ERN ReCONNET

Lay Versions

Disease: Systemic Sclerosis

Systemic Sclerosis Lay Versions

Lay versions are an adaptation of the original documents (recommendations, clinical practice guidelines, etc.) into an English-lay version, in order to facilitate the patients’ access to information about their disease and thank to this to make well-informed decision about their health.
This lay version is dedicated to Systemic Sclerosis and it was developed by the ERN ReCONNET Systemic Sclerosis Disease Coordinators Vanessa Smith and Marco Matucci Cerinic, ePAG representative llaria Galetti and the ERN ReCONNET Team (Simone Ticciati and Diana Marinello) on the basis of the paper “Systemic Sclerosis: state of the art on clinical practice guidelines“.
Special thanks to the patient representatives who made this work possible: Silvia Sandulescu, Sue Farrington, Catarina Leite, Rita Schriemer, Joep Welling, Nele Cayers and Charissa Frank.

Introduction

Introduction

“Scleroderma”, also known as Systemic Sclerosis (SSc), is a rare connective tissue disease. The immune system attacks the body’s own tissues (=autoimmunity) affecting the entire body including the skin and the internal organs (heart, lungs, kidneys, the gastrointestinal system as well as blood vessels).

Since 2017, the European Reference Network on Rare and Complex Connective Tissue and Musculoskeletal Diseases (ERN ReCONNET) is working to improve the management of SSc and to facilitate access to better, safer and more standardized healthcare for patients.

The ERN ReCONNET is a European Network composed of clinicians, researchers and patients’ representatives that work together to improve the care of patients affected by rare and complex connective tissue diseases. Patients’ representatives (ePAGs) bring within the ERNs the unmet needs of their communities and the experience of living with the disease. Their training and knowledge allow them to evaluate and design, together with clinicians, all the necessary actions to achieve a better care for patients suffering from rare and complex diseases. Within ERN ReCONNET, 7 ePAG Representatives are working to give voice to rare and complex connective tissue and musculoskeletal diseases. One of the 7 ePAG Representatives is working for Systemic Sclerosis.

The ERN ReCONNET is working on many topics, including the Clinical Practice Guidelines (CPGs). CPGs are statements that advise clinicians about appropriate patient care. They are based on evidence and carefully take into account the benefits and harms of alternative options of care. CPGs also aim at harmonising the delivery of high-quality healthcare. In this work we present the results of one of the activities of the ERN ReCONNET that was performed thanks to a collaboration among ePAGs and experts in SSc. This work was dedicated to the identification and evaluation of existing CPGs on the management (diagnosis, monitoring and treatment) of SSc patients.

The ERN ReCONNET SSc group, composed of clinicians and ePAGs, have searched in the scientific literature and have identified 893 articles, including 28 CPGs. Unfortunately, guidelines taking into consideration the patient’s perspective were not found, even if they are highly needed.

Below you can find a summary of the CPGs that were identified, starting from the diagnosis – which is crucial for a better management of the disease – to the unmet needs, that could address future steps of clinicians and patient representatives. The CPGs cover different topics; we decided to group them in different domains, to collect them in an organic way and to make them easier to consult. For example, the CPGs concerning the procedures leading to the healing or to the cure of the disease, will be in the section Treatment. For each topic, a list of the existing publications is available at the end of the section.

 

List of references

Diagnosis

Diagnosis

One guideline informs about clinical manifestations and classification criteria; procedures to diagnose SSc, through capillaroscopy and serum antibodies; possible involved organs and their diagnostic work-up; therapeutic options for each SSc related organ manifestation. However, even if not retained as clinical practice guidelines, criteria can guide doctors in the very early and early diagnosis of SSc and in the classification.

List of references

Treatment

Treatment

CPGs give recommendations for the treatment of different SSc-related organ manifestations. Some of them focus on the medicinal treatment of SSc-related Raynaud’s Phenomenon, digital ulcers, skin involvement, heart and lung problems, kidney involvement and digestive tract problems. Other guidelines additionally focus on heart failure, calcinosis and musculoskeletal problems. Moreover, they give advice on general measures and treatments without medicines.

List of references

Smallest blood vessels

Smallest blood vessels

Raynaud’s Phenomenon, an uncommon response to cold exposure or an emotionally stressful situation, is typically the first sign of SSc, and involves the smallest blood vessels causing reduced blood flow to the extremities of the body.

Three CPGs (of which one is specific for children) focus on the screening and diagnosis of SSc-related Raynaud’s Phenomenon; they recommend performing a thorough review of the patient’s clinical history, clinical examination, blood tests to search for the presence of autoantibodies (including SSc specific antibodies) and nailfold videocapillaroscopy to find signs indicative of SSc-related Raynaud’s Phenomenon.

