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The Unseen Problem With Drugs

Judith Graves developed a rare medical condition called jawbone death after taking Fosamax, a drug used by millions of American women with thinning bones.

The F.D.A. said the optimal period for using drugs like Fosamax was unknown.

In a civil trial now under way in Manhattan, Mrs. Graves is suing Merck, the maker of Fosamax. Her lawyer, Timothy M. O’Brien, told the jury that Fosamax had caused such debilitating jawbone deterioration that Mrs. Graves required five major operations, including a lengthy surgery to replace her broken jaw with bone from her left arm.

Merck has argued that Fosamax is not the culprit. In its defense, Merck contends that Mrs. Graves took other prescriptions — like steroids to treat rheumatoid arthritis — that weakened her immune system, leading to her jaw infection and healing problems, said Paul F. Strain, outside counsel for the company.

The lawsuit is one of a handful of bellwether cases against Merck representing litigation involving about 1,400 people across the country who say they developed jawbone ailments after taking Fosamax, Mr. O’Brien said. Merck won an earlier case; but in another, a judge proposed to reduce a plaintiff’s jury award to $1.5 million from $8 million (both sides plan to appeal).

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A questionDosage and indication “creep” with the new biologics to treat inflammatory diseases have payers enforcing strict utilization policies. Physicians counter that payers can’t dictate treatment. With even more biologics on the horizon, and drug spend spiralling upward, both sides need to seek a middle ground. The question is how?

“It’s a bit like solving a Rubik’s Cube” when dealing with new immunomodulators, says Helen Sherman, PharmD, with RegenceRX. “We keep track of all the science and potential uses, but this is a complex category.”

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Bullous pemphigoid (BP) is a prototypical organ-specific autoimmune disease. Autoantibodies unfold their blister-inducing potential by triggering an Fcγ-dependent inflammatory reaction. The study by Iwata et al.  in this issue provides the first direct evidence that IgG autoantibodies from BP patients may also weaken cell–matrix adhesion by depleting BP180/type XVII collagen from cultured keratinocytes. These novel findings shed new light on additional mechanisms of blister formation in pemphigoid diseases and open the way for further informative studies.

Bullous pemphigoid (BP) is a subepidermal blistering disease that typically affects the elderly and is associated with an autoimmune response against hemidesmosomal proteins (Liu and Diaz, 2001; Mihai and Sitaru, 2007; Olasz and Yancey, 2008). Extensive clinical and experimental evidence strongly suggests that autoantibodies cause the pathology in this disease (Sitaru and Zillikens, 2005; Leighty et al., 2007). Circulating autoantibodies in BP patients exhibit a heterogeneous specificity to several hemidesmosomal components, including BP230, an intracellular constituent of the hemidesmosomal plaque, and the transmembrane protein BP180/type XVII collagen (Sitaru and Zillikens, 2005; Leighty et al, 2007). Mutations in COL17A1 in patients with generalized atrophic benign epidermolysis bullosa and in knockout mice result in low or absent expression of BP180/type XVII collagen and subepidermal blistering (McGrath et al., 1995; Nishie et al., 2007). These findings suggest that a decrease in the expression of this hemidesmosomal antigen may weaken cell–matrix adhesion in the skin and eventually result in dermal–epidermal separation.

Autoantibodies to the transmembrane antigen BP180, but not to the intracellularly located BP230, were hypothesized to be pathogenically relevant (Liu and Diaz, 2001; Sitaru and Zillikens, 2005). Indeed, experimental evidence generally supports the pathogenic role of autoantibodies to BP180 for blister formation. IgG autoantibodies, affinity purified against recombinant BP180 from patients with BP and pemphigoid gestationis, induce dermal–epidermal separation in cryosections of human skin when co-incubated with leukocytes from healthy donors (Sitaru and Zillikens, 2005). In 1993, Liu et al. first provided evidence for a pathogenic role of autoantibodies to type XVII collagen/BP180 in vivo (Liu et al., 1993). The authors demonstrated that rabbit antibodies generated against murine BP180 induce subepidermal blisters when passively transferred into neonatal mice. More recently, further animal models reproducing blister formation in BP have been developed using mice that express the human form of the BP180 antigen injected with BP patient autoantibodies. Studies performed mainly with the experimental model developed by Liu et al. (1993) revealed that subepidermal blistering triggered by rabbit IgG specific to murine BP180 depends on complement activation, mast cell degranulation, macrophage activation, and neutrophilic infiltration. Reactive oxygen species and proteases, such as gelatinase B/MMP-9 and elastase, are critically involved in blister formation

