The changing incidence of rheumatoid arthritis over time in north-west Greece: data from a referral centre.

OBJECTIVE: Rheumatoid arthritis (RA) is a chronic inflammatory disease of unknown aetiology that affects approximately 1% of the population. The disease presents a temporal variability in different geographic areas. We investigated RA incidence over a 40-year-period in a defined area of north-west Greece, with a total population of about 400 000 inhabitants. METHOD: This incidence study was based on retrospective review of clinical records among adults with RA newly diagnosed from 1980 to 2019 at the referral university hospital of Ioannina. An incident case was defined as any patient diagnosed with RA based on the 1987 American College of Rheumatology criteria, over 16-years-old, and resident in the study area for at least 1 year before diagnosis. RESULTS: Out of 1411 cases diagnosed, women constituted a 2.65-fold higher number than men, with a lower mean age at diagnosis. The overall age-adjusted annual incidence rate (95% confidence interval) was 9.5 (8.5-10.5) for the total observation period, 11.7 (10.7-13.0) in 1980-1989, 10.4 (9.4-10.8) in 1990-1999, 9.8 (8.9-10.8) in 2000-2009, and 6.1 (5.3-6.9) in 2010-2019, presenting a statistically significant decline over time, along with a constant decrease in rheumatoid factor (RF)-positive incidence for both sexes. CONCLUSION: Our findings suggest a decrease in the incidence of RA over 40 years in a geographically defined Greek population. Also, the progressive decrease in the incidence of RF-positive disease may relate to less severe expression of RA in Greek patients. These trends could be explained by different clinical, serological, and genetic factors reported in Greece compared to northern European countries.

The effects of biologic agents on cardiovascular risk factors and atherosclerosis in rheumatoid arthritis patients: a prospective observational study.

We aimed to evaluate the impact of biologic treatment on subclinical atherosclerosis and risk factors for cardiovascular disease (CVD) in patients with rheumatoid arthritis (RA). Forty-nine biologic naïve RA patients, treated with conventional synthetic disease-modifying anti-rheumatic drugs (csDMARDs), who were eligible for treatment with a biologic agent, were included in the study. The serum levels of lipid parameters, as well as disease activity parameters were determined in RA patients before and after 3 and 6 months of therapy. Carotid artery intima-media thickness (cIMT) was measured before and after treatment. A comparison analysis of change of these parameters was also performed between anti-tumor necrosis factor (anti-TNF) and non-anti-TNF users. Furthermore, 31 non-smoking healthy volunteers, matched for age and gender, were used as a control group. At baseline, RA patients had a decrease in serum total cholesterol (TC) and high-density lipoprotein cholesterol (HDL-C) levels compared with controls (209 ± 63 vs 233 ± 44 and 58 ± 15 vs 61 ± 14, p < 0.004), while cIMT was higher versus controls [0.9 (0.8-1) vs 0.6 (0.5-0.7), p < 0.001]. TC, HDL-C and apolipoprotein A1 levels were significantly increased 3 months after treatment (209 ± 63, 58 ± 15, 162 ± 32, vs 227 ± 45, 60 ± 15, 169 ± 29, respectively, p < 0.03) and this observation remained stable at a 6-month follow-up. After 6 months, there was also a statistically significant decrease in the cIMT [0.9 (0.8-1) vs 0.7 (0.6-0.8), p < 0.001]. Anti-TNF and non-anti-TNF users had comparable changes in cardiovascular risk parameters. The atherogenic lipid profile and subclinical atherosclerosis are features of RA, which appeared improved after biologic therapy initiation.

TNFα inhibitor biosimilars associated with alopecia areata. Case-based review.

