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In patients with dcSSc, skin thickening occurs in the hands and feet and extends proximally beyond the elbows or knees and often involves the trunk; whereas in patients with lcSSc, skin thickening is confined to the distal extremities, or may only affect the fingers (i.e.

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In patients with dcSSc, skin thickening occurs in the hands and feet and extends proximally beyond the elbows or knees and often involves the trunk; whereas in patients with lcSSc, skin thickening is confined to the distal extremities, or may only affect the fingers (i.e. The cutaneous manifestations of SSc not only cause functional disability but they substantially contribute to pain, psychological distress, and body image dissatisfaction [8]. While the natural history of cutaneous sclerosis in dcSSc often involves a gradual improvement over time [9], randomized-controlled trials (RCTs) have demonstrated that treatment with immunosuppression can lead to a greater reduction in the extent of cutaneous sclerosis [10]. The mRSS is a measure of skin thickness and is often used as the primary outcome in clinical trials of patients with dcSSc. For instance, in Scleroderma Lung Study (SLS) I (12 months of oral cyclophosphamide [CYC] versus 12 months of placebo for SSc-ILD), patients with dcSSc randomized to CYC had an improvement in their mRSS of −5.3 at 12 months; whereas the dcSSc patients randomized to placebo group had an improvement in mRSS of only −1.7 at 12 months (P = 0.008) [10].

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The mRSS (score range of 0 [no skin thickening] to 51 [most severe]) is a measure of skin thickness and is often used as the primary outcome in clinical trials of patients with dcSSc. A number of studies have demonstrated that it is sensitive to change in the context of SSc clinical trials; however, it should ideally be performed by the same examiner in a trial who has experience with this assessment to reduce inter-observer variability [11]. In addition to CYC, studies have demonstrated that treatment with mycophenolate mofetil (MMF) leads to improvements in cutaneous sclerosis [12,13]. In SLS II (12 months of CYC, followed by 12 months of placebo versus 24 months of MMF), change in mRSS was a key secondary outcome and improved in a clinically meaningful manner in both treatment groups (CYC: −5.35; MMF: −4.90) [11,12]. In a post-hoc analysis comparing the MMF arm of SLS II, with the placebo arm of SLS I, patients in the MMF arm experienced a greater reduction in the extent of cutaneous sclerosis at 24 months (−4.9 versus −2.4, respectively) in all patients, and in patients with dcSSc (−6.3 versus −3.9, respectively), and this difference was statistically significant [14]. The cutaneous manifestations of SSc not only cause functional disability but they substantially contribute to pain, psychological distress, and body image dissatisfaction [8].

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While the natural history of cutaneous sclerosis in dcSSc often involves a gradual improvement over time [9], randomized-controlled trials (RCTs) have demonstrated that treatment with immunosuppression can lead to a greater reduction in the extent of cutaneous sclerosis [10]. The mRSS is a measure of skin thickness and is often used as the primary outcome in clinical trials of patients with dcSSc. For instance, in Scleroderma Lung Study (SLS) I (12 months of oral cyclophosphamide [CYC] versus 12 months of placebo for SSc-ILD), patients with dcSSc randomized to CYC had an improvement in their mRSS of −5.3 at 12 months; whereas the dcSSc patients randomized to placebo group had an improvement in mRSS of only −1.7 at 12 months (P = 0.008) [10].

The mRSS (score range of 0 [no skin thickening] to 51 [most severe]) is a measure of skin thickness and is often used as the primary outcome in clinical trials of patients with dcSSc. A number of studies have demonstrated that it is sensitive to change in the context of SSc clinical trials; however, it should ideally be performed by the same examiner in a trial who has experience with this assessment to reduce inter-observer variability [11]. In addition to CYC, studies have demonstrated that treatment with mycophenolate mofetil (MMF) leads to improvements in cutaneous sclerosis [12,13]. In SLS II (12 months of CYC, followed by 12 months of placebo versus 24 months of MMF), change in mRSS was a key secondary outcome and improved in a clinically meaningful manner in both treatment groups (CYC: −5.35; MMF: −4.90) [11,12]. In a post-hoc analysis comparing the MMF arm of SLS II, with the placebo arm of SLS I, patients in the MMF arm experienced a greater reduction in the extent of cutaneous sclerosis at 24 months (−4.9 versus −2.4, respectively) in all patients, and in patients with dcSSc (−6.3 versus −3.9, respectively), and this difference was statistically significant [14].

