Discontinuing long-term iloprost treatmentfor Raynaud'sphenomenon andsystemic sclerosis: a single-center, randomized, placebo-controlled;, double-blind study G. Bali, G. Schwantzer, F. Aberer, B. Kraenke, E. Aberer KEY WORDS Raynaud's phenomenon, scleroderma, sclerosis, iloprost, randomized study, long-term treatment -Abstract Background Iloprost has been reported to reduce Raynaud's phenomenon (RP) and to inhibit progression of systemic sclerosis (SSc). Objective The aim of our study was to compare monthly iloprost infusions with placebo in patients treated long-term. Methods Seventeen patients, six with RP and 11 with SSc on monthly treatment with iloprost, received either a 3-hour intravenous infusion of iloprost or an equal volume of placebo once per month for 4 months in a monocentric, randomized, placebo-controlled, double-blind study. Raynaud attacks as measured by diary entries, skin temperature, skin sclerosis, fist closure, mouth opening, and digital ulcers were recorded during the observation period. Results Whereas mouth opening improved significantly (p = 0.043) in the iloprost-treated group, RS improved in both patient groups. However, no significant differences were found in the outcome measures. Conclusion Although iloprost influences the inflammatory cascade in SSc, no statistical differences were seen in our study, indicating that treatment strategies with iloprost should be modified. Introduction Systemic sclerosis (scleroderma) (SSc) is an autoimmune disease of unknown origin affecting multiple organ systems (1). Treatment of SSc is still challenging and should specifically target the pathomechanism of the disorder, including the vascular and the immune systems and the connective tissue (2). Many vasoactive drugs such as calcium channel blockers, ACE inhibitors, angiotensin-II-receptor antagonists, and sildenafil have proven to reduce Ray- naud attacks (3—5). Further, bosentan has been reported to be effective in the inhibition of new acral skin ulcers (6). Iloprost, a stable prostacyclin analogue, is not only an effective vasodilator that reduces Raynaud attacks, but also an inhibitor of the adhesion and activation of thrombocytes that also has an antifibrotic effect (7) through suppression of transforming growth factor (TGF)-[3—induced connective tissue growth factor production of scleroderma fibroblasts, which are re- sponsible for the abundant collagen production. Serum levels of soluble adhesion molecule 1 (sICAM-1), vascular adhesion molecule 1 (sVCAM-1), and E-se-lectin are elevated in SSc and are a significant marker of microvascular damage correlated with disease activity (8, 9). Iloprost infusions significantly reduced the serum level of all markers (10) for 6 months after the infusions (11). Iloprost may therefore play an important role in the inhibition of the pathways in the pathogenetic process in RP and SSc. We recently published a review of long-term studies (12). In line with this evaluation, we have treated our RP and SSc patients according to a standardized treatment protocol since 2003, with a 3-hour infusion on 5 consecutive days as initial therapy and a 3-hour infusion once a month regularly as maintenance therapy in the highest tolerated dose of 0.5 to 2.0 ng/kg/ min. The aim of our study was to evaluate whether discontinuation of the monthly iloprost infusion has an effect on the Raynaud attacks. We therefore designed a randomized study to compare the effect of the monthly iloprost infusion with placebo. Methods Patients The trial was approved by the local ethics committee, and all participants gave written informed consent. Seventeen patients (13 women, 4 men) with RP and/or SSc were selected for the study. These patients had been on maintenance therapy with iloprost for 2 months to 10 years with a 3-hour infusion of iloprost once a month. All of these patients had had initial therapy with iloprost on 5 consecutive days with a well-tolerated dose of 0.5 to 2.0 ng/kg/min for 3 hours. The diagnosis of RP was based on the verification of vasospasm by pulse oscillography upon cold provocation with a 10°C water bath. Scleroderma was classified according to the Le Roy criteria and also met the ACR criteria (13). The demographic data are outlined in Table 1, which also shows risk factors and organ involvement in the investigated patients. Eight patients described their disease as stable at the time of enrollment, two patients reported recurrent flares, six patients reported disease progression, and one had noticed improvement. Study design In this single-center, randomized, placebo-controlled, double-blind study, every patient received an infusion with iloprost upon enrollment (visit —1). One month thereafter (visit 0, baseline), patients were assigned using a web-based randomization service (www.randomizer.at) to one of the two treatment groups, with either a 3-hour infusion with iloprost or placebo (0.5% sodium chloride solution). The