Alopecia areata (AA) is a common non-scaring hair loss associated with many inflammatory and autoimmune disorders. Anti-tumor necrosis factor alpha (TNFα) therapy is used to treat many chronic inflammatory disorders and has been proven to be effective and relatively safe. However, several immune-mediated skin reactions have been described with the use of TNFα inhibitors, among them AA. In this report, we describe two patients, a 32-year-old woman with ankylosing spondylitis and a 48-year-old man with rheumatoid arthritis who were both treated with SB4 (Benepali®), an etanercept biosimilar, and developed AA, 6 and 12 months respectively after the initiation of TNFα blocker biosimilar. These, are the first two cases of AA development during TNFα inhibitors biosimilar. Thus, physicians when dealing with patients treated with these agents, should be aware of possible immune skin reactions, among them AA. To this end, a close follow-up and monitoring is mandatory.

Fibroblastic rheumatism: an uncommon arthritis. A case-based review.

Fibroblastic rheumatism (FR) is an uncommon disease of the skin, characterized by the presence of non-tender cutaneous nodules accompanied often by other rheumatic manifestations. This condition shows male predominance, no age preference and unpredictable course, resulting frequently in permanent joint damage. A 60-year-old man came to our department with a 4-year history of multiple non-tender nodules and morning stiffness affecting mainly the upper extremities. Clinical examination revealed arthritis of the hands, confirmed by imaging tests. Laboratory exams were unremarkable. A skin nodule biopsy showed a dermal collagenous lesion with myxoid areas composed of spindle and stellate cells. Immunohistochemical staining demonstrated positivity for CD68 and negativity for CD34, S100, EMA and desmine. FR was diagnosed and the patient started methylprednisolone 16 mg/day. Hydroxychloroquine 400 mg/day and methotrexate 15 mg/weekly were further added as steroid-sparing agents with clinical benefit. Clinicians should be aware of this underreported entity, which can rapidly lead to irreversible deformities.

Occupational mimics of rheumatoid arthritis: hair dye-induced arthritis.

Hair dye (HD) and its component para-phenylenediamine (PPD) are commonly used to enhance beauty and youth. HD is associated with allergic contact reactions and the development of autoimmune phenomena. A 28-year-old woman presented to us complaining of pain and swelling affecting the small joints of the hands bilaterally lasting for 7 weeks. Laboratory evaluation was remarkable only for an increase of acute-phase reactants, while the rest of laboratory tests including serological tests for viruses, as well as immunological tests were negative or within normal limits. She noticed a close correlation between the onset of symmetrical polyarthritis and the use of HD product. Thus, after excluding other possibilities of inflammatory arthritides, the diagnosis of HD-induced arthritis was made. The patient was treated with naproxen, and after 3 weeks, she had a complete clinical response with decrease of acute-phase reactants. Thus, we review and discuss the relevant literature of cases related with the use of HD and arthritis development. This is the first described case of HD-induced arthritis. Physicians must be aware and recognize these symptoms and signs of patients exposed to HD and treat them appropriately.

Certolizumab for rheumatoid arthritis.

This is a review of the pharmacology of certolizumab pegol and its efficacy and safety in the treatment of patients with rheumatoid arthritis refractory to synthetic disease-modifying anti-rheumatic drugs (DMARDs). Certolizumab is a new anti-TNF-α biologic agent injected subcutaneously with an innovative molecular structure and unique pharmacodynamic and pharmacokinetic properties. Data from controlled clinical trials indicate that the drug is effective in reducing disease activity and disability. It also inhibits radiographic progression. Certolizumab administration has an acceptable safety profile. The clinical data available suggest that the nature of adverse events is generally comparable to that of other TNF-α blockers. Given its rapid onset of action certolizumab presents an attractive alternative therapeutic option for patients with moderate to severe RA refractory to DMARDs.

Antibodies against oxidized LDL and atherosclerosis in rheumatoid arthritis patients treated with biological agents: a prospective controlled study.

