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Ann Rheum Dis. 2017 Jul;76(7):1207-1218. doi: 10.1136/annrheumdis-2016-210503. Epub 2017 Feb 10.

Treatment outcome in early diffuse cutaneous systemic sclerosis: the European Scleroderma Observational Study (ESOS).

Author information

1
Centre for Musculoskeletal Research, The University of Manchester, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK.
2
NIHR Manchester Musculoskeletal Biomedical Research Unit, Central Manchester NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK.
3
Centre for Musculoskeletal Research, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK.
4
Department of Rheumatology, Lund University, Lund, Sweden.
5
Service de Médecine Interne, Hôpital Cochin, Centre de Référence pour les Vascularites Nécrosantes et la Sclérodermie Systémique, Université Paris Descartes, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France.
6
Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences,University of Oxford, Oxford, UK.
7
Member of Steering Committee, contact via Professor Herrick, The University of Manchester, Manchester, UK.
8
Department of Rheumatology and Immunology, Medical Center, University of Pécs, Pecs, Hungary.
9
Department of Internal Medicine 3, University of Erlangen-Nuremberg, Erlangen, Germany.
10
Department of Rheumatology, University of Zurich, Zurich, Switzerland.
11
Royal Free London NHS Foundation Trust, London, UK.
12
Rehabilitation Services, Salford Royal NHS Foundation Trust, Salford, UK.
13
Department of the Rheumatic Diseases, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands.
14
Rheumatology 2 Department, "Grigore T. Popa" University of Medicine and Pharmacy, Clinical Rehabilitation Hospital, Iași, Romania.
15
UCL Division of Medicine, Centre for Rheumatology and Connective Tissue Diseases, London, UK.
16
Unité Clinique de Médecine Interne, Maladies Auto-immunes et Pathologie Vasculaire, UF 04, Hôpital Saint-Louis, AP-HP Assistance Publique des Hôpitaux de Paris, INSERM UMRS 1160, Paris Denis Diderot University, France.
17
Jewish General Hospital, Lady Davis Institute and McGill University, Montreal, Canada.
18
Department Experimental and Clinical Medicine, Division of Rheumatology AOUC, University of Florence, Florence, Italy.
19
Shine Rheumatology Unit, Rambam Heath Care Campus; Rappaport Faculty of Medicine, Haifa, Israel.
20
Rheumatology Unit, Oslo University Hospital Rikshospitalet, Oslo, Norway.
21
Queen Elizabeth Hospital Birmingham, UHB Foundation Trust, Birmingham, UK.
22
St Vincent's Hospital, Melbourne, Australia.
23
Department for Dermatology, University of Cologne Kerpenerstr. 62, Köln, Germany.
24
Cambridge University NHS Hospital Foundation Trust, Cambridge, UK.
25
Department of Internal Medicine, Hôtel-Dieu Hospital, University of Nantes, Nantes, France.
26
University of Liverpool, Aintree University Hospital, Liverpool, UK.
27
Service de Médecine Interne, Hôpital Bretonneau Tours Cedex, France.
28
Centre for Rheumatic Diseases, Glasgow Royal Infirmary, Glasgow, UK.
29
Sheffield Teaching Hospitals, Sheffield, UK.
30
Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds and NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust, UK.
31
Stanford University, Stanford, California, USA.
32
University of Belgrade School of Medicine, Institute of Rheumatology, Belgrade, Serbia.
33
Clinical and Academic Rheumatology, North Bristol NHS Trust, Bristol, UK.
34
Nottingham University Hospitals NHS Trust, and Nottingham NHS Treatment Centre, Nottingham, UK.
35
Peter Maddison Rheumatology Centre, Llandudno, UK.
36
Queens Hospital, Romford, UK.
37
University of Copenhagen, Copenhagen Lupus and Vasculitis Clinic, Center for Rheumatology and Spine Diseases, Rigshospitalet, Copenhagen, Denmark.
38
Norwich Medical School, University of East Anglia, Norwich, UK.
39
Royal National Hospital for Rheumatic Diseases, Bath, UK.
40
Department of Rheumatology and Clinical Immunology, Justus-Liebig University Giessen, Bad Nauheim, Germany.
41
Department of Rheumatology, University of Lübeck, Lübeck, Germany.
42
Department of Rheumatology and Clinical Immunology, University Hospital Charité Berlin, Berlin, Germany.
43
Department of Rheumatology, Royal Perth Hospital, Perth, Australia.
44
Servicio de Reumatologia. Hospital Universitario 12 de Octubre, Madrid, Spain.
45
Internal Medicine Unit, Limoges University Hospital, France.
46
Département de Médecine Interne et Immunologie Clinique, Centre National de Référence Maladies Systémiques etAuto-immunes Rares, Université de Lille, Inserm, U995, FHU Immune-Mediated Inflammatory Diseases and Targeted Therapies, Lille, France.
47
Gateshead Hospitals Foundation Trust, Gateshead, UK.
48
Department of Internal Medicine, Division of Rheumatology, Istanbul University, Istanbul, Turkey.
49
Fife Rheumatic Diseases Unit, Whyteman's Brae Hospital, Kirkcaldy, UK.
50
Department of Rheumatology and Clinical Immunology, UMC Utrecht, Utrecht, The Netherlands.
51
James Cook University Hospital, Middlesbrough, UK.
52
Rheumatology Unit, Royal Adelaide Hospital, and Discipline of Medicine, University of Adelaide, Adelaide, South Australia.
53
Department of Rheumatology and Inflammation Research, The Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden.
54
Monash Centre for Inflammatory Diseases, Monash University, Clayton, Melbourne, Australia.
55
Department of Internal Medicine, Hôpital Edouard Herriot, Lyon, France.
56
Department of Internal Medicine, Foundation Hospital Saint Joseph, Marseille, France.
57
Cannock Chase Hospital, Cannock, UK.
58
St Vincent's University Hospital, Dublin, Ireland.
59
Department of Internal Medicine, Centre Hospitalier Lyon Sud, Pierre Benite, France.
60
Internal Medecine, Ambroise Paré Hospital, Boulogne Billancourt, France.

