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Curel CJM, Nobeli I, Thornton C. Leflunomide Treatment Does Not Protect Neural Cells following Oxygen-Glucose Deprivation (OGD) In Vitro. Cells 2024; 13:631. [PMID: 38607070 PMCID: PMC11011260 DOI: 10.3390/cells13070631] [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: 01/31/2024] [Revised: 03/25/2024] [Accepted: 03/29/2024] [Indexed: 04/13/2024] Open
Abstract
Neonatal hypoxia-ischemia (HI) affects 2-3 per 1000 live births in developed countries and up to 26 per 1000 live births in developing countries. It is estimated that of the 750,000 infants experiencing a hypoxic-ischemic event during birth per year, more than 400,000 will be severely affected. As treatment options are limited, rapidly identifying new therapeutic avenues is critical, and repurposing drugs already in clinical use offers a fast-track route to clinic. One emerging avenue for therapeutic intervention in neonatal HI is to target mitochondrial dysfunction, which occurs early in the development of brain injury. Mitochondrial dynamics are particularly affected, with mitochondrial fragmentation occurring at the expense of the pro-fusion protein Optic Atrophy (OPA)1. OPA1, together with mitofusins (MFN)1/2, are required for membrane fusion, and therefore, protecting their function may also safeguard mitochondrial dynamics. Leflunomide, an FDA-approved immunosuppressant, was recently identified as an activator of MFN2 with partial effects on OPA1 expression. We, therefore, treated C17.2 cells with Leflunomide before or after oxygen-glucose deprivation, an in vitro mimic of HI, to determine its efficacy as a neuroprotection and inhibitor of mitochondrial dysfunction. Leflunomide increased baseline OPA1 but not MFN2 expression in C17.2 cells. However, Leflunomide was unable to promote cell survival following OGD. Equally, there was no obvious effect on mitochondrial morphology or bioenergetics. These data align with studies suggesting that the tissue and mitochondrial protein profile of the target cell/tissue are critical for taking advantage of the therapeutic actions of Leflunomide.
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Affiliation(s)
- Claire J. M. Curel
- Department of Comparative Biomedical Sciences, Royal Veterinary College, London NW1 0TU, UK
| | - Irene Nobeli
- School of Natural Sciences, Institute of Structural and Molecular Biology, Birkbeck, University of London, London WC1E 7HX, UK
| | - Claire Thornton
- Department of Comparative Biomedical Sciences, Royal Veterinary College, London NW1 0TU, UK
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Zhang D, Xia B, Zhang X, Liang P, Hu X. Efficacy and safety of low-dose corticosteroids combined with leflunomide for progressive IgA nephropathy: a systematic review and meta-analysis. BMC Urol 2024; 24:56. [PMID: 38468247 PMCID: PMC10926645 DOI: 10.1186/s12894-024-01438-3] [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: 05/28/2023] [Accepted: 02/22/2024] [Indexed: 03/13/2024] Open
Abstract
BACKGROUND AND OBJECTIVE The effectiveness of immunosuppressive and corticosteroid treatments for Immunoglobulin A (IgA) nephropathy (IgAN) remains thoroughly evaluated. We undertook a meta-analysis to investigate the efficacy and safety of low-dose corticosteroids plus leflunomide for progressive IgA nephropathy. METHODS Eligible studies were obtained from PubMed, Embase, and Cochrane Library databases. We also searched the references of the included studies. Our protocol followed the preferred reporting items for systematic reviews and meta-analyses (PRISMA) checklist. Eligibility criteria were defined using a PICOS framework. RESULTS Our study included three articles presenting 342 patient cases. Findings revealed that low-dose corticosteroids combined with the leflunomide group were effective in relieving urine protein excretion (UPE) [mean difference (MD) = -0.35, 95% confidence interval (CI): -0.41 to -0.30, P < 0.00001] compared with the full-dose corticosteroids group. Regarding serum creatinine (SCr), estimated glomerular filtration rate (eGFR), complete remission rate, and overall response rate, there was no difference between the groups (p > 0.05). Regarding safety, low-dose corticosteroids combined with leflunomide significantly reduced the risk of serious adverse events [odds ratio (OR): 0.11, 95% CI: 0.01 to 0.91, P = 0.04]. Besides, no significant differences were observed between the two groups in the incidence of respiratory infection, abnormal liver function, diarrhea, herpes zoster, alopecia, pruritus, insomnia, pneumonia, diabetes, and urinary tract infection (P > 0.05). CONCLUSIONS Low-dose corticosteroids combined with leflunomide are a safe and effective treatment for progressive IgA nephropathy. TRIAL REGISTRATION The PROSPERO registration number is CRD42022361883.
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Affiliation(s)
- Dongxu Zhang
- Department of Urology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
- Institute of Urology, Capital Medical University, Beijing, China
| | - Bowen Xia
- Department of Urology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
- Institute of Urology, Capital Medical University, Beijing, China
| | - Xin Zhang
- Department of Urology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
- Institute of Urology, Capital Medical University, Beijing, China
| | - Pu Liang
- Beijing Key Laboratory of Emerging Infectious Diseases, Institute of Infectious Diseases, Beijing Ditan Hospital, Capital Medical University, Beijing, China.
- Beijing Institute of Infectious Diseases, Beijing, China.
- National Center for Infectious Diseases, Beijing Ditan Hospital, Capital Medical University, Beijing, 100015, P.R. China.
| | - Xiaopeng Hu
- Department of Urology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China.
- Institute of Urology, Capital Medical University, Beijing, China.
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Siddiqui B, Ur Rehman A, Gul R, Chaudhery I, Shah KU, Ahmed N. Folate decorated chitosan-chondroitin sulfate nanoparticles loaded hydrogel for targeting macrophages against rheumatoid arthritis. Carbohydr Polym 2024; 327:121683. [PMID: 38171692 DOI: 10.1016/j.carbpol.2023.121683] [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: 07/17/2023] [Revised: 11/14/2023] [Accepted: 12/08/2023] [Indexed: 01/05/2024]
Abstract
Inflammatory cell infiltration, particularly macrophages, plays a major contribution to the pathogenesis of Rheumatoid Arthritis (RA). Exploiting the overexpression of folate receptors (FR-β) on these recruited macrophages has gained significant attraction for ligand-targeted delivery. Leflunomide (LEF), being an immunomodulatory agent is considered the cornerstone of the therapy, however, its oral efficacy is impeded by low solubility and escalating adverse effects profile. Therefore, in the present work, we developed Folate-conjugated chitosan-chondroitin sulfate nanoparticles encapsulating LEF for selective targeting at inflammatory sites in RA. For this purpose, the folate group was first conjugated with the chitosan polymer. After which, Folate Leflunomide Nanoparticles (FA-LEF-NPs) were synthesized through the ionotropic gelation method by employing FA-CHI and CHS. The polymers CHI and CHS were also presented with innate anti-inflammatory and anti-rheumatic attributes that were helpful in provision of synergistic effects to the formulation. These nanoparticles were further fabricated into a hydrogel, employing almond oil (A.O) as a permeation enhancer. The in vivo studies justified the preferential accumulation of FA-conjugated nanoparticles at inflamed joints more than any other organ in comparison to the free LEF and LEF-NPs formulation. The FA-LEF-NPs loaded hydrogel also ascertained a minimal adverse effect profile with an improvement of inflammatory cytokines expression.
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Affiliation(s)
- Bazla Siddiqui
- Department of Pharmacy, Quaid-i-Azam University, 45320 Islamabad, Pakistan
| | - Asim Ur Rehman
- Department of Pharmacy, Quaid-i-Azam University, 45320 Islamabad, Pakistan
| | - Rabia Gul
- Shifa College of Pharmaceutical Sciences, Shifa Tameer e Millat University, Islamabad, Pakistan
| | - Iqra Chaudhery
- Department of Pharmacy, Quaid-i-Azam University, 45320 Islamabad, Pakistan
| | - Kifayat Ullah Shah
- Department of Pharmacy, Quaid-i-Azam University, 45320 Islamabad, Pakistan
| | - Naveed Ahmed
- Department of Pharmacy, Quaid-i-Azam University, 45320 Islamabad, Pakistan.
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Yang JO, Dry S, Weiss GA. Leflunomide-induced collagenous colitis: a case report and literature review. Clin J Gastroenterol 2024; 17:65-68. [PMID: 37796437 PMCID: PMC10830581 DOI: 10.1007/s12328-023-01862-2] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Accepted: 09/11/2023] [Indexed: 10/06/2023]
Abstract
We describe a patient with rheumatoid arthritis and Hashimoto's thyroiditis who developed chronic diarrhea and subsequently diagnosed with collagenous colitis (CC) 5 years after leflunomide initiation. Cessation of leflunomide resulted in complete resolution of diarrhea within 2 months. Although rare, leflunomide-induced colitis should be considered in patients with otherwise unexplained chronic diarrhea. Diagnosis is challenging as symptom onset can occur many years after leflunomide initiation, but diarrheal symptoms typically resolve within weeks to months of stopping the instigating drug.
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Affiliation(s)
- Jamie O Yang
- UCLA Department of Internal Medicine, Los Angeles, CA, USA.
| | - Sarah Dry
- UCLA Department of Pathology & Lab Sciences, Los Angeles, CA, USA
| | - Guy A Weiss
- Vatche and Tamar Manoukian Division of Digestive Diseases, UCLA David Geffen School of Medicine, Los Angeles, CA, USA
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Qiu L, Chen P, Ou C, Deng J, Huang Z, Lin Z, Ma Q, Huang X, Yu L, Ran H, Liu W. Long-term efficacy and safety of leflunomide combined with low-dose prednisone in treatment of myasthenia gravis: a retrospective study. Acta Neurol Belg 2024; 124:175-182. [PMID: 37656361 DOI: 10.1007/s13760-023-02367-y] [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: 03/03/2023] [Accepted: 08/16/2023] [Indexed: 09/02/2023]
Abstract
BACKGROUND Leflunomide and low-dose prednisone (0.25 mg/kg/day) (LEF + Pred) rapidly improved the clinical symptoms of myasthenia gravis (MG) patients. Here, we aimed to analyze the long-term efficacy and safety of LEF + Pred in MG patients. METHODS This retrospective cohort study enrolled MG patients treated with LEF + Pred in our center between 2012 and 2020. We reviewed all the MG patients continuously treated with LEF + Pred for more than 1 year. MG activities of daily living (MG-ADL) profile score and quantitative MG scale (QMG) score in each clinical follow-up visits were collected for the efficacy analysis. The laboratory testing results of MG patients, the relevant chief complain and physical examination results in each follow-up visits were collected for the safety evaluation. RESULTS In total, 103 patients were examined. Effective treatment was achieved in 58.3% of patients after 1 month and in 88.4% after 12 months. Overall, 63 patients (61.2%) exhibited only minimal manifestations after 12 months of treatment. The average MG-ADL score decreased from 6.0 to 1.0, while the average QMG score decreased from 10.0 to 4.0. The decrease in MG-ADL and QMG scores of patients with generalized MG was more pronounced than those of the ocular MG patients. Patients with MG who had a thymectomy had a smaller decrease in MG-ADL and QMG scores than those who did not have a thymectomy. Sixteen adverse effects associated with LEF + Pred were observed; none was severe. CONCLUSIONS Long-term LEF + Pred therapy could considerably improve clinical symptoms in MG patients while being well tolerated with just few side effects.
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Affiliation(s)
- Li Qiu
- Department of Neurology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Diagnosis and Treatment of Major Neurological Diseases, Guangzhou, China
- National Key Clinical Department and Key Discipline of Neurology, Guangzhou, China
| | - Pei Chen
- Department of Neurology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Diagnosis and Treatment of Major Neurological Diseases, Guangzhou, China
- National Key Clinical Department and Key Discipline of Neurology, Guangzhou, China
| | - Changyi Ou
- Department of Neurology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Diagnosis and Treatment of Major Neurological Diseases, Guangzhou, China
- National Key Clinical Department and Key Discipline of Neurology, Guangzhou, China
| | - Juan Deng
- Department of Neurology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Diagnosis and Treatment of Major Neurological Diseases, Guangzhou, China
- National Key Clinical Department and Key Discipline of Neurology, Guangzhou, China
| | - Zhidong Huang
- Department of Neurology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Diagnosis and Treatment of Major Neurological Diseases, Guangzhou, China
- National Key Clinical Department and Key Discipline of Neurology, Guangzhou, China
| | - Zhongqiang Lin
- Department of Neurology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Diagnosis and Treatment of Major Neurological Diseases, Guangzhou, China
- National Key Clinical Department and Key Discipline of Neurology, Guangzhou, China
| | - Qian Ma
- Department of Neurology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Diagnosis and Treatment of Major Neurological Diseases, Guangzhou, China
- National Key Clinical Department and Key Discipline of Neurology, Guangzhou, China
| | - Xin Huang
- Department of Neurology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Diagnosis and Treatment of Major Neurological Diseases, Guangzhou, China
- National Key Clinical Department and Key Discipline of Neurology, Guangzhou, China
| | - Lu Yu
- Department of Neurology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Diagnosis and Treatment of Major Neurological Diseases, Guangzhou, China
- National Key Clinical Department and Key Discipline of Neurology, Guangzhou, China
| | - Hao Ran
- School of Pharmaceutical Sciences, Sun Yat-sen University, Guangzhou, China.
| | - Weibin Liu
- Department of Neurology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.
- Guangdong Provincial Key Laboratory of Diagnosis and Treatment of Major Neurological Diseases, Guangzhou, China.
- National Key Clinical Department and Key Discipline of Neurology, Guangzhou, China.
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He WJ, Wang J, Liu N, Li GY, Zhu XW, Yao L, Liu LL. The efficacy and safety of hydroxychloroquine versus leflunomide in patients with IgA nephropathy: a single-center experience. J Nephrol 2024:10.1007/s40620-023-01839-x. [PMID: 38225440 DOI: 10.1007/s40620-023-01839-x] [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: 07/18/2023] [Accepted: 11/18/2023] [Indexed: 01/17/2024]
Abstract
PURPOSE To date, our understanding of IgA nephropathy (IgAN) pathophysiology has remained incomplete; therefore, treatment remains largely empiric, and the efficacy and safety of immunosuppressants remain controversial. We aimed to assess the efficacy and safety of hydroxychloroquine and leflunomide therapy in a retrospective cohort of patients with IgAN. METHODS We screened the IgAN registration database in our department, and a total of 159 kidney patients with biopsy-confirmed IgAN were enrolled, with 57 patients receiving hydroxychloroquine plus a renin-angiotensin system inhibitor (hydroxychloroquine group), 52 patients receiving leflunomide plus a renin-angiotensin system inhibitor (leflunomide group), and 50 patients receiving only a renin-angiotensin system inhibitor (renin-angiotensin system inhibitor-only group). Changes in proteinuria, hematuria, and the estimated glomerular filtration rate (eGFR), as well as adverse events, were analyzed during the follow-up period. RESULTS At the end of 6-month follow-up, proteinuria significantly decreased by 70.36 (57.54, 79.33)%, 57.29 (46.79, 67.29)% and 41.20 (25.76, 48.94)% in the hydroxychloroquine, leflunomide and renin-angiotensin system inhibitor-only groups, respectively, compared to baseline (all P values < 0.001). Hematuria significantly decreased by 71.07 (56.48, 82.47)% in the leflunomide group (P < 0.001). The eGFR improved by 3.72 ± 2.97%, 3.16 ± 2.00% and 1.91 ± 2.41%, respectively, in the hydroxychloroquine, leflunomide and renin-angiotensin system inhibitor-only groups, but without statistical significance. No serious adverse events occurred during the follow-up period. CONCLUSION Both hydroxychloroquine combined with a renin-angiotensin system inhibitor and leflunomide combined with a renin-angiotensin system inhibitor were more effective than a renin-angiotensin system inhibitor alone in improving proteinuria in IgAN patients. Hydroxychloroquine was more effective in reducing proteinuria, and leflunomide showed superiority in reducing hematuria. Our results need to be verified in large-scale randomized controlled trials.
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Affiliation(s)
- Wei-Jie He
- Department of Nephrology, The First Affiliated Hospital of China Medical University, 155 Nan Jing North Street, He Ping District, Shenyang, 110001, Liaoning, China
| | - Juan Wang
- Department of Nephrology, The First Affiliated Hospital of China Medical University, 155 Nan Jing North Street, He Ping District, Shenyang, 110001, Liaoning, China
| | - Nan Liu
- Department of Nephrology, The First Affiliated Hospital of China Medical University, 155 Nan Jing North Street, He Ping District, Shenyang, 110001, Liaoning, China
| | - Gu-Yue Li
- Department of Pharmacy, The First Hospital of China Medical University, Shenyang, 110001, China
| | - Xin-Wang Zhu
- Department of Nephrology, The First Affiliated Hospital of China Medical University, 155 Nan Jing North Street, He Ping District, Shenyang, 110001, Liaoning, China
| | - Li Yao
- Department of Nephrology, The First Affiliated Hospital of China Medical University, 155 Nan Jing North Street, He Ping District, Shenyang, 110001, Liaoning, China
| | - Lin-Lin Liu
- Department of Nephrology, The First Affiliated Hospital of China Medical University, 155 Nan Jing North Street, He Ping District, Shenyang, 110001, Liaoning, China.
