Nobis Nobis Cartel windows 7 home premium activation key 70-290

Guidelines for the Management of Pemphigus Vulgaris

The initial aim of treatment is to induce disease remission and should be followed by a period of maintenance treatment using the minimum drug doses.

BIBLIOGRAPHIC SOURCE(S)
Harman KE, Albert S, Black MM. Guidelines for the management of pemphigus vulgaris. Br J Dermatol 2003 Nov;149(5):926-37. [112 references] PubMed

GUIDELINE STATUS
This is the current release of the guideline.


** REGULATORY ALERT **

FDA WARNING/REGULATORY ALERT
Note from the National Guideline Clearinghouse: This guideline references drugs for which important revised regulatory information has been released.

  • February 12, 2009 – CellCept (mycophenolate mofetil): The U.S. Food and Drug Administration (FDA) and Roche Laboratories notified healthcare professionals of the introduction of a CellCept Medication Guide to provide important safety information in language that patients can easily comprehend and regulations that require a pharmacist to distribute a copy of the Medication Guide to every patient who fills a CellCept prescription. FDA has also required the introduction of a Medication Guide for mycophenolic acid, marketed as Myfortic by Novartis.
  • June 30, 2008, CellCept (mycophenolate mofetil) and Myfortic (mycophenolate acid): Novartis and Roche have agreed to include additional labeling revisions to the WARNINGS and ADVERSE REACTIONS sections of the Myfortic and CellCept prescribing information, based on post-marketing data regarding cases of Progressive Multifocal Leukoencephalopathy (PML) in patients treated with these drugs.


BRIEF SUMMARY CONTENT
** REGULATORY ALERT **

RECOMMENDATIONS
EVIDENCE SUPPORTING THE RECOMMENDATIONS
IDENTIFYING INFORMATION AND AVAILABILITY
DISCLAIMER

Contents | Top


RECOMMENDATIONS
MAJOR RECOMMENDATIONS
Levels of evidence (I-IV) and grading of recommendations (A-E) are defined at the end of the “Major Recommendations” field.

Laboratory Diagnosis

A skin or mucosal biopsy should be taken for histology and direct immunofluorescence (DIF), the latter requiring perilesional, intact skin or clinically uninvolved skin. Suprabasal acantholysis and blister formation is highly suggestive of pemphigus vulgaris (PV) but the diagnosis should be confirmed by the characteristic deposition of immunoglobulin G (IgG) in the intercellular spaces of the epidermis. Indirect immunofluorescence (IIF) is less sensitive than DIF but may be helpful if a biopsy is difficult (e.g., children and uncooperative adults). Enzyme-linked immunosorbent assays (ELISA) are now available for direct measurement of desmoglein (Dsg)1 and Dsg 3 antibodies in serum. They offer advantages over IIF and may supersede this technique. Five millilitres of blood is sufficient for IIF and ELISA.

In patients with oral pemphigus, an intraoral biopsy is the optimum but IIF or DIF on a skin biopsy may suffice. One study showed that the sensitivity of DIF was 71% in oral biopsies compared with 61% in normal skin taken from 28 patients with oral PV. Another study reported that the sensitivity of DIF was 89% in oral biopsies compared with 85% for IIF.

Baseline Investigations

The following investigations are suggested prior to commencing treatment: biopsy (or IIF) as above, full blood count and differential, urea and electrolytes, liver function tests, glucose, antinuclear antibody (differential of pemphigus erythematosus), thiopurine methyltransferase (TPMT) levels (if azathioprine is to be used), chest x-ray, urinalysis, and blood pressure. Current guidelines on osteoporosis should be followed, so a bone density scan early in the course of treatment may be recommended.

General Principles of Management

The initial aim of treatment is to induce disease remission. This should be followed by a period of maintenance treatment using the minimum drug doses required for disease control in order to minimize their side-effects. Occasional blisters are acceptable and indicate that the patient is not being overtreated. The ultimate aim of management should be treatment withdrawal and a recent study reported complete remission rates of 38%, 50%, and 75% achieved 3, 5, and 10 years from diagnosis.

Most patients are treated with systemic corticosteroids (CS), which are effective. Adjuvant drugs are commonly used in combination with the aims of increasing efficacy and of having a steroid-sparing action, thereby allowing reduced maintenance CS doses and reduced CS side effects. Although mortality and complete remission rates have improved since the introduction of adjuvant drugs, this is in comparison with historical controls; a more recent study of PV patients treated with CS alone demonstrated outcomes comparable with studies using adjuvants. There are no prospective, controlled studies that conclusively demonstrate the benefits of adjuvant drugs in PV. Therefore, some respected authorities do not use adjuvant drugs unless there are contraindications or side-effects of CS, or if tapering the CS dose is associated with repeated relapses. However, most centres do use adjuvant drugs as standard practice. In general, adjuvant drugs are slower in onset than CS and are therefore rarely used alone to induce remission in PV.

Oral Corticosteroids (CS)

Systemic CS are the best established therapy for the management of PV (Strength of recommendation A, Quality of evidence II-iii).

