From the Guidelines
The treatment of autoimmune scleroderma should prioritize mycophenolate mofetil (MMF) and methotrexate as first-line options for skin manifestations, given their effectiveness in improving skin thickening and reducing disease progression, as supported by recent guidelines 1. When considering treatment options, it's essential to evaluate the specific manifestations and organ involvement of the disease. For skin manifestations, MMF (1-2 g daily in divided doses) and methotrexate (starting at 7.5-10 mg weekly, gradually increasing to 15-25 mg weekly) are recommended as first-line treatments, with rituximab and tocilizumab considered for patients with early, inflammatory disease or those who do not respond to initial therapy 1. For interstitial lung disease associated with scleroderma, MMF, cyclophosphamide, or rituximab are recommended, with nintedanib considered for patients with progressive disease 1. Some key points to consider when treating autoimmune scleroderma include:
- The use of glucocorticoids is generally not recommended as first-line treatment for interstitial lung disease due to the risk of scleroderma renal crisis 1.
- Calcium channel blockers, such as nifedipine or amlodipine, are effective for treating Raynaud's phenomenon, a common feature of the disease 1.
- Phosphodiesterase-5 inhibitors, such as sildenafil, or endothelin receptor antagonists, like bosentan, are effective for treating digital ulcers 1.
- Pulmonary arterial hypertension requires specialized therapy with endothelin receptor antagonists, phosphodiesterase-5 inhibitors, or prostacyclin analogs 1.
- Gastrointestinal symptoms can be managed with proton pump inhibitors for reflux and prokinetic agents like metoclopramide for motility issues 1. Treatment should be individualized based on disease severity, organ involvement, and patient tolerance, with a focus on improving morbidity, mortality, and quality of life outcomes.
From the Research
Autoimmune Scleroderma Treatment
The treatment of autoimmune scleroderma, also known as systemic sclerosis, typically involves the use of immunosuppressive drugs to manage the disease's progression.
Drugs of Choice
Some of the commonly used drugs for treating scleroderma include:
- Cyclophosphamide: a nonselective immunosuppressant that remains the main treatment for progressing skin involvement and active interstitial lung disease 2
- Mycophenolate mofetil: a promising alternative to cyclophosphamide, which has shown to be safer and better tolerated 2, 3, 4
- Methotrexate: an immunosuppressant that is being used more frequently, especially in patients with diffuse cutaneous systemic sclerosis 5
- Cyclosporine: an immunosuppressant that has been limited by modest efficacy and serious renal toxicity 2
- Sirolimus and alefacept: newer T-cell targeted therapies that have provided some encouraging results in small pilot studies 2
- Rituximab: a B-cell targeted therapy that has shown promise in treating scleroderma 2
Treatment Considerations
When treating scleroderma, it is essential to consider the following factors:
- Disease subtype: classifying the subtype of scleroderma can help determine the best course of treatment 6
- Disease activity: assessing the activity of the disease process can help guide treatment decisions 6
- Organ involvement: determining the degree of specific organ involvement can help identify the most effective treatment approach 6
- Patient tolerance: considering the patient's ability to tolerate certain medications can help minimize side effects and improve treatment outcomes 3, 4