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Venetsanopoulou AI, Voulgari PV, Drosos AA. Advances in non-biological drugs for the treatment of rheumatoid arthritis. Expert Opin Pharmacother 2024; 25:45-53. [PMID: 38126739 DOI: 10.1080/14656566.2023.2297798] [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: 11/01/2023] [Accepted: 12/18/2023] [Indexed: 12/23/2023]
Abstract
INTRODUCTION Rheumatoid arthritis (RA) is a complex autoimmune disease that affects millions of people worldwide, with a systemic impact. This review explores the role of non-biological conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) in its management. AREAS COVERED We discuss the effectiveness and safety of key csDMARDs such as Nonsteroidal anti-inflammatory drugs, corticosteroids, Hydroxychloroquine, Sulfasalazine, Methotrexate, and Leflunomide in relieving symptoms and slowing the progression of the disease. We also highlight the importance of combination therapy using csDMARDs, supported by clinical studies demonstrating the benefits of various csDMARD combinations. Early intervention with these drugs is emphasized to prevent joint damage, improve clinical symptoms, and enhance patient outcomes. EXPERT OPINION Overall, csDMARDs have proven pivotal in managing RA, providing cost-effective and versatile treatment options. We acknowledge the advantages of biologics but highlight the associated challenges, making the choice between non-biological and biological drugs a personalized decision. This comprehensive overview aims to provide a deeper understanding of RA treatment strategies, contributing to improving the quality of life for patients with this chronic condition.
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Affiliation(s)
- Aliki I Venetsanopoulou
- Department of Rheumatology, School of Health Sciences, Faculty of Medicine, University of Ioannina, Ioannina, Greece
| | - Paraskevi V Voulgari
- Department of Rheumatology, School of Health Sciences, Faculty of Medicine, University of Ioannina, Ioannina, Greece
| | - Alexandros A Drosos
- Department of Rheumatology, School of Health Sciences, Faculty of Medicine, University of Ioannina, Ioannina, Greece
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Kim SH, Oh YI, Park SM, An JH, Kim TH, Kim SS, Ah JG, Seo KW, Youn HY. Retrospective evaluation of prognosis and survival with various immunosuppressants in 82 dogs diagnosed with meningoencephalitis of unknown etiology (2010-2021). BMC Vet Res 2023; 19:269. [PMID: 38087262 PMCID: PMC10714563 DOI: 10.1186/s12917-023-03800-3] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 10/30/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND Meningoencephalomyelitis of unknown etiology (MUE) is a comprehensive term for non-infectious inflammatory brain diseases of the central nervous system (CNS) caused by abnormal autoimmune responses. This study aims to compare the differences in survival and clinical response of MUE according to the adjuvant immunosuppressant use. Medical records of 82 dogs diagnosed with MUE were reviewed retrospectively. RESULTS The overall survival time was 769 days (range 14-2687 days). The median survival time for each adjunctive was: leflunomide 1035 days (range 126-2163 days), mycophenolate mofetil 865 days (range 39-2191 days), cyclosporin 441 days (range 11-2176 days), cytosine arabinoside 754 days (range 6-1898 days) and a combination of mycophenolate mofetil and cytosine arabinoside 132 days (range 23-1227 days). There was no significant difference in the incidence rate of adverse events according to the immunosuppressants, but moderate to severe anemia was confirmed in 3 patients (18.7%) in the leflunomide group. CONCLUSIONS The survival time and response rate of MUE dogs differed depending on which adjunctive immunosuppressants were used. Leflunomide showed a long survival time and a relatively good response rate in dogs with MUE. However, a large-scale further study with standardized doses of immunosuppressants and supportive treatment and constant monitoring interval is needed.
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Affiliation(s)
- So-Hee Kim
- Laboratory of Veterinary Internal Medicine, Department of Veterinary Clinical Science, College of Veterinary Medicine, Seoul National University, Seoul, 00826, Republic of Korea
| | - Ye-In Oh
- Department of Veterinary Internal Medicine, College of Veterinary Medicine, Kyungpook National University, Daegu, 41566, Republic of Korea
| | - Su-Min Park
- Laboratory of Veterinary Internal Medicine, Department of Veterinary Clinical Science, College of Veterinary Medicine, Seoul National University, Seoul, 00826, Republic of Korea
| | - Ju Hyun An
- Department of Veterinary Emergency and Critical Care Medicine and Institute of Veterinary Science, College of Veterinary Medicine, Kangwon National University, Chuncheon-si, 24341, Republic of Korea
| | - Tae-Hee Kim
- Laboratory of Veterinary Internal Medicine, Department of Veterinary Clinical Science, College of Veterinary Medicine, Seoul National University, Seoul, 00826, Republic of Korea
| | - Sung-Soo Kim
- VIP Animal Medical Center KR, Seoul, 02830, Republic of Korea
| | - Jae-Gon Ah
- VIP Animal Medical Center KR, Seoul, 02830, Republic of Korea
| | - Kyoung-Won Seo
- Laboratory of Veterinary Internal Medicine, Department of Veterinary Clinical Science, College of Veterinary Medicine, Seoul National University, Seoul, 00826, Republic of Korea
| | - Hwa-Young Youn
- Laboratory of Veterinary Internal Medicine, Department of Veterinary Clinical Science, College of Veterinary Medicine, Seoul National University, Seoul, 00826, Republic of Korea.
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Alothman R, Yeung J, Waterman E, Lepik C, Amiri N. Leflunomide exposure through second trimester of pregnancy: A case report. Birth Defects Res 2023; 115:1566-1569. [PMID: 37462087 DOI: 10.1002/bdr2.2221] [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: 01/07/2023] [Revised: 04/25/2023] [Accepted: 06/23/2023] [Indexed: 10/03/2023]
Abstract
Leflunomide is a commonly used disease modifying antirheumatic agent. However, its use is contraindicated in pregnancy. The American College of Rheumatology (ACR) guidelines recommend discontinuing Leflunomide at least 24 months before conception. If a woman is found to be pregnant while on Leflunomide, ACR suggests close monitoring and cholestyramine washout. We describe a case of a patient with a history of juvenile idiopathic arthritis who was on Leflunomide throughout the first and second trimester of her pregnancy. A cholestyramine washout regimen was started but not completed. The patient was induced at 37 weeks of gestation due to non-reassuring fetal heart rate. She ultimately delivered a healthy baby via emergency cesarian section.
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Affiliation(s)
- Rawan Alothman
- Division of Rheumatology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - James Yeung
- Division of Rheumatology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Elizabeth Waterman
- Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Christa Lepik
- Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Neda Amiri
- Division of Rheumatology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Arthritis Research Canada, Vancouver, British Columbia, Canada
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Nashaat D, Elsabahy M, Hassanein KMA, El-Gindy GA, Ibrahim EH. Development and in vivo evaluation of therapeutic phytosomes for alleviation of rheumatoid arthritis. Int J Pharm 2023; 644:123332. [PMID: 37625602 DOI: 10.1016/j.ijpharm.2023.123332] [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: 03/20/2023] [Revised: 07/12/2023] [Accepted: 08/17/2023] [Indexed: 08/27/2023]
Abstract
Rheumatoid arthritis (RA) is a chronic inflammatory autoimmune disease associated with progressive articular damage, functional loss and comorbidity. Conventional RA therapy requires frequent dosing and prolonged use, and usually results in poor efficacy and severe toxicity. In the current study, for the first time, we describe a combination strategy using phytosomes co-loaded with curcumin (CUR) and leflunomide (LEF) to improve the clinical outcomes of RA therapy. Exploiting 23 factorial design, various compositions of CUR and LEF co-loaded phytosomes (CUR/LEF-phytosomes) were successfully prepared and were extensively characterized (e.g., particle size, zeta potential, drugs encapsulation efficiency, morphology, DSC, FTIR and release kinetics). The optimal CUR/LEF-loaded phytosomes (F2) demonstrated high stability and spherical morphology with a particle size of ca. 760 nm and negative zeta potential value of - 55.7, high entrapment for both drugs, and sustained release profile of the entrapped medications. In vivo, oral administration of the CUR/LEF-phytosomes (F2) in arthritic rats resulted in significant reduction of paw swelling and inflammatory markers, compared to the free drugs and their physical mixture. Histopathological examination revealed significant improvement in phytosomes-treated animal group with no signs of arthritis. CUR/LEF-loaded phytosomes provide an auspicious strategy for alleviation of RA.
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Affiliation(s)
- Dalia Nashaat
- Department of Pharmaceutics, Faculty of Pharmacy, Assiut University, Assiut 71515, Egypt
| | - Mahmoud Elsabahy
- Department of Pharmaceutics, Faculty of Pharmacy, Assiut University, Assiut 71515, Egypt; School of Biotechnology and BUC Research Center, Badr University in Cairo, Badr City, Cairo 11829, Egypt.
| | - Khaled M A Hassanein
- Pathology and Clinical Pathology Department, Faculty of Veterinary Medicine, Assiut University, Assiut 71526, Egypt
| | - Gamal A El-Gindy
- Department of Pharmaceutics, Faculty of Pharmacy, Assiut University, Assiut 71515, Egypt
| | - Ehsan H Ibrahim
- Department of Pharmaceutics, Faculty of Pharmacy, Assiut University, Assiut 71515, Egypt
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Chen Y, Wang Q, Liu H, Jin L, Feng X, Dai B, Chen M, Xin F, Wei T, Bai B, Fan Z, Li J, Yao Y, Liao R, Zhang J, Jin X, Fu L. The prognostic value of whole-genome DNA methylation in response to Leflunomide in patients with Rheumatoid Arthritis. Front Immunol 2023; 14:1173187. [PMID: 37744384 PMCID: PMC10513488 DOI: 10.3389/fimmu.2023.1173187] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 08/14/2023] [Indexed: 09/26/2023] Open
Abstract
Objective Although Leflunomide (LEF) is effective in treating rheumatoid arthritis (RA), there are still a considerable number of patients who respond poorly to LEF treatment. Till date, few LEF efficacy-predicting biomarkers have been identified. Herein, we explored and developed a DNA methylation-based predictive model for LEF-treated RA patient prognosis. Methods Two hundred forty-five RA patients were prospectively enrolled from four participating study centers. A whole-genome DNA methylation profiling was conducted to identify LEF-related response signatures via comparison of 40 samples using Illumina 850k methylation arrays. Furthermore, differentially methylated positions (DMPs) were validated in the 245 RA patients using a targeted bisulfite sequencing assay. Lastly, prognostic models were developed, which included clinical characteristics and DMPs scores, for the prediction of LEF treatment response using machine learning algorithms. Results We recognized a seven-DMP signature consisting of cg17330251, cg19814518, cg20124410, cg21109666, cg22572476, cg23403192, and cg24432675, which was effective in predicting RA patient's LEF response status. In the five machine learning algorithms, the support vector machine (SVM) algorithm provided the best predictive model, with the largest discriminative ability, accuracy, and stability. Lastly, the AUC of the complex model(the 7-DMP scores with the lymphocyte and the diagnostic age) was higher than the simple model (the seven-DMP signature, AUC:0.74 vs 0.73 in the test set). Conclusion In conclusion, we constructed a prognostic model integrating a 7-DMP scores with the clinical patient profile to predict responses to LEF treatment. Our model will be able to effectively guide clinicians in determining whether a patient is LEF treatment sensitive or not.
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Affiliation(s)
- Yulan Chen
- Department of Clinical Epidemiology and Evidence-Based Medicine, the First Affiliated Hospital, China Medical University, Shenyang, China
| | - Qiao Wang
- Department of Clinical Epidemiology and Evidence-Based Medicine, the First Affiliated Hospital, China Medical University, Shenyang, China
| | - Haina Liu
- Department of Rheumatology, The First Affiliated Hospital, China Medical University, Shenyang, China
| | - Lei Jin
- Department of Rheumatology, ShengJing Hospital Affiliated of China Medical University, Shenyang, China
| | - Xin Feng
- Department of Rheumatology, First Affiliated Hospital of Jinzhou Medical University, Jinzhou, China
| | - Bingbing Dai
- Department of Rheumatology and Immunology, Dalian Municipal Central Hospital, Dalian, China
| | - Meng Chen
- Department of Clinical Epidemiology and Evidence-Based Medicine, the First Affiliated Hospital, China Medical University, Shenyang, China
| | - Fangran Xin
- Department of Clinical Epidemiology and Evidence-Based Medicine, the First Affiliated Hospital, China Medical University, Shenyang, China
| | - Tingting Wei
- Department of Clinical Epidemiology and Evidence-Based Medicine, the First Affiliated Hospital, China Medical University, Shenyang, China
| | - Bingqing Bai
- Department of Clinical Epidemiology and Evidence-Based Medicine, the First Affiliated Hospital, China Medical University, Shenyang, China
| | - Zhijun Fan
- Department of Clinical Epidemiology and Evidence-Based Medicine, the First Affiliated Hospital, China Medical University, Shenyang, China
| | - Jiahui Li
- Department of Clinical Epidemiology and Evidence-Based Medicine, the First Affiliated Hospital, China Medical University, Shenyang, China
| | - Yuxin Yao
- Department of Clinical Epidemiology and Evidence-Based Medicine, the First Affiliated Hospital, China Medical University, Shenyang, China
| | - Ruobing Liao
- Department of Clinical Epidemiology and Evidence-Based Medicine, the First Affiliated Hospital, China Medical University, Shenyang, China
| | - Jintao Zhang
- Department of Rheumatology and Immunology, Dalian Municipal Central Hospital, Dalian, China
| | - Xiangnan Jin
- Department of Rheumatology, First Affiliated Hospital of Jinzhou Medical University, Jinzhou, China
| | - Lingyu Fu
- Department of Clinical Epidemiology and Evidence-Based Medicine, the First Affiliated Hospital, China Medical University, Shenyang, China
- Department of Medical Record Management Center, the First Affiliated Hospital, China Medical University, Shenyang, China
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12
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Machaj F, Rosik J, Szostak B, Malinowski D, Safranow K, Olędzka G, Wiechec E, Pawlik A. The association between CYB5A gene rs1790834 polymorphism and clinical improvement after 6 months of leflunomide treatment in women with rheumatoid arthritis. Clin Rheumatol 2023; 42:2477-2483. [PMID: 37289314 DOI: 10.1007/s10067-023-06653-1] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 05/15/2023] [Accepted: 05/26/2023] [Indexed: 06/09/2023]
Abstract
INTRODUCTION/OBJECTIVES Rheumatoid arthritis (RA) is a disease affecting around 1% of the population in developed countries and can be treated with leflunomide. The higher prevalence of RA among women and numerous previous studies suggested the crucial role of sex hormones. Cytochrome CYB5A regulates the synthesis of androgens. Therefore, the aim of this study was to determine the association between common CYB5A gene polymorphism and the response to leflunomide in women with RA. METHODS This study included 111 patients. All of them received oral leflunomide monotherapy at a dose of 20 mg daily. Women were genotyped for the presence of CYB5A rs1790834 polymorphism and evaluated monthly for 6 months following the initiation of treatment. RESULTS After 6 months of therapy, patients with the GG genotype had higher DAS28 values and less improvement in DAS28 compared to patients with the GA and AA genotypes (p = 0.04). No statistically significant differences were found in relation to other disease activity parameters. CONCLUSIONS The results of the current study suggest a possible association of the CYB5A rs1790834 polymorphism with some disease activity parameters in RA patients treated with leflunomide during the initial therapy period. However, confirmation of the effect of this polymorphism on the efficacy of leflunomide treatment requires further studies. Key Points • Leflunomide is the synthetic disease-modifying anti-rheumatic drug used in the therapy of rheumatoid arthritis. • CYB5A rs1790834 gene polymorphism may influence the clinical improvement after 6 months of leflunomide treatment in women with rheumatoid arthritis.
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Affiliation(s)
- Filip Machaj
- Department of Physiology, Pomeranian Medical University, 70-111, Szczecin, Poland
- Department of Medical Biology, Medical University of Warsaw, 00-575, Warsaw, Poland
| | - Jakub Rosik
- Department of Physiology, Pomeranian Medical University, 70-111, Szczecin, Poland
| | - Bartosz Szostak
- Department of Physiology, Pomeranian Medical University, 70-111, Szczecin, Poland
| | - Damian Malinowski
- Department of Pharmacokinetics and Therapeutic Drug Monitoring, Pomeranian Medical University, 70-111, Szczecin, Poland
| | - Krzysztof Safranow
- Department of Biochemistry and Medical Chemistry, Pomeranian Medical University, 70-111, Szczecin, Poland
| | - Gabriela Olędzka
- Department of Medical Biology, Medical University of Warsaw, 00-575, Warsaw, Poland
| | - Emilia Wiechec
- Division of Cell Biology, Department of Biomedical and Clinical Sciences, Linköping University, 581 85, Linköping, Sweden
- Faculty of Medicine, Academy of Silesia, 40-555, Katowice, Poland
| | - Andrzej Pawlik
- Department of Physiology, Pomeranian Medical University, 70-111, Szczecin, Poland.
