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Effects of cyclophosphamide on pulmonary function in patients with scleroderma and interstitial lung disease: a systematic review and a meta-analysis of randomized controlled trials and observational prospective cohort studies
Arthritis Research & Therapy 2008, 10:R124 doi:10.1186/ar2534

Carlotta Nannini (nannini.carlotta@mayo.edu) Colin P West (west.colin@mayo.edu) Patricia J Erwin (erwin.patricia@mayo.edu) Eric L Matteson (matteson.eric@mayo.edu)

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1478-6354 Research article 25 June 2008 20 October 2008 20 October 2008 http://arthritis-research.com/content/10/5/R124

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2008 Nannini et al. , licensee BioMed Central Ltd. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Effects of cyclophosphamide on pulmonary function in patients with scleroderma and interstitial lung disease: a systematic review and a meta-analysis of randomized controlled trials and observational prospective cohort studies Carlotta Nannini, MD1, Colin P. West, MD PhD2-3, Patricia J. Erwin, MLS4, Eric L. Matteson, MD, MPH1 Divisions of Rheumatology1 and General Internal Medicine2, Biostatistics3 and Medical Library4, Mayo Clinic College of Medicine, Rochester, MN USA

Institution address: Mayo Clinic 200 First Street SW Rochester, Minnesota 55905 USA

Authors affiliations Carlotta Nannini: Division of Rheumatology, Mayo Clinic, 200 First Street SW, Rochester, Minnesota, 55905, USA Colin P West: Division of General Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester, Minnesota, 55905, USA Patricia J. Erwin: Medical Library, Mayo Clinic, 200 First Street SW, Rochester, Minnesota, 55905, USA Eric L Matteson: Division of Rheumatology, Mayo Clinic 200 First Street SW, Rochester, Minnesota, 55905, USA

Corresponding author: Carlotta Nannini, M.D. Email: nannini.carlotta@mayo.edu

ABSTRACT Introduction: The purpose of the study was to systematically review the effect of cyclophosphamide treatment on pulmonary function in patients with systemic sclerosis and interstitial lung disease. Methods: The primary outcomes were the mean change in forced vital capacity and diffusing capacity for carbon monoxide after 12 months of therapy in patients treated with cyclophosphamide. Results: Three randomized clinical trials and 6 prospective observational studies were included for analysis. In the pooled analysis forced vital capacity and diffusing capacity for carbon monoxide predicted values were essentially unchanged after 12 months of therapy with mean changes of 2.83% (95% confidence interval: 0.35; 5.31) and 4.56% (95% confidence interval: -0.21; 9.33), respectively. Conclusions: Cyclophosphamide treatment in patients with systemic sclerosis related interstitial lung disease does not result in clinically significant improvement of pulmonary function.

Introduction Scleroderma (systemic sclerosis) is an autoimmune connective tissue disorder that is characterized by micro-vascular injury, excessive fibrosis of the skin and distinctive visceral changes that can involve lungs, heart, kidneys and gastrointestinal tract [1]. Interstitial lung disease (ILD) occurs in patients who have limited CREST (Calcinosis, Raynaud, ESophagitis, Telangiectases), limited cutaneous systemic sclerosis-lcSSc and diffuse cutaneous scleroderma (dcSSc), but it is somewhat more common in patients who have diffuse disease [2,3]. The ILD which occurs in scleroderma patients includes a number of entities, as summarized in Table 1 [4]. The prevalence of ILD in scleroderma varies from 25% to 90% depending on the ethnic background of the patients studied and the method that is used to detect the ILD [5].

Pulmonary function tests (PFTs) with evaluation of forced vital capacity (FVC), total lung capacity (TLC) and diffusing lung capacity of carbon monoxide (DLCO), chest radiography (CXR) and high resolution computed tomography (HRCT) are common clinical tests used to evaluate lung disease in scleroderma. Imaging reveals fibrotic changes of lung parenchyma. Previous research has found PFTs to reveal a restrictive pattern in 23% of patients with limited disease, and 40% of patients with diffuse disease have pulmonary fibrosis [4,5]. ILD as assessed by CXR has been reported in 33% of patients with limited scleroderma and 40% of patients with diffuse SSc [5]. HRCT detects ILD changes in 90-100% of SSc patients [2,5].