same therapy was given at the visits in the following 4 months (visits 1 to 4). The infusion or a similar volume of placebo was administered through a peripheral vein at the individually tolerated dose. Inclusion criteria: Male and female patients at least 18 years old with RP with or without SSc already on therapy with iloprost were selected to enter the study. Patients were allowed to continue their individual medications, such as vasoactive substances or im-munosuppressive drugs. Women of childbearing age were asked to practice a medically accepted method of birth control and to have a negative pregnancy test on the morning of the day of every infusion. Different researchers were involved: one that used the randomization service, another that prepared the iloprost/ placebo infusions, and a third that performed ther-mography and collected diary data. Exclusion criteria: Bleeding diathesis or platelet disorder, therapy with anticoagulants, therapy with ace-tylsalicylic acid within 2 weeks of inclusion, active gastrointestinal ulcer, polytrauma, intracranial bleeding, severe untreated diabetes or hypertension, hypervis-cosity, severe coronary heart disease, unstable angina pectoris, myocardial infarction within 6 months, heart failure NYHA II-IV, relevant arrhythmias, pulmonary edema, chronic alcoholism, nicotine abuse, and severe acute infection. Evaluations Diary: Patients received a questionnaire in diary form and were instructed to record daily for the study period of 5 months the total number of Raynaud attacks, an estimate of the duration of an average attack, and the duration of the longest attack in minutes. A 10-point, patient-completed scale was used to determine the severity of attacks, in which 0 represented no attack and 10 represented a very severe attack. Patients were asked for subjective symptoms such as numbness, burning, pain, tingling, and hand disability. Patients started the diary at study entry (visit —1) and made daily entries until the study end (visit 4). Diary data between two visits were summarized, yielding monthly aggregations of month 0 (= baseline, comprising data from visit —1 to visit 0) to month 4. Thermography: Digital temperature was measured by thermography (FLIR Thermacam PM 595, FLIR Systems, Sweden) before and after infusions at every visit starting with study entry (visit —1). Before recording, patients had to acclimate themselves for 15 minutes in a special climatic chamber under stable environmental Vf) u X 0 i^ e Q H "d -o w co 0 s 01 o S S u « O CO £ ¡g ft A ¡3 CO ^ co M V 3 Ü * C« o a •iH "<3 u ■Ö o S a « W a ;h ü tJ X co W '53 u V 3 u ° <4H -S3 u 13 -3 (A ?H « i-H ^ ö a pi 3 tfl u < en o r— "Ö < Z < ^_^ CO C« p Pi on CL q: < 00 CD co i §l S2 - CD < —' z < CO cl z lu ll O CC < Z < 15 £ O S cl cc cl CC cl cc z « < < EE m cl z lu O < z < CO cl CO cl z lu O Z < < z < cc 2E < z < < z < cc cp -A W ZD CO J- ro 10.0 £ ° 8.0 C 0 'ñ 6.0 Ü 4.0 rç T3 1 2.0 0.0 .O ■O---- —O— Iloprost Placebo 2 Months Figure 2. Median duration per Raynaud attack. Side effects of treatment were rare. In the iloprost group one patient had epistaxis and dizziness and one patient a headache; in the placebo group, one patient had a headache. Number of Raynaud attacks: The number of patients showing no attack at all during an entire observation interval increased from baseline to the end of the study. At baseline, all 10 patients (100%) in the iloprost group reported attacks whereas 7/10 patients (70%) were free of attacks at month 4. In the placebo group, 6/7 patients (86%) reported attacks at baseline but 5/7 patients (71%) at month 4. The median number of Raynaud attacks per day at baseline was 1.06 (range: 0.1—3.0) in the iloprost group and 1.37 (0.0—2.5) in the placebo group and decreased to 0.53 (0.0-1.2) in the iloprost group and 0.50 (0.0-3.0) in the placebo group at month 4 (Figure 1). The changes in the two groups (mean —0.70 [SD: 0.85] for iloprost; -0.48 [SD: 0.90] for placebo) did not differ significantly from each other (p = 0.601). Duration of Raynaud attacks: The median duration of an attack in the 10 iloprost patients (100%) at baseline was 11.72 (range: 2.0—304.3) minutes and in the seven patients (70%) with attacks at month 4, 11.11 (3.3250.7) minutes (Figure 2). In the placebo group, the median duration of a Raynaud attack was 14.98 (range: 3.3—1440.0) minutes in the six patients (86%) with attacks at baseline and 17.16 (range: 3.0—1440.0) minutes in the five patients (71%) with attacks at month 4. The changes in the two groups (mean —10.08 [SD 19.78] for seven iloprost patients; —0.76 [SD 3.71] for five placebo patients) did not differ significantly (p = 0.432). 