IgG autoantibodies deplete BP180 from keratinocytes.

in vivo and in vitro (Liu and Diaz, 2001; Liu, 2004; Sitaru and Zillikens, 2005; Leighty et al., 2007). These findings partially match the pathology observed in BP patients and support the prevailing view that triggering an Fcγ-dependent inflammatory reaction is necessary for blister induction by autoantibodies in BP (Figure 1).
Figure 1.
Figure 1 – Unfortunately we are unable to provide accessible alternative text for this. If you require assistance to access this image, please contact or the author

Mechanisms of blister formation in bullous pemphigoid (BP). The left lower panel illustrates several structural proteins of the epidermal basement membrane that function as major autoantigens in autoimmune subepidermal bullous skin diseases. The main autoantigens in BP patients include the BP antigen 230 (BP230) and the BP antigen 180 (BP180)/type XVII collagen. BP autoantibodies accumulate in tissue and bind to antigens at the epithelial basement membrane. Binding of pathogenic autoantibodies triggers an inflammatory reaction, including fixation of complement and Fc-dependent activation of leukocytes. In addition to granulocytes, mast cells likely contribute to the antibody-induced inflammation at the dermal–epidermal junction. Activated granulocytes release reactive oxygen intermediates and proteases, leading to epithelial damage and blister formation. Alternatively, as shown by Iwata et al. (2009), IgG autoantibodies may deplete BP180 from basal keratinocytes and thus contribute to blister formation. LN 332, laminin 332; ROS, reactive oxygen species.
Full figure and legend (158K)

Although the description of the relatively uncommon variant of BP with a paucicellular dermal infiltrate suggested the existence of alternative noninflammatory mechanisms of blister formation, until now experimental data did not support this hypothesis. A further hint that a full inflammatory response may not be required for subepidermal blistering by autoantibodies against BP180/type XVII collagen was provided by Yamamoto et al. (2002). They demonstrated that rabbit antibodies generated against hamster BP180 induced subepidermal blisters when passively transferred into neonatal hamsters. The blister formation in this model necessitates complement activation, but not the recruitment and activation of leukocytes (Yamamoto et al., 2002).

In this issue, Iwata et al. show that IgG autoantibodies from patients with BP deplete keratinocytes of BP180/type XVII collagen. When IgG from BP patients was added to cultured keratinocytes, the authors found that this treatment depleted BP180, but not α6β4 integrin, from cells as assessed by densitometric analysis of immunoblots. In addition, keratinocytes treated with IgG from BP patients showed a reduction in their adhesive strength as revealed by a standardized detachment assay (Iwata et al., 2009).

These findings describe new and potentially relevant mechanisms of blistering in BP and may have important consequences for the development of new treatment modalities. The fact that autoantibodies from patients with BP deplete BP180 from keratinocytes strongly suggests that alternative noninflammatory mechanisms contribute to blister formation in the pemphigoid diseases. Animal models of BP allow the in vivo relevance of these findings to be addressed and the relative contributions of the noninflammatory and inflammatory mechanisms of blister formation by autoantibodies to be dissected.

Autoantibodies in BP are thought to be heterogeneous with respect to their blister-inducing potential. Major intrinsic determinants of autoantibody pathogenicity include their specificity and their ability to activate complement and leukocytes (Sitaru and Zillikens, 2005). Future research should answer the question of whether the specificity of antigen-depleting autoantibodies differs when compared with that of autoantibodies that activate putative inflammatory mechanisms. BP autoantibodies belong to different isotypes, which may be associated with distinct effector functions. On the basis of previous experimental evidence, it has been proposed that blistering is induced primarily by IgG1, whereas IgG4 autoantibodies are less pathogenic or even protective (Liu, 2002; Sitaru et al., 2007). In light of the novel noninflammatory mechanisms of blister formation by autoantibodies as suggested by the study by Iwata et al. (2009), the role of different isotypes of autoantibodies in the pathogenesis of BP requires reappraisal.

In conclusion, this study strongly suggests the existence of noninflammatory mechanisms of blister formation by autoantibodies in BP. Further exploration of this line of research should provide relevant mechanistic insights into BP pathogenesis and greatly facilitate the development of more effective therapeutic approaches.


MedWire News: Having a neurological or psychiatric disorder, being bedridden, or being a chronic user of various drugs significantly increases the risk for bullous pemphigoid (BP) in elderly individuals, say researchers.