ILD is associated with increased mortality in patients who have SSc. The greatest loss of lung volume occurs within the first two years of the disease, and pulmonaryrelated deaths occur with greater frequency in the second 5 years from disease onset [5]. Patients with severe lung involvement (defined as a FVC < 55% and DLCO <40% of predicted) have a worse prognosis, with a mortality of 42% within 10 years of the onset of disease [5].

A number of agents have been evaluated for treatment of SSc-related ILD but none have proven effective in altering the disease course. Cyclophosphamide (CYC) is a cytotoxic

immunosuppressive agent that suppresses lymphokine production and modulates lymphocyte function by alkylating various cellular constituents and depressing the inflammatory response. Of all drugs studied for the treatment of SSc related ILD, only CYC has shown much promise of benefit in slowing down the decrease in or even improving lung function and survival [1], with retrospective studies, pilot studies, and open label clinical trials supporting the effectiveness of 3

CYC therapy in preventing a decline in lung function and premature death in patients with SSc and ILD.

Despite these individual study results, previous systematic reviews of retrospective studies of CYC effect in SSc lung disease have yielded conflicting results, suggesting either some or no benefit of this agent [6, 7]. In order to determine the possible benefit of CYC as management for SSc-related ILD, we examined the benefit of CYC on lung function as measured by PFTs by conducting a systematic review and metaanalysis of randomized clinical trials and prospective observational studies in patients with SSc treated with CYC.

MATERIALS AND METHODS Study selection, assessment of eligibility criteria, data extraction and statistical analysis were performed based on a pre-specified protocol according to the Cochrane Collaboration guidelines [8]. This article has been prepared in accordance with the QUORUM statement [9]. An expert medical librarian searched Ovid EMBASE, Ovid MEDLINE, and the Ovid Cochrane Library from 1986 to 2008 using the terms systemic scleroderma, autoimmune diseases, cyclophosphamide, immunosuppressive therapies, interstitial lung disease, randomized controlled trials, observational studies, multicenter studies, clinical trials phase II, clinical trials phase III, clinical trials phase IV. To locate unpublished trials, we searched the electronic abstract databases of the annual scientific meetings of the European League Against Rheumatism (EULAR), the American College of Rheumatology (ACR) and the American Thoracic Society from the approval of cyclophosphamide as a treatment for autoimmune disease (1986) to present. No restriction for language was used.

Assessment of eligibility criteria for inclusion or exclusion and extraction of outcome variables was performed independently by 2 investigators (CN and ELM) with an intraobserver agreement kappa statistic of 1.

Selection and Outcomes We selected randomized clinical trials [1,10,11] and prospective observational studies [12,14-18)] which included patients classified as having limited and/or diffuse systemic sclerosis according to the ACR criteria [19] and a diagnosis of ILD [20] treated with oral or intravenous CYC. The dose of CYC administered differed across the various cohorts of patients. Some studies expressed the CYC dose in mg/kg/day and others in mg/m2 of body surface. The oral dose of CYC ranged from 1 mg/kg/day to 2.5 mg/kg/day and the intravenous dose of CYC ranged from 500 mg/m2 to 750 4

mg/m2, except for one study in which 900 mg/kg/day of intravenous CYC was administered (Tables 2, 3).

In the randomized clinical trials patients were randomly allocated to receive treatment with CYC versus placebo [1,10] or azathioprine [11] for at least 12 months. In the observational prospective studies scleroderma patients were treated with CYC for at least 12 months, and were evaluated at baseline and after 12 months of therapy. Corticosteroid treatment was permitted in both the randomized clinical trials and observational studies.

A clinically important change between two groups of treatment (CYC vs non-CYC) has been previously reported as an improvement of 10% of the predicted value at 12 months or from baseline value of FVC or DLCO [12, 13], and we adopted this standard.

Data abstraction and study validity Data were abstracted for the difference in forced vital capacity (FVC) and diffusing lung carbon monoxide (DLCO) predicted value between baseline and 12 months of therapy. In these studies, single breath diffusing capacity was assessed by a carbon-monoxide/helium gas mixture and corrected for hemoglobin (DLCO). Forced vital capacity (FVC) was measured by spirometry using flow-volume loops [21]. Results are expressed as a percentage of normal predicted values based on patient sex, age and height.