Pulsed Intravenous Corticosteroids

Pulsed CS could be considered in severe or recalcitrant PV to induce remission, particularly if there has been no response to high oral doses (C, IV).

Adjuvant Drugs

Azathioprine

Azathioprine is a well-established choice as an adjuvant drug for the management of pemphigus (B, II-iii).

Oral Cyclophosphamide

Oral cyclophosphamide could be considered as an alternative to azathioprine (B, III).

Pulsed Intravenous Cyclophosphamide with Dexamethasone or Methylprednisolone

Pulsed CS cyclophosphamide therapy could be considered in severe or recalcitrant cases of PV. However, it may not be practical to administer repeated courses (B, II-iii).

Mycophenolate Mofetil

On the basis of current evidence, MMF could be considered in recalcitrant cases or when azathioprine and cyclophosphamide cannot be used (B, III).

Gold

Gold could be considered as an alternative to more established adjuvant drugs if they cannot be used (B/C, III).

Methotrexate

Methotrexate could be considered as an adjuvant drug if more established drugs cannot be used (C, III).

Ciclosporin

On the basis of current evidence, ciclosporin cannot be recommended as an adjuvant drug in PV (C, I).

Tetracyclines/Nicotinamide

Tetracyclines with or without nicotinamide could be considered as adjuvant treatment, perhaps in milder cases of PV (C, IV).

Dapsone/Sulphonamides

Dapsone was reported to be beneficial as an adjuvant drug in four cases of PV. However, in two of these cases, it was started either with or shortly after prednisolone, and in two cases it was started after the long-standing prednisolone was increased to high doses. Therefore, it is difficult to be certain if dapsone had a significant role and there is little evidence to recommend the use of dapsone in PV (C, IV).

Chlorambucil

Chlorambucil could be considered as an adjuvant drug if more established options cannot be used but there are limited data to support its use (C, IV).

Intravenous Immunoglobulin (IVIG)

Repeated courses of intravenous immunoglobulin could be considered as an adjuvant, maintenance agent in patients with recalcitrant disease who have failed more conventional therapies. In view of reports of a rapid action in some cases, it could be used to help induce remission in patients with severe PV while slower-acting drugs take effect (B, III).

Plasma Exchange (PE)

Plasma exchange cannot be recommended as a routine treatment option in newly presenting patients with PV. However, it could be considered in difficult cases if combined with CS and immunosuppressant drugs (C, I).

Extracorporeal Photopheresis (ECP)

ECP could be considered in recalcitrant cases of PV where there has been failure to improve with more conventional therapy (B, III).

Topical Therapy

PV is largely managed with systemic therapy but adjuvant topical therapy may be of additional benefit, although there are no controlled studies to confirm this. Rarely, patients with mild disease, particularly if confined to the mucosal surfaces, can be managed on topical therapy alone.

For oral pemphigus, measures such as soft diets and soft toothbrushes help minimize local trauma. Topical analgesics or anaesthetics, for example benzydamine hydrochloride 0.15% (Difflam Oral Rinse®), are useful in alleviating oral pain, particularly prior to eating or tooth brushing. Oral hygiene is crucial. Otherwise PV may be complicated by dental decay; tooth brushing should be encouraged and antiseptic mouthwashes may be used, such as chlorhexidine gluconate 0.2% Corsodyl®), hexetidine 0.1% (Oraldene®), or 1:4 hydrogen peroxide solutions. Patients are susceptible to oral candidiasis, which should be treated. Topical CS therapy may help reduce the requirement for systemic agents. For multiple oral erosions, mouthwashes are most practical, for example, soluble betamethasone sodium phosphate 0.5 mg tablet dissolved in 10 mL water may be used up to four times daily, holding the solution in the mouth for about 5 minutes. Isolated oral erosions could be treated with application of triamcinolone acetonide 0.1% in adhesive paste (Adcortyl in Orabase®), 2.5 mg hydrocortisone lozenges or sprayed directly with an asthma aerosol inhaler, for example beclomethasone dipropionate 50-200 micrograms or budesonide 50-200 micrograms. Topical ciclosporin (100 mg/mL) in oral pemphigus has been described and may be of some benefit but is expensive.

Follow-up

Once remission is induced, there should follow a period of maintenance treatment using the minimum drug doses required for disease control and during which occasional blisters are acceptable. Drug doses should be slowly reduced and patients should remain under follow-up while they remain on therapy. Ultimately, treatment may be withdrawn if there has been prolonged clinical remission. This decision should largely be clinical but the chances of relapse are reduced if immunofluorescence studies are negative (e.g., the risk of relapse is 13-27% if DIF is negative, 44-100% if DIF is positive, 24% if IIF is negative, and 57% if IIF is positive). However, DIF can occasionally remain positive in patients who are in remission and off treatment.