1.5 1.0 0.5 o.o —0— Iloprost ...0... placebo baseline 2 S Months Figure 3. Median severity per Raynaud attack. Median severity: The median severity of a Raynaud attack at baseline was 1.83 (range: 1.1—5.0) points in the 10 (100%) iloprost patients and 2.33 (range: 0.9— 5.1) in the six (86%) placebo patients with attacks, which decreased to 1.28 (range: 0.9—4.5) for the seven (70%) iloprost and 1.13 (range: 0.3—5.0) for the five (71%) placebo patients with attacks at month 4 (Figure 3). The changes in the two groups (mean —0.02 [SD 0.77] points for seven iloprost patients; —0.05 [SD 1.03] for five placebo patients) did not differ significantly (p > 0.999). Thermography The mean digital temperature, measured in each case before the administration of the infusions, increased from the baseline (visit 0) from 29.5°C [SD > 1.4 Si 1.2 14.0 1.ü ■a 12.0 ;; 0.2 ü.ü 4 4 2.5 ö 2.0 4 Figure 4. Mean digital temperature before infusions. 3.42] to 31.6°C [SD 2.95] at visit 1 in the iloprost group and then decreased to 28.1 °C [SD 3.44] at visit 4 (Figure 4). In the placebo group, the digital temperature increased from baseline (29.2°C [SD 3.23]) to visit 2 (31.3°C [SD: 3.34]) and then decreased to visit 4 (28.8°C [SD 3.79]). The ANOVA results showed a significant effect of the temperature over time (p = 0.006) with no differences between the two groups. Scores Scleroderma patients: The Rodnan scores in SSc patients, six of whom were treated with iloprost and five with placebo, varied greatly in both groups among patients and ranged at baseline from 1 to 40 in the iloprost group and from 0 to 19 in the placebo group, but the values showed no statistically significant difference for any patient throughout the entire study period. At study end, the modified Rodnan score ranged from 2 to 35 in the iloprost group and from 0 to 17 in the placebo group. The ischemic lesion score (ILS) varied between 0 and 35 in the iloprost and between 0 and 20 in the placebo treated group with no relevant difference among the groups within the observation period. Similarly, fist closure showed no statistically significant changes in the verum and placebo group (data not shown). Mouth opening: The median values for mouth opening differed considerably even at the beginning of the study in both the iloprost and placebo groups. Mouth opening increased between baseline and visit 4 in the iloprost group by 0.47 (SD 0.38) cm, indicating a statistically significant change (p = 0.043); in the placebo group the increase of 0.06 (SD 0.92) cm was not statistically significant (Figure 5). Figure 5. Median value for mouth opening (cm) in scleroderma patients. Discussion In this study, the number of patients with Raynaud attacks and the severity of the attacks decreased, and no worsening of the disease was observed in either group. There was a trend that iloprost reduced the number of Raynaud attacks, but statistical analyses gave no significant difference in the number, duration, or severity of Raynaud attacks or temperature before and after infusion in patients with RP with or without SSc. Mouth openingimproved significantly in the iloprost-treated SSc patients but no difference in the Rodnan and ischemic lesion scores or in fist closure was seen during the observation period. Limitations of the study were that the treated patient groups were relatively small and highly heterogeneous and that the follow-up period of 4 months was relatively short. The onset, severity, and course of the disease were very different from patient to patient, as was treatment duration with iloprost before enrollment. Furthermore, patients were being treated with various vasoactive and immunosuppressive therapies according to organ involvement and severity of the disease before the study. We did not want to withdraw previous medications for ethical reasons and to rule out unwanted changes in the course of disease. Several studies have shown the efficacy of iloprost in RP and SSc (7, 15—22). Mazzone et al. observed a significant increase in skin temperature and oxygen saturation after iloprost infusions in two different studies in comparison with sodium chloride infusion and acetylsalicylic acid (17, 19). In other studies, the beneficial effect of iloprost on the microcirculation and the increase in the digital peripheral blood flow lasted for 4 to 9 weeks after infusion (15, 16, 20). Caramaschi et al. reported that the finger skin temperature increased not only immediately after the infusions but that the effect could be maintained for 1 month, in contrast to our data (23). However, iloprost could not influence skin temperature after cold provocation in their study. Our study was performed during the summer months, when the number of Raynaud attacks is generally diminished; existing differences so might not have appeared to the expected extent. We found that increasing skin temperature was strongly influenced by air temperature rising earlier in the iloprost group as seen in the first 2 months of the study period (Figure 4). At the end of the study period, in a rather rainy August/September at the beginning of the cold season, skin temperature had fallen in both the iloprost and placebo groups. In a long-term not placebo-controlled study, Biasi et al. treated patients with cyclic 5-day infusions every 3 months for 1 year (18). They found a significant decrease in skin sclerosis and ischemic lesion score. Della Bella et al. (21) compared intravenous iloprost to oral nifedipine given for 5 days and then repeated for 1 day every 6 weeks for 1 year in a prospective, randomized, parallel-group, observer blind trial. The capillaroscopic patterns and skin scores showed significant improvement. Similarly, in contrast to the stable Rodnan score, mouth opening improved significantly in our patients in the iloprost group, which can also be seen as a marker of the extent of facial skin sclerosis and therefore might indicate that iloprost is efficacious. Filaci et al., however, reported a lack of clinical efficacy for iloprost (25). They compared iloprost infusion therapy with a combination therapy of cyclo-sporine A and iloprost administered for 5 days every month. A significant improvement of the plicometer skin score and the capillaroscopic parameters was seen only in the combination group. No long-term studies of more than 1 year have been performed so far, and iloprost has been administered to patients with RP and/or SSc in several studies with different treatment protocols and outcome measurements that preclude direct comparison. Infusion rates of 0.5 to 2.0 ng/kg/min were used for 5 to 8 hours daily. In short-term studies, iloprost was given on 3 to 14 consecutive days. The length of follow-up References in long-term studies varied from 1 to 12 months. Most of the studies were not placebo controlled, although a response to placebo has also been reported in RP (22, 26). Contrary to our expectations, although the number of patients with Raynaud attacks and the severity of attacks in iloprost-treated patients improved, we did not see significant differences in the outcome measures. The reasons might be too brief an observation period, that the study was performed in the summer months, during which RP tends to improve, or an insufficient treatment regimen with an effective agent. Milio et al. used three different treatment protocols in comparison; the best seemed to be infusions on 5 working days over 2 weeks (10 days), repeated every 3 months taking quality of life and dimensions of attacks into account (26). The effective dose of iloprost is highly individual and seems to vary in a relatively wide range. A comparative randomized clinical trial did not find any difference in the efficacy of low-dose (0.5 ng/kg/min) and high-dose (5 ng/kg/min) iloprost (27). To validate the modified Rodnan score, the study period was too short to see changes or to recognize stabilization of disease, although in the inflammatory active disease stage the score could worsen in a short period in spite of treatment. This was not the case in our patients, particularly because four were on additional immunosuppressive therapy. Thus, although we could not prove a significant effect of iloprost treatment, we think that iloprost might still have a place in the therapeutic armamentarium in RP and SSc with treatment protocols in which dosage, infusion time, and treatment intervals are modified. Acknowledgements G. Bali's work was supported by funds from the "Semmelweis University Leonardo Mobility Programme" in Budapest. Name of the trial: "Open, single-center, randomized, placebo-controlled, double-blind clinical study in patients with Raynaud's phenomenon with/without systemic sclerosis for systemic treatment with iloprost versus placebo." https:// eudract.emea.europa.eu/eudract/index.do. EudraCT number: 2006-000905-41 1. Krieg T, Meurer M. Systemic scleroderma. J Am Acad Dermatol. 1988;18(3):457-81. 2. Charles C, Clements P, Furst D. Systemic sclerosis: hypothesis-driven treatment strategies. Lancet. 2006 May 20;367:1683-91. 3. Riemekasten G, Schulze-Koops H. Medicinal vasoactive therapy of microcirculation disorders in rheumatoid arthritis. Z Rheumatol. 2005;64(2):123-36. 4. Akerkar Shasank M, Bichile Lata S. Therapeutic options for systemic sclerosis. Indian I Dermatol. 2004;70(2):67-75. 5. Rosenkranz S, Caglayan E, Diet F, Karasch D, Weihrauch J, Wassermann K, et al. 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I Rheumatol. 2008;35(9):1830-7. authors' Gabor Bali, MD, MVZ Attendorn GmbH, Ostwall 94, D-57439 Attendorn, addresses E-mail: gaborbali@hotmail.com Gerold Schwantzer, MSc, Institute for Medical Informatics, Statistics and Documentation, Medical University of Graz, Auenbruggerplatz 9/III, A-8036 Graz, Austria, E-mail: gerold.schwantzer@meduni-graz.at Felix Aberer, Department of Dermatology and Venerology, Medical University of Graz, Auenbrugger Platz 8; A-8036 Graz, Austria, E-mail: felix_aberer@gmx.net Birger Kraenke, MD, same address, E-Mail: birger.kraenke@meduni-graz.at Elisabeth Aberer, MD, same address, corresponding author, Tel. : +43 316 385 80317; Fax: +43 316 385 2466; E-mail: elisabeth.aberer@meduni-graz.at