agenda informs directions within EULAR and other communities interested in PsA.

Current psoriasis treatments in an Italian population and their association with socio-demographical and clinical features

BACKGROUND

Patient adherence is a key element for therapeutic success and represents a major concern for all healthcare professionals.

OBJECTIVE

Aim of our study was to assess the frequency of use of treatments currently available for psoriasis and its association with specific socio-demographical and clinical variables.

METHODS

The study population consisted of 1689 patients, aged 12-85 years. Information concerning socio-demographical variables, clinical features and the type of current treatment was collected. Items on patients' satisfaction of current treatments and of dermatologist-patient relationship were also included. The chi-squared test was used to estimate the association between the categorical variables, whereas Wilcoxon and Kruskal-Wallis tests were applied to the interval and ordinal variables. The Cochran-Mantel-Haenszel chi-squared trend test was used to evaluate the degree of satisfaction related to dermatologist-patient relationship.

RESULTS

Of the 1689 psoriatic patients, 54.1% did not use any treatments and 45.9% used at least one treatment. The use of drugs was significantly associated exclusively to severity of disease and affected body surface area. Systemic therapies, both traditional treatments and biological agents, were mainly used in patients with disease duration >10 years and disease severity. Treatment adherence was significantly associated to the degree of patient's satisfaction of his/her relationship with the dermatologist. Alternative treatment such as over the counter medications and acupuncture were used by 33% of patients.

CONCLUSION

The majority of psoriatic patients do not use any treatments. However, treatment adherence significantly increases when dermatologists clarify the treatment schedule, inform patients and meet the patients' needs.

European S3-guidelines on the systemic treatment of psoriasis vulgaris

Of the 131 studies on monotherapy or combination therapy assessed, 56 studies on the different forms of phototherapy fulfilled the criteria for inclusion in the guidelines. Approximately three-quarters of all patients treated with phototherapy attained at least a PASI 75 response after 4 to 6 weeks, and clearance was frequently achieved (levels of evidence 2 and 3). Phototherapy represents a safe and very effective treatment option for moderate to severe forms of psoriasis vulgaris. The onset of clinical effects occurs within 2 weeks. Of the unwanted side effects, UV erythema from overexposure is by far the most common and is observed frequently. With repeated or long-term use, the consequences of high, cumulative UV doses (such as premature aging of the skin) must be taken into consideration. In addition, carcinogenic risk is associated with oral PUVA and is probable for local PUVA and UVB. The practicability of the therapy is limited by spatial, financial, human, and time constraints on the part of the physician, as well as by the amount of time required by the patient. From the perspective of the cost-bearing institution, phototherapy has a good cost-benefit ratio. However, the potentially significant costs for, and time required of, the patient must be considered.

[Encapsulating sclerosing peritonitis: report of 2 cases]

SEP is an increasingly seen complication of CAPD; we have the occasion to see again this condition because two patients came under our observation. We have remarked the unknown etiology and pathogenesis, the difficult diagnosis and therapy, and the often poor prognosis.

["Banding" of the venous side of an arteriovenous fistula for hemodialysis complicated with steal syndrome: a clinical case]

The duration of an arteriovenous fistula has a limit. In fact there are some complications that compromise a good working of them. We have dealed on of these complications, a steal syndrome of an omero-cephalic fistula by a simple operation of "banding" using a ring of Teflon around the arterialized vein getting a good clinical result with a good preservation of the blood flow trans-fistula.

HCV in a group of chronic hemodialysis patients

Since HCV appears to be the major cause of post-transfusion non-A, non-B hepatitis in Italy, this study determines the presence of anti-HCV in a risk group. Among 26 patients, 9 were anti-HCV in a risk group. Among 26 patients, 9 were anti-HCV positive with the ELISA test and all of them were confirmed with the RIBA test of 2nd generation. Only 1 had a poussés movement of ALT levels. Hemodialyzed patients are reactive for HCV probably for the transfusional therapy.