The methodological features of all randomized clinical trials most relevant to the prevention of bias (including the Jadad criteria of randomization, blinding and completeness of follow-up and outcome assessment [22]) were evaluated by 2 assessors (CN and ELM) independently, with disagreement resolved by consensus (see Additional data file 1). Validity of observational studies was assessed following the Newcastle-Ottawa quality assessment scale for cohort studies (see Additional data file 2) [23].

Statistical Analysis Pre-post comparisons were made using paired t-tests. Two observational studies [15, 17] had a length of follow up of 18 months [15] and 24 months [17]; the FVC and DLCO values in these studies at 12 months after CYC introduction were used. Dichotomous variables were compared using chi-square tests. Adverse event (occurrence of infections that required antibiotic therapy, hemorrhagic cystitis, hematuria and hospitalization) rates were calculated using relative risks for 5

the randomized control trials representing the risk of an adverse event occurring in the CYC group compared to the non-CYC group.

Two of the three randomized clinical trials [8, 9] reported the FVC and DLCO value at baseline and after 12 months in the CYC group but did not report standard errors (SE). Authors were contacted but were unable to provide SE data. Therefore we imputed the mean value of the SE of the other studies, and performed sensitivity analyses across the range of reported SEs of these studies.

We used a random-effects model assessing weighted mean difference in the meta-analysis. The overall pooled analysis included the mean changes of FVC and DLCO after 12 months of therapy obtained from the observational studies and from the CYC experimental arm of the randomized clinical trials. Additionally, we performed a meta-analysis of the RCT results comparing CYC with control treatments. We performed a subgroup analysis of the change in FVC and DLCO values from baseline to 12 months in studies using oral administration of CYC versus those studies with intravenous administration using a test of interaction. Analysis was conducted using Review Manager Version 4.2 (The Cochrane Collaboration, Software Update, Oxford, UK).

RESULTS Using the search key words, 249 references were identified and screened for retrieval. From this list, 47 potentially relevant full text publications were selected. Of these, 31 full publications and 202 abstracts were excluded based on unsuitable study population, type of intervention or lack of appropriate outcome assessment. A total of 16 studies (3 randomized double blind controlled studies and 13 observational studies) were then examined in detail. Five of the 13 observational studies were excluded due to inadequate length of follow up (less than 12 months) and/or no information on FVC and DLCO as outcome assessments (Figure 1).

In the randomized controlled trials, both FVC and DLCO were evaluated at baseline and after 12 months in CYC and non-CYC treatment groups. In the observational study group, 4 of 6 studies assessed FVC at baseline and after 12 months and 5 of 6 studies assessed DLCO at baseline and after 12 months. In one study [12], half of patients received oral CYC and half of patients were treated with intravenous CYC. We analyzed the two cohorts of patients in this study separately. In addition, in this study FVC and DLCO were assessed in both cohorts at baseline and after 12 months, but it was not possible to calculate the standard error (SE) of the difference of FVC at 12 months since the authors reported only that this difference was not statistically meaningfully 6

different, p > 0.05. In another study [16], 16 of 28 patients were treated with high dose corticosteroids (1 mg/kg/day for 4 weeks) and 12 of 28 patients with lower dose corticosteroids (<10 mg/day). FVC and DLCO were assessed in both cohorts at baseline and after 12 months, and these cohorts were analyzed separately.

In the three randomized controlled clinical trials patients and outcome assessors were masked to treatment allocation. In two trials, corticosteroid treatment was allowed [10, 11] and in one the control group was treated with azathioprine instead of placebo [11]. In the observational studies patients were allowed to use corticosteroid treatment with varying dose and tapering schemes. One study permitted enrollment of patients who had received treatment with disease modifying drugs (dpenicillamine, cyclosporine, and combination of methotrexate, cyclosporine and azathioprine) but had discontinued their use at least 6 months prior to study onset [15].