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Ravi GC, Nitha T, Greeshma PG, Uthaiah S, Famida PA, Nair RR, Aniketh VR. Kimura Disease in an Adult Indian Female, A Rare Presentation: A Novel Treatment with a Review of Literature. Indian J Otolaryngol Head Neck Surg 2023; 75:2394-2399. [PMID: 37636677 PMCID: PMC10447749 DOI: 10.1007/s12070-023-03664-x] [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: 01/16/2023] [Accepted: 03/03/2023] [Indexed: 03/31/2023] Open
Abstract
Kimura disease (KD) is a chronic inflammatory disorder, which is quite rare and has an unclear and much debated etiology. KD is characterized by painless, nodular, subcutaneous swellings along with lymphadenopathy, encountered in the head and neck region more often. It is also known to affect major salivary glands. It is also associated with elevated Immunoglobulins (IgE) and peripheral blood and tissue eosinophilia. Kimura disease generally affects young Asian males. There is considerable difficulty in arriving at clinical diagnosis and often it is frustrating to both patients and the treating physicians because of the difficulty in its management. We are presenting and reporting a case of Kimura disease in a young adult Indian female patient who presented with a swelling in the left parotid region. We have successfully managed this patient medically with a unique combination of drugs, most of which have already been tried and reported in literature by various authors.
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Affiliation(s)
- G. C. Ravi
- Department of Otorhinolaryngology, Sri Siddhartha Institute of Medical Sciences, T Begur, Nelamangala Taluk, Bangalore Rural District, 562123 India
- Bangalore, India
| | - T. Nitha
- Department of Otorhinolaryngology, Adichunchanagiri Institute of Medical Sciences, BG Nagara, Nagamangala Taluk, Mandya District, 571448 India
| | - P. G. Greeshma
- Department of Otorhinolaryngology, Adichunchanagiri Institute of Medical Sciences, BG Nagara, Nagamangala Taluk, Mandya District, 571448 India
| | | | - P. A. Famida
- Department of Otorhinolaryngology, Adichunchanagiri Institute of Medical Sciences, BG Nagara, Nagamangala Taluk, Mandya District, 571448 India
| | - Reshma Radhakrishnan Nair
- Department of Otorhinolaryngology, Adichunchanagiri Institute of Medical Sciences, BG Nagara, Nagamangala Taluk, Mandya District, 571448 India
| | - V. R. Aniketh
- Department of Otorhinolaryngology, Adichunchanagiri Institute of Medical Sciences, BG Nagara, Nagamangala Taluk, Mandya District, 571448 India
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Couture-Lapointe C, Grenier PO, Bessette L, Veillette H. Late onset leflunomide-induced cutaneous ulcers in a seronegative arthritis patient: A case report. SAGE Open Med Case Rep 2023; 11:2050313X231195480. [PMID: 37654548 PMCID: PMC10467160 DOI: 10.1177/2050313x231195480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 06/01/2023] [Indexed: 09/02/2023] Open
Abstract
The differential diagnosis for chronic cutaneous ulcers is wide. Once the common causes have been excluded, infrequent ones, including drugs, should be considered. We report the case of a 67 year old woman with multiple ulcers not responding to conventional treatment. Multiple investigations including laboratory testing, skin biopsies and tissue cultures were negative. A few cases of leflunomide-induced cutaneous ulcers are reported in the literature. Our patient was on this drug for 12 years. Discontinuation of leflunomide led to ulcers resolution. This is the longest reported time interval between leflunomide initiation and ulceration onset.
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Affiliation(s)
| | - Pierre-Olivier Grenier
- Division of Dermatology, CHU de Québec, Laval University, Quebec, QC, Canada
- Dermatology Department, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Louis Bessette
- Division of Rheumatology, CHU de Québec, Laval University, Quebec, QC, Canada
| | - Hélène Veillette
- Division of Dermatology, CHU de Québec, Laval University, Quebec, QC, Canada
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Zewail MB, El-Gizawy SA, Asaad GF, Shabana ME, El-Dakroury WA. Chitosan coated clove oil-based nanoemulsion: An attractive option for oral delivery of leflunomide in rheumatoid arthritis. Int J Pharm 2023; 643:123224. [PMID: 37451327 DOI: 10.1016/j.ijpharm.2023.123224] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [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: 05/13/2023] [Revised: 06/25/2023] [Accepted: 07/11/2023] [Indexed: 07/18/2023]
Abstract
Rheumatoid arthritis (RA), a distressing inflammatory autoimmune disease, is managed mainly by Disease-modifying antirheumatic drugs (DMARDs), e.g. leflunomide (LEF). LEF (BCS class II) has limited solubility and adverse effects following its systemic exposure. The appealing antirheumatic properties of both clove oil and chitosan (CS) were exploited to design oral leflunomide (LEF)-loaded nanoemulsion (NE) system to augment the therapeutic action of LEF and decrease its systemic side effects as well. Different LEF-NEs were prepared using clove oil, Tween® 20 (surfactant), and PEG 400(co-surfactant) and characterized by thermodynamic stability, percentage transmittance, cloud point, size analysis, and drug content. Optimized LEF-NE was subjected to CS coating forming LEF-CS-NE that exhibited nanometric size range, prolonged drug release, and good physical stability. In vivo anti-rheumatic activity of pure LEF, market LEF, and LEF-CS-NE was assessed utilizing a complete Freund's adjuvant (CFA) rat model. Treatment with LEF-CS-NE reduced edema rate (48.68% inhibition) and caused a marked reduction in interleukin-6 (IL-6) (510.9 ± 2.48 pg/ml), tumor necrosis factor- α (TNF-α) (397.3 ± 2.53 pg/ml), and rheumatoid factor (RF) (42.58 ± 0.49 U/ml). Furthermore, LEF-CS-NE reduced serum levels of glutamic pyruvic transaminase (GPT) to (83.19%) and glutamic oxaloacetic transaminase (GOT) to (40.68%) compared to the control + ve group. The effects of LEF-CS-NE were also superior to both pure and market LEF and showed better results in histopathological studies of paws, liver, kidney, lung, and heart. The remarkable therapeutic and safety profile of LEF-CS-NE makes it a potential oral system for the management of RA.
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Affiliation(s)
- Moataz B Zewail
- Department of Pharmaceutics and Industrial Pharmacy, Faculty of Pharmacy, Badr University in Cairo (BUC), Badr City, Cairo 11829, Egypt.
| | - Sanaa A El-Gizawy
- Department of Pharmaceutical Technology, Faculty of Pharmacy, Tanta University, Tanta, Egypt
| | - Gihan F Asaad
- Department of Pharmacology, Medical Research and Clinical Studies Institute, National Research Centre, Dokki, Cairo 12622, Egypt
| | - Marwa E Shabana
- Pathology Department, National Research Centre, Dokki, Giza, Egypt
| | - Walaa A El-Dakroury
- Department of Pharmaceutics and Industrial Pharmacy, Faculty of Pharmacy, Badr University in Cairo (BUC), Badr City, Cairo 11829, Egypt
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Alhelal HM, Mehta S, Kadian V, Kakkar V, Tanwar H, Rao R, Aldhubiab B, Sreeharsha N, Shinu P, Nair AB. Solid Lipid Nanoparticles Embedded Hydrogels as a Promising Carrier for Retarding Irritation of Leflunomide. Gels 2023; 9:576. [PMID: 37504455 PMCID: PMC10379097 DOI: 10.3390/gels9070576] [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: 05/11/2023] [Revised: 07/02/2023] [Accepted: 07/11/2023] [Indexed: 07/29/2023] Open
Abstract
Leflunomide (LEF), a disease-modifying anti-rheumatic drug, has been widely explored for its anti-inflammatory potential in skin disorders such as psoriasis and melanoma. However, its poor stability and skin irritation pose challenges for topical delivery. To surmount these issues, LEF-loaded solid lipid nanoparticles (SLNs) integrated with hydrogels have been developed in the present investigation. SLNs developed by microemulsion techniques were found ellipsoidal with 273.1 nm particle size and -0.15 mV zeta potential. Entrapment and total drug content of LEF-SLNs were obtained as 65.25 ± 0.95% and 93.12 ± 1.72%, respectively. FTIR and XRD validated the successful fabrication of LEF-SLNs. The higher stability of LEF-SLNs (p < 0.001) compared to pure drug solution was observed in photostability studies. Additionally, in vitro anti-inflammatory activity of LEF-SLNs showed good potential in comparison to pure drugs. Further, prepared LEF-SLNs loaded hydrogel showed ideal rheology, texture, occlusion, and spreadability for topical drug delivery. In vitro release from LEF-SLN hydrogel was found to follow the Korsmeyer-Peppas model. To assess the skin safety of fabricated lipidic formulation, irritation potential was performed employing the HET-CAM technique. In conclusion, the findings of this investigation demonstrated that LEF-SLN hydrogel is capable of enhancing the photostability of the entrapped drug while reducing its skin irritation with improved topical delivery characteristics.
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Affiliation(s)
- Hawra Mohammed Alhelal
- Department of Pharmaceutical Sciences, College of Clinical Pharmacy, King Faisal University, Al-Ahsa 31982, Saudi Arabia
| | - Sidharth Mehta
- Department of Pharmaceutical Sciences, Guru Jambheshwar University of Science and Technology, Hisar 125001, India
| | - Varsha Kadian
- Department of Pharmaceutical Sciences, Guru Jambheshwar University of Science and Technology, Hisar 125001, India
| | - Vandita Kakkar
- Department of Pharmaceutics, University Institute of Pharmaceutical Sciences, Panjab University, Chandigarh 160014, India
| | - Himanshi Tanwar
- Department of Pharmaceutical Sciences, Guru Jambheshwar University of Science and Technology, Hisar 125001, India
| | - Rekha Rao
- Department of Pharmaceutical Sciences, Guru Jambheshwar University of Science and Technology, Hisar 125001, India
| | - Bandar Aldhubiab
- Department of Pharmaceutical Sciences, College of Clinical Pharmacy, King Faisal University, Al-Ahsa 31982, Saudi Arabia
| | - Nagaraja Sreeharsha
- Department of Pharmaceutical Sciences, College of Clinical Pharmacy, King Faisal University, Al-Ahsa 31982, Saudi Arabia
- Department of Pharmaceutics, Vidya Siri College of Pharmacy, Off Sarjapura Road, Bangalore 560035, India
| | - Pottathil Shinu
- Department of Biomedical Sciences, College of Clinical Pharmacy, King Faisal University, Al-Ahsa 31982, Saudi Arabia
| | - Anroop B Nair
- Department of Pharmaceutical Sciences, College of Clinical Pharmacy, King Faisal University, Al-Ahsa 31982, Saudi Arabia
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Shin Y, Chae D, Park K. Development of a population pharmacokinetic model and optimal dosing regimen of leflunomide in Korean population. Eur J Pharm Sci 2023; 184:106402. [PMID: 36754259 DOI: 10.1016/j.ejps.2023.106402] [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: 08/15/2022] [Revised: 02/01/2023] [Accepted: 02/05/2023] [Indexed: 02/08/2023]
Abstract
PURPOSE Leflunomide is an immunosuppressive drug indicated for the treatment of rheumatoid arthritis (RA). While the pharmacokinetics (PK) of its active metabolite A771726 reportedly show large interindividual variability, no efficient dose individualization strategy is currently available. The goal of this work was to develop a population PK model for A771726 and propose an optimal individualized dosing strategy. METHODS A771726 plasma concentration data were collected from 50 healthy male volunteers participating in two leflunomide PK studies given a single oral dose of 40 mg. Concentrations were elevated in low body weight (WT) subjects and showed multiple peaks. Thus, A771726 PK modeling was conducted incorporating allometry scaling and enterohepatic circulation (EHC). For dose optimization, simulating a set of 1000 virtual subjects from the developed model and dividing the subjects into 5 groups with WT of 50, 60, 70, 80, 90 kg, respectively, the optimal dose was explored that achieves the drug concentration most similar to the target, which was defined as the concentration for the 70 kg subject treated with the current standard dosage regimen (the loading dose of 100 mg QD for 3 days, followed by the maintenance dose of 20 mg QD). RESULTS The data were best described by a two compartment model with first order absorption incorporating EHC with the bile released into the intestine. None of the covariates tested was found to be significant other than WT used in allometry. Simulation showed that the optimal loading dose increased by 15 mg for every 10 kg increment in WT while the optimal maintenance dose was 15 and 25 mg for 50 and 90 kg groups, respectively, and the same (= 20 mg) for the others. Large concentration differences from the target observed in low and high WT groups disappeared when optimal doses were given. CONCLUSIONS This work demonstrates the importance of a population PK model-based dose optimization approach in maintaining drug therapeutic concentrations in leflunomide treatment.
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Affiliation(s)
- Yesong Shin
- Department of Pharmacology, Yonsei University College of Medicine, Seoul 03722, Korea; Brain Korea 21 Plus Project for Medical Science, Yonsei University, Seoul 03722, Korea
| | - Dongwoo Chae
- Department of Pharmacology, Yonsei University College of Medicine, Seoul 03722, Korea
| | - Kyungsoo Park
- Department of Pharmacology, Yonsei University College of Medicine, Seoul 03722, Korea.
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Xu K, Zhang M, Yang S, Yu G, Zheng P, Qin X, Feng J. Subacute cutaneous lupus erythematosus as a rare complication of disease-modifying therapy administration in multiple sclerosis: case report. BMC Neurol 2023; 23:168. [PMID: 37101279 PMCID: PMC10131458 DOI: 10.1186/s12883-023-03146-1] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 02/27/2023] [Indexed: 04/28/2023] Open
Abstract
BACKGROUND Teriflunomide, the active metabolite of leflunomide, is a disease-modifying therapy drug used for the treatment of multiple sclerosis (MS), yet the complications associated with this drug remain not fully understood. Here we present the rare case of a 28-year-old female MS patient who developed subacute cutaneous lupus erythematosus (SCLE) following teriflunomide treatment. Though SCLE has been reported to be associated with leflunomide, the current report represents the first documented evidence demonstrating SCLE as a potential teriflunomide treatment-related complication. Additionally, a literature review on the leflunomide-induced SCLE was conducted to emphasize the association of SCLE with teriflunomide, specifically amongst the female demographic with a preexisting autoimmune diathesis. CASE PRESENTATION A 28-year-old female first presented with MS symptoms in the left upper limb along with blurred vision in the left eye. Medical and family histories were unremarkable. The patient exhibited positive serum biomarkers including ANA, Ro/SSA, La/SSB, and Ro-52 antibodies. Relapsing-remitting MS was diagnosed according to the 2017 McDonald's diagnostic criteria, and remission was achieved upon intravenous administration of methylprednisolone followed by teriflunomide sequential therapy. Three months post-teriflunomide treatment, the patient developed multiple facial cutaneous lesions. SCLE was subsequently diagnosed and was attributed to treatment-related complication. Interventions include oral administration of hydroxychloroquine and tofacitinib citrate effectively resolved cutaneous lesions. Discontinuation of hydroxychloroquine and tofacitinib citrate treatment led to recurring SCLE symptoms under continuous teriflunomide treatment. Full remission of facial annular plaques was achieved after re-treatment with hydroxychloroquine and tofacitinib citrate. The patient's clinical condition remained stable in long-term outpatient follow-ups. CONCLUSIONS As teriflunomide has become a standard disease-modifying therapy for MS, the current case report highlights the importance of monitoring treatment-related complications, specifically in relation to SCLE symptoms.
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Affiliation(s)
- Ke Xu
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
- National Health Commission Key Laboratory of Diagnosis and Treatment On Brain Functional Diseases, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Mengjie Zhang
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Shilin Yang
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Gang Yu
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Peng Zheng
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
- National Health Commission Key Laboratory of Diagnosis and Treatment On Brain Functional Diseases, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xinyue Qin
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China.
| | - Jinzhou Feng
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China.
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Narváez J, Estrada P, LLop D, Vidal-Montal P, Brugarolas E, Maymó-Paituvi P, Palacios-Olid J, Nolla JM. Efficacy and safety of leflunomide in the management of large vessel vasculitis: A systematic review and metaanalysis of cohort studies. Semin Arthritis Rheum 2023; 59:152166. [PMID: 36645992 DOI: 10.1016/j.semarthrit.2023.152166] [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: 10/16/2022] [Revised: 12/06/2022] [Accepted: 01/06/2023] [Indexed: 01/13/2023]
Abstract
OBJECTIVE The search for new glucocorticoid-sparing disease-modifying anti-rheumatic drugs continues to be an unmet need in large vessel vasculitis (LVV). This report aims to assess the effectiveness and safety of leflunomide (LEF) in Takayasu arteritis (TA) and giant cell arteritis (GCA). METHODS We systematically reviewed the literature, searching for studies evaluating the efficacy of LEF in LVV. A meta-analysis was conducted using the random-effects method. RESULTS The literature search identified eight studies that assessed LEF in TAK and seven in GCA. All were uncontrolled observational studies with a high risk of bias, implying a low or very-low certainty of evidence. In TAK, the pooled proportion of patients achieving at least a partial remission was 75% (95% CI: 0.64-0.84), angiographic stabilization was observed in 86% (0.77-0.94) and relapses in 12% (0.05-0.21). The mean reduction in the prednisolone dose (MRPD) after LEF treatment was 15.7 mg/d (10.28-21.16). Adverse events were observed in 8% of patients (0.02-0.16). Comparison of LEF with methotrexate (MTX) or cyclophosphamide revealed LEF to be superior in terms of remission induction, relapse prevention, and tolerance. When compared with tofacitinib, both drugs demonstrated comparable efficacy. In GCA, the pooled proportion of patients achieving at least a partial remission was 60% (0.17-0.95). The MRPD after LEF treatment was 15.63 mg/d (1.29-32.55) and 53% of the patients were able to discontinue glucocorticoids (0.25 - 0.80). Relapses were observed in 21% of cases (0.14- 0.28) and adverse events in 28% (0.12-0.46). Comparison of LEF with MTX showed similar efficacy and tolerance. CONCLUSION LEF is well tolerated and might be effective for patients with TAK and GCA.