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Promising therapeutic agents, such as tocilizumab [18] and abatacept [19], have failed to meet the primary endpoint of change in mRSS in RCTs, leaving an unmet clinical need (Table 2). In a phase II study of 43 patients with dcSSc, treatment with lenabasum was associated with an improvement in the American College of Rheumatology (ACR) Combined Response Index in diffuse cutaneous Systemic Sclerosis (CRISS) score (33% achieved a positive response in the lenabasum arm compared with 0% in the placebo arm) and there was a trend for a significant treatment effect on mRSS (P = 0.085) [21]. The CRISS is a composite response index derived from patients with dcSSc and is comprised of the following endpoints with differential weighting: mRSS, forced vital capacity (FVC)%-predicted, Health Assessment Questionnaire Disability Index (HAQ-DI), Patient Global Assessment, and Physician Global Assessment [22]. In the open-label extension to the Phase II study, a clinically meaningful improvement in mRSS was observed under treatment with lenabasum (−8.4 points at 6 months, −9.8 points at 12 months, and −10.7 points at 18 months), although given that there was no placebo arm in the extension study, it is unclear whether this represents a continued treatment effect versus the natural history of the disease [23]. The drug appears to be well-tolerated, and the phase III study (NCT03398837) has completed enrollment (N = 365), and the expected study completion date is in 2020.

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The anti-fibrotic, pirfenidone, is currently under investigation in a phase II trial for SSc-ILD (SLS III), in which a key secondary endpoint is a change in mRSS (NCT03221257). An open-label phase oral sildenafil II study of pirfenidone in SSc-ILD suggested an acceptable safety and tolerability profile of this agent [24]. In SLS III, pirfenidone is combined with upfront MMF therapy to determine whether combining an anti-fibrotic with MMF leads to an improvement in skin and lung outcomes compared with MMF alone. Another novel anti-fibrotic, nintedanib was recently approved by the FDA for the treatment of SSc-ILD as described further below; however, this phase III study failed to detect a significant treatment effect for nintedanib on mRSS [25]. The B-cell depleting agent, rituximab, is frequently used in clinical practice to treat patients with dcSSc who fail to respond to conventional immunosuppressive therapies. In this post-hoc analysis, mRSS was also a key secondary outcome. In light of the evidence from the aforementioned studies, MMF and CYC are often considered first-line therapies for the treatment of cutaneous sclerosis in patients with dcSSc, with CYC typically reserved for patients with severe cutaneous sclerosis who do not respond to MMF.

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Although the most recent EULAR treatment guidelines for SSc [15] include methotrexate as a first-line treatment for cutaneous sclerosis in SSc, the evidence for this approach is poor as there have been no RCTs comparing methotrexate with placebo for the treatment of cutaneous sclerosis in SSc. Hematopoietic stem cell transplant (HSCT) is a potentially viable option for patients with rapidly evolving dcSSc refractory to treatment with immunosuppression. treatment-related side effects and early treatment-related mortality) associated with this procedure, this option is typically reserved for patients with rapidly progressive cutaneous sclerosis and underlying organ involvement refractory to treatment with immunosuppression. In 200mg sildenafil citrate the Autologous Stem Cell Transplantation International Scleroderma (ASTIS) trial (autologous HSCT versus monthly intravenous CYC for 12 months), the mean improvement in mRSS from baseline to 24 months was greater in the HSCT group (−19.9) than in the control group (−9.8) (P < .001) [16].

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In the Scleroderma: Cyclophosphamide Or Transplantation (SCOT) trial (autologous HSCT versus monthly intravenous CYC for 12 months) [17], numerically more patients in the HSCT arm experienced a clinically meaningful improvement in mRSS compared with patients in the CYC arm. There was also a long-term survival benefit associated with HSCT in the SCOT trial; however, the results of the survival analysis should be interpreted with caution since the comparator arm only received CYC for 12 months, and typically patients with SSc receive immunosuppression beyond 1 year. In clinical practice, a considerable proportion of patients with dcSSc do not respond adequately or are intolerant to treatment with CYC or MMF.

New treatment options are needed for patients who possess a progressive, treatment-resistant phenotype of cutaneous sclerosis. Promising therapeutic agents, such as tocilizumab [18] and abatacept [19], have failed to meet the primary endpoint of change in mRSS in RCTs, leaving an unmet clinical need (Table 2). In a phase II study of 43 patients with dcSSc, treatment with lenabasum was associated with an improvement in the American College of Rheumatology (ACR) Combined Response Index in diffuse cutaneous Systemic Sclerosis (CRISS) score (33% achieved a positive response in the lenabasum arm compared with 0% in the placebo arm) and there was a trend for a significant treatment effect on mRSS (P = 0.085) [21].