Included trials were somewhat heterogeneous in terms of initial FVC and DLCO % predicted value (FVC % predicted value range 51.4% to 90.4%, mean value 70%; DLCO % predicted value range 38.2% to 83.5%, mean value 53.9%), the range of time from SSc-ILD diagnosis (24 months to 7 years), ILD stage assessment method (computed tomography [CT] scan, chest radiography or bronchoalveolar lavage [BAL]), and specific CYC treatment regimen. Table 2 describes the characteristics of all included randomized (table 2) and observational (table 3) trials. There was no clear evidence of heterogeneity by study quality, although this evaluation was limited by the small number of eligible studies and lack of variability in quality across studies.

Results of the meta-analysis

In the randomized clinical trials, the FVC mean difference at 12 months between patients treated with CYC and patients treated with placebo or other immunosuppressant showed a positive trend in favor of the CYC group (mean difference 4.15%), but did not reach statistical significance (95% CI: -0.51; 8.80; Figure 2A). The mean difference in DLCO favored the control group (mean difference -1.41%) but also did not reach statistical significance (CI 95%: -7.63; 4.82; Figure 2B).

In the observational studies, both FVC and DLCO predicted values after 12 months of therapy showed statistically significant improvement compared with baseline, with a mean difference of 4.73% (95% CI: 0.74; 8.73) and 7.48% (95% CI: 3.64; 11.32) respectively (data not shown). The pooled analysis of the treatment arms of the randomized clinical trials and the observational studies 7

suggested that both FVC and DLCO predicted values improved after 12 months of therapy, with a mean difference of 2.83% (95% CI: 0.35; 5.31) and 4.56% (95% CI: -0.21; 9.33), respectively, although the latter change was not statistically significant (Figure 3A, 3B).

Subgroup analysis of route of CYC administration Change in FVC and DLCO values after 12 months of therapy did not differ between IV and oral CYC administration. Patients treated with oral CYC had a mean FVC change of 3% (95% CI: 0.88; 6.87) and patients treated with intravenous CYC had a mean FVC change of 1.29% (95% CI: -1.76; 4.33; test of interaction p=0.086). Similarly, the group treated with oral CYC had a mean change in DLCO of 6.38% (95% CI: 2.11; 10.64), and patients treated with intravenous CYC had a mean change in DLCO of 4.68% (95% CI: -0.31; 9.67; test of interaction p= 0.6) (data not shown).

Sensitivity analysis We conducted a sensitivity analysis by introducing a range of standard error values for the mean difference between baseline and 12 months from both the randomized and observational studies, since assumptions were necessary at this step as described in the methods. No standard error within the range of those reported in the literature altered the results.

Adverse events We evaluated the relative risk of having adverse events in the CYC group compared with the control groups in the randomized studies; the open observational studies did not provide sufficient information to evaluate these adverse events. We considered as adverse events the occurrence of infections that required antibiotic therapy, hemorrhagic cystitis, hematuria and hospitalization. Only Tashkin et al [1] reported deaths, 2 (3%) in the CYC group and 3 (4%) in the placebo group. The relative risk for adverse event occurrence did not differ among the treatment group and the control group (RR 1.22, 95% CI: 0.75; 2.00).

Discussion Cyclophosphamide is frequently recommended as treatment for scleroderma related ILD. The results of this meta-analysis suggest that patients with systemic sclerosis and ILD who are treated with CYC may experience a modest increase in FVC and DLCO after 12 months of therapy. However, neither improvement in FVC nor DLCO achieved clinical significance as defined by an improvement of at least 10% of predicted value of each measure [12,13]. The oral or intravenous

administration of CYC did not influence the mean difference of FVC or DLCO after 12 months of therapy, and CYC did not alter the risk of adverse events.

A change of more than 10% in the pulmonary function parameters evaluated in the studies reviewed in this metaanalysis (or more) would have been considered clinically meaningful for the purposes of this study. Since this may or may not translate to clinically meaningful improvement, the conclusion that CYC treatment did not result in statistically meaningful improvement (rather than "clinically meaningful improvement") could be justified. To achieve a moderate Cohen effect size of 0.5 with 80% power, 64 patients per group would be required to detect a 10% difference in the FVC and DLCO predicted value [24]. This sample size was achieved by only one of the studies, which enrolled 73 patients per treatment arm but did not demonstrate an effect size of this magnitude [1]. The fact that this meta-analysis, including 125 patients per group, did not achieve an effect size of this magnitude suggests again that the treatment approach is unlikely to be clinically meaningfully effective as assessed by these outcome measures.