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Affiliation(s)
- Javier Narváez
- Department of Rheumatology. Hospital Universitario de Bellvitge. Barcelona, Spain.
| | - Paula Estrada
- Servicio de Reumatología. Hospital de Sant Joan Despí - Moisés Broggi. Barcelona, Spain
| | - Dídac LLop
- Unitat de Recerca de Lípids i Arteriosclerosi. Universitat Rovira i Virgili, Reus. Institut d'Investigació Sanitària Pere Virgili. Tarragona, Spain
| | - Paola Vidal-Montal
- Department of Rheumatology. Hospital Universitario de Bellvitge. Barcelona, Spain
| | - Emma Brugarolas
- Department of Rheumatology. Hospital Universitario de Bellvitge. Barcelona, Spain
| | - Pol Maymó-Paituvi
- Department of Rheumatology. Hospital Universitario de Bellvitge. Barcelona, Spain
| | - Judith Palacios-Olid
- Department of Rheumatology. Hospital Universitario de Bellvitge. Barcelona, Spain
| | - Joan Miquel Nolla
- Department of Rheumatology. Hospital Universitario de Bellvitge. Barcelona, Spain
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Fatima M, Azimi SS, Ashwini S, Radhakrishna MH. Leflunomide Induced Atypical DRESS: A Case Report and Literature Review. Mediterr J Rheumatol 2023; 34:91-96. [PMID: 37223589 PMCID: PMC10201105 DOI: 10.31138/mjr.34.1.91] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 08/12/2022] [Indexed: 05/25/2023] Open
Abstract
Drug rash with eosinophilia and systemic symptoms syndrome (DRESS syndrome) is a potentially life-threatening, drug-induced, multi-organ system reaction, the most frequently involved organ is liver, followed by the kidneys and lungs.1 Early detection and diagnosis followed by withdrawal of the offending agent is vital to minimise the associated morbidity and mortality. A detailed drug history is vital to identify the causative drugs. Although Spanish guidelines were developed by a panel of allergy specialists from the Drug Allergy Committee of the Spanish Society of Allergy and Clinical Immunology (SEAIC) and are available in literature from 2020, many clinicians are still unaware about the management of this syndrome. Framing national guidelines for the early diagnosis and Pharmaco-therapeutic management of DRESS will help the healthcare professionals to save the patients from unintended vulnerability. Leflunomide, a drug widely used in rheumatology and orthopaedics must be used with caution since it has the potential to cause DRESS syndrome. We report a case of a lady aged 32 years, presented to our hospital with a history of leflunomide intake and symptoms of DRESS.
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Affiliation(s)
| | - Salwa Sahar Azimi
- Clinical Pharmacist intern, Department of Pharmacy Practice, G. Pulla Reddy College of Pharmacy, India
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21
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Nafea M, Elharoun M, Abd-Alhaseeb MM, Helmy MW. Leflunomide abrogates neuroinflammatory changes in a rat model of Alzheimer's disease: the role of TNF-α/NF-κB/IL-1β axis inhibition. Naunyn Schmiedebergs Arch Pharmacol 2023; 396:485-498. [PMID: 36385687 PMCID: PMC9898334 DOI: 10.1007/s00210-022-02322-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Accepted: 11/02/2022] [Indexed: 11/18/2022]
Abstract
Alzheimer's disease (AD) is one of the most common neurodegenerative diseases and is associated with disrupted cognition and behavior. Neuroinflammatory pathogenesis is the main component that contributes to AD initiation and progression through microglial activation and neuronal damage. Thus, targeting inflammatory pathways may help manage AD. In this study, for the first time, the potential prophylactic and therapeutic effects of leflunomide were investigated either alone or in combination with rivastigmine in aluminum chloride (AlCl3)-induced AD-like rats using behavioral, biochemical, and histological approaches. Thirty-six adult male albino rats were divided into two protocols: the treatment protocol, subdivided into five groups (n = 6)-(1) control group, (2) AlCl3 (50, 70, 100 mg/kg/I.P) group, (3) reference group (rivastigmine 2 mg/kg/P.O.), (4) experimental group (leflunomide 10 mg/kg/P.O.), and (5) combination group (rivastigmine + leflunomide); and the prophylactic protocol (leflunomide 10 mg/kg/P.O.), which started 2 weeks before AlCl3 induction. The results showed that AlCl3 disrupted learning and memory parameters in rats and increased amyloid-β plaque deposition and neurofibrillary tangle aggregation. Moreover, AlCl3 administration markedly elevated acetylcholinesterase activity, nuclear factor-kappa β, tumor necrosis factor-α, and interleukin-1 beta, and marked degenerative changes in the pyramidal neurons. However, administration of leflunomide alone or with rivastigmine in AlCl3-induced AD rats restored most of the behavioral, biochemical, and histological parameters triggered by AlCl3 in rats. Our findings suggest that leflunomide can potentially restore most of the neuronal damage in the hippocampal tissues of AlCl3-induced AD rats. However, these preclinical findings still need to be confirmed in clinical trials.
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Affiliation(s)
- Menna Nafea
- Department of Pharmacology and Biochemistry, College of Pharmacy, Arab Academy for Science, Technology & Maritime Transport, Alexandria, Egypt
| | - Mona Elharoun
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Damanhour University, Damanhour, El-Bahira, Egypt
| | | | - Maged Wasfy Helmy
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Damanhour University, Damanhour, El-Bahira, Egypt.
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22
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Springer JM, Kermani TA. Recent advances in the treatment of giant cell arteritis. Best Pract Res Clin Rheumatol 2023; 37:101830. [PMID: 37328409 DOI: 10.1016/j.berh.2023.101830] [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: 03/28/2023] [Revised: 04/20/2023] [Accepted: 04/23/2023] [Indexed: 06/18/2023]
Abstract
Giant cell arteritis (GCA) is a systemic, granulomatous, large-vessel vasculitis that affects individuals over the age of 50 years. Morbidity from disease includes cranial manifestations which can cause irreversible blindness, while extra-cranial manifestations can cause vascular damage with large-artery stenosis, occlusions, aortitis, aneurysms, and dissections. Glucocorticoids while efficacious are associated with significant adverse effects. Furthermore, despite treatment with glucocorticoids, relapses are common. An understanding of the pathogenesis of GCA has led to the discovery of tocilizumab as an efficacious steroid-sparing therapy while additional therapeutic targets affecting different inflammatory pathways are under investigation. Surgical treatment may be indicated in cases of refractory ischemia or aortic complications but data on surgical outcomes are limited. Despite the recent advances, many unmet needs exist, including the identification of patients or subsets of GCA who would benefit from earlier initiation of adjunctive therapies, patients who may warrant long-term immunosuppression and medications that sustain permanent remission. The impact of medications like tocilizumab on long-term outcomes, including the development of aortic aneurysms and vascular damage also warrants investigation.
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Affiliation(s)
- Jason M Springer
- Vanderbilt University Medical Center, 1161 21st Avenue Sound, T3113 Medical Center North, Nashville, TN, 37232, USA.
| | - Tanaz A Kermani
- University of California Los Angeles, 2020 Santa Monica Boulevard, Suite 540, Santa Monica, CA, 90404, USA.
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23
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Chen Y, Li R, Luo X, Wu T, Li J, Liu Z, Peng Y, Lu H, Peng L, Zhou J, Zhao Y, Zeng X, Fei Y, Zhang W. Comparison of the efficacy and safety of leflunomide versus mycophenolate mofetil in treating IgG4-related disease: a retrospective cohort study. Clin Rheumatol 2023:10.1007/s10067-023-06528-5. [PMID: 36781683 DOI: 10.1007/s10067-023-06528-5] [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: 11/28/2022] [Revised: 01/07/2023] [Accepted: 01/27/2023] [Indexed: 02/15/2023]
Abstract
OBJECTIVE Combination therapy of glucocorticoids (GCs) plus leflunomide (LEF) and GCs plus mycophenolate mofetil (MMF) was reported to have good efficacy and safety in the management of IgG4-RD. However, studies comparing the efficacy and safety of these two combination therapies were unavailable. Herein, this study aimed to compare the efficacy and safety of GCs plus LEF and GCs plus MMF in treating IgG4-RD. METHODS This study included 130 newly diagnosed IgG4-RD patients who received the therapy of GCs plus LEF (group I) and GCs plus MMF (group II). Clinical data at baseline and after treatment, treatment response, relapse rate, and adverse effects were recorded and analyzed. RESULTS Patients in both groups responded well to the treatment in the 1st-month follow-up, and 100% of patients achieved treatment response. However, at the 6th and 12th-month follow-up, the total response rate of group II was higher than that in group I (75.6 vs. 53.7%, p = 0.038 and 85.4% vs. 61.0%, p = 0.013, respectively). In addition, the duration of disease remission in group II was longer than that in group I (9 (6-9) vs. 6 (6-6) months, p = 0.014). Moreover, more patients in group I had adverse effects compared with group II (36.6 vs. 7.3%, p < 0.01); and the most common adverse events of LEF were rash (12.2%) and elevation of liver enzymes (9.8%). CONCLUSION The combination therapy of GCs plus low-dose MMF had better efficacy and safety in the management of IgG4-RD compared with the therapy of GCs plus LEF.
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Affiliation(s)
- Yingying Chen
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China.,National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, Beijing, China.,State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH), Beijing, China.,Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, 100730, China
| | - Rongli Li
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China.,National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, Beijing, China.,State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH), Beijing, China.,Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, 100730, China
| | - Xuan Luo
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China.,National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, Beijing, China.,State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH), Beijing, China.,Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, 100730, China
| | - Tianmin Wu
- Department of Biostatistics, Bioinformatics, and Biomathematics, Georgetown University, Washington, DC, USA
| | - Jieqiong Li
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China.,National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, Beijing, China.,State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH), Beijing, China.,Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, 100730, China
| | - Zheng Liu
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China.,National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, Beijing, China.,State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH), Beijing, China.,Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, 100730, China
| | - Yu Peng
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China.,National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, Beijing, China.,State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH), Beijing, China.,Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, 100730, China
| | - Hui Lu
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China.,National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, Beijing, China.,State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH), Beijing, China.,Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, 100730, China
| | - Linyi Peng
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China.,National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, Beijing, China.,State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH), Beijing, China.,Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, 100730, China
| | - Jiaxin Zhou
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China.,National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, Beijing, China.,State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH), Beijing, China.,Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, 100730, China
| | - Yan Zhao
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China.,National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, Beijing, China.,State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH), Beijing, China.,Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, 100730, China
| | - Xiaofeng Zeng
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China.,National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, Beijing, China.,State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH), Beijing, China.,Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, 100730, China
| | - Yunyun Fei
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China. .,National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, Beijing, China. .,State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH), Beijing, China. .,Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, 100730, China.
| | - Wen Zhang
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China. .,National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, Beijing, China. .,State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH), Beijing, China. .,Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, 100730, China.
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24
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Huang X, Qiu L, Lu Y, Chen J, Yang W, Ou C, Ran H, Liu W. Clinical evaluation of efficacy of leflunomide combined with low-dose prednisone for treatment of myasthenia gravis. Acta Neurol Belg 2023; 123:153-160. [PMID: 34410678 DOI: 10.1007/s13760-021-01769-0] [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: 03/24/2021] [Accepted: 07/28/2021] [Indexed: 11/25/2022]
Abstract
This study evaluated the clinical efficacy of leflunomide combined with low-dose prednisone (0.25 mg/kg/day) for treatment of myasthenia gravis (MG). We enrolled 32 MG patients treated with leflunomide combined with low-dose prednisone. In the control group, 14 patients were treated with low-dose prednisone. Improvement in MG composite (MGC) score of ≥ 3 points from enrollment to 12-week follow-up indicated that the treatment was effective. In the leflunomide combined low-dose prednisone group, the median of MGC score at the time of enrollment was 8.5 points. After 12 weeks, the MGC score dropped to four points. There was statistically significant difference in MGC score before and after treatment (p < 0.001). In the low-dose prednisone group also followed up for 12 weeks, the median of MGC score of the patients decreased from 7 to 4 points, and the change was not statistically significant (p = 0.05). In the leflunomide combined low-dose prednisone group, the improvement of clinical symptoms occurred mainly in the first 4 weeks and the last 4 weeks. Relatively, the decline of the score was mostly seen during the first 8 weeks in the low-dose prednisone group. In leflunomide combined with low-dose prednisone group, the effective rate of generalized MG(gMG) was significantly higher than ocular MG(oMG) (χ2 test, p = 0.036). However, there is no significant difference in the effective rate between AChR-Ab-positive and -negative groups (Fisher's Exact Test, p = 0.625). No serious side effects were observed in any of the subjects. Leflunomide combined with low-dose prednisone rapidly improved the clinical symptoms of patients with MG. It may be a promising treatment for gMG.
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Affiliation(s)
- Xin Huang
- Guangdong Provincial Key Laboratory of Diagnosis and Treatment of Major Neurological Diseases, National Key Clinical Department and Key Discipline of Neurology, Department of Neurology, The First Affiliated Hospital, Sun Yat-Sen University, No. 58 Zhongshan Road 2, Guangzhou, 510080, China
| | | | | | | | | | | | - Hao Ran
- School of Pharmaceutical Sciences, Sun Yat-Sen University, No. 135 West Xingang Road, Guangzhou, 510275, China.
| | - Weibin Liu
- Guangdong Provincial Key Laboratory of Diagnosis and Treatment of Major Neurological Diseases, National Key Clinical Department and Key Discipline of Neurology, Department of Neurology, The First Affiliated Hospital, Sun Yat-Sen University, No. 58 Zhongshan Road 2, Guangzhou, 510080, China.
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25
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Wang Y, Zhao Z, Gao D, Wang H, Liao S, Luo G, Ji X, Li Y, Wang X, Zhao Y, Li K, Zhang J, Jin J, Zhang Y, Zhu J, Zhang J, Huang F. Clinical value of plasmablasts in predicting disease relapse in patients with IgG4-related disease. Clin Rheumatol 2023; 42:135-143. [PMID: 36074221 DOI: 10.1007/s10067-022-06339-0] [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: 02/04/2022] [Revised: 07/10/2022] [Accepted: 08/15/2022] [Indexed: 01/11/2023]
Abstract
OBJECTIVES To explore the value of plasmablasts in predicting disease relapse in IgG4-related diseases (IgG4-RD). METHODS Treatment-naïve IgG4-RD patients treated with glucocorticoid (GC) monotherapy or leflunomide (LEF) and GC combination therapy diagnosed at the Chinese PLA General Hospital during February 2017 and January 2018 were included in this study. The absolute plasmablast count was measured by using the absolute count tubes with flow cytometry. Patients were categorized into high and low plasmablast level groups by defining the median number of plasmablasts as the cut-off value. The characteristics of the clinical manifestations between the two groups were compared. In addition, the correlation of plasmablast count with other indicators and its clinical value in predicting disease relapse were evaluated. RESULTS Data of 37 treatment-naïve IgG4-RD patients were analyzed. The median (IQR) absolute count of plasmablasts was 4.0 (2.8-7.5)/μL, which was correlated with the lymphocyte percentage, serum IgG, IgG4, and IgG4/IgG. The baseline absolute count of plasmablasts was an independent risk factor for disease relapse in IgG4-RD patients (HR, 1.199; 95% CI, 1.030-1.396, P = 0.019), and the application of LEF was an independent protective factor (HR, 0.283; 95% CI, 0.106-0.759, p = 0.012). CONCLUSIONS The present study preliminarily indicated that baseline absolute plasmablast count may independently predict disease relapse in patients with IgG4-RD treated with GC monotherapy or LEF and GC combination therapy. More efforts are still needed to be performed in the future. Key Points • The absolute count of plasmablasts is correlated with the lymphocyte percentage, serum IgG, IgG4 and IgG4/IgG. • The baseline absolute plasmablast count may predict disease relapse in patients with IgG4-RD treated with GC monotherapy or LEF and GC combination therapy. • The application of LEF is an independent protective factor for disease relapse in IgG4-RD.