OBJECTIVES: The aim of this study was to investigate the relation among atherosclerosis, antibodies against oxidized LDL (anti-oxLDL), and inflammation in rheumatoid arthritis (RA) patients treated with biological (b) disease-modifying anti-rheumatic drugs (DMARDs). METHODS: Fifty-nine patients who were receiving conventional synthetic DMARDs and were eligible for treatment with a biological agent were included in the study. Total cholesterol (TC), triglycerides (TG), high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), and IgG antibodies against oxidized LDL (anti-oxLDL) as well as carotid intima-media thickness (cIMT) were determined before and after 6 months of treatment. Thirty-one healthy individuals were used as a control group. RESULTS: At baseline, RA patients had lower TC and HDL-C levels and increased cIMT compared to controls. After a 6-month follow-up, the re-evaluation of carotids revealed a statistically important decrease of cIMT values. This observation was accompanied by a statistically important elevation of HDL-C levels and a reduction of the titer of anti-oxLDL antibodies regardless of the bDMARD that was administered. No statistically significant association was found between the cIMT and anti-oxLDL, HDL-C, CRP, or DAS28 score neither before nor 6 months after treatment using linear regression analyses adjusted for age and gender. CONCLUSIONS: We provide evidence that atherogenic lipid profile and ongoing atherosclerosis which characterize RA patients appear to improve after biological therapy, and we also suggest a possible atherogenic effect of IgG anti-ox LDL antibodies.

Altered sequence of the ETS1 transcription factor may predispose to rheumatoid arthritis susceptibility.

OBJECTIVE: ETS1 belongs to the ETS family of transcription factors that regulate the expression of various immune-related genes. The aim of this study was to identify whether the ETS1 single nucleotide polymorphism (SNP) rs11221332, described in Caucasian subjects, plays a role in rheumatoid arthritis (RA) susceptibility. METHODS: We genotyped this polymorphism in 136 unrelated patients with RA and 147 healthy individuals with no history of autoimmune disease. Genotyping was performed with a polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) assay and the data were analysed using SPSS statistical software. RESULTS: A statistically significant difference was observed in the distribution of the rs11221332 genotypes between RA patients and controls (p = 0.041). Comparing the distribution of rs11221332 alleles between the groups studied, a greater difference was found [odds ratio (OR) 1.504, 95% confidence interval (CI) 1.036-2.183; p = 0.039]. CONCLUSIONS: The present study revealed, for first time, the positive association of a polymorphism in the sequence of the ETS1 transcription factor with RA susceptibility. Further studies in other ethnic groups of patients are needed to confirm the results of the present genetic association study related to ETS1, a widely used transcription factor in the regulation of the expression of various genes.

Effects of 12 months of treatment with disease-modifying anti-rheumatic drugs on low and high density lipoprotein subclass distribution in patients with early rheumatoid arthritis: a pilot study.

OBJECTIVES: Patients with rheumatoid arthritis (RA) have increased cardiovascular risk. The aim of the present study was the assessment of low density lipoprotein (LDL) and high density lipoprotein (HDL) subclass distribution in patients with early RA (ERA, n = 30) compared with age- and sex-matched healthy subjects (n = 30), as well the effect of treatment for 12 months with the disease-modifying anti-rheumatic drugs (DMARDs) methotrexate and prednisone in this distribution. METHOD: LDL and HDL subclass distribution was determined using a polyacrylamide gel-tube electrophoresis method. RESULTS: ERA patients exhibited increased levels of inflammatory markers and high disease activity score. ERA patients had higher serum levels of total cholesterol (TC), LDL cholesterol (LDL-C), and triglycerides (TG) whereas their serum HDL cholesterol (HDL-C) levels were significantly lower compared with controls. ERA patients exhibited significantly higher plasma levels of small dense LDL-C (sdLDL-C), leading to a significantly decreased mean LDL diameter. ERA patients had significantly decreased small HDL particles (HDL-3) concentration whereas serum levels of large HDL particles (HDL-2) did not differ compared with controls. Treatment with DMARDs resulted in a significant decrease in inflammatory markers and disease activity, along with a significant increase in HDL-C serum levels. The concentration of sdLDL-C did not change significantly during treatment. We observed a significant increase in the levels of large HDL-2 whereas the concentration of small HDL-3 did not significantly change. CONCLUSIONS: Patients with ERA have increased sdLDL-C levels and decreased HDL-C levels because of decreased concentration of the small HDL-3 subclass. The administration of DMARDs induced a significant increase in HDL-C levels, which was attributed to the increase in large HDL-2 serum concentration.