Similar results were obtained in a retrospective study conducted in 103 SSc patients who were treated with oral CYC (1-2 mg/Kg/day). The FVC and DLCO improved by 4.3% and 1.0%, respectively, at thirteen months of therapy compared with patients who were not treated with CYC [5]. However, another retrospective study suggested that patients treated with CYC had a larger increase in FVC after 24 months of therapy (around 8% from baseline to 24 months of therapy) when compared with other treatment groups (prednisone, other immunosuppressant, Dpenicillamine and no treatment) [25]. DLCO demonstrated less consistent change [24]. The differences in results across between these studies may be due in part to patient selection, as patients in these studies were not selected on the basis of ILD stage or progression.

Long-term CYC therapy may cause adverse events and treatment-related toxicity [3]. While reporting of adverse events in the included studies was limited, we found that the odds ratio of developing adverse events was similar among patients treated with CYC compared with patients in the non-CYC groups (OR: 1.29, 95% CI: 0.69; 2.39). This lack of difference could also be due in part to the fact that Nadashkevich et al [11] permitted comparison between patients treated with CYC and patients treated with azathioprine, which has a number of side effects in common with CYC. Previous studies have reported no or very mild adverse events in patients with SSc related ILD who were treated with CYC [26, 27]. Other studies have reported bladder complications secondary to the drug in patients with SSc [28, 29]. The adverse events counted in our 9 studies 9

included 2 cases of hemorrhagic cystitis [17] and several cases of hematuria (1 case in Valentini et al [18], 2 cases in Hoyles et al [10] and 9 cases in Tashkin et al [1]); bladder cancer was not reported. A doubling of bladder cancer risk in Wegeners granulomatosis patients for every 10 gram increase in the cumulative dose of CYC and eight fold increased risk for treatment duration longer than one year has been reported [30]. Since the results of our meta-analysis are based on 12 months of follow-up they may not reflect adverse events developing over longer durations of treatment or follow-up.

Our study has additional limitations. Number of patients enrolled, dose of CYC, concomitant corticosteroid use, SSc-ILD disease extent and SSc disease duration and comparator treatments varied across studies. For example, some evidence suggests that glucocorticoids may be effective in SSc related ILD in certain situations [5,25,31,32]. There may be other factors contributing to heterogeneity unidentified by our review. The shortage of RCTs on this topic is a limitation and larger RCTs are needed to better understand CYC's role in the care of these patients. In our metaanalysis two of the three greatest mean differences of FVC after 12 months of therapy were achieved in observational studies using higher doses of corticosteroids, [15,16] limiting our ability to draw a clear conclusion of beneficial effect of CYC alone. It is also possible that azathioprine has a beneficial treatment effect, which would reduce the magnitude of difference in benefit seen in comparison with CYC. A further limitation is that several studies, particularly the observational studies, had small numbers of patients.

CONCLUSIONS Based on available data, cyclophosphamide treatment in patients with systemic sclerosis related interstitial lung disease does not appear to result in clinically significant improvement of pulmonary function. Since none of the patients included in these studies were selected on the basis of progression of ILD or the time from the SSc related ILD diagnosis, further randomized clinical studies are needed to evaluate whether CYC (or any) therapy might exert a beneficial effect in patients with worsening ILD. It is possible, for example, that patients treated sooner after diagnosis or at earlier stages of SSc related ILD might have a better response to CYC treatment. Based on current understanding, however, SSc related ILD will be only effectively addressed when better understanding of the immunopathophysiology of the disease is understood and treatment options more effective than CYC become available.

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ABBREVIATIONS: ACR: American College of Rheumatology AZA: azathioprine BAL: bronchoalveolar lavage CI: confidence interval CREST: Calcinosis, Raynaud, ESophagitis, Sclerodactylia, Telangiectases CT: computed tomography CXR: chest radiography CYC: cyclophosphamide dcSSC: diffuse cutaneous systemic sclerosis DLCO: diffusing lung capacity of carbon monoxide EULAR: European League Against Rheumatism FVT: forced vital capacity HRTC: high resolution computed tomography ILD: Interstitial Lung Disease IV: intravenous lcSSc: limited cutaneous systemic sclerosis PFT: pulmonary function test RR: relative risk SE: standard error SSC: systemic sclerosis SSc-ILD: systemic sclerosis related interstitial lung disease TLC: total lung capacity UK: United Kingdom

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Competing interests

The authors declare that they have no competing interests.