Abstract

OBJECTIVES:

The rarity of early diffuse cutaneous systemic sclerosis (dcSSc) makes randomised controlled trials very difficult. We aimed to use an observational approach to compare effectiveness of currently used treatment approaches.

METHODS:

This was a prospective, observational cohort study of early dcSSc (within three years of onset of skin thickening). Clinicians selected one of four protocols for each patient: methotrexate, mycophenolate mofetil (MMF), cyclophosphamide or 'no immunosuppressant'. Patients were assessed three-monthly for up to 24 months. The primary outcome was the change in modified Rodnan skin score (mRSS). Confounding by indication at baseline was accounted for using inverse probability of treatment (IPT) weights. As a secondary outcome, an IPT-weighted Cox model was used to test for differences in survival.

RESULTS:

Of 326 patients recruited from 50 centres, 65 were prescribed methotrexate, 118 MMF, 87 cyclophosphamide and 56 no immunosuppressant. 276 (84.7%) patients completed 12 and 234 (71.7%) 24 months follow-up (or reached last visit date). There were statistically significant reductions in mRSS at 12 months in all groups: -4.0 (-5.2 to -2.7) units for methotrexate, -4.1 (-5.3 to -2.9) for MMF, -3.3 (-4.9 to -1.7) for cyclophosphamide and -2.2 (-4.0 to -0.3) for no immunosuppressant (p value for between-group differences=0.346). There were no statistically significant differences in survival between protocols before (p=0.389) or after weighting (p=0.440), but survival was poorest in the no immunosuppressant group (84.0%) at 24 months.

CONCLUSIONS:

These findings may support using immunosuppressants for early dcSSc but suggest that overall benefit is modest over 12 months and that better treatments are needed.

TRIAL REGISTRATION NUMBER:

NCT02339441.

KEYWORDS:

Cyclophosphamide; Methotrexate; Systemic Sclerosis; Treatment

PMID:
28188239
PMCID:
PMC5530354
DOI:
10.1136/annrheumdis-2016-210503
[Indexed for MEDLINE]
Free PMC Article

Conflict of interest statement

Competing interests: ALH has done consultancy work for Actelion, served on a Data Safety Monitoring Board for Apricus, received research funding and speaker's fees from Actelion, and speaker's fees from GSK. JHWD has consultancy relationships and/or has received research funding from Actelion, BMS, Celgene, Bayer Pharma, Boehringer Ingelheim, JB Therapeutics, Sanofi-Aventis, Novartis, UCB, GSK, Array Biopharma, Active Biotech, Galapagos, Inventiva, Medac, Pfizer, Anamar and RuiYi and is stock owner of 4D Science GmbH. OD has received consultancy fees from 4D Science, Actelion, Active Biotech, Bayer, Biogenidec, BMS, Boehringer Ingelheim, EpiPharm, Ergonex, espeRare Foundation, Genentech/Roche, GSK, Inventiva, Lilly, Medac, Medimmune, Pharmacyclics, Pfizer, Serodapharm, and Sinoxa and received research grants from Actelion, Bayer, Boehringer Ingelheim, Ergonex, Pfizer and Sanofi, and has a patent mir-29 for the treatment of systemic sclerosis licenced. WG has received teaching fees from Pfizer. FH has received research funding from Actelion. MEA has undertaken advisory board work and received honoraria from Actelion, and received speaker's fees from Bristol-Myers Squibb. LC has done advisory board work for Gilead and served Data Safety Monitoring Boards for Cytori and Reata. HG has done consultancy work and received honoraria from Actelion. UM-L is funded in part bu EUSTAR/EULAR. JMvL has received honoraria from Eli Lilly, Pfizer, Roche, MSD and BMS. AR receives funding from AstraZeneca. CPD has done consultancy for GSK, Actelion, Bayer, Inventiva and Merck-Serono, received research grant funding from GSK, Actelion, CSL Behring and Inventiva, received speaker's fees from Bayer and given trial advice to Merck-Serono.

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