Definitions:

Levels of Evidence

I: Evidence obtained from at least one properly designed, randomized controlled trial

II-I: Evidence obtained from well designed controlled trials without randomization

II-ii: Evidence obtained from well designed cohort or case-control analytic studies, preferably from more than one centre or research group

II-iii: Evidence obtained from multiple time series with or without the intervention. Dramatic results in uncontrolled experiments (such as the introduction of penicillin treatment in the 1940s) could also be regarded as this type of evidence.

III: Opinions of respected authorities based on clinical experience, descriptive studies, or reports of expert committees

IV: Evidence inadequate owing to problems of methodology (e.g. sample size, or length or comprehensiveness of follow-up or conflicts of evidence).

Recommendation Grades

A. There is good evidence to support the use of the procedure.
B. There is fair evidence to support the use of the procedure.
C. There is poor evidence to support the use of the procedure.
D There is fair evidence to support the rejection of the use of the procedure.
E. There is good evidence to support the rejection of the use of the procedure

CLINICAL ALGORITHM(S)
None available

Contents | Top


EVIDENCE SUPPORTING THE RECOMMENDATIONS

TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of supporting evidence is identified and graded for selected recommendations (see “Major Recommendations”).

Contents | Top


IDENTIFYING INFORMATION AND AVAILABILITY

BIBLIOGRAPHIC SOURCE(S)

Harman KE, Albert S, Black MM. Guidelines for the management of pemphigus vulgaris. Br J Dermatol 2003 Nov;149(5):926-37. [112 references] PubMed

ADAPTATION

Not applicable: The guideline was not adapted from another source.

DATE RELEASED

2003 Nov

GUIDELINE DEVELOPER(S)

British Association of Dermatologists – Medical Specialty Society

SOURCE(S) OF FUNDING

British Association of Dermatologists

GUIDELINE COMMITTEE

British Association of Dermatologists Therapy Guidelines and Audit Subcommittee

COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

Primary Authors: K.E. Harman; S. Albert; M.M. Black

British Association of Dermatologists Therapy Guidelines and Audit Committee Members: N.H. Cox (Chairman); A.S. Highet; D. Mehta; R.H. Meyrick Thomas; A.D. Ormerod; J.K. Schofield; C.H. Smith; J.C. Sterling

FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

None stated

GUIDELINE STATUS

This is the current release of the guideline.

GUIDELINE AVAILABILITY

Electronic copies: Available in Portable Document Format (PDF) from the British Association of Dermatologists Web site.

AVAILABILITY OF COMPANION DOCUMENTS

The following is available:

PATIENT RESOURCES

The following is available:

Please note: This patient information is intended to provide health professionals with information to share with their patients to help them better understand their health and their diagnosed disorders. By providing access to this patient information, it is not the intention of NGC to provide specific medical advice for particular patients. Rather we urge patients and their representatives to review this material and then to consult with a licensed health professional for evaluation of treatment options suitable for them as well as for diagnosis and answers to their personal medical questions. This patient information has been derived and prepared from a guideline for health care professionals included on NGC by the authors or publishers of that original guideline. The patient information is not reviewed by NGC to establish whether or not it accurately reflects the original guideline’s content.

NGC STATUS

This NGC summary was completed by ECRI on April 20, 2005. The information was verified by the guideline developer on August 16, 2005. This summary was updated by ECRI Institute on November 6, 2007, following the U.S. Food and Drug Administration advisory on CellCept (mycophenolate mofetil). This summary was updated by ECRI Institute on July 8, 2008, following the updated U.S. Food and Drug Administration (FDA) advisory on CellCept (mycophenolate mofetil) and Myfortic (mycophenolate acid). This summary was updated by ECRI Institute on February 19, 2009, following the U.S. Food and Drug Administration (FDA) advisory on CellCept (mycophenolate mofetil).

COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which is subject to the guideline developer’s copyright restrictions.

Contents | Top


DISCLAIMER
NGC DISCLAIMER

The National Guideline Clearinghouse™ (NGC) does not develop, produce, approve, or endorse the guidelines represented on this site.

All guidelines summarized by NGC and hosted on our site are produced under the auspices of medical specialty societies, relevant professional associations, public or private organizations, other government agencies, health care organizations or plans, and similar entities.

Guidelines represented on the NGC Web site are submitted by guideline developers, and are screened solely to determine that they meet the NGC Inclusion Criteria which may be found at http://www.guideline.gov/about/inclusion.aspx .

NGC, AHRQ, and its contractor ECRI Institute make no warranties concerning the content or clinical efficacy or effectiveness of the clinical practice guidelines and related materials represented on this site. Moreover, the views and opinions of developers or authors of guidelines represented on this site do not necessarily state or reflect those of NGC, AHRQ, or its contractor ECRI Institute, and inclusion or hosting of guidelines in NGC may not be used for advertising or commercial endorsement purposes.

Readers with questions regarding guideline content are directed to contact the guideline developer.

Contents | Top

Posted in Around the Globe

JOIN TODAY!

The P/P Registry has been approved by the Western Institutional Review Board (WIRB) and is actively enrolling participants.

ENGLISH VERSION