Autoimmunity Reviews 10 (2011) 653–654

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Autoimmunity Reviews

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Refractory disease in autoimmune diseases☆

Carlos Vasconcelos a,⁎, Cees Kallenberg b, Yehuda Shoenfeld c

a Centro Hospitalar Porto, Hospital Santo António, Unidade de Imunologia Clinica and UMIB, Instituto Biomedicas Abel Salazar, Porto, Portugalb Department of Rheumatology & Clinical Immunology, AA21 University Medical Center Groningen, University of Groningen, The Netherlandsc Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center (Affiliated to Tel-Aviv University) Tel-Hashomer 52621, Israel

☆ Disclosures: Carlos Vasconcelos received consultaMyers Squibb, MSD.⁎ Corresponding author. Tel.: +351 222077500; fax:

E-mail address: cvcarlosvasconcelos@gmail.com (C.

1568-9972/$ – see front matter © 2011 Elsevier B.V. Aldoi:10.1016/j.autrev.2011.04.026

a b s t r a c t

a r t i c l e i n f o

Available online 17 May 2011

Refractory disease (RD) definition has different meanings but it is dynamic, according to knowledge and theavailability of new drugs. It should be differentiated from severe disease and damage definitions and it musttake into account duration of adequate therapy and compliance of the patient. It can be related to inadequateor inefficacious treatment or to pathogenesis. RD definition has multiple implications to clinical guidelinesand to the use of off-label drugs. It should not be regarded as lost cases and prospective studies, registries andclinical trials should be planned.

tion fees from Roche, Bristol

+351 220900633.Vasconcelos).

l rights reserved.

© 2011 Elsevier B.V. All rights reserved.

1. Introduction

The indication of refractory disease (RD) has been used in severalmedical settings although with different meanings.

RD is usually defined as an absence of response to the standardtherapy, where its definition is dependent on factors external to thedisease itself. RD should not be confused with high severity of thedisease. The latter is able to respond to a standard therapy, usuallywith a combination of the most efficient drugs. The question, not yetanswered to the best of our knowledge, is: do cases with a highseverity disease have a greater chance of developing RD whencompared with patients with low severity disease? The answer is noteasy because patients with severe disease are treated intensively,hence masking their natural history; the opposite can happen withpatients with low disease activity not being treated which may allowfor the development of RD.

It is the time to define what RD in autoimmune diseases (AID) is,not only because we are using this terminology more and more, butalso because it has multiple implications, namely in terms of clinicalguidelines, the use of off-label drugs and perhaps immunopathogen-esis. As new therapeutics, new immunological knowledge and newdefinitions are coming up, we should be careful when comparingclinical series.

There are multiple ways to reach the point of having “so-called”RD: cases related to inadequate or inefficacious treatment, includingthose due to late access to the physician, lack of patient's complianceor tolerability, and those which may be related to the pathogenesis

itself. Inadequate treatment can generate an RD. Diseases have awindow of opportunity for optimal treatment and, although there areno absolute well-defined rules in AID therapeutics, there are standardtreatments. Therefore, a lack of treatment with the right drug(s) in anadequate sequence and dosage can lead to an RD state.

Inefficient treatment is one way that fails to reach the desiredclinical endpoint. We know that when describing endpoints to thesuccess of therapy there is a lot of variability — complete or partialremission, absence of response, disease relapse, etc.— leading authorsto define RD according to different definition criteria of response tothe treatment. An important factor in defining RD is the minimumtime we should wait under therapy to consider the case to be an RD.On the other hand, if there is no effective treatment for an organmanifestation, this would necessarily correspond to RD.

Regarding the relation between RD and pathogenesis, we knowfrom many other diseases that there are more and less aggressivepatterns of the disease. For example, in HIV infection there are long-term survivors, reflecting differences in susceptibility/resistance inthe relationship between the host and the virus [1]. Does RD reflect anevolution in immunopathogenesis? Does it mean changing patterns ofthe autoimmune response? or new targets for autoimmune response?(i.e. different viruses may induce different patterns of disease likewith EBV and SLE [2])?

RD is usually a consequence of current therapeutic guidelines,which means that the definition of RD is dynamic: a disease classifiedas RD at a specific moment can later be classified differently as newmore effective treatment guidelines come out. RD is a non-returnsituation without aggressive and frequently off-label therapy, exclud-ing spontaneous relief of the disease.