Digital ulcers (sometimes very painful) can occur spontaneously at the fingers and/or at the toes and are a severe sign of Raynaud’s Phenomenon. Due to the reduced or poor blood flow, digital ulcers are slow to heal and more prone to infections. If not treated, the underlying bone can become infected (i.e. osteomyelitis) or the involved skin tissue may die (i.e. gangrene).

One CPG proposes standard definitions to help medical doctors classify finger wounds as being active, indeterminate or healed.

List of references

Digestive system

Digestive system

Fibrotic tissue can appear in the different organs of the digestive system: mouth, oesophagus, stomach and the intestines, reducing their ability to work properly. Up to 90% of people with SSc experience problems with their digestive system.

The following problems might appear due to oral involvement: dry mouth, difficulty swallowing, limited mouth opening. One GPG gives recommendations on the preventive and curative treatment of oral and dental complications.

Other gastro-intestinal problems are reflux, vomiting, abdominal pain and distension, weight loss and nutritional problems (such as malnutrition), diarrhoea, incontinence and constipation. One CPG proposes a technical calculation to guide medical doctors in the diagnosis and treatment of gastro-intestinal manifestations. Another one provides a practical approach to manage malnutrition, including:

  1. screening and evaluation of malnutrition based on their clinical history, physical examination, questionnaires, blood tests and breath tests;
  2. interventions to diagnose and to pharmacologically (and non-pharmacologically) treat patients in whom malnutrition is expected; and
  3. how to evaluate and follow-up malnutrition in SSc patients.

List of references

Heart & Lungs

Heart & Lung

The lungs can be seriously involved in SSc patients. In interstitial lung disease, normal lung tissue becomes fibrotic and breathing becomes difficult. Very recently, one guideline has been published on the identification and management of this complication. It suggests to perform a high-resolution computed tomography at baseline in all SSc patients to identify the presence of interstitial lung disease and to regularly perform pulmonary function tests both as a screening method and for the monitoring of progression. Of note, this guideline states that the treatment should depend on the severity of the disease (which can be seen on high-resolution computed tomography).

Another complication is the pulmonary arterial hypertension, the rise in the blood pressure of the pulmonary artery (the big blood vessel that transports the blood to the lungs). Pulmonary arterial hypertension can cause the heart to overload as it needs to pump harder to push the blood through the blood vessels. As a result, the pumping function of the heart can be insufficient (heart failure), can beat too fast (tachycardia) or too slow (bradycardia). In some cases, inflammation of the tissues around the heart (pericarditis) or of the heart muscle (myocarditis) can occur.

Three guidelines were found on the management of this complication. Two of them recommend to perform ultrasound of the heart (echocardiography) as a screening test in patients with no symptoms, followed by yearly echocardiography, lung function and blood tests. Other guidelines give recommendations about how and when to perform an examination (catheterisation) to make a diagnosis of pulmonary arterial hypertension in patients affected by systemic sclerosis.

One guideline suggests a practical approach to manage heart involvement.
Three major steps are outlined:

  • identification of warning signs;
  • investigation of the risk to develop heart involvement;
  • treatment of heart disease with medication or implantation of devices.

Another guideline gives recommendations on when and how to use cardiac magnetic resonance imaging to diagnose heart diseases.

List of references

Kidney

Kidney involvement

Kidneys involvement may lead to an acute loss of their function. This acute deterioration is called scleroderma renal crisis, and a first sign is the sudden increase of the systolic blood pressure (the first number) or the occurrence of severe hypertension (i.e. blood pressure higher than 150/85 mmHg).

One CPG highlights the early identification, diagnosis and prompt treatment of scleroderma renal crisis, recommending twice weekly blood pressure monitoring at home as a screening test in all SSc patients with diffuse skin involvement in the first 4 years of diagnosis. A combination of sudden onset hypertension, blood test and findings in urine tests pointing to kidney serious involvement and the results of kidney biopsy might result in a diagnosis of scleroderma renal crisis. An acute treatment with blood pressure control in highly experienced centres is recommended.

List of references

Stem cell

Haematopoietic stem cell transplantation

Highly specialized treatment possibilities have been advised in separate CPGs. Three of them regard the use of haematopoietic stem cell transplantation (HSCT). One recommends that HSCT should be considered as an alternative therapy for SSc, especially regarding lung involvement, in patients without severe heart or gastro-intestinal involvement. Moreover, a guideline states that “HSCT should be considered for the treatment of selected patients with rapidly progressive SSc at risk of organ failure”. Two CPGs have been published to reduce the possible toxic side-effect of HSCT on the heart muscle and its high risk of early treatment-related mortality. The most recent guideline additionally recommends investigating the lungs and digestive system. This recommendation applies to patients under 65 years of age, with a disease duration of less than 5 years and who have fast evolving diffuse skin involvement with no symptoms of pulmonary arterial hypertension.

List of references

ribbon

Cancer

Some SSc patients have a higher risk to develop cancers, especially those with a particular type of SSc-specific (serum) (auto-) antibodies (i.e. anti-RNA polymerase III antibodies).