“A rise in the incidence of BP was documented recently in Europe, and the main risk factors for BP remain unknown,” write Sylvie Bastuji-Garin (Université Paris-Est, Créteil, France) and co-workers. This condition is also much more common in people over the age of 60 years than in younger individuals.

To investigate possible reasons for this, the team selected 201 individuals (64.7% female), aged 84.2 years on average, with incident BP and 345 controls who were matched for gender, age, place of residence, and center.

Diagnosis of BP was based on identification of typical clinical features and on direct immunofluorescence showing linear deposits of immunoglobulin G and/or C3 along the basement membrane zone.

Drug use over 3 months, comorbidities, and physical and cognitive impairments were compared between cases and controls.

As reported in the Journal of Investigative Dermatology, multivariate analysis showed that major cognitive impairment, being bedridden, having Parkinson’s disease or unipolar/bipolar disorder, or chronic use of spironolactone or phenothiazines with aliphatic side chains increased the risk for BP a significant 2.19-, 2.19-, 2.16-, 5.25-, 2.30, and 3.70-fold, respectively.

In contrast, chronic use of analgesics reduced the relative risk for BP by a significant 51%.

“These findings may have implications for the management of BP patients,” write the authors.

“Moreover, they indicate a need for further investigations into the association of BP with neurological disorders,” they conclude.


Pemphigus vulgaris (PV) is the most severe autoimmune blistering disorder of the skin that is mediated by circulating autoantibodies against desmoglein 3 (Dsg3). It has been reported that in Jews the associated haplotype in PV is human leukocyte antigen (HLA) B38, DRB1*0402, DQB1*0302. Significant associations with HLA were observed also in non-Jews. Dsg3-specific T-cell responses were detected in PV patients but also in healthy individuals who were either carriers of the PV-associated DRB1*0402 allele or alleles that share similar or identical peptide binding motifs to DRB1*0402. This suggests that genes other than the classical major histocompatibility complex (MHC) genes are associated with the development of the autoimmune response. We used 16 microsatellite probes that span the entire MHC region to screen DNA samples from 38 PV patients and 76 healthy controls. Results demonstrated that some markers were associated with class II region including a TAP associated marker. However, four probes, D6S265, C_527, D6S510, and MOGC, which are all mapped to the region of HLA-A, were highly associated with PV. These results suggest that a gene, or genes in the class I region are important in the initiation of the autoimmune cascade. Activation/suppression of these genes might act as the trigger mechanism that starts the autoimmune destructive process.


Dosage and indication “creep” with the new biologics to treat inflammatory

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diseases have payers enforcing strict utilization policies. Physicians counter that payers can’t dictate treatment. With even more biologics on the horizon, and drug spend spiralling upward, both sides need to seek a middle ground. The question is how?

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In the latest effort to break up the often cozy relationship between doctors and the medical industry, the University of Michigan Medical School has become the first to decide that it will no longer take any money from drug and device makers to pay for coursework doctors need to renew their medical licenses.

We’re fresh off of the delight of connecting with everyone available at the Annual Meeting (AM) in Philadelphia. Read more in this issue and visit our website at for additional materials.

The IPPF capstone project for 2010 is documenting 1,000 pemphigus/pemphigoid patient medical data records in our Registry — launched at the AM. This many records in the registry places us in position to ask for funding to support a research grant, inspire a scientist to conduct research, or provide data to move drug company developments in treatments.

Last year we addressed personal patient support needs with the Health Management Program (HMP). If you need personal support managing your disease, have specific questions, or want to discuss options with someone who’s been there, you need the Health Management Program and a relationship with one of our Peer Health Coaches (PHC). (See Dr. Sirois’ article on the demonstrated benefits in improved heath from participation on page 4)  Let us know and we can set you up.

The Registry is an animal of a different stripe. In the Registry, instead, we need something from each one of you  — we need your data — all confidential, of course (read more about our Registry’s privacy policy at Not “we” so much, but P/P patients of the future. For the benefit of the future collective of P/P patients, we need you to complete the registry so your challenges can be counted and addressed.

We will be sending every patient that we have email contact with a unique log-in to privately enter your information from your personal computer. Please, please take the 15 minutes or so to document your experience and illuminate the urgent needs of this community — for awareness, resources, scientific discovery and everyday solutions. Last year we asked you to dig deep to help us leverage the opportunity for a matching grant of financial support. This year we need to dig deep to make the collective of your voices and experiences heard — for everyone’s progress.

We are at an exciting milestone, providing proof of the burden of disease and the path to discovery of effective new treatments. Please dig deep, once again — this year with your time — to support this community.

If you don’t, who will?