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In this post-hoc analysis, mRSS was also a key secondary outcome. In light of the evidence from the aforementioned studies, MMF and CYC are often considered first-line therapies for the treatment of cutaneous sclerosis in patients with dcSSc, with CYC typically reserved for patients with severe cutaneous sclerosis who do not respond to MMF. Although the most recent EULAR treatment guidelines for SSc [15] include methotrexate as a first-line treatment for cutaneous sclerosis in SSc, the evidence for this approach is poor as there have been no RCTs comparing methotrexate with placebo for the treatment of cutaneous sclerosis in SSc. Hematopoietic stem cell transplant (HSCT) is a potentially viable option for patients with rapidly evolving dcSSc refractory to treatment with immunosuppression. treatment-related side effects and early treatment-related mortality) associated with this procedure, this option is typically reserved for patients with rapidly progressive cutaneous sclerosis and underlying organ involvement refractory to treatment with immunosuppression.

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In 200mg sildenafil citrate the Autologous Stem Cell Transplantation International Scleroderma (ASTIS) trial (autologous HSCT versus monthly intravenous CYC for 12 months), the mean improvement in mRSS from baseline to 24 months was greater in the HSCT group (−19.9) than in the control group (−9.8) (P < .001) [16]. In the Scleroderma: Cyclophosphamide Or Transplantation (SCOT) trial (autologous HSCT versus monthly intravenous CYC for 12 months) [17], numerically more patients in the HSCT arm experienced a clinically meaningful improvement in mRSS compared with patients in the CYC arm. There was also a long-term survival benefit associated with HSCT in the SCOT trial; however, the results of the survival analysis should be interpreted with caution since the comparator arm only received CYC for 12 months, and typically patients with SSc receive immunosuppression beyond 1 year. In clinical practice, a considerable proportion of patients with dcSSc do not respond adequately or are intolerant to treatment with CYC or MMF. New treatment options are needed for patients who possess a progressive, treatment-resistant phenotype of cutaneous sclerosis. The CRISS is a composite response index derived from patients with dcSSc and is comprised of the following endpoints with differential weighting: mRSS, forced vital capacity (FVC)%-predicted, Health Assessment Questionnaire Disability Index (HAQ-DI), Patient Global Assessment, and Physician Global Assessment [22]. In the open-label extension to the Phase II study, a clinically meaningful improvement in mRSS was observed under treatment with lenabasum (−8.4 points at 6 months, −9.8 points at 12 months, and −10.7 points at 18 months), although given that there was no placebo arm in the extension study, it is unclear whether this represents a continued treatment effect versus the natural history of the disease [23]. The drug appears to be well-tolerated, and the phase III study (NCT03398837) has completed enrollment (N = 365), and the expected study completion date is in 2020. The anti-fibrotic, pirfenidone, is currently under investigation in a phase II trial for SSc-ILD (SLS III), in which a key secondary endpoint is a change in mRSS (NCT03221257). An open-label phase oral sildenafil II study of pirfenidone in SSc-ILD suggested an acceptable safety and tolerability profile of this agent [24].

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In SLS III, pirfenidone is combined with upfront MMF therapy to determine whether combining an anti-fibrotic with MMF leads to an improvement in skin and lung outcomes compared with MMF alone. Another novel anti-fibrotic, nintedanib was recently approved by the FDA for the treatment of SSc-ILD as described further below; however, this phase III study failed to detect a significant treatment effect for nintedanib on mRSS [25].

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Large RCTs of rituximab for SSc have not been performed; however, one relatively small RCT demonstrated that rituximab treatment led to a greater improvement in mRSS at 6 months compared with CYC [26]. In addition, small, open-label studies have demonstrated favorable effects on skin thickening [27,28]. A case-control analysis of 63 SSc patients from European Scleroderma Trial and Research (EUSTAR) cohort demonstrated that the patients with dcSSc who received rituximab experienced a greater reduction in MRSS compared with matched controls (N = 25; −24.0 ± 5.2% vs −7.7 ± 4.3%; p = 0.03) [29]. A small observational study of 18 patients with SSc demonstrated that combining rituximab with MMF is safe and leads to significant improvements in mRSS [30]. As discussed further below, there is also evidence that rituximab may possess disease-modifying effects on ILD in SSc, suggesting that this agent may play a role in the management of patients with treatment-resistant skin and lung disease.

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A chew sildenafil phase II study combining rituximab with belimumab and MMF is ongoing (NCT03222492). The majority of patients with SSc have interstitial abnormalities identified on high-resolution computed tomography (HRCT) imaging [31]. Patients with both lcSSc and dcSSc can develop ILD, and when present, the development of ILD in SSc increases the risk of mortality by at least threefold [32]. Furthermore, data from observational studies in both the US [33] and Europe [34] suggest that ILD is likely the leading cause of SSc-related death. While progression rates of ILD in SSc vary [35], patients typically experience progression within the first 4–5 years of their presentation [33]; therefore, treatment should be initiated early in affected patients to prevent ILD progression, especially in patients who possess features that increase their likelihood of ILD progression (e.g. The B-cell depleting agent, rituximab, is frequently used in clinical practice to treat patients with dcSSc who fail to respond to conventional immunosuppressive therapies. Large RCTs of rituximab for SSc have not been performed; however, one relatively small RCT demonstrated that rituximab treatment led to a greater improvement in mRSS at 6 months compared with CYC [26]. In addition, small, open-label studies have demonstrated favorable effects on skin thickening [27,28]. A case-control analysis of 63 SSc patients from European Scleroderma Trial and Research (EUSTAR) cohort demonstrated that the patients with dcSSc who received rituximab experienced a greater reduction in MRSS compared with matched controls (N = 25; −24.0 ± 5.2% vs −7.7 ± 4.3%; p = 0.03) [29]. A small observational study of 18 patients with SSc demonstrated that combining rituximab with MMF is safe and leads to significant improvements in mRSS [30]. As discussed further below, there is also evidence that rituximab may possess disease-modifying effects on ILD in SSc, suggesting that this agent may play a role in the management of patients with treatment-resistant skin and lung disease. A chew sildenafil phase II study combining rituximab with belimumab and MMF is ongoing (NCT03222492).

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The majority of patients with SSc have interstitial abnormalities identified on high-resolution computed tomography (HRCT) imaging [31]. Patients with both lcSSc and dcSSc can develop ILD, and when present, the development of ILD in SSc increases the risk of mortality by at least threefold [32].

Furthermore, data from observational studies in both the US [33] and Europe [34] suggest that ILD is likely the leading cause of SSc-related death. While progression rates of ILD in SSc vary [35], patients typically experience progression within the first 4–5 years of their presentation [33]; therefore, treatment should be initiated early in affected patients to prevent ILD progression, especially in patients who possess features that increase their likelihood of ILD progression (e.g. Scl-70 antibody presence, male sex, African American race) [36].

The treatment paradigm for SSc-ILD has historically involved the initiation of immunosuppressive therapy in patients who exhibit signs of or risk factors for the progression of ILD. In SLS I (oral CYC versus placebo), treatment with CYC led to significant improvements in the FVC%-predicted [10], total lung capacity (TLC)%-predicted [10], radiographic fibrosis [37], and quality of life [38] at 12 months. However, a year after cessation of CYC, there was no difference in the FVC%-predicted and TLC%-predicted between patients randomized to CYC versus placebo [39]. Moreover, during a 12-year follow-up period, there was no difference in long-term morbidity and mortality outcomes between patients randomized to CYC versus placebo in SLS I [40], suggesting that 1 year of treatment does not lead to a sustained improvement in health outcomes in SSc-ILD, and maintenance therapy is important.

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Scl-70 antibody presence, male sex, African American race) [36]. The treatment paradigm for SSc-ILD has historically involved the initiation of immunosuppressive therapy in patients who exhibit signs of or risk factors for the progression of ILD. In SLS I (oral CYC versus placebo), treatment with CYC led to significant improvements in the FVC%-predicted [10], total lung capacity (TLC)%-predicted [10], radiographic fibrosis [37], and quality of life [38] at 12 months. However, a year after cessation of CYC, there was no difference in the FVC%-predicted and TLC%-predicted between patients randomized to CYC versus placebo [39]. Moreover, during a 12-year follow-up period, there was no difference in long-term morbidity and mortality outcomes between patients randomized to CYC versus placebo in SLS I [40], suggesting that 1 year of treatment does not lead to a sustained improvement in health outcomes in SSc-ILD, and maintenance therapy is important. In SLS II [12], treatment with MMF for 24 months led to a significant improvement in FVC%-predicted [12], quantitative radiographic fibrosis [37], and patient-reported outcomes [41].

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In SLS II [12], treatment with MMF for 24 months led to a significant improvement in FVC%-predicted [12], quantitative radiographic fibrosis [37], and patient-reported outcomes [41].