Authors contributions CN conceived the study and participated in its design, coordination, data acquisition and analysis, and manuscript preparation. CPW and ELM participated in the study design, data analysis and analysis, and manuscript preparation. PJE participated in data acquisition and manuscript preparation All authors read and approved the final manuscript.

ACKNOWLEDGMENTS The authors would like to thank Drs. Victor Montori and Hassan Murad for their expertise and advice in the conduct of this study. There was no funding support for this study.

ADDITIONAL DATA FILES The following additional data are available with the online version of this paper: Additional data file 1 is a table that reports the assessment of quality of randomized controlled trials. Additional data file 2 is a table that reports the assessment of quality of observational studies.

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13. White B, Moore WC, Wigley FM, Xiao HQ, Wise RA: Cyclophosphamide is associated with pulmonary function and survival benefit in patients with scleroderma and alveolitis. Ann Intern Med 2000, 132:947-954. 14. Beretta L, Caronni M, Raimondi M, Ponti A, Viscuso T, Origgi L, Scorza R: Oral cyclophosphamide improves pulmonary function in scleroderma patients with fibrosing alveolitis: experience in one centre. Clin Rheumatol 2007, 26:168-172. 15. Air P, Danieli E, Rossi M, Frassi M, Cavazzana I, Scarsi M, Grottolo A, Franceschini F, Zambruni A: Intravenous cyclophosphamide for interstitial lung disease associated to systemic sclerosis: results with an 18 month long protocol including a maintenance phase. Clin Exp Rheumatol 2007, 25:293-296. 16. Pakas I, Ioannidis JP, Malagari K, Skopouli FN, Moutsopoulos HM, Vlachoyiannopoulos PG: Cyclophosphamide with low or high dose prednisolone for systemic sclerosis lung disease. J Rheumatol 2002, 29:298-304. 17. Silver RM, Warrick JH, Kinsella MB, Staudt LS, Baumann MH, Strange C: Cyclophosphamide and low-dose prednisone therapy in patients with systemic sclerosis (scleroderma) with interstitial lung disease. J Rheumatol 1993, 20:838-844. 18. Valentini G, Paone C, La Montagna G, Chiarolanza I, Menegozzo M, Colutta E, Ruocco L: Low-dose intravenous cyclophosphamide in systemic sclerosis: an open prospective efficacy study in patients with early diffuse disease. Scand J Rheumatol 2006, 35:35-38. 19. Subcommittee for Scleroderma Criteria of the American Rheumatism Association Diagnostic and Therapeutic Criteria Committee: Preliminary criteria for the classification of systemic sclerosis (scleroderma). Arthritis Rheum 1980, 23:581-590. 20. American Thoracic Society/European Respiratory Society International Multidisciplinary Consensus Classification of the Idiopathic Interstitial Pneumonias. Am J Resp Crit Care Med 2002, 165:277-304. 21. Guidelines for the measurement of respiratory function: recommendations of the British Thoracic Society and the Association of Respiratory Technicians and Physiologists. Resp Med 1994, 88:165-194. 22. Jadad AR, Moore RA, Carroll D, Jenkinson C, Reynolds DJ, Gavaghan DJ, McQuay HJ: Assessing the quality of reports of randomized clinical trials: is blinding necessary? Control Clin Trials. 1996,17:1-12. 23. Wells GA Shea B, O'Connell D: The Newcastle-Ottawa scale (NOS) for assessing the quality of nonrandomized studies in meta-analysis. 3rd Symposium on systematic reviews: behind the basics, Oxford, 2000. [http://www.ohri.ca/programs/clinical_epidemiology/oxford.htm] 14

