RESUMO
BACKGROUND: This study examines the association of standard-of-care systemic lupus erythematosus (SLE) medications with key outcomes such as low disease activity attainment, flares, damage accrual, and steroid-sparing, for which there is current paucity of data. METHODS: The Asia Pacific Lupus Collaboration (APLC) prospectively collects data across numerous sites regarding demographic and disease characteristics, medication use, and lupus outcomes. Using propensity score methods and panel logistic regression models, we determined the association between lupus medications and outcomes. RESULTS: Among 1707 patients followed over 12,689 visits for a median of 2.19 years, 1332 (78.03%) patients achieved the Lupus Low Disease Activity State (LLDAS), 976 (57.18%) experienced flares, and on most visits patients were taking an anti-malarial (69.86%) or immunosuppressive drug (76.37%). Prednisolone, hydroxychloroquine and azathioprine were utilised with similar frequency across all organ domains; methotrexate for musculoskeletal activity. There were differences in medication utilisation between countries, with hydroxychloroquine less frequently, and calcineurin inhibitors more frequently, used in Japan. More patients taking leflunomide, methotrexate, chloroquine/hydroxychloroquine, azathioprine, and mycophenolate mofetil/mycophenolic acid were taking ≤ 7.5 mg/day of prednisolone (compared to > 7.5 mg/day) suggesting a steroid-sparing effect. Patients taking tacrolimus were more likely (Odds Ratio [95% Confidence Interval] 13.58 [2.23-82.78], p = 0.005) to attain LLDAS. Patients taking azathioprine (OR 0.67 [0.53-0.86], p = 0.001) and methotrexate (OR 0.68 [0.47-0.98], p = 0.038) were less likely to attain LLDAS. Patients taking mycophenolate mofetil were less likely to experience a flare (OR 0.79 [0.64-0.97], p = 0.025). None of the drugs was associated with a reduction in damage accrual. CONCLUSIONS: This study suggests a steroid-sparing benefit for most commonly used standard of care immunosuppressants used in SLE treatment, some of which were associated with an increased likelihood of attaining LLDAS, or reduced incidence of flares. It also highlights the unmet need for effective treatments in lupus.
Assuntos
Antimaláricos , Azatioprina , Glucocorticoides , Hidroxicloroquina , Imunossupressores , Lúpus Eritematoso Sistêmico , Metotrexato , Prednisolona , Padrão de Cuidado , Humanos , Lúpus Eritematoso Sistêmico/tratamento farmacológico , Feminino , Imunossupressores/uso terapêutico , Hidroxicloroquina/uso terapêutico , Masculino , Glucocorticoides/uso terapêutico , Adulto , Azatioprina/uso terapêutico , Prednisolona/uso terapêutico , Metotrexato/uso terapêutico , Antimaláricos/uso terapêutico , Estudos de Coortes , Pessoa de Meia-Idade , Ácido Micofenólico/uso terapêutico , Leflunomida/uso terapêutico , Inibidores de Calcineurina/uso terapêutico , Modelos Logísticos , Pontuação de Propensão , Índice de Gravidade de Doença , Tacrolimo/uso terapêutico , Exacerbação dos Sintomas , Resultado do Tratamento , Antirreumáticos/uso terapêuticoRESUMO
The term autoimmune/autoinflammatory syndrome induced by adjuvants (ASIA) or Shoenfeld's syndrome refers to a wide group of immune-mediated diseases triggered by external agents. Several substances, such as vaccine adjuvants, squalene and silicone implants, are implied in the pathogenesis of ASIA syndrome. Treatment and prognosis of this complex condition are not completely known due to lack of good quality evidence. After a brief introductory literature review on ASIA, we report here two cases of patients that developed rapidly progressive systemic sclerosis clinical features after multiple intramuscular local injections of a substance recommended by a non-medical professional called ADE. ADE is an oily vitamin complex for veterinary use, and it was used in these cases for cosmetic muscular definition and enhancement purpose. To our knowledge, this is the first paper to describe the relation between injections of ADE and the development of ASIA with severe systemic sclerosis phenotype. Further investigation is needed to better understand the pathophysiology and to provide the basis for the treatment of this condition.
Assuntos
Adjuvantes Farmacêuticos/efeitos adversos , Esclerodermia Difusa/induzido quimicamente , Adjuvantes Farmacêuticos/administração & dosagem , Adulto , Humanos , Injeções Intramusculares , Masculino , Rituximab/uso terapêutico , Esclerodermia Difusa/tratamento farmacológico , Esclerodermia Difusa/patologia , Síndrome , Vitamina A/administração & dosagem , Vitamina D/administração & dosagem , Vitamina E/administração & dosagem , Vitaminas/administração & dosagemRESUMO
Systemic sclerosis is a complex disease due to the variety of clinical presentations, often superimposed on other conditions, related or not to the connective tissue. We report a 43-year-old Brazilian woman with limited systemic sclerosis and pulmonary symptoms secondary to gastroesophageal reflux disease, with a clinical presentation similar to a diffuse interstitial lung disease. Because of the frequency of interstitial lung injury due to systemic sclerosis, this was an important differential diagnosis, which could be excluded after optimized treatment of reflux disease, with clinical and radiological improvement. Clinical management of patients with collagen diseases requires clinician skills to identify the natural history and understand its nuances. This is a common situation in clinical practice, but with a few discussions in international literature.
RESUMO
Lúpus eritematoso sistêmico (LES) é uma condição autoimune com processo fisiopatológico complexo, no qual sua atividade inflamatória é potencializadora da doença coronariana através de inflamação sistêmica, disfunção endotelial e predisposição à trombose. O acometimento cardiovascular no LES não é critério diagnóstico, sendo considerado somente como dano já estabelecido em longo prazo de doença. O objetivodeste artigo é destacar a importância da visão clínica para a identificação precoce do acometimento cardiovascular no LES. É feita uma análise crítica da abordagem cardiológica no LES, com ênfase nos aspectos clínicos, biomarcadores cardiovasculares e genética e solicitação racional dos exames complementares. Aparticularidade dos pacientes com nefrite lúpica e síndrome do anticorpo antifosfolipídeo também é destacada.A percepção do dano cardíaco subclínico é fundamental para interromper o ciclo de agressão miocárdica e evitar progressão de doença cardíaca.
Systemic lupus erythematosus (SLE) is an autoimmune condition with a complex pathophysiological process in which its inflammatory activity is an enhancer of coronary disease by systemic inflammation, endothelial dysfunction and predisposition to thrombosis. Thecardiovascular involvement in SLE is not a diagnostic criterion and is considered only as damage established in the long-term of the disease. The objective of this study is to highlight the importance of clinical vision for the early identification of cardiovascular involvement in SLE. A critical analysis of the cardiac approach in SLE, with emphasis on clinical aspects, cardiovascular biomarkers and genetics and rational request of additional tests. The particularity of patients with lupus nephritis and antiphospholipid antibodysyndrome is also highlighted. The perception of subclinical cardiac damage is critical for interrupting the cycle of myocardial injury and to avoid progression of heart disease.