One guideline suggests to screen for cancers at the time of diagnosis of SSc with a special focus on breast cancer. Cancer tests should preferably be performed using non-invasive tools with the lowest possible dose of radiation such as mammography, ultrasonography, magnetic resonance imaging, occurrence of blood in stool samples, blood tests or positron emission tomography scan. Regular tests for cancer are recommended in the first 2 to 5 years of SSc diagnosis with anti-RNA polymerase III antibody positivity.

List of references

Clinical trials

Clinical trials

Clinical trials are scientific studies or experiments that investigate new methods to screen, diagnose, treat or prevent diseases.

At the time of analysis, three CPGs give recommendations on the design of future clinical trials in SSc, one focusing on future clinical trials in SSc patients in general, the other in patients with lung disease and the third one in patients with Raynaud’s Phenomenon.

Of note, recently, eight guidelines have been published that advise how to set up clinical trials investigating the following topics in SSc patients: quality of life, joint inflammation, digestive tract problems, heart and lung problems, musculoskeletal involvement, finger wounds and kidney involvement.

List of references

Unmet needs

Unmet needs

This is the first manuscript that identifies, evaluates and summarizes existing CPGs for the management (diagnosis, monitoring and treatment) of SSc patients. Moreover, it is the first manuscript that identifies gaps in the management of SSc patients from both patients’ and doctors’ perspective.

1. Gaps in the management of SSc patients from the patients’ perspective

Ilaria Galetti, the patient representative who represents the voice of the European SSc patients, collected from the European community, points out gaps in the management of SSc patients from the patients’ perspective.

The name of the disease creates uncertainty among SSc patients, as “sclerosis” can be confused with multiple sclerosis and as systemic sclerosis and scleroderma are often interchangeably used in literature. Another uncertainty for SSc patients exists due to a lack of harmonization of treatment amongst healthcare providers and amongst different treatment centres (e.g. patients from different places receive different therapeutic procedures, dosages or treatment duration). Moreover, do health care systems not always provide a reimbursement for some crucial and fundamental therapies (e.g. psychotherapy and physiotherapy). Of note do patients experience a limited access to uniform information as there are only a limited number of trained professionals who are fully aware of the currently existing guidelines.

Some disease related manifestations, such as loss of physical mobility and hand function as well as pain, imply a heavy burden and can make patients feel lonely in carrying their disease. This can lead to a major deterioration of the health-related quality of life of SSc patients. At present, no clinical practice guidelines exist that advise on how to improve the health-related quality of life of SSc patients using non-medicinal treatment (e.g. psychological, educational or physical therapy). The “Scleroderma Patient centred Intervention Network”, an organisation of researchers, health care providers and people living with SSc from around the world, was established to address this need.

Another important gap is the fact that SSc patients are not included in the development of the patient reported outcome measures for clinical trials in SSc. These are health outcomes directly reported by the patient who experienced them and they are useful to provide a better understanding of the condition from a patient’s perspective.

Last but not least, SSc patients experience that the impact of their disease on their daily life (loss of self-esteem due to facial changes, fatigue, sexual dysfunction, job related problems, feeding and relational problems) is underestimated in the global population, due to a lack of knowledge of the disease. 

2. Gaps in the management of SSc patients from doctors’ perspectiv

Finally, the ERN ReCONNET SSc scientific team (Marco Matucci-Cerinic and Vanessa Smith) summarized gaps in the management of SSc patients from doctors’ perspective.

High quality CPGs that focus on the entire management of each possible SSc-related organ involvement or damage are lacking. This could provide access to uniform management of SSc patients on a national and/or international level.

Although some research projects are being performed (i.e. development of criteria to assess the scleroderma renal crisis or a standardized definition for finger wounds), yet the ideal use of high-resolution computed tomography in SSc patients and the role of steroids in SSc patients still need to be explored. In addition, although there are criteria in literature, no clinical practice guidelines exist for the very early and early diagnosis of SSc, nor to definitely diagnose SSc. Their existence, however, would ensure an early referral to tertiary centres and a better management.

It should also be noted that nailfold videocapillaroscopy is an important tool to early detect those patients with Raynaud’s Phenomenon who will develop SSc. As such, the performance and interpretation of nailfold videocapillaroscopy need to be standardized. Of note it should be interesting to standardise SSc-specific investigational techniques (e.g. antibody assays for SSc-specific antibodies). This may further help to definitively reach an agreement on the standardized evaluation of SSc patients.

List of references

KEY

CPGs Clinical Practice Guidelines
ePAGs European Patient Advocacy Groups
ERN ReCONNET European Reference Network on Rare and Complex Connective Tissue and Musculoskeletal Diseases
HSCT Haematopoietic stem cell transplantation
SSc Systemic Sclerosis
Subscribe to our Newsletter