24. Kazerooni EA, Martinez FJ, Flint A, Jamadar DA, Gross BH, Spizarny DL, Cascade PN, Whyte RI, Lynch JP 3rd, Toews G: Thin-section CT obtained at 10-mm increments versus limited three-level thin-section CT for idiopathic pulmonary fibrosis: Correlation with pathologic scoring. Am J Roentgenol 1997, 169:977-983. 25. Cohen J: A power primer. Psychological Bulletin, 1992, 112: 155-159. [http://psycnet.apa.org/index.cfm?fa=search.displayRecord&uid=1992-37683-001] 26. Steen VD, Lanz JK Jr, Conte C, Owens GR, Medsger TA Jr.: Therapy for severe interstitial lung disease in systemic sclerosis. A retrospective study. Arthritis Rheum 1994, 9:1290-1296. 27. Tashkin DP, Elashoff R, Clements PJ, Roth MD, Furst DE, Silver RM, Goldin J, Arriola E, Strange C, Bolster MB, Seibold JR, Riley DJ, Hsu VM, Varga J, Schraufnagel D, Theodore A, Simms R, Wise R, Wigley F, White B, Steen V, Read C, Mayes M, Parsley E, Mubarak K, Connolly MK, Golden J, Olman M, Fessler B, Rothfield N, et al.: Effect of 1-year treatment with cyclophosphamide on outcomes at 2 years in scleroderma lung disease. Am J Respir Crit Care Med 2007,176:1026-1034. 28. Giacomelli R, Valentini G, Salsano F, Cipriani P, Sambo P, Conforti ML, Fulminis A, De Luca A, Farina G, Candela M, Generini S, De Francisci A, Tirri E, Proietti M, Bombardieri S, Gabrielli A, Tonietti G, Cerinic MM: Cyclophosphamide pulse regimen in the treatment of alveolitis in systemic sclerosis. J Rheumatol 2002, 29:731-736. 29. Plotz PH, Klippel JH, Decker JL, Grauman D, Wolff B, Brown BC, Rutt G: Bladder complications in patients receiving cyclophosphamide for systemic lupus erythematosus and rheumatoid arthritis. Ann Intern Med 1979, 91:221-223. 30. Talar-Williams C, Hijazi YM, Walther MM, Linehan WM, Hallahan CW, Lubensky I, Kerr GS, Hoffman GS, Fauci AS, Sneller MC: Cyclophosphamide-induced cystitis and bladder cancer in patients with Wegner granulomatosis. Ann Intern Med 1996, 124:477-484. 31. Knight A, Askling J, Granath F, Sparen P, Ekbom A:Urinary bladder cancer in Wegeners granulomatosis: risks and relation to cyclophosphamide. Ann Rheum Dis 2004, 63:1307-1311. 32. Griffiths B, Miles S, Moss H, Robertson R, Veale D, Emery P: Systemic sclerosis and interstitial lung disease: a pilot study using pulse intravenous methylprednisolone and cyclophosphamide to assess the effect on high resolution computed tomography scan and lung function. J Rheumatol 2002, 29:2371-2378. 33. Pai BS, Srinivas CR, Sabitha L, Shenoi SD, Balachandran CN, Acharya S : Efficacy of dexamethasone pulse therapy in progressive systemic sclerosis. Int J Dermatol 1995, 34:726728.

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Table 1: Interstitial lung disease entities associated with systemic sclerosis Pulmonary fibrosis 1. Nonspecific interstitial pneumonia (NSIP) 2. Usual interstitial pneumonia (UIP) Fibrosing alveolitis Diffuse alveolar damage Cryptogenetic organizing pneumonia

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Table 2: Randomized Clinical Trial Study Characteristics Outcome measure Mean (%predicted Age value at (years) baseline) FVC 80.110.3 DLCO 55 52.91.6 FVC 90.31.9 DLCO 38-36 83.51.6 FVC 67.61.3 47.91. DLCO 0 47.21.6 Length of followup

Study RCT

Number of patients

CYC treatment IV: 600 mg/m2 monthly Oral: 2 mg/kg/day monthly

Placebo/ alternative treatment

Corticosteroi ds Prednisone 20 mg alternate days

Hoyles RK et al. 2006 [10] Nadashkevic h O et al. 2006 [11]

45

Placebo

12 months

60

AZA 2.5 mg/Kg

Prednisolone 15mg/day

12 months

Tashkin DP et al. 2006 [1]