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Affiliation(s)
- Yiwen Wang
- Department of Rheumatology and Immunology, First Medical Center, Chinese PLA General Hospital, 28 Fuxing Road, Haidian District, Beijing, 100853, China
| | - Zheng Zhao
- Department of Rheumatology and Immunology, First Medical Center, Chinese PLA General Hospital, 28 Fuxing Road, Haidian District, Beijing, 100853, China
| | - Dai Gao
- Department of Rheumatology and Immunology, First Medical Center, Chinese PLA General Hospital, 28 Fuxing Road, Haidian District, Beijing, 100853, China
| | - Hui Wang
- Department of Rheumatology and Immunology, First Medical Center, Chinese PLA General Hospital, 28 Fuxing Road, Haidian District, Beijing, 100853, China
| | - Simin Liao
- Department of Rheumatology and Immunology, First Medical Center, Chinese PLA General Hospital, 28 Fuxing Road, Haidian District, Beijing, 100853, China
| | - Gui Luo
- Department of Rheumatology and Immunology, First Medical Center, Chinese PLA General Hospital, 28 Fuxing Road, Haidian District, Beijing, 100853, China
| | - Xiaojian Ji
- Department of Rheumatology and Immunology, First Medical Center, Chinese PLA General Hospital, 28 Fuxing Road, Haidian District, Beijing, 100853, China
| | - Yan Li
- Department of Rheumatology and Immunology, First Medical Center, Chinese PLA General Hospital, 28 Fuxing Road, Haidian District, Beijing, 100853, China
| | - Xiuru Wang
- Department of Rheumatology and Immunology, First Medical Center, Chinese PLA General Hospital, 28 Fuxing Road, Haidian District, Beijing, 100853, China
| | - Yurong Zhao
- Department of Rheumatology and Immunology, First Medical Center, Chinese PLA General Hospital, 28 Fuxing Road, Haidian District, Beijing, 100853, China
| | - Kunpeng Li
- Department of Rheumatology and Immunology, First Medical Center, Chinese PLA General Hospital, 28 Fuxing Road, Haidian District, Beijing, 100853, China
| | - Jie Zhang
- Department of Rheumatology and Immunology, First Medical Center, Chinese PLA General Hospital, 28 Fuxing Road, Haidian District, Beijing, 100853, China
| | - Jingyu Jin
- Department of Rheumatology and Immunology, First Medical Center, Chinese PLA General Hospital, 28 Fuxing Road, Haidian District, Beijing, 100853, China
| | - Yamei Zhang
- Department of Rheumatology and Immunology, First Medical Center, Chinese PLA General Hospital, 28 Fuxing Road, Haidian District, Beijing, 100853, China
| | - Jian Zhu
- Department of Rheumatology and Immunology, First Medical Center, Chinese PLA General Hospital, 28 Fuxing Road, Haidian District, Beijing, 100853, China.
| | - Jianglin Zhang
- Department of Rheumatology and Immunology, First Medical Center, Chinese PLA General Hospital, 28 Fuxing Road, Haidian District, Beijing, 100853, China
| | - Feng Huang
- Department of Rheumatology and Immunology, First Medical Center, Chinese PLA General Hospital, 28 Fuxing Road, Haidian District, Beijing, 100853, China.
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26
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Lv G, Ming C. Efficacy and safety of leflunomide combined with corticosteroids for the treatment of IgA nephropathy: a Meta-analysis of randomized controlled trials. Ren Fail 2022; 44:1011-1025. [PMID: 35786300 PMCID: PMC9262374 DOI: 10.1080/0886022x.2022.2085576] [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] [Indexed: 10/26/2022] Open
Abstract
OBJECTIVE We performed a meta-analysis of randomized controlled trials (RCTs) to evaluate the efficacy and safety of leflunomide combined with corticosteroids, compared with corticosteroids alone, for IgA nephropathy. MATERIALS AND METHODS Studies were retrieved by searching of PubMed, Embase, Cochrane's Library, China National Knowledge Infrastructure (CNKI), and Wanfang databases on 11 October 2021. A random-effect model incorporating the heterogeneity was used to pool the results. The efficacy outcomes included the complete remission rate of proteinuria, overall response rate (the combined rates of patients with complete and partial remission of proteinuria), changes of urine protein excretion (UPE), serum creatinine (SCr), and estimated glomerular infiltrating rate (eGFR). RESULTS Nineteen studies were included. Patients receiving the combined therapy had a higher complete remission rate (relative risk [RR]: 1.29, 95% CI: 1.08-1.55, p = 0.006; I2 = 0%) and overall response rate (RR: 1.18, 95% CI: 1.10-1.26, p < 0.001, I2 = 0%) compared to patients who received CS alone. Besides, combined therapy was associated with significantly reduced levels of UPE (mean difference [MD]: -0.30 g/24h, 95% CI: -0.43 to -0.16, p < 0.001; I2 = 34%) and SCr (MD: -7.55 mmol/L, 95% CI: -11.06 to -4.04, p < 0.001; I2 = 34%), and increased level of eGFR (MD: 6.51 mL/min/1.73 m2, 95% CI: 4.06-8.97, p < 0.001; I2 = 0%). The incidence of adverse events was not significantly different. CONCLUSIONS Combined treatment with leflunomide and corticosteroids was more effective than corticosteroids alone for patients with IgA nephropathy.
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Affiliation(s)
- Guangxin Lv
- Key Laboratory of Microecology-immune Regulatory Network and Related Diseases, School of Basic Medicine, Jiamusi University, Jiamusi, Heilongjiang Province, China
| | - Chengyuan Ming
- Department of Urology, Jiamusi Central Hospital, Jiamusi, China
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27
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Broadwell A, Albert JA, Padnick-Silver L, LaMoreaux B. Community Practice Experiences with a Variety of Immunomodulatory Agents Co-Administered with Pegloticase for the Treatment of Uncontrolled Gout. Rheumatol Ther 2022; 9:1549-1558. [PMID: 36136270 PMCID: PMC9561461 DOI: 10.1007/s40744-022-00492-3] [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: 08/08/2022] [Accepted: 08/30/2022] [Indexed: 11/28/2022] Open
Abstract
Objective Patients with uncontrolled/refractory gout have heavy disease burden, but few treatment options. Pegloticase lowers serum urate (SU), but anti-drug antibodies can limit treatment efficacy. Evidence supports immunomodulator-pegloticase co-administration to increase sustained urate-lowering rates, but published cases are limited. This study investigated experience with pegloticase-immunomodulation co-therapy at two community rheumatology practices. Methods Patients initiating pegloticase with immunomodulation in 2017 or later were included. Patient/treatment characteristics and proportion of responders (≥ 12 pegloticase infusions, SU < 6 mg/dl at infusion-12) were examined. Patients on therapy at data collection with < 12 infusions were excluded from response analyses. eGFR before and after therapy was examined. Results Thirty-four patients (79% male, 62.4 ± 16.3 years) with uncontrolled gout (SU = 9.1 ± 2.0 mg/dl, 91% tophaceous) were included. Most-reported comorbidities were hypertension (76%), obesity (71%), osteoarthritis (68%), and CKD (47%). Pre-therapy eGFR was 65.4 ± 25.2 ml/min/1.73 m2 (41% eGFR < 60 ml/min/1.73 m2). All patients initiated immunomodulation before (5.3 ± 3.0 weeks, n = 32) or at (n = 2) first pegloticase infusion. Subcutaneous methotrexate (15.4 ± 4.9 mg/week, n = 20), oral methotrexate (15.3 ± 3.6 mg/week, n = 9), mycophenolate mofetil (1000 mg/day, n = 3), and azathioprine (100 mg/day, n = 2) were administered. Patients received 14.6 ± 7.1 infusions over 28.5 ± 14.9 weeks. Overall response rate was 89%, ranging among immunomodulators (subcutaneous methotrexate: 93%, oral methotrexate: 89%, mycophenolate mofetil: 100%, azathioprine: 50%). On average, eGFR increased during therapy (+ 10.3 ± 16.9 ml/min/1.73 m2), with CKD stability/improvement in 85%. Nineteen patients (56%) experienced gout flares. No infusion reactions or infections were noted. No new safety concerns were identified. Conclusions These real-world findings provide further support for increased pegloticase response rates when co-treatment with immunomodulating therapy is used. Patients with gout that does not respond to oral urate-lowering therapies have heavy disease burden and few treatment options. Pegloticase lowers serum urate levels (SU) and resolves tophi, but anti-drug antibodies can limit urate-lowering efficacy duration. Evidence increasingly supports co-administering an immunomodulator with pegloticase to increase the proportion of patients with sustained urate-lowering response. However, there are few published cases from real-world clinical practice. This study examined treatment with pegloticase + immunomodulation at two community rheumatology practices. Patients who began treatment with pegloticase and an immunomodulator in 2017 or later were included. The proportion of patients with sustained urate-lowering response (≥ 12 infusions received, SU < 6 mg/dl at infusion 12) was investigated. Renal function before and after therapy was also examined. Thirty-four patients were included. Before treatment, SU averaged 9.1 mg/dl and most-reported comorbidities were hypertension (76%), obesity (71%), osteoarthritis (68%), and chronic kidney disease (47%). All patients began using an immunomodulator before or at first pegloticase infusion (subcutaneous methotrexate [20 patients], oral methotrexate [9 patients], mycophenolate mofetil [3 patients], and azathioprine [2 patients]). On average, 14.6 infusions were administered over 28.5 weeks and overall response rate was 89%. Response rate varied among different immunomodulators: subcutaneous methotrexate: 93%, oral methotrexate: 89%, mycophenolate mofetil: 100%, azathioprine: 50%. On average, kidney function improved, with chronic kidney disease stage stability/improvement in 85% of patients. Nineteen patients (56%) experienced gout flares. No infusion reactions or infections were noted and no new safety concerns were identified. These real-world findings provide further support for administering immunomodulation as co-therapy to pegloticase.
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Affiliation(s)
- Aaron Broadwell
- Rheumatology and Osteoporosis Specialists, Shreveport, LA, USA
| | | | | | - Brian LaMoreaux
- Horizon Therapeutics plc, 1 Horizon Way, Deerfield, IL, USA.
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Kramarič J, Ješe R, Tomšič M, Rotar Ž, Hočevar A. COVID-19 among patients with giant cell arteritis: a single-centre observational study from Slovenia. Clin Rheumatol 2022; 41:2449-2456. [PMID: 35366735 PMCID: PMC8976457 DOI: 10.1007/s10067-022-06157-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [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: 03/01/2022] [Revised: 03/28/2022] [Accepted: 03/28/2022] [Indexed: 12/24/2022]
Abstract
OBJECTIVES Patients with giant cell arteritis (GCA) represent a fragile population with an increased infection risk. In a recent study, older age, a higher number of comorbidities, higher disease activity and prednisolone ≥ 10 mg/day were associated with worse COVID-19 outcome. We aimed to evaluate the frequency and severity of COVID-19 in a well-defined GCA cohort. METHODS We reviewed medical records of histologically and/or by imaging-proven GCA patients diagnosed between September 2011 and February 2020 at our secondary/tertiary centre and followed during the COVID-19 pandemic between March 2020 and February 2022 (24 months). Descriptive statistics were used to explore the studied population. RESULTS Of 314 patients with GCA diagnosed for the first time during a 102-month period, 49 patients died before March 2020. Of the remaining 265 patients, 55 (20.8%) patients suffered from a total of 57 SARS-CoV-2 infections. We observed 44 (77.2%) mild and 13 (22.8%) severe COVID-19 episodes (the latter defined as needing hospitalization, death or thrombotic complication). Patients with severe COVID-19 were more likely to have arterial hypertension (12 [92.3%] vs. 25 [56.8%]; p = 0.022), cardiovascular disease (7 [53.8%] vs. 10 [22.7%]; p = 0.043) or obesity (5 [38.5%] vs. 5 [11.4%]; p = 0.038). Neither prednisolone dose 1-5 mg/day (p = 0.483) nor leflunomide use (p = 1.000) was associated with COVID-19 course. There were no significant differences in sex, age, GCA type, GCA disease duration and other comorbidities in patients with mild and severe COVID-19 in our cohort. CONCLUSION More than a fifth of our GCA patients had severe COVID-19. Treatment with leflunomide or low doses of glucocorticoids were not associated with severe course in our cohort. Key Points • Treatment with leflunomide or low doses of glucocorticoids were not associated with worse COVID-19 outcome. • Outcomes of COVID-19 improved as the COVID-19 pandemic, prevention and treatment options evolved. • Arterial hypertension, cardiovascular disease or obesity were associated with severe COVID-19.
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Affiliation(s)
- Jelka Kramarič
- Department of Rheumatology, University Medical Centre Ljubljana, Vodnikova 62, 1000, Ljubljana, Slovenia.
| | - Rok Ješe
- Department of Rheumatology, University Medical Centre Ljubljana, Vodnikova 62, 1000, Ljubljana, Slovenia
| | - Matija Tomšič
- Department of Rheumatology, University Medical Centre Ljubljana, Vodnikova 62, 1000, Ljubljana, Slovenia
- Medical Faculty, University of Ljubljana, Ljubljana, Slovenia
| | - Žiga Rotar
- Department of Rheumatology, University Medical Centre Ljubljana, Vodnikova 62, 1000, Ljubljana, Slovenia
- Medical Faculty, University of Ljubljana, Ljubljana, Slovenia
| | - Alojzija Hočevar
- Department of Rheumatology, University Medical Centre Ljubljana, Vodnikova 62, 1000, Ljubljana, Slovenia
- Medical Faculty, University of Ljubljana, Ljubljana, Slovenia
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Wang J, Dai X, Ma L, Wu S, Jin X, Ji Z, Chen H, Ma L, Ding Z, Jiang L, Kong X. Efficacy and safety of tofacitinib versus leflunomide with glucocorticoids treatment in Takayasu arteritis: A prospective study. Semin Arthritis Rheum 2022; 55:152018. [PMID: 35523066 DOI: 10.1016/j.semarthrit.2022.152018] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 04/05/2022] [Accepted: 04/25/2022] [Indexed: 12/25/2022]
Abstract
To investigate the efficacy and safety of leflunomide (LEF) versus tofacitinib (TOF) in Takayasu arteritis (TAK) patients. Sixty-seven active patients were recruited from an ongoing observational TAK cohort, including 35 patients treated with glucocorticoids (GCs) and LEF and 32 patients treated with GCs and TOF. The observation period was 12 months. The effectiveness rate (ER), remission rate, inflammatory parameters reduction, vascular imaging changes, GCs tapering, disease relapse and side-effects were evaluated between two groups. These aspects were also assessed separately among treatment-naïve or -refractory patients. The ER at 6 and 12 months was 88.57% (31/35) vs. 87.50% (28/32) (p = 1.00) and 71.43% (25/35) vs. 71.88% (23/32) (p = 1.00) in the LEF and TOF group. The percentage of patients with persistent remission from 6th to 12th months and GCs≤7.5 mg/day at 12 months was higher in TOF group (15 (46.88%) vs. 6 (17.14%) p = 0.02). The relapse prevalence was 6 (17.14%) and 7 (21.88%) (p = 0.76), respectively. Erythrocyte sedimentation rate (ESR) was decreased significantly at 6 months in both groups (p<0.05), whereas C-reactive protein (CRP) level was reduced significantly at 6 months only in the TOF group (p = 0.007). The proportion of patients with imaging improvement was higher in the TOF group (eight (25.00%) and two (5.71%), p = 0.04). Side-effect prevalence was higher in the LEF group (11 (31.43%) vs. 3 (9.38%), p = 0.04). In conclusion, LEF and TOF were comparable for TAK treatment. TOF might be a potential agent to maintain disease remission at a low dose of glucocorticoids in TAK.
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Hsieh CH, Huang YW, Tsai TF. Oral Conventional Synthetic Disease-Modifying Antirheumatic Drugs with Antineoplastic Potential: a Review. Dermatol Ther (Heidelb) 2022; 12:835-860. [PMID: 35381976 PMCID: PMC9021342 DOI: 10.1007/s13555-022-00713-1] [Citation(s) in RCA: 3] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Indexed: 01/17/2023] Open
Abstract
There is an increasing trend of malignancy worldwide. Disease-modifying antirheumatic drugs (DMARDs) are the cornerstones for the treatment of immune-mediated inflammatory diseases (IMIDs), but risk of malignancy is a major concern for patients receiving DMARDs. In addition, many IMIDs already carry higher background risks of neoplasms. Recently, the black box warning of malignancies has been added for Janus kinase inhibitors. Also, the use of biologic DMARDs in patients with established malignancies is usually discouraged owing to exclusion of such patients in pivotal studies and, hence, lack of evidence. In contrast, some conventional synthetic DMARDs (csDMARDs) have been reported to show antineoplastic properties and can be beneficial for patients with cancer. Among the csDMARDs, chloroquine and hydroxychloroquine have been the most extensively studied, and methotrexate is an established chemotherapeutic agent. Even cyclosporine A, a well-known drug associated with cancer risk, can potentiate the effect of some chemotherapeutic agents. We review the possible mechanisms behind and clinical evidence of the antineoplastic activities of csDMARDs, including chloroquine and hydroxychloroquine, cyclosporine, leflunomide, mycophenolate mofetil, mycophenolic acid, methotrexate, sulfasalazine, and thiopurines. This knowledge may guide physicians in the choice of csDMARDs for patients with concurrent IMIDs and malignancies.
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Affiliation(s)
- Cho-Hsun Hsieh
- Department of Medical Education, National Taiwan University Hospital, Taipei, Taiwan
| | - Yi-Wei Huang
- Department of Dermatology, National Taiwan University Hospital, 7 Chung Shan S Rd, Taipei, 10048, Taiwan
| | - Tsen-Fang Tsai
- Department of Dermatology, National Taiwan University Hospital, 7 Chung Shan S Rd, Taipei, 10048, Taiwan. .,Department of Dermatology, National Taiwan University Hospital & National Taiwan University College of Medicine, Taipei, Taiwan.
