Cancer Treatment Today » Rheumatology

Rituxan and vasculitis

M Levin, MD — Sun, 20 Jan 2013 22:05:26 +0000

The U.S. Food and Drug Administration in April 2011approved Rituxan (rituximab), in combination with glucocorticoids (steroids), to treat patients with Wegener’s granulomatosis (WG) and microscopic polyangiitis (MPA), two rare disorders that cause blood vessel inflammation (vasculitis). Case reports and sereis suggest that it may also be effective in otehr types of vasculitis, particularly those with antineutrophil cytoplasmic antibody (ANCA)–associated vasculitis. Several patients with chronic cutaneous small-vessel vasculitis have also been treated effectively with this agent. Interestingly, one case report suggested that Rituxan itself can cause leukocytoclastic vasculitis.

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Rituxan for scleroderma lung disease

M Levin, MD — Mon, 12 Nov 2012 23:32:00 +0000

Rituximab is an agent with a variety of immunologic effects mediated thorugh its effects on B-lymphocytes. Unfortunately, there is no effective therapy for severe lung disease caused by scleroderma that is not responding to immunosuppression. Two observational studies, one with 8 and one with 15 patients revealed conflicting results. One very small prospective study with 8 patients who received rituximab and six who had not had been performed and showed encouraging results(Daoussius et al). These remain preliminary findings and more research clearly needs to be conducted.

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Cyclophosphamide(Cytoxan) in the treatment of Pulmonary Vasculitis – pro

M Levin, MD — Fri, 07 Sep 2012 20:51:50 +0000

Pulmonary vasculitis describes a number of distinct disorders that are pathologically characterized by the destruction of blood vessels. Before the institution of immunosuppressive therapy, the mortality rate of patients with a systemic vasculitis was 75%, with a median survival of 5 mo. The addition of corticosteroid therapy improved mortality at 1 yr but had no impact at 3 yr (there was significant steroid-associated mortality and morbidity). The 5-yr mortality remained at 50%. The major breakthrough occurred when cyclophosphamide was added to corticosteroids, and this lowered the 5-yr mortality to 12%.

EUVAS study, Non-Renal Alternative With Methotrexate (NORAM) trial compared methotrexate with cyclophosphamide for the induction of remission in early disease. There were similar rates of induction of remission at 6 months; however, the time to remission was longer in the methotrexate arm (5.2 months vs 3.2 months), and the relapse rate was statistically higher in the methotrexate arm (74% vs 42%). On the other hand, the methotrexate was better tolerated than the cyclophosphamide. Hence, cycophosphamide with steroids is first line and methotrexate, in combination with corticosteroids, is now considered an alternative first-line regimen for the treatment of early, generalized disease.

Stephen K. Frankel, MD, FCCP, The Diagnosis and Treatment of Pulmonary Vasculitis
PCCSU Article | 04.01.08http://www.chestnet.org/accp/pccsu/diagnosis-and-treatment-pulmonary-vasculitis?page=0,3

CURRENT Medical Diagnosis & Treatment 2013
Pulmonary Vasculitis, The McGraw-Hill Companies

Stephen K. Frankel, MD, FCCP; Gregory P. Cosgrove, MD, FCCP; Aryeh Fischer, MD; Richard T. Meehan, MD; Kevin K. Brown, MD, FCCP February 2006, Vol 129, No. 2Update in the Diagnosis and Management of Pulmonary Vasculitis.
For Lay version see here

Nutritional Deficiencies in Scleroderma and Related Disorders

M Levin, MD — Sun, 05 Aug 2012 13:57:43 +0000

Nutritional deficiencies in scleroderma and related disorders often include folate and Vit. B12, and more recently reported, Vit. D and E, due to bacterial overgrowth in the gut. Metanx is sometimes prescribed for these conditions. Metanx is a food which is formulated to be consumed or administered by mouth under the supervision of a physician and which is intended for the specific dietary management of a disease or condition for which distinctive nutritional requirements, based on recognized scientific principles, are established by medical evaluation. Specifically it is formulated for diabetic neuropathy. The usual adult dosage of Metanx® is one tablet twice daily .Each Metanx® tablet contains: L-methylfolate Calcium (as Metafolin®) 3mg, Pyridoxal 5′-phosphate 35mg, Methylcobalamin.

Metanx is a “legend vitamin”. Legend vitamins are specific formulations that are intended to reverse nutritional deficiencies in various conditions. Metanx® tablets are indicated for the distinct nutritional requirements of patients with who present with loss of protective sensation and neuropathic pain in their arms and legs associated with diabetic peripheral neuropathy. Metanx® tablets are also indicated for the distinct nutritional requirements of patients with endothelial dysfunction and/or hyperhomocysteinemia who present with lower extremity ulceration(s). Rigorous research on “legend vitamins” is lacking but there is usually little downside to using them with the consent of your healthcare provider.

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Sacroiliac Injection

M Levin, MD — Tue, 19 Jun 2012 19:48:52 +0000

Sacroiliac steroid injection can be used diagnostically or therapeutically. There are no prospective a controlled trials to support this procedure. Most support comes from case reports or case series. Case series are unreliable evidence due to the variable natural history of back pain, the presence of factors that can influence outcome and mislead the investigators, and the potential for a placebo effect. In general, the literature regarding injection therapy on joints in the back is of poor quality. The current evidence on sacroiliac joint arthrography and injections is insufficient to consider it medically appropriate.

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