Efek Obat Imunosupresan Pada Pasien Autoimun dengan COVID-19 (A Scoping Review of The Clinical Evidence)

The main modality in autoimmune disease is a long-term immunosuppressant treatment aiming to control disease progression and increase patient life expectancy. This scoping review aims to evaluate the effect of immunosuppressant treatment in autoimmune patients with COVID-19 on clinical outcomes and disease progression. This scoping review was conducted following the PRISMA extension for scoping review (PRISMA-ScR) guidelines. The Pubmed and Science Direct databases are used to find articles that match the study objectives. Thirteen articles met the inclusion criteria, and all of them were classified as observational studies. Most immunosuppressant treatments are the disease-modifying anti-rheumatic drugs (DMARD) and glucocorticoids. The highest number of autoimmune patients with rheumatoid arthritis (RA) was 43.4%, systemic lupus erythematosus (SLE) 13.6%, and others was 43%. Autoimmune patients with COVID-19 taking immunosuppressant medications, particularly glucocorticoids, significantly increased the risk of hospitalization and the use of ventilators. However, there was no mention of the dosage and duration of immunosuppressant therapy in most of the studies. In general, the use of immunosuppressant drugs was not associated with an increased risk of COVID-19 infection and mortality compared with the general population. Increasing age and comorbidities were associated with poor clinical outcomes. In conclusion, autoimmune patients with COVID-19 who are taking immunosuppressant therapy particularly glucocorticoid exacerbate clinical outcomes. Periodic clinical monitoring and appropriate pharmacological interventions are required in autoimmune patients with COVID-19 to improve clinical outcomes and prevent death.Keywords: Autoimmune, COVID-19, Immunosuppressant, Clinical outcome.

Manajemen Perawatan Neurointensif pada Miastenia Gravis

Myasthenia gravis (MG) is an autoimmune disorder that affects neuromuscular transmission, causing generalized or localized weakness characterized by fatigue. Myasthenia gravis is most commonly associated with antibodies to the acetylcholine receptor (AChR) on the motor end plate in the postsynaptic neuron. This article aims to determine the appropriate neurointensive management in patients with myasthenia gravis with complications of myasthenic crisis. The writing of this article includes various sources originating from scientific journals and government guidelines and related agencies. Source searches were carried out on online portals for journal publications such as MedScape, Google Scholar (scholar.google.com) and the National Center for Biotechnology Information (ncbi.nlm.nih.gov), with the keyword “Myasthenia Gravis”. The management of myasthenia gravis can be done in various ways, namely, mechanical intubation and ventilation, non-invasive ventilation, pridostigmine as an anticholinesterase inhibitor, immunosuppressant therapy, short term immunotherapy, intravenous immunoglobulin, and surgical therapy. In the treatment of myasthenia gravis, the main goal is to restore muscle condition, especially patient productivity where the management of myasthenia gravis consists of management of myasthenic crisis, cholinergic crisis, symptoms, immunosuppressant therapy, and thymectomy surgical therapy if a tumor is indicated.

Management in patient with rheumatoid arthritis and tuberculous arthritis: a case report

Rheumatoid arthritis (RA) is mainly treated with immunosuppressive drugs, which affects the immunological system. Therefore, the risk of tuberculosis was increased two to ten times in RA patients. Moreover, immunosuppressant is contraindicated in patients with tuberculosis arthritis. A 51-year-old male was presented with pain in his left elbow after he slipped on the floor. He was diagnosed with RA for 16 years and only took prednisone for six years. Six months before, he came to a rheumatologist and was given corticosteroid for six months for RA. The left elbow radiograph and joint aspiration revealed a tuberculosis infection. The patient treated with chloroquine and oral antituberculosis for one year and showed good clinical outcomes. Other diseases should be suspected in RA with uncommon symptoms. Chloroquine is the drug of choice in RA patients with tuberculosis who are contraindicated in immunosuppressant therapy because chloroquine has no immunosuppressant effect.

Efficacy and Safety of Immunosuppressant Therapy for Noninfectious Uveitis: A Systematic Review and Meta-Analysis

Objective. To analyze efficacy and safety of immunosuppressant therapy for noninfectious uveitis. Methods. A network search of PubMed, ResearchGate, and EMBASE databases was conducted for relative literature and studies from the inception of each database to April 2021. Primary outcomes were efficacy and time to treatment failure of immunosuppressant for noninfectious uveitis. Secondary outcome was incidence of adverse events (AEs). Cochrane risk of bias tool was used to assess risk of bias of included studies. Fixed effects model or random effects model was implemented to assess statistical heterogeneity. Subgroup analysis was employed to analyze heterogeneous sources. Results. Eight studies were deemed eligible for inclusion with a total of 848 patients. Six studies were randomized controlled trials (RCTs). Among them, a single-blind RCT had relatively high measurement bias and performance bias. Immunosuppressant presented favorable efficacy for noninfectious uveitis than placebo, and RR was 1.43 (95% CI: 1.12-1.82). Immunosuppressant for noninfectious uveitis prolonged the time before failure, and HR was 0.43 (95% CI: 0.32-0.54). AEs increased after immunosuppressant was applied. Compared with immunosuppressant, RR of AEs with placebo was 0.88 (95% CI: 0.71-1.08). Conclusion. Immunosuppressant contributed to controlling progression of noninfectious uveitis to some extent. Compared with placebo, it increased incidence of AEs. More studies with low heterogeneity are warranted for stronger evidence in clinical.