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Xue H, Ci X, Luo M, Wu L, Du X, Li L, Lu X. Tofacitinib combined with leflunomide for treatment of psoriatic arthritis with IgA nephropathy: a case report with literature review. Clin Rheumatol 2022. [PMID: 35192086 DOI: 10.1007/s10067-022-06113-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 02/16/2022] [Accepted: 02/17/2022] [Indexed: 11/03/2022]
Abstract
Psoriasis is a systemic inflammatory disease that is associated with increased risk of several diseases, such as psoriatic arthritis (PsA), inflammatory bowel disease, and cardiovascular diseases. About 20 to 30% patients with psoriasis subsequently develop PsA. IgA nephropathy is the most common primary glomerular disease world-wide. Psoriasis and IgA nephropathy appear to be associated, but the mechanism underlying this connection is unclear. Tofacitinib and leflunomide are common treatments for psoriatic arthritis. We administered tofacitinib combined with leflunomide to a 38-year-old female patient who presented with PsA and IgA nephropathy. After treatment, she experienced significant reductions in the psoriatic lesions, pain in the right knee joint, and proteinuria. Administration of tofacitinib combined with leflunomide for treatment of a patient who had PsA complicated with IgA nephropathy led to significant resolution of the symptoms of both conditions. These results suggest similarities in the pathogenesis of PsA and IgA nephropathy and a possible new treatment for IgA nephropathy.
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Masri KR, Padnick-Silver L, Winterling K, LaMoreaux B. Effect of Leflunomide on Pegloticase Response Rate in Patients with Uncontrolled Gout: A Retrospective Study. Rheumatol Ther 2022; 9:555-563. [PMID: 34997911 PMCID: PMC8964845 DOI: 10.1007/s40744-021-00421-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [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: 11/16/2021] [Accepted: 12/20/2021] [Indexed: 12/27/2022] Open
Abstract
Background Pegloticase,
a PEGylated uricase for uncontrolled gout, rapidly lowers serum urate (SU). Not all patients complete a full-therapy course because anti-pegloticase antibodies can develop, causing efficacy loss and infusion reactions. The literature and clinical trial data indicate that methotrexate co-administration markedly improves pegloticase response rates from the established monotherapy response rate of 42%. Unfortunately, methotrexate use is restricted by kidney disease, which is often present in uncontrolled gout patients. Leflunomide is less restricted in patients with renal dysfunction. This study examined the treatment response rate of pegloticase co-administered with leflunomide. Methods Patients co-treated with pegloticase (8 mg biweekly infusion) and oral leflunomide (20 mg/day) were included. Patient/treatment characteristics and safety parameters (adverse events [AEs], laboratory parameters) were examined. Pre-infusion prophylaxis was administered (day of infusion: IV solumedrol, night before and morning of infusion: oral fexofenadine or diphenhydramine). Patients were considered treatment responders if ≥ 12 pegloticase infusions were administered and pre-infusion SU < 6 mg/dl at infusion-12. Results Ten patients (five male, 72.7 ± 12.5 years) were included. The most common comorbidities were chronic kidney disease (90%), hypertension (70%), diabetes mellitus (60%), obesity (60%), and congestive heart failure (50%). Baseline SU was 7.1 ± 2.4 mg/dl and nine patients (90%) had subcutaneous tophi noted. Seven patients (70%) met responder criteria, receiving 26.6 ± 14.0 infusions (range 13–55) with a pre-infusion-12 SU of 0.9 ± 1.5 mg/dl. The three non-responders received < 12 infusions because of unrelated AEs or loss of follow-up. Three patients (30%) experienced AEs. One had unrelated cardiac disease worsening and three gout flares, one had a pre-infusion solumedrol reaction (wooziness/loss of consciousness), and one had two mild, transient increases in liver enzymes. Conclusions This study supports leflunomide as co-therapy to pegloticase in uncontrolled gout patients. Heterogeneity and high comorbidity burden in uncontrolled gout patients makes having a variety of immunomodulators options important.
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Affiliation(s)
| | | | | | - Brian LaMoreaux
- Horizon Therapeutics, Lake Forest, IL, USA.
- , 1 Horizon Way, Deerfield, IL, 600615, USA.
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Rabie AM. Teriflunomide: A possible effective drug for the comprehensive treatment of COVID-19. Curr Res Pharmacol Drug Discov 2021; 2:100055. [PMID: 34870153 DOI: 10.1016/j.crphar.2021.100055] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [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: 07/26/2021] [Revised: 08/30/2021] [Accepted: 09/08/2021] [Indexed: 01/18/2023] Open
Abstract
The coronavirus disease 2019 (COVID-19) pandemic has undoubtedly become a global crisis. Consequently, discovery and identification of new or known potential drug candidates to solve the health problems caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) have become an urgent necessity. This current research study sheds light on the possible direct repurposing of the antirheumatic drug teriflunomide to act as an effective and potent anti-SARS-CoV-2 agent. Herein, an interesting computational molecular docking study of teriflunomide, to investigate and evaluate its potential inhibitory activities on the novel coronaviral-2 RNA-dependent RNA polymerase (nCoV-RdRp) protein, was reported. The docking procedures were accurately carried out on nCoV-RdRp (with/without RNA) using the COVID-19 Docking Server, through adjusting it on the small molecule docking mode. Remdesivir and its active metabolite (GS-441524) were used as the active references for the comparison and evaluation purpose. Interestingly, the computational docking analysis of the best inhibitory binding mode of teriflunomide in the binding pocket of the active site of the SARS-CoV-2 RdRp revealed that teriflunomide may exhibit significantly stronger inhibitory binding interactions and better inhibitory binding affinities (teriflunomide has considerably lower binding energies of -9.70 and -7.80 kcal/mol with RdRp-RNA and RdRp alone, respectively) than both references. It was previously reported that teriflunomide strongly inhibits the viral replication and reproduction through two mechanisms of action, thus the results obtained in the present study surprisingly support the double mode of antiviral action of this antirheumatic ligand. In conclusion, the current research paved the way to practically prove the hypothetical theory of the promising abilities of teriflunomide to successfully attack the SARS-CoV-2 particles and inhibit their replication in a triple mode of action through integrating the newly-discovered nCoV-RdRp-inhibiting properties with the previously-known two anticoronaviral mechanisms of action. Based on the previous interesting facts and results, the triple SARS-CoV-2/sextet COVID-19 attacker teriflunomide can further undergo in vitro/in vivo anti-COVID-19 assays together with preclinical/clinical studies and trials in an attempt to evaluate and prove its comprehensive pharmacological activities against the different SARS-CoV-2 strains to be effectively used in COVID-19 therapy in the very near future.
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Li Y, Xiong Y, Huang T, Liu X, Xu G. Clinical efficacy and safety of full-dose versus half-dose corticosteroids plus leflunomide for IgA nephropathy. BMC Nephrol 2021; 22:364. [PMID: 34736419 PMCID: PMC8567572 DOI: 10.1186/s12882-021-02555-z] [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: 03/01/2021] [Accepted: 06/19/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The results of leflunomide (LEF) in patients with IgA nephropathy (IgAN) were inconsistent. METHODS A total of 149 kidney biopsy-confirmed IgAN patients with an estimated glomerular filtration rate (eGFR) ≥ 50 ml/min/1.73 m2 and protein excretion levels ≥0.75 g/d were enrolled, with 65 subjects receiving half-dose CS plus LEF (LEF group), and the 84 counterpart patients accepting full-dose corticosteroid (Full CS group). The primary outcomes included the complete remission (CR) rates and incidence of adverse events (AEs). The secondary outcomes were the overall remission (OR) rates and a combined event (eGFR reduced ≥30%, end-stage renal disease [ESRD], hemodialysis, peritoneal dialysis or kidney transplantation). RESULTS During the 18 months of follow-up, the CR rates were 72 and 64% in the LEF and Full CS groups (P = 0.299), respectively. The proportion of patients with OR rates in the LEF group and Full CS group was 89% versus 75%, respectively (P = 0.027). Serious AEs were observed only in the Full CS group (P = 0.017). The incidences of total AEs (P = 0.036) and infections (P = 0.024) were lower in the LEF group than in the Full CS group. CONCLUSIONS LEF combined with half-dose CS is superior to full-dose CS in the treatment of IgAN.
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Affiliation(s)
- Yebei Li
- Department of Nephrology, The Second Affiliated Hospital of Nanchang University, No. 1, Minde Road, Donghu District, Nanchang, 330006, P.R. China
| | - Yi Xiong
- Department of Nephrology, The Second Affiliated Hospital of Nanchang University, No. 1, Minde Road, Donghu District, Nanchang, 330006, P.R. China
| | - Tianlun Huang
- Department of Nephrology, The Second Affiliated Hospital of Nanchang University, No. 1, Minde Road, Donghu District, Nanchang, 330006, P.R. China
| | - Xin Liu
- Department of Nephrology, The Second Affiliated Hospital of Nanchang University, No. 1, Minde Road, Donghu District, Nanchang, 330006, P.R. China
| | - Gaosi Xu
- Department of Nephrology, The Second Affiliated Hospital of Nanchang University, No. 1, Minde Road, Donghu District, Nanchang, 330006, P.R. China.
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Otto-Ślusarczyk D, Graboń W, Mielczarek-Puta M, Chrzanowska A. Teriflunomide - The common drug with underestimated oxygen - Dependent anticancer potential. Biochem Biophys Rep 2021; 28:101141. [PMID: 34611552 PMCID: PMC8476349 DOI: 10.1016/j.bbrep.2021.101141] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 09/17/2021] [Accepted: 09/20/2021] [Indexed: 12/29/2022] Open
Abstract
Leflunomide (LFN) is a well-known immunomodulatory and anti-inflammatory prodrug of teriflunomide (TFN). Due to pyrimidine synthesis inhibition TFN also exhibits potent anticancer effect. Because, there is the strict coupling between the pyrimidine synthesis and the mitochondrial respiratory chain, the oxygen level could modify the cytostatic TNF effect. The aim of the study was to evaluate the cytostatic effect of pharmacologically achievable teriflunomide (TFN) concentrations at physiological oxygen levels, i.e. 1% hypoxia and 10% tissue normoxia compared to 21% oxygen level occurred in routine cell culture environment. The TFN effect was evaluated using TB, MTT and FITC Annexin tests for human primary (SW480) and metastatic (SW620) colon cancer cell lines at various oxygen levels. We demonstrated significant differences between proliferation, survival and apoptosis at 1, 10 and 21% oxygen in primary and metastatic colon cancer cell lines (SW480, SW620) under TFN treatment. The cytostatic TFN effect was more pronounced at hypoxia compared to tissue and atmospheric normoxia in both cancer cell lines, however metastatic cells were more resistant to antiproliferative and proapoptotic TFN action. The early apoptosis was predominant in physiological oxygen tension while in atmospheric normoxia the late apoptosis was induced. Our findings showed that anticancer TFN effect is more strong in physiological oxygen compared to atmospheric normoxia. It suggests that results obtained from in vitro studies could be underestimated. Thus, it gives assumption for future comprehensive studies at real oxygen environment involving TNF use in combination with other antitumor agents affecting oxygen-dependent pyrimidine synthesis.
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Affiliation(s)
- Dagmara Otto-Ślusarczyk
- Chair and Department of Biochemistry, Medical University of Warsaw, 02-097 Warsaw, Banacha 1, Poland
| | - Wojciech Graboń
- Chair and Department of Biochemistry, Medical University of Warsaw, 02-097 Warsaw, Banacha 1, Poland
| | - Magdalena Mielczarek-Puta
- Chair and Department of Biochemistry, Medical University of Warsaw, 02-097 Warsaw, Banacha 1, Poland
| | - Alicja Chrzanowska
- Chair and Department of Biochemistry, Medical University of Warsaw, 02-097 Warsaw, Banacha 1, Poland
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Belani PJ, Kavadichanda CG, Negi VS. Comparison between leflunomide and sulfasalazine based triple therapy in methotrexate refractory rheumatoid arthritis: an open-label, non-inferiority randomized controlled trial. Rheumatol Int 2021; 42:771-782. [PMID: 34586472 DOI: 10.1007/s00296-021-04994-1] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 09/13/2021] [Indexed: 10/20/2022]
Abstract
To compare efficacy and safety of two different combination csDMARD therapy in Methotrexate-failed Rheumatoid arthritis patients. In this 24-week open-label, parallel-group non-inferiority, single-center clinical trial, Methotrexate-failed Rheumatoid arthritis patients with disease duration < 2 years, were randomized to either of the two treatment regimens-Methotrexate + Leflunomide + Hydroxychloroquine or Methotrexate + Sulfasalazine + Hydroxychloroquine. Primary endpoint was proportion of patients achieving EULAR good response at 12 weeks. Non-inferiority of Leflunomide based therapy was confirmed if the upper limit of the 2-sided 95% confidence interval of treatment difference between the 2 groups was lower than the selected non-inferiority margin of (- 20%) in primary endpoint at 12 weeks. Secondary endpoints were improvement in DAS28, functional outcome and adverse events at 24 weeks. 136 eligible patients were randomized to either Leflunomide or Sulfasalazine group (68 in each group).63 and 59 patients in Leflunomide and 66 and 61 patients in Sulfasalazine group completed 12 and 24 weeks of trial, respectively. In Intension-to-treat analysis, EULAR good response was achieved by 58.8% and 54.4% patients (p = 0.7) at the end of 12 weeks, and 61.7% and 64.7% patients (p = 0.8) at the end of 24 weeks-in Leflunomide and Sulfasalazine group respectively. At 12 weeks, the difference in EULAR good response with 2-sided 95% confidence interval between 2 groups was 4.4% (- 12%, 20%) in intention-to-treat and 5.8% (- 11%, 23%) in perprotocol analysis.15 and 21 adverse events were recorded in Leflunomide and Sulfasalazine group respectively. Parenteral Methotrexate was required more in Sulfasalazine group due to gastrointestinal intolerance. Leflunomide based csDMARD therapy is non-inferior to Sulfasalazine based csDMARD therapy in Methotrexate-failed Rheumatoid arthritis patients with comparable safety profile. Trial registered at clinicaltrials.gov (NCT02930343) dated 10.09.2016.
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Affiliation(s)
- Pooja J Belani
- Department of Clinical Immunology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, 605006, India.,Divine Life Hospital, Adipur, Kutch, Gujarat, India
| | - Chengappa G Kavadichanda
- Department of Clinical Immunology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, 605006, India
| | - Vir Singh Negi
- Department of Clinical Immunology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, 605006, India. .,All India Institute of Medical Sciences, Bilaspur, Himachal Pradesh, India.
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Carrión-Barberà I, Polino L, Mejía-Torres M, Pérez-García C, Ciria M, Pros A, Rodríguez-García E, Monfort J, Salman-Monte TC. Leflunomide: A safe and effective alternative in systemic lupus erythematosus. Autoimmun Rev 2021; 21:102960. [PMID: 34560304 DOI: 10.1016/j.autrev.2021.102960] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 09/19/2021] [Indexed: 11/02/2022]
Affiliation(s)
- I Carrión-Barberà
- Rheumatology Department, Hospital del Mar/Parc de Salut Mar, Barcelona, Spain.
| | - L Polino
- Rheumatology Department, Hospital del Mar/Parc de Salut Mar, Barcelona, Spain.
| | - M Mejía-Torres
- Rheumatology Department, Hospital del Mar/Parc de Salut Mar, Barcelona, Spain.
| | - C Pérez-García
- Rheumatology Department, Hospital del Mar/Parc de Salut Mar, Barcelona, Spain.
| | - M Ciria
- Rheumatology Department, Hospital del Mar/Parc de Salut Mar, Barcelona, Spain.
| | - A Pros
- Rheumatology Department, Hospital del Mar/Parc de Salut Mar, Barcelona, Spain.
| | - E Rodríguez-García
- Nephrology Department, Hospital del Mar/Parc de Salut Mar, Barcelona, Spain.
| | - J Monfort
- Rheumatology Department, Hospital del Mar/Parc de Salut Mar, Barcelona, Spain.
| | - T C Salman-Monte
- Rheumatology Department, Hospital del Mar/Parc de Salut Mar, Barcelona, Spain.
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Abstract
BACKGROUND Henoch-Schönlein purpura (HSP), also called IgA vasculitis, is a systemic vasculitis characterized by deposits of immunoglobulin A in blood vessels. Renal impairment of these patients is the main determinant of prognosis. The optimal treatment of HSP nephritis (HSPN) in children remains controversial, but many clinicians administer an immunosuppressive agent with a corticosteroid. A previous study reported that leflunomide (LEF) with a corticosteroid was effective for adult patients with HSPN and nephrotic proteinuria. However, data on this treatment in pediatric patients is limited. METHODS We described our experience at a single center on the use of LEF in 5 pediatric patients who had IgA vasculitis with proteinuria that was nearly 50 mg/kg (nephrotic range) and remained high despite administration of intravenous steroid, and biopsy-proven nephritis. All patients had class II to IIIb lesions based on the International Study of Kidney Disease in Children (ISKDC). RESULTS We successfully treated all 5 children who had IgA vasculitis with nephritis using LEF with a corticosteroid. Four patients achieved a complete remission of proteinuria, and 1 patient had significantly reduced proteinuria. The children received LEF for 6 months to 12 months, and none of them had severe adverse events. CONCLUSIONS To our knowledge, this is the first case series to report successful treatment of pediatric HSPN with LEF in combination with a corticosteroid.
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Affiliation(s)
- Ling Hou
- Department of Pediatrics, Shengjing Hospital of China Medical University, No. 36 Sanhao Street Heping District, 110004, Shenyang, China
| | - Zhou Zhang
- Department of Pediatrics, Shengjing Hospital of China Medical University, No. 36 Sanhao Street Heping District, 110004, Shenyang, China
| | - Yue Du
- Department of Pediatrics, Shengjing Hospital of China Medical University, No. 36 Sanhao Street Heping District, 110004, Shenyang, China.
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Kaur H, Sarma P, Bhattacharyya A, Sharma S, Chhimpa N, Prajapat M, Prakash A, Kumar S, Singh A, Singh R, Avti P, Thota P, Medhi B. Efficacy and safety of dihydroorotate dehydrogenase (DHODH) inhibitors " leflunomide" and "teriflunomide" in Covid-19: A narrative review. Eur J Pharmacol 2021; 906:174233. [PMID: 34111397 PMCID: PMC8180448 DOI: 10.1016/j.ejphar.2021.174233] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [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: 12/12/2020] [Revised: 05/30/2021] [Accepted: 06/02/2021] [Indexed: 01/12/2023]
Abstract
Dihydroorotate dehydrogenase (DHODH) is rate-limiting enzyme in biosynthesis of pyrimidone which catalyzes the oxidation of dihydro-orotate to orotate. Orotate is utilized in the biosynthesis of uridine-monophosphate. DHODH inhibitors have shown promise as antiviral agent against Cytomegalovirus, Ebola, Influenza, Epstein Barr and Picornavirus. Anti-SARS-CoV-2 action of DHODH inhibitors are also coming up. In this review, we have reviewed the safety and efficacy of approved DHODH inhibitors (leflunomide and teriflunomide) against COVID-19. In target-centered in silico studies, leflunomide showed favorable binding to active site of MPro and spike: ACE2 interface. In artificial-intelligence/machine-learning based studies, leflunomide was among the top 50 ligands targeting spike: ACE2 interaction. Leflunomide is also found to interact with differentially regulated pathways [identified by KEGG (Kyoto Encyclopedia of Genes and Genomes) and reactome pathway analysis of host transcriptome data] in cogena based drug-repurposing studies. Based on GSEA (gene set enrichment analysis), leflunomide was found to target pathways enriched in COVID-19. In vitro, both leflunomide (EC50 41.49 ± 8.8 μmol/L) and teriflunomide (EC50 26 μmol/L) showed SARS-CoV-2 inhibition. In clinical studies, leflunomide showed significant benefit in terms of decreasing the duration of viral shredding, duration of hospital stay and severity of infection. However, no advantage was seen while combining leflunomide and IFN alpha-2a among patients with prolonged post symptomatic viral shredding. Common adverse effects of leflunomide were hyperlipidemia, leucopenia, neutropenia and liver-function alteration. Leflunomide/teriflunomide may serve as an agent of importance to achieve faster virological clearance in COVID-19, however, findings needs to be validated in bigger sized placebo controlled studies.
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Affiliation(s)
- Hardeep Kaur
- Department of Pharmacology, PGIMER, Chandigarh, India
| | - Phulen Sarma
- Department of Pharmacology, PGIMER, Chandigarh, India
| | | | | | | | | | - Ajay Prakash
- Department of Pharmacology, PGIMER, Chandigarh, India
| | - Subodh Kumar
- Department of Pharmacology, PGIMER, Chandigarh, India
| | | | - Rahul Singh
- Department of Pharmacology, PGIMER, Chandigarh, India
| | - Pramod Avti
- Department of Biophysics, PGIMER, Chandigarh, India
| | - Prasad Thota
- Department of Pharmacology, PGIMER, Chandigarh, India
| | - Bikash Medhi
- Department of Pharmacology, PGIMER, Chandigarh, India.
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Heidarian R, Zahedi-Tabrizi M. Effect of the Intramolecular Hydrogen Bond on the Active Metabolite Analogs of Leflunomide for Blocking the Plasmodium falciparum Dihydroorotate Dehydrogenase Enzyme: QTAIM, NBO, and Docking Study. Curr Comput Aided Drug Des 2021; 17:480-491. [PMID: 32459610 DOI: 10.2174/1573409916666200527133126] [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: 12/13/2019] [Revised: 02/17/2020] [Accepted: 05/06/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Leflunomide (LFM) and its active metabolite, teriflunomide (TFM), have drawn a lot of attention for their anticancer activities, treatment of rheumatoid arthritis and malaria due to their capability to inhibit dihydroorotate dehydrogenase (DHODH) and Plasmodium falciparum dihydroorotate dehydrogenase (PfDHODH) enzyme. In this investigation, the strength of intramolecular hydrogen bond (IHB) in five analogs of TFM (ATFM) was analyzed employing density functional theory (DFT) using B3LYP/6-311++G (d, p) level and molecular orbital analysis in the gas phase and water solution. A detailed electronic structure study was performed using the quantum theory of atoms in molecules (QTAIM) and the hydrogen bond energies (EHB) of stable conformer obtained in the range of 76-97 kJ/mol, as a medium hydrogen bond. The effect of substitution on the IHB nature was studied by natural bond orbital analysis (NBO). 1H NMR calculations showed an upward trend in the proton chemical shift of the enolic proton in the chelated ring (14.5 to 15.7ppm) by increasing the IHB strength. All the calculations confirmed the strongest IHB in 5-F-ATFM and the weakest IHB in 2-FATFM. Molecular orbital analysis, including the HOMO-LUMO gap and chemical hardness, was performed to compare the reactivity of inhibitors. Finally, molecular docking analysis was carried out to identify the potency of inhibition of these compounds against PfDHODH enzyme. TFM acts as an inhibitor of dihydroorotate dehydrogenase (DHODH) and Plasmodium falciparum dihydroorotate dehydrogenase (PfDHODH) enzyme. Leflunomide and its active metabolite teriflunomide have been identified as drugs for treatment of some diseases, such as multiple sclerosis (MS), rheumatoid arthritis (RA), malaria, and cancer. Hydrogen bonds play a key role in the interaction between drugs and enzymes. OBJECTIVES The aim of the present work is to investigate the effect of the strength of intramolecular hydrogen bonds (IHBs) in the active metabolite analogs of leflunomide or analogs of teriflunomide (ATFMs) and study the interaction of these inhibitors against the PfDHODH enzyme using quantum mechanical methods. METHODS At first, intramolecular hydrogen bonds in five ATFMs were evaluated by the DFT method, quantum theory of atoms in molecules (QTAIM), nuclear magnetic resonance (NMR), natural bond orbital (NBO), and molecular orbital (MO) analyses. Then, the interaction of these inhibitors against the PfDHODH enzyme were compared using molecular docking study. RESULTS All the computed results confirm the following trend in the intramolecular hydrogen bond strength in five mono-halo-substituted 2-cyano-3-hydroxy-N-phenylbut-2-enamide (ATFM): 5-FATFM> 4-Br-ATFM ≈ 3-Br-ATFM>3-Cl-ATFM>TFM-Z>2-F-ATFM which is in agreement with QTAIM, NMR, and NBO results. Docking results show that 5-F-ATFM (EHB=97kJ/mol) has the minimum MolDock score due to its considerable IHB strength. CONCLUSION For strong IHBs (EHB>100kJ/mol), C=O and O-H group are involved in the intramolecular interactions and do not contribute to the external interactions. Also, the docking study revealed maximum binding energy between TFM-Z and PfDHODH enzyme.
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Affiliation(s)
- Reihaneh Heidarian
- Department of Chemistry, Faculty of Physics and Chemistry, Alzahra University, Tehran, Iran
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Villgran VD, Rabold E, Nasrullah A, Disilvio B, Bajwa O. Leflunomide-induced interstitial pneumonitis: A rare occurrence in a case without underlying lung disease. Respir Med Case Rep 2021; 33:101468. [PMID: 34401304 PMCID: PMC8349012 DOI: 10.1016/j.rmcr.2021.101468] [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] [Received: 04/09/2021] [Revised: 05/31/2021] [Accepted: 07/06/2021] [Indexed: 11/24/2022] Open
Abstract
Pneumonitis from leflunomide is uncommon due to leflunomide's relatively favorable drug profile. Leflunomide-induced pneumonitis (LEIP) is a rare condition reported mainly in Asia. We present a case of LEIP from an accidental leflunomide overdose in the setting of concomitant methotrexate use and no underlying lung disease. Our patient was treated successfully with cholestyramine and steroids. Due to its high mortality, clinicians should be aware of this condition and its treatment.
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Affiliation(s)
- V D Villgran
- Pulmonary & Critical Care Medicine, Allegheny Health Network, Pittsburgh, PA, United States
| | - E Rabold
- Pulmonary & Critical Care Medicine, Allegheny Health Network, Pittsburgh, PA, United States
| | - A Nasrullah
- Internal Medicine, Allegheny Health Network, Pittsburgh, PA, United States
| | - B Disilvio
- Pulmonary & Critical Care Medicine, Allegheny Health Network, Pittsburgh, PA, United States
| | - O Bajwa
- Pulmonary & Critical Care Medicine, Allegheny Health Network, Pittsburgh, PA, United States
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Łączna M, Malinowski D, Paradowska-Gorycka A, Safranow K, Dziedziejko V, Pawlik A. Lack of association between CYB5A gene rs1790834 polymorphism and the response to leflunomide in women with rheumatoid arthritis. Eur J Clin Pharmacol 2021; 77:1673-1678. [PMID: 34160668 PMCID: PMC8528780 DOI: 10.1007/s00228-021-03172-3] [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: 02/03/2021] [Accepted: 06/09/2021] [Indexed: 11/29/2022]
Abstract
Aim Leflunomide is a disease-modifying antirheumatic drug used in therapy for rheumatoid arthritis (RA). Previous studies indicated that oestrogens and androgens may affect the response to leflunomide in RA patients. The synthesis of androgens is regulated by cytochrome CYB5A. The aim of this study was to examine the association between the CYB5A gene rs1790834 polymorphism and the response to leflunomide in women with RA. Methods The study included 111 women diagnosed with RA. Leflunomide was administered in monotherapy at a dose of 20 mg/day. All patients underwent a monthly evaluation for 12 months after the initiation of treatment with leflunomide. Results After 12 months of therapy, the changes in individual disease activity parameters, such as: DAS28, ESR, CRP and VAS, were not statistically significantly different between rs1790834 genotypes in the Kruskal–Wallis test. Conclusions The results of our study suggest lack of statistically significant association between the CYB5A gene rs1790834 polymorphism and the response to leflunomide in women with RA.
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Affiliation(s)
- Małgorzata Łączna
- Department of Physiology, Pomeranian Medical University, 70-111, Szczecin, Poland
| | - Damian Malinowski
- Department of Experimental and Clinical Pharmacology, Pomeranian Medical University, 70-111, Szczecin, Poland
| | - Agnieszka Paradowska-Gorycka
- Department of Molecular Biology, National Institute of Geriatrics, Rheumatology and Rehabilitation, 02-637, Warsaw, Poland
| | - Krzysztof Safranow
- Department of Biochemistry and Medical Chemistry, Pomeranian Medical University, 70-111, Szczecin, Poland
| | - Violetta Dziedziejko
- Department of Biochemistry and Medical Chemistry, Pomeranian Medical University, 70-111, Szczecin, Poland
| | - Andrzej Pawlik
- Department of Physiology, Pomeranian Medical University, 70-111, Szczecin, Poland.
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Shields MD, Skelton WP, Laber DA, Verbosky M, Ashraf N. A Novel Case of Leflunomide-Induced Thrombotic Thrombocytopenic Purpura. J Hematol 2021; 10:139-142. [PMID: 34267852 PMCID: PMC8256916 DOI: 10.14740/jh837] [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] [Received: 04/03/2021] [Accepted: 04/23/2021] [Indexed: 02/01/2023] Open
Abstract
Leflunomide has not been previously associated with thrombotic thrombocytopenic purpura (TTP), a rare life-threatening clinical syndrome characterized by thrombotic microangiopathy (TMA) due to inability to cleave ADAMTS13. Here, we present the first case of leflunomide-induced TTP. Our patient developed encephalopathy, thrombocytopenia, anemia and hyperbilirubinemia 2 months after starting leflunomide. Schistocytes were noted on peripheral smear and ADAMTS13 activity was low (< 5%), consistent with acquired TTP. He received therapeutic plasma exchange, corticosteroids, rituximab and caplacizumab with normalization of hemolysis labs and ADAMTS13 activity. However, pancytopenia persisted, raising the suspicion for leflunomide toxicity. Oral cholestyramine treatment was empirically started before teriflunomide (a leflunomide metabolite) level was found to be elevated. Blood counts normalized after cholestyramine and have remained normal at last follow-up over a year later. This is the first reported case of TTP precipitated by leflunomide. Our case highlights the importance of recognizing drugs as an etiology of TMA and adds leflunomide to this list.
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Affiliation(s)
- Misty Dawn Shields
- H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA.,Morsani School of Medicine, University of South Florida, Tampa, FL, USA
| | - William Paul Skelton
- H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA.,Morsani School of Medicine, University of South Florida, Tampa, FL, USA
| | - Damian A Laber
- H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA.,Morsani School of Medicine, University of South Florida, Tampa, FL, USA
| | - Michael Verbosky
- H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Noman Ashraf
- Morsani School of Medicine, University of South Florida, Tampa, FL, USA.,Department of Hematology Oncology, James A. Haley Veterans Hospital, Tampa, FL, USA
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Ferjani HL, Boussaa H, Maatallah K, Kaffel D, Hamdi W. The first case of leflunomide-induced discoid lupus erythematosus. Therapie 2021; 77:487-488. [PMID: 34176667 DOI: 10.1016/j.therap.2021.06.002] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 04/14/2021] [Accepted: 06/08/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Hanene Lassoued Ferjani
- Department of Rheumatology, Mohamed Kassab Institute of Orthopedics, 2010 La Manouba, Tunisia; University of Tunis El Manar, Faculty of Medicine of Tunis, 1007 Tunis, Tunisia; Research Unit UR17SP04, Ksar Said, 2010 Tunis, Tunisia
| | - Hiba Boussaa
- Department of Rheumatology, Mohamed Kassab Institute of Orthopedics, 2010 La Manouba, Tunisia.
| | - Kaouther Maatallah
- Department of Rheumatology, Mohamed Kassab Institute of Orthopedics, 2010 La Manouba, Tunisia; University of Tunis El Manar, Faculty of Medicine of Tunis, 1007 Tunis, Tunisia; Research Unit UR17SP04, Ksar Said, 2010 Tunis, Tunisia
| | - Dhia Kaffel
- Department of Rheumatology, Mohamed Kassab Institute of Orthopedics, 2010 La Manouba, Tunisia; University of Tunis El Manar, Faculty of Medicine of Tunis, 1007 Tunis, Tunisia; Research Unit UR17SP04, Ksar Said, 2010 Tunis, Tunisia
| | - Wafa Hamdi
- Department of Rheumatology, Mohamed Kassab Institute of Orthopedics, 2010 La Manouba, Tunisia; University of Tunis El Manar, Faculty of Medicine of Tunis, 1007 Tunis, Tunisia; Research Unit UR17SP04, Ksar Said, 2010 Tunis, Tunisia
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Samara E, Siasios I, Katsiardanis K, Liaptsi E, Tsoleka K, Deretzi G. Brain abscess in a rheumatoid arthritis patient treated with leflunomide - A case presentation and review. Surg Neurol Int 2021; 12:97. [PMID: 33880202 PMCID: PMC8053466 DOI: 10.25259/sni_886_2020] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 02/11/2021] [Indexed: 11/07/2022] Open
Abstract
Background: Immunosuppression is a significant parameter in the pathogenesis of brain abscesses (BA) and it could be the result of severe infections such as acquired immunodeficiency syndrome or drug-induced, by several medications used for systemic autoimmune diseases. Leflunomide is a pyrimidine synthesis inhibitor that affects the proliferation of lymphocytes and is used as a disease-modifying antirheumatic drug. Mild infections, particularly those of the respiratory tract and herpes zoster, are one of its most common adverse effects. However, atypical and severe infections have also been reported under treatment with leflunomide. Case Description: A 70-year old female was referred to our hospital with headache, aphasia, and right-sided hemiparesis and a lesion of the left parietal lobe initially interpreted as a malignancy. Her medical history revealed a 12-year old history of rheumatoid arthritis under current treatment with leflunomide. A cerebral magnetic resonance imaging (MRI) revealed typical findings for a BA. She subsequently underwent a left craniotomy, which confirmed the MRI-based diagnosis. The abscess was evacuated and cultures were obtained intraoperatively. In the postoperative examination, the patient showed no neurological deficit. Conclusion: The differential diagnostic considerations in immunocompromised patients with neurologic deficits should include focal central nervous system infections such as a BA, even in the absence of fever or immunosuppressant-induced leukopenia. It also demonstrates the importance of early neurosurgical intervention for the prevention of sequelae. To the best of our knowledge, this is the second-to-date reported case of a BA under immunomodulatory therapy with leflunomide.