RD corresponds to the absence of response to treatment guidelinesat a specific time, but can respond to off-label therapies. This indicatesa distinction between “primary RD”, a conventional/legal definition ofRD — unresponsive to current guidelines or labeled therapeutics —

654 C. Vasconcelos et al. / Autoimmunity Reviews 10 (2011) 653–654

and a “secondary RD”, a clinical meaningful definition — that isunresponsive to any treatment including off-label drugs available. RDmay correspond to the absence of complete response in dysfunction ofsome organ or some diseases, such as in Pemphigus where theimpossibility to obtain a complete response is an unacceptableimpairment of the patient's quality of life, although not in otherdiseases, like lupus nephritis, where a partial response does not fulfillthe definition of RD. The magnitude of the clinical response totreatment, therefore, is specific to each organ and disease and itshould be included in the definition of RD.

RD definition is not a damage index. Differentiating activity of thedisease from damage is important but, if we have not been able toprevent the increase in damage with adequate therapeutics, then itcould be classified as an RD.

Refractory disease does not mean it is a lost case. It is “merely” apatient with a disease where, for the moment, known therapy is notefficient. Indeed, we should not give up trying to save our patient'slife.

RD should be the aim of prospective studies and registries. Clinicaltrials should include definition of RD and those patients who areunresponsive and whomay fit into its definition, should be part of theRD registries. They should be offered the opportunity to take part inclinical trials with new drugs.

This issue of the Autoimmunity Review is entirely dedicated to RD. Itwill discuss the definition and epidemiology in some AID, such as insystemic lupus erythematosus [3,4], systemic sclerosis [5], rheumatoidarthritis [6], vasculitis [7], myositis [8], antiphospholipid syndrome[9,10] and themanagement of RD [11], including the role of plasmadruglevels [12].

We put forward a proposal summarizing a definition of RD in AID:

a) RD corresponds to an absence of response to a standard therapy(primary RD);

b) Secondary RD corresponds to an absence of response to all therapy,including off-label drugs;

c) RD should be defined according to the criteria of response totreatment for each organ and every disease; depending on thesituation, it may be an absence of any response or an absence of acomplete response;

d) RD should be defined by taking into account the minimum timeunder therapy according to a standard therapy;

e) RD is a clinical non-return situation unless new drugs becomeavailable;

f) Intolerance to available drugs that consequently leads to thedisease being classified as an RD,

g) If there is no effective treatment to an organ manifestation, thiscorresponds to RD,

Could HLA-DRB1 genotype predict therapeutic success or failure in pat

Multiple Sclerosis (MS) is an autoimmune disease of the central nervousisolated, relapsing-remittingMS. Up of 40% of patients develop antibodiethe therapeutic effect of IFN-β. Buck D et al. (Arch Neurol 2011; 68:480patientswere included in the discovery cohort and 825 in the validation c04:01, 04:08, 16:01 and anti-IFN-β antibodies production. By contrast,antibody development. Thus, the knowledge of HLA haplotype of the pa

h) RD does not correspond to damage;i) RD may lead to an increase in damage in spite of adequate

therapies.

Exclusion criteria/reminders:

a) A high severity disease is not necessarily RD;b) A lack of therapy compliance must be checked, with determination

of serum drug levels if possible;c) Clinical situations that could imitate disease activity should be

excluded.

Take-home messages

• RD corresponds to an absence of response, any or completeresponse depending on the situation, to available therapy

• RD should be defined according to the criteria of response to thetreatment for each organ, each disease

• RD must take into account time under therapy and tolerance todrugs

• RD is a clinical non-return situation, but it is not damage• RD should not be confounded with severe disease, lack ofcompliance or other disease mimics.

References

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ients affected with Multiple Sclerosis treated with interferon-beta?

system. Interferon-beta (IFN-β) is approved as treatment of clinicallys against IFN-β, most of themwith neutralizing capacity, diminishing–7) studied 1093 patients receiving long-term IFN-β treatment, 268ohort. The authors demonstrated the association betweenHLA-DRB1alleles HLA-DRB1 03:01, 04:04 and 11:04 seem to protect againsttient might help clinicians in managing patients affected with MS.