158

Oral: 1 mg/kg/day

Placebo

none

12 months

17

Table 3: Observational Study Characteristics Outcome measure (% Mean predicted Observationa Number value at of AgeSD l prospective patients (years) baselineSD) studies FVC 74% Airo P et al. 13 48 DLCO 41% 2007 [15] Length of followup 18 months

CYC treatment IV: 750 mg/m2 every 3 wks

Beretta L et al. 2007 (14) Davas EM et al 1999 Pulse CYC [12] Davas EM et al 1999 Oral CYC [12] Pakas I et al. 2002 Low dose prednisone cohort [16] Pakas I et al. 2002 High dose prednisone cohort [16]

33

49.710. DLCO 4 48.813.5 FVC 86.1% DLCO 60%

Oral: 2 mg/kg/day IV: 750 mg/m2 monthly

Corticosteroids Methylprednisolone 125 mg every 3 wks Prednisone 25 mg/day in the first 3 months, 5 mg for 9 months Prednisone 10 mg/day

12 months 12 months

NA

NA

Oral: 2-2.5 FVC 73.2% DLCO 59.9 % mg/kg/day

Prednisone 10 mg/day

12 months

12

48.612. FVC 54.8% 3 DLCO 38.2%

IV: 900 mg/kg (mean value)

Prednisone low dose:<10 mg/day

12 months

16

Silver et RM al 1993 [17] Valentini G et al. 2006 [18]

14

48.612. FVC 57.5% 3 DLCO 48.3% FVC 51.4%2.5, DLCO 46.42.4 54.5%7.4

IV: 900 mg/kg (mean value)

Prednisone: high dose: 1 mg/kg/day for 4 wks

12 months

13

37.4

DLCO 58.5%

Oral: 1-2 mg/kg/day IV: 500 mg/m2 on day 1, day 8 and day 15 and every 4 wks

Prednisone 7.7 1.2 mg/day (in 10 pts) Low dose corticosteroids (dose not specified)

24 months

12 months

18

Figure 1. Meta-analysis Study Selection. DLCO= diffusing capacity for carbon monoxide FVC=forced vital capacity Figure 2. Forest plot of the overall meta-analysis results in the randomized clinical trials comparing A) FVC=forced vital capacity (FVC) and B) DLCO= diffusing capacity for carbon monoxide DLCO at 12 months for patients with scleroderma lung disease treated with cyclophosphamide versus control group. RCT= randomized clinical trial; SE: standard error; CI: confidence interval; Chi2 = chi squared; df: degree of freedom; I2=I-squared; Z=Z-value; Mean difference = weighted mean difference; Random = random-effects model

Figure 3. Forest plot of the overall metaanalysis results for 12 month versus baseline changes in A) FVC and B) DLCO, pooled from the CYC arms of randomized clinical trials and observational studies. SE: standard error; CI: confidence interval; Chi2 = chi squared; df: degree of freedom; I2=I-squared; Z=Z-value; CYC: cyclophosphamide; High Pred: high dose of prednisone; Low Pred: low dose of prednisone; Oral: oral administration; Pulse: intravenous administration; FVC=forced vital capacity (FVC); DLCO= diffusing capacity for carbon; RCT = randomized clinical trial; Mean difference = weighted mean difference; Random = random-effects model

19

Figure 1.

249 references potentially relevant were identified and screened for retrieval

Excluded 233 on the basis of title, abstract, and screening

3 randomized controlled trials retrieved for more detailed assessment of inclusion and exclusion criteria

13 prospective observational studies retrieved for more detailed assessment of inclusion and exclusion criteria 7 prospective observational trials excluded (follow-up <12 months, outcome assessment other than DLCO, FVC)

3 randomized controlled trial included in the systematic review.

6 prospective observational trials included in the systematic review

All included for the analysis of FVC and DLCO

5 cohorts for FVC pooled analysis

7 cohorts for DLCO pooled analysis

1
Figure 1

Figure 2. A) FVC

B) DLCO

1
Figure 2

Figure 3. A) FVC

B) DLCO

1
Figure 3

Additional files provided with this submission: Additional file 1: additional data files nannini.doc, 49K http://arthritis-research.com/imedia/7234099822892773/supp1.doc