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Affiliation(s)
- Efthymia Samara
- Department of Neurology, Papageorgiou Hospital of Thessaloniki, Periferiaki Odos N. Efkarpia, Thessaloniki, Central Macedonia, Greece
| | - Ioannis Siasios
- Department of Neurosurgery, Papageorgiou Hospital of Thessaloniki, Periferiaki Odos N. Efkarpia, Thessaloniki, Central Macedonia, Greece
| | - Konstantinos Katsiardanis
- Department of Neurology, Papageorgiou Hospital of Thessaloniki, Periferiaki Odos N. Efkarpia, Thessaloniki, Central Macedonia, Greece
| | - Eirini Liaptsi
- Department of Neurology, Papageorgiou Hospital of Thessaloniki, Periferiaki Odos N. Efkarpia, Thessaloniki, Central Macedonia, Greece
| | - Kalliopi Tsoleka
- Department of Neurosurgery, Papageorgiou Hospital of Thessaloniki, Periferiaki Odos N. Efkarpia, Thessaloniki, Central Macedonia, Greece
| | - Georgia Deretzi
- Department of Neurology, Papageorgiou Hospital of Thessaloniki, Periferiaki Odos N. Efkarpia, Thessaloniki, Central Macedonia, Greece
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Zewail M, Nafee N, Boraie N. Intra-Articular Dual Drug Delivery for Synergistic Rheumatoid Arthritis Treatment. J Pharm Sci 2021; 110:2808-2822. [PMID: 33848528 DOI: 10.1016/j.xphs.2021.04.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [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: 01/22/2021] [Revised: 03/30/2021] [Accepted: 04/01/2021] [Indexed: 11/16/2022]
Abstract
Systemic rheumatoid arthritis (RA) regimens fail to attain effective drug level at the affected joints and are associated with serious side effects. Herein, an attempt made to improve therapeutic outcomes of both leflunomide (LEF) which is a disease modifying antirheumatic and dexamethasone (Dex) through local delivery of combination therapy by intra-articular route. LEF and Dex were encapsulated in nanostructured lipid carriers (NLCs) and PLGA nanoparticles (NPs), respectively. Both nanocarriers were loaded into chitosan/β glycerophosphate (CS/βGP) thermo-sensitive hydrogels and injected intra-articularly in adjuvant induced RA rat model. Particle size of LEF NLCs and selected Dex NPs formulations were 200 and 119 nm, respectively. Dex NPs and LEF NLCs showed a sustained release profile for up to 58 and 17 days, respectively. After 14 days of treatment remarkable joint healing was observed for groups treated with Dex NPs in combination with either free LEF or LEF NLCs in CS/βGP hydrogel. Joint diameter measurements, TNF α levels and histopathological examination of dissected joints showed comparable values to the negative control group. This might be attributed to the synergistic effect of drug combination besides the ability of nanocarriers loaded hydrogel to prolong joint residence time and enhance joint healing potential.
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Affiliation(s)
- Mariam Zewail
- Department of Pharmaceutics, Faculty of Pharmacy, Damanhour University, El Gomhoria Street, Damanhour, Egypt.
| | - Noha Nafee
- Department of Pharmaceutics, Faculty of Pharmacy, Alexandria University, Alexandria, Egypt; Department of Pharmaceutics, Faculty of Pharmacy, Kuwait University, Kuwait
| | - Nabila Boraie
- Department of Pharmaceutics, Faculty of Pharmacy, Alexandria University, Alexandria, Egypt
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Nakafero G, Grainge MJ, Card T, Mallen CD, Zhang W, Doherty M, Taal MW, Aithal GP, Abhishek A. What is the incidence of methotrexate or leflunomide discontinuation related to cytopenia, liver enzyme elevation or kidney function decline? Rheumatology (Oxford) 2021; 60:5785-5794. [PMID: 33725120 PMCID: PMC8645271 DOI: 10.1093/rheumatology/keab254] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [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] [Received: 10/19/2020] [Accepted: 03/05/2021] [Indexed: 11/25/2022] Open
Abstract
Objectives To examine incidence of treatment changes due to abnormal blood-test results and, to explore rates of treatment changes due to liver, kidney and haematological blood-test abnormalities in autoimmune rheumatic diseases (AIRD) treated with low-dose MTX or LEF. Methods Data for people with AIRDs prescribed MTX or LEF were extracted from the Clinical Practice Research Datalink. Participants were followed-up from first prescription of MTX or LEF in primary care. Primary outcome of interest was drug discontinuation, defined as a prescription gap of ≥90 days following an abnormal (or severely abnormal) blood-test result. Dose reduction was examined between consecutive prescriptions. Incidence rates per 1000 person-years were calculated. Results 15, 670 and 2,689 participants contributing 46, 571 and 4,558 person-years follow-up were included in MTX and LEF cohorts, respectively. The incidence of MTX and LEF discontinuation with abnormal (severely abnormal) blood-test was 42.24 (6.16) and 106.53 (9.42)/1000 person-years in year 1, and 22.44 (2.84) and 31.69 (4.40)/1000 person years, respectively, thereafter. The cumulative incidence of MTX and LEF discontinuation with abnormal (severely abnormal) blood tests was 1 in 24 (1 in 169), 1 in 9 (1 in 106) at 1 year; and 1 in 45 (1 in 352), 1 in 32 (1 in 227) per-year, respectively, thereafter. Raised liver enzymes were the commonest abnormality associated with drug discontinuation. MTX and LEF dose reduction incidence were comparable in year 1, however, thereafter MTX dose was reduced more often than LEF [16.60 (95% CI 13.05, 21.13) vs 8.10 (95% CI 4.97, 13.20)/1000 person-years]. Conclusion MTX and LEF were discontinued for blood-test abnormalities after year 1 of treatment, however, discontinuations for severely abnormal results were uncommon.
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Affiliation(s)
- Georgina Nakafero
- Academic Rheumatology, School of Medicine, University of Nottingham, Nottingham, UK
| | - Matthew J Grainge
- Epidemiology and Public Health, School of Medicine, University of Nottingham, Nottingham, UK
| | - Tim Card
- Epidemiology and Public Health, School of Medicine, University of Nottingham, Nottingham, UK.,Nottingham Digestive Diseases Centre, School of Medicine, University of Nottingham
| | - Christian D Mallen
- Primary Care Centre Versus Arthritis, School of Medicine, Keele University, Keele
| | - Weiya Zhang
- Academic Rheumatology, School of Medicine, University of Nottingham, Nottingham, UK
| | - Michael Doherty
- Academic Rheumatology, School of Medicine, University of Nottingham, Nottingham, UK
| | - Maarten W Taal
- Division of Medical Sciences and Graduate Entry Medicine, University on Nottingham
| | - Guruprasad P Aithal
- Nottingham Digestive Diseases Centre, School of Medicine, University of Nottingham.,NIHR Nottingham BRC, Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK
| | - Abhishek Abhishek
- Academic Rheumatology, School of Medicine, University of Nottingham, Nottingham, UK.,NIHR Nottingham BRC, Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK
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Alamri RD, Elmeligy MA, Albalawi GA, Alquayr SM, Alsubhi SS, El-Ghaiesh SH. Leflunomide an immunomodulator with antineoplastic and antiviral potentials but drug-induced liver injury: A comprehensive review. Int Immunopharmacol 2021; 93:107398. [PMID: 33571819 PMCID: PMC7869628 DOI: 10.1016/j.intimp.2021.107398] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Revised: 01/11/2021] [Accepted: 01/11/2021] [Indexed: 12/11/2022]
Abstract
Leflunomide (LF) represents the prototype member of dihydroorotate dehydrogenase (DHODH) enzyme inhibitors. DHODH is a mitochondrial inner membrane enzyme responsible for catalytic conversion of dihydroorotate into orotate, a rate-limiting step in the de novo synthesis of the pyrimidine nucleotides. LF produces cellular depletion of pyrimidine nucleotides required for cell growth and proliferation. Based on the affected cells the outcome can be attainable as immunosuppression, antiproliferative, and/or the recently gained attention of the antiviral potentials of LF and its new congeners. Also, protein tyrosine kinase inhibition is an additional mechanistic benefit of LF, which inhibits immunological events such as cellular expansion and immunoglobulin production with an enhanced release of immunosuppressant cytokines. LF is approved for the treatment of autoimmune arthritis of rheumatoid and psoriatic pathogenesis. Also, LF has been used off-label for the treatment of relapsing-remitting multiple sclerosis. However, LF antiviral activity is repurposed and under investigation with related compounds under a phase-I trial as a SARS CoV-2 antiviral in cases with COVID-19. Despite success in improving patients' mobility and reducing joint destruction, reported events of LF-induced liver injury necessitated regulatory precautions. LF should not be used in patients with hepatic impairment or in combination with drugs elaborating a burden on the liver without regular monitoring of liver enzymes and serum bilirubin as safety biomarkers. This study aims to review the pharmacological and safety profile of LF with a focus on the LF-induced hepatic injury from the perspective of pathophysiology and possible protective agents.
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Affiliation(s)
- Raghad D Alamri
- Faculty of Medicine, University of Tabuk, Tabuk 47713, Saudi Arabia
| | | | | | - Sarah M Alquayr
- Faculty of Medicine, University of Tabuk, Tabuk 47713, Saudi Arabia
| | | | - Sabah H El-Ghaiesh
- Deaprtment of Pharmacology, Faculty of Medicine, Tanta University, Tanta 31527, Egypt; Department of Pharmacology, Faculty of Medicine, University of Tabuk, Tabuk 47713, Saudi Arabia.
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Huang H, Ran H, Liu X, Yu L, Qiu L, Lin Z, Ou C, Lu Y, Yang W, Liu W. Leflunomide ameliorates experimental autoimmune myasthenia gravis by regulating humoral and cellular immune responses. Int Immunopharmacol 2021; 93:107434. [PMID: 33556668 DOI: 10.1016/j.intimp.2021.107434] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 01/22/2021] [Accepted: 01/23/2021] [Indexed: 12/12/2022]
Abstract
Leflunomide, an immunosuppressive disease-modifying anti-rheumatic drug (DMARD), is widely used in the treatment of rheumatoid arthritis (RA), psoriatic arthritis (PA) as well as multiple sclerosis. However, its role in myasthenia gravis (MG) has not yet been clearly explored. Here, we investigated the effect of leflunomide on experimental autoimmune myasthenia gravis (EAMG) in vivo and in vitro. The results demonstrated that leflunomide alleviated the severity of EAMG associated with reduced serum total anti-acetylcholine receptor (AChR) IgG levels. During the development of EAMG, the increase of follicular helper T cells (Tfh) 1, Tfh 17 cells and decrease of follicular regulatory T cells (Tfr) were reversely altered after leflunomide administration. Our work further found that leflunomide might inhibit Tfh cells through the IL-21/STAT3 pathway to reduce the secretion of antibodies by B cells. In addition, leflunomide rebuilt the balance of Th1/Th2/Th17/Treg subsets. These results suggested that leflunomide ameliorated EAMG severity by regulating humoral immune responses and Th cell profiles thereby providing a novel effective treatment strategy for MG.
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Affiliation(s)
- Huan Huang
- Department of Neurology, The First Affiliated Hospital, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Diagnosis and Treatment of Major Neurological Diseases, National Key Clinical Department and Key Discipline of Neurology, Sun Yat-Sen University, Guangzhou, Guangdong 510080, China
| | - Hao Ran
- School of Pharmaceutical Sciences, Sun Yat-Sen University, Guangzhou, Guangdong 510080, China
| | - Xiaoxi Liu
- Department of Neurology, The First Affiliated Hospital, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Diagnosis and Treatment of Major Neurological Diseases, National Key Clinical Department and Key Discipline of Neurology, Sun Yat-Sen University, Guangzhou, Guangdong 510080, China
| | - Lu Yu
- Department of Neurology, The First Affiliated Hospital, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Diagnosis and Treatment of Major Neurological Diseases, National Key Clinical Department and Key Discipline of Neurology, Sun Yat-Sen University, Guangzhou, Guangdong 510080, China
| | - Li Qiu
- Department of Neurology, The First Affiliated Hospital, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Diagnosis and Treatment of Major Neurological Diseases, National Key Clinical Department and Key Discipline of Neurology, Sun Yat-Sen University, Guangzhou, Guangdong 510080, China
| | - Zhongqiang Lin
- Department of Neurology, The First Affiliated Hospital, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Diagnosis and Treatment of Major Neurological Diseases, National Key Clinical Department and Key Discipline of Neurology, Sun Yat-Sen University, Guangzhou, Guangdong 510080, China
| | - Changyi Ou
- Department of Neurology, The First Affiliated Hospital, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Diagnosis and Treatment of Major Neurological Diseases, National Key Clinical Department and Key Discipline of Neurology, Sun Yat-Sen University, Guangzhou, Guangdong 510080, China
| | - Yaru Lu
- Department of Neurology, The First Affiliated Hospital, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Diagnosis and Treatment of Major Neurological Diseases, National Key Clinical Department and Key Discipline of Neurology, Sun Yat-Sen University, Guangzhou, Guangdong 510080, China
| | - Wenhao Yang
- Department of Neurology, The First Affiliated Hospital, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Diagnosis and Treatment of Major Neurological Diseases, National Key Clinical Department and Key Discipline of Neurology, Sun Yat-Sen University, Guangzhou, Guangdong 510080, China
| | - Weibin Liu
- Department of Neurology, The First Affiliated Hospital, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Diagnosis and Treatment of Major Neurological Diseases, National Key Clinical Department and Key Discipline of Neurology, Sun Yat-Sen University, Guangzhou, Guangdong 510080, China.
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Zhuang J, Ji X, Zhu Y, Liu W, Sun J, Jiao X, Xu X. Restriction of intracellular Salmonella typhimurium growth by the small-molecule autophagy inducer A77 1726 through the activation of the AMPK-ULK1 axis. Vet Microbiol 2021; 254:108982. [PMID: 33461007 DOI: 10.1016/j.vetmic.2021.108982] [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: 10/20/2020] [Accepted: 01/05/2021] [Indexed: 11/28/2022]
Abstract
Autophagy plays an important role in restricting the growth of invading intracellular microbes. Salmonella (S) Typhimurium, an intracellular pathogen that causes gastroenteritis and food poisoning in humans, evades autophagic detection by multiple mechanisms. There has been growing interest in developing autophagy inducers as novel antimicrobial agents for treating intracellular bacterial infections. We recently reported that A77 1726, the active metabolite of the anti-inflammatory drug leflunomide, induces autophagy by activating AMP-activated protein kinase (AMPK) and Unc-51 like autophagy activating kinase 1 (ULK1). Our present study aims to determine if A77 1726 was able to restrict intracellular Salmonella growth by inducing autophagy. We first confirmed the ability of A77 1726 to induce autophagy by activating the AMPK-ULK1 axis in uninfected RAW264.7 (a murine macrophage cell line) and HeLa cells (a human cervical carcinoma cell line). A77 1726 enhanced autophagy in S. Typhimurium-infected cells, as evidenced by increased levels of LC3 lipidation and increased numbers of autophagosomes and autolysosomes. Confocal microscopy revealed that A77 1726 induced xenophagy in macrophages, as evidenced by an increased number of LC3-coated bacteria in the cytoplasm. A77 1726 significantly decreased the number of intracellular S. Typhimurium in macrophages. Taken together, our study has demonstrated the ability of A77 1726 to restrict intracellular S. Typhimurium growth in vitro by enhancing xenophagy.
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Affiliation(s)
- Jing Zhuang
- Institute of Comparative Medicine, College of Veterinary Medicine, Yangzhou University, Yangzhou, 225009, Jiangsu Province, PR China
| | - Xiaoyue Ji
- Institute of Comparative Medicine, College of Veterinary Medicine, Yangzhou University, Yangzhou, 225009, Jiangsu Province, PR China
| | - Yue Zhu
- Institute of Comparative Medicine, College of Veterinary Medicine, Yangzhou University, Yangzhou, 225009, Jiangsu Province, PR China
| | - Wei Liu
- Institute of Comparative Medicine, College of Veterinary Medicine, Yangzhou University, Yangzhou, 225009, Jiangsu Province, PR China
| | - Jing Sun
- Institute of Comparative Medicine, College of Veterinary Medicine, Yangzhou University, Yangzhou, 225009, Jiangsu Province, PR China
| | - Xinan Jiao
- Jiangsu Key Laboratory of Zoonosis, Yangzhou University, Yangzhou, 225009, PR China; Jiangsu Co-innovation Center for Prevention and Control of Important Animal Infectious Diseases and Zoonosis, Yangzhou University, Yangzhou, 225009, Jiangsu Province, PR China
| | - Xiulong Xu
- Institute of Comparative Medicine, College of Veterinary Medicine, Yangzhou University, Yangzhou, 225009, Jiangsu Province, PR China; Jiangsu Co-innovation Center for Prevention and Control of Important Animal Infectious Diseases and Zoonosis, Yangzhou University, Yangzhou, 225009, Jiangsu Province, PR China; Joint International Research Laboratory of Agriculture and Agri-Product Safety, the Ministry of Education of China, Yangzhou University, Yangzhou, 225009, PR China.
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