Effect of very early treatment in rheumatoid arthritis on bone oedema and synovitis, using magnetic resonance imaging.

OBJECTIVE: To evaluate the magnetic resonance imaging (MRI) findings of hand involvement before and 1 year after treatment in patients with early rheumatoid arthritis (RA). METHOD: MRI of the dominant hand was performed in 22 patients fulfilling the new criteria for early RA. The patients were divided into three groups. Nine had very early RA (VERA; disease duration < 3 months), seven had early RA (ERA; disease duration < 6 months), and six had established RA (ESTRA; disease duration > 12 months). The MRI protocol consisted of fat-suppressed T2, and plain and contrast-enhanced T1-weighted sequences. Assessment of bone marrow oedema, synovitis, and bone erosions was performed by the OMERACT RA MRI scoring system. Patients were treated with methotrexate (MTX) 0.2 mg/kg/body weight/week and prednisone 7.5 mg/day. Clinical assessment was evaluated using the Disease Activity Score for 28 joint indices (DAS28). RESULTS: After treatment, a significant decrease was observed: (a) in DAS28 of VERA (6.2 ± 0.9 vs. 2.4 ± 1.2), ERA (5.3 ± 0.8 vs. 2.8 ± 1.0), and ESTRA patients (5.7 ± 8.0 vs. 2.7 ± 0.7; p < 0.05); (b) in bone oedema (16.77 ± 13.78 vs. 5.88 ± 6.31) and synovitis (12.44 ± 6.44 vs. 2.88 ± 3.25) of VERA patients; and (c) in synovitis (7.57 ± 6.32 vs. 1.42 ± 1.81) of ERA patients (p < 0.05). No significant difference was found in erosions in any group. CONCLUSION: Bone marrow oedema and synovitis decrease significantly when RA is diagnosed and treated early. MRI is useful in the early detection of these changes. MTX treatment resulted in a significant decrease in DAS28 score and significant improvement in bone oedema and synovitis.

Survival of TNF-alpha antagonists in rheumatoid arthritis: a long-term study.

OBJECTIVES: To investigate the efficacy, safety and survival of tumour necrosis factor (TNF) α antagonists in patients with rheumatoid arthritis (RA). METHODS: One hundred and fifty-one RA patients treated with TNF-α inhibitors during the time period 2000 to 2009 were studied. Kaplan-Meier statistic analysis was applied, in which discontinuation from anti-TNF-α therapy was used as the terminal event. RESULTS: Eighty-two patients received infliximab, 49 adalimumab and 20 etanercept: they were followed up over 7, 5 and 4 years, respectively. Anti-TNF-α therapy resulted in a rapid clinical improvement associated with a reduction in inflammatory markers in the first year of the treatment, which was sustained throughout the following years. Ninety (59.6%) patients were withdrawn during the observational period overall. The patients who discontinued infliximab, adalimumab and etanercept therapy were 55/82 (67.1%), 27/49 (55.1%) and 8/20 (40%) respectively. The main reasons for discontinuation were drug adverse events and inefficacy. According to Kaplan-Meier methods, the 'survival rate' of infliximab after the first year of treatment reached 82.9%, while after 7 years the proportion was 32.9%. With regard to adalimumab, after the first year of treatment its 'survival rate' was 83.7% and after 5 years it reached 44.9%. As far as etanercept is concerned, after the first year of treatment, the 'survival rate' reached 70% and after 4 years it remained 60%. CONCLUSIONS: TNF-α antagonists constitute an effective therapeutic option for patients with RA refractory to disease-modifying anti-rheumