Current treatment options in rheumatology最新文献

Purpose of the review: Systemic sclerosis (SSc) is a rare immune-mediated connective tissue disease with high morbidity and mortality. Interstitial lung disease (ILD) is now the leading cause of death for patients with SSc. While several therapeutic agents have been approved for SSc-ILD, opportunities remain for a personalized medicine approach to improve patient outcomes. The purpose of this narrative review is to summarize the current state of personalized medicine for SSc-ILD and future directions to facilitate earlier diagnosis, disease stratification, prognostication, and determination of treatment response. We also review opportunities for personalized medicine approaches within clinical trial design for SSc-ILD.

Recent findings: The management of SSc-ILD remains challenging due to its variable clinical course and current deficits in predicting which individuals will develop progressive pulmonary fibrosis. There have additionally been many challenges in clinical trial design due to limitations in enrichment strategies. Emerging data suggest that serum, radiologic, and other novel biomarkers could be utilized to assess disease activity and treatment response on an individual level.

Summary: Personalized medicine is emerging as a way to address unmet challenges in SSc-ILD and has applicability for identifying stratifying, prognostic, and therapeutic markers for routine clinical care and clinical trial design.

Purpose of review: Eosinophilic fasciitis (EF) is a rare inflammatory disease characterized by skin induration. Although some guidelines from scientific societies exist, standard recommendations on monitoring and therapy are lacking.

Recent findings: Current therapy for patients diagnosed with EF includes glucocorticoids plus at least one immunosuppressive drug in cases of relapse or refractory disease. Methotrexate and mycophenolate mofetil are the most recommended, although recently a myriad of case reports or small series reporting the effectivity of biological agents or JAK inhibitors for treating relapses or refractory disease have been published. Anti-IL5 may have a role in those rare refractory cases with persistent eosinophilia. Intravenous immunoglobulins and photopheresis (in those centers with experience) may act as adjuvant therapies. Monitoring the disease activity is a cornerstone to ascertain if the treatment is useful or not. MRI, PET/TC, and more specifically POCUS have recently demonstrated their value for assessing therapy response.

Summary: High-quality data focused on therapy and monitoring is lacking in EF. Strategies for improving scientific quality of observational studies and consensus about "activity", "sequela", "relapse" or "refractoriness" terms in EF patients are necessary to implement prospective clinical trials and generate evidence-based medicine. Meanwhile we have to deal with the available information.

Purpose of review: To summarize the current treatment landscape of rheumatoid arthritis-associated interstitial lung disease (RA-ILD) in the context of the recent 2023 American College of Rheumatology/American College of Chest Physicians guideline for ILD treatment in systemic autoimmune rheumatic diseases.

Recent findings: The guideline conditionally recommends mycophenolate, azathioprine, and rituximab for first-line RA-ILD therapy, with cyclophosphamide and short-term glucocorticoids as additional options. For RA-ILD progression after first line, mycophenolate, rituximab, nintedanib, tocilizumab, cyclophosphamide, and pirfenidone are conditionally recommended, while long-term glucocorticoids are conditionally recommended against. Only three randomized controlled trials (RCTs) enrolled patients with RA-ILD (total n=217). All other recommendations for RA-ILD were based on RCTs for other diseases or observational data. Antifibrotics might be particularly effective for patients with RA-ILD and the usual interstitial pneumonia pattern (RA-UIP). There is uncertainty of the utility of azathioprine and glucocorticoids in RA-UIP since these medications had worse outcomes compared to placebo in an RCT of patients with idiopathic pulmonary fibrosis. RA-ILD treatment decisions should consider articular activity, ILD activity, comorbidities, and potential for infection.

Summary: We summarized the current treatment landscape for RA-ILD. Since only three RCTs included patients with RA-ILD, most guideline recommendations were conditional and based on low-quality evidence. This highlights the urgent need for additional high-quality RCT data for efficacy and safety of anti-inflammatory and antifibrotic medications for RA-ILD.