Corticosteroid and Immunosuppressant Therapy for Cardiac Sarcoidosis: A Systematic Review

Background Corticosteroid therapy for the treatment of clinically manifest cardiac sarcoidosis is generally recommended. Our group previously systematically reviewed the data in 2013; since then, there has been increasing quality and quantity of data and also interest in nonsteroid agents. Methods and Results Studies were identified from MEDLINE, EMBASE, Cochrane Controlled Trials Register, Cochrane Database of Systematic Reviews, and the National Institutes of Health ClinicalTrials.gov database. The quality of included articles was rated using Scottish Intercollegiate Guidelines Network 50. Outcomes examined were atrioventricular conduction, left ventricular function, ventricular arrhythmias, and mortality. A total of 3527 references were retrieved, and 34 publications met the inclusion criteria. There were no randomized trials, and only 2 studies were rated good quality. In the 34 reports (total of 1297 patients), 1125 patients received corticosteroids, 235 received additional or other immunosuppressant therapy, and 97 patients received no therapy. There were 178 patients treated for atrioventricular conduction disease, with 76/178 (42.7%) improving. In contrast, 21 patients were not treated with corticosteroids and/or immunosuppressant therapy, and none of them improved. Therapy was associated with the prevention of deterioration in left ventricular function. A total of 8 publications reported on ventricular arrhythmia burden, and 19 reported on mortality; the data quality was too limited to draw conclusions for the latter 2 outcomes. Conclusions The best quality data relate to atrioventricular nodal conduction and left ventricular function recovery. In both situations, therapy with corticosteroids and/or immunosuppressant therapy were sometimes associated with positive outcomes. The data quality is too limited to draw conclusions for ventricular arrhythmias and mortality.

Incidence and Treatment Outcome of Rhinosinusitis before Kidney Transplantation: A Retrospective Cohort Study

Background: The use of immunosuppressants after transplantation can aggravate sinus infections. Although kidney transplantation (KT) recipients are administered strong immunosuppressant therapy, there is few consensus or reports on incidence and treatment of rhinosinusitis before KT. This study was undertaken to analyze the results of a cohort of KT recipients that underwent sinonasal evaluation before KT. Methods: Observational retrospective cohort data were analyzed from adults who underwent a KT between January 2015 and December 2018. In total, 966 patients were screened by clinical history, nasal endoscopy, and plain X-ray before KT. Results: A total of 86 patients (8.9%) were diagnosed with rhinosinusitis. Twenty-three of the eighty-six patients (26.7%) who underwent plain X-ray on second follow up were successfully treated with primary and secondary antibiotics, saline irrigation, and INS. From the remaining 63 patients who underwent additional CT on second follow up, 43 patients were treated with primary or secondary antibiotics and 20 patients (10 with chronic rhinosinusitis and 10 with fungal ball) were treated with endoscopic sinus surgery. There were no serious complications affecting patient mortality after KT. Conclusion: We report that 8.9% of patients showed abnormal findings in sinonasal evaluation before KT. Although most patients did not require surgery, surgery is recommended for active rhinosinusitis, which does not respond to medication, and for fungal rhinosinusitis to prevent postoperative sinonasal infection.

The Use of Cellular- and/or Tissue-Based Therapy for the Management of Pyoderma Gangrenosum: A Case Series and Review of the Literature

Pyoderma gangrenosum (PG) is an uncommon inflammatory neutrophilic disorder with a spectrum of clinical presentations with variable courses. Most cases are associated with an autoimmune disorder and manifest in middle-aged adults as a painful lesion that progresses to painful necrotizing ulcers of the lower extremity. Owing to its variability, clinical diagnosis remains difficult and many patients are often misdiagnosed, with resulting delay in treatment. While early immunosuppressant therapy is key to preventing progression of PG, surgical treatment has been met with criticism because of the risk of potentiating pathergy, an exaggerated skin reaction due to trauma. This article presents a case series in which 3 patients with PG lesions underwent different treatment methods, including surgical debridement and use of fetal bovine dermis (FBD). The use of FBD in conjunction with medical treatment provided pain relief and wound coverage as well as encouraged growth of granulation tissue and long-term stability. Commercial cellular and tissue-based products used to aid in accelerating PG wound closure are also reviewed.