Scleroderma medical therapy: Difference between revisions
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====Kidney Disease==== | ====Kidney Disease==== | ||
Scleroderma renal crisis, the occurrence of [[acute renal failure]] and [[malignant hypertension]] (very high blood pressure with evidence of organ damage) in people with scleroderma, is effectively treated with drugs from the class of the [[ACE inhibitor]]s. The benefit of ACE inhibitors extends even to those who have to commence [[hemodialysis|dialysis]] to treat their kidney disease, and may give sufficient benefit to allow the discontinuation of renal replacement therapy.<ref name=Zandberg/> [[ACE inhibitors]] are also used for [[prophylaxis]],<ref name= | Scleroderma renal crisis, the occurrence of [[acute renal failure]] and [[malignant hypertension]] (very high blood pressure with evidence of organ damage) in people with scleroderma, is effectively treated with drugs from the class of the [[ACE inhibitor]]s. The benefit of ACE inhibitors extends even to those who have to commence [[hemodialysis|dialysis]] to treat their kidney disease, and may give sufficient benefit to allow the discontinuation of renal replacement therapy.<ref name=Zandberg/> [[ACE inhibitors]] are also used for [[prophylaxis]],<ref name="pmid14706971">{{cite journal |author=Jimenez SA, Derk CT |title=Following the molecular pathways toward an understanding of the pathogenesis of systemic sclerosis |journal=[[Annals of Internal Medicine]] |volume=140 |issue=1 |pages=37–50 |year=2004 |month=January |pmid=14706971 |doi= |url=http://www.annals.org/article.aspx?volume=140&page=37 |accessdate=2012-08-30}}</ref><ref name=steen11033587/> and [[renal transplantation]]. Transplanted kidneys are known to be affected by scleroderma and patients with early onset renal disease (within one year of the scleroderma diagnosis) are thought to have the highest risk for recurrence.<ref>Pham PT, Pham PC, Danovitch GM, Gritsch HA, Singer J, Wallace WD, Hayashi R, Wilkinson AH. Predictors and risk factors for recurrent scleroderma renal crisis in the kidney allograft: case report and review of the literature. Am J Transplant. 2005 Oct;5(10):2565-9. PMID 16162209.</ref> | ||
====Lung Disease and Pulmonary Hypertension==== | ====Lung Disease and Pulmonary Hypertension==== | ||
Revision as of 21:36, 7 November 2012
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Overview
Medical Therapy
There is no cure for every patient with scleroderma, though there is treatment for some of the symptoms, including drugs that soften the skin and reduce inflammation. Some patients may benefit from exposure to heat.[1]
Digital ulcerations and pulmonary hypertension can be helped by prostacyclin (iloprost) infusion. Iloprost being a drug which increases blood flow by relaxing the arterial wall.[2]
Pharmacotherapy
Topical/Symptomatic
Topical treatment for the skin changes of scleroderma do not alter the disease course, but may improve pain and ulceration. A range of NSAIDs (nonsteroidal anti-inflammatory drugs) can be used to ease painful symptoms, such as naproxen. There is limited benefit from steroids such as prednisone. Episodes of Raynaud's phenomenon sometimes respond to nifedipine or other calcium channel blockers; severe digital ulceration may respond to prostacyclin analogue iloprost, and the dual endothelin-receptor antagonist bosentan may be beneficial for Raynaud's phenomenon.[3] The skin tightness may be treated systemically with methotrexate and cyclosporin.[3] If there is esophageal dysmotility (in CREST or systemic sclerosis), care must be taken with NSAIDs as they are gastric irritants, and so a proton pump inhibitor (PPI) such as omeprazole can be given in conjunction.
Kidney Disease
Scleroderma renal crisis, the occurrence of acute renal failure and malignant hypertension (very high blood pressure with evidence of organ damage) in people with scleroderma, is effectively treated with drugs from the class of the ACE inhibitors. The benefit of ACE inhibitors extends even to those who have to commence dialysis to treat their kidney disease, and may give sufficient benefit to allow the discontinuation of renal replacement therapy.[3] ACE inhibitors are also used for prophylaxis,[4][5] and renal transplantation. Transplanted kidneys are known to be affected by scleroderma and patients with early onset renal disease (within one year of the scleroderma diagnosis) are thought to have the highest risk for recurrence.[6]
Lung Disease and Pulmonary Hypertension
Active alveolitis is often treated with pulses of cyclophosphamide, often together with a small dose of steroids. The benefit of this intervention is modest.[7][8]
Pulmonary hypertension may be treated with epoprostenol, bosentan and possibly aerolized iloprost.[3]
References
- ↑ Oliver GF, Winkelmann RK (1989). "The current treatment of scleroderma". Drugs. 37 (1): 87–96. PMID 2651089.
- ↑ Zandman-Goddard G, Tweezer-Zaks N, Shoenfeld Y (2005). "New therapeutic strategies for systemic sclerosis--a critical analysis of the literature". Clin. Dev. Immunol. 12 (3): 165–73. PMID 16295521.
- ↑ 3.0 3.1 3.2 3.3 Zandman-Goddard G, Tweezer-Zaks N, Shoenfeld Y (2005). "New therapeutic strategies for systemic sclerosis--a critical analysis of the literature". Clin. Dev. Immunol. 12 (3): 165–73. PMID 16295521. PMC 2275417
- ↑ Jimenez SA, Derk CT (2004). "Following the molecular pathways toward an understanding of the pathogenesis of systemic sclerosis". Annals of Internal Medicine. 140 (1): 37–50. PMID 14706971. Retrieved 2012-08-30. Unknown parameter
|month=ignored (help) - ↑
- ↑ Pham PT, Pham PC, Danovitch GM, Gritsch HA, Singer J, Wallace WD, Hayashi R, Wilkinson AH. Predictors and risk factors for recurrent scleroderma renal crisis in the kidney allograft: case report and review of the literature. Am J Transplant. 2005 Oct;5(10):2565-9. PMID 16162209.
- ↑ Tashkin DP, Elashoff R, Clements PJ; et al. (2006). "Cyclophosphamide versus placebo in scleroderma lung disease". N. Engl. J. Med. 354 (25): 2655–66. doi:10.1056/NEJMoa055120. PMID 16790698. Unknown parameter
|month=ignored (help) - ↑ Hoyles RK, Ellis RW, Wellsbury J; et al. (2006). "A multicenter, prospective, randomized, double-blind, placebo-controlled trial of corticosteroids and intravenous cyclophosphamide followed by oral azathioprine for the treatment of pulmonary fibrosis in scleroderma". Arthritis Rheum. 54 (12): 3962–70. doi:10.1002/art.22204. PMID 17133610. Unknown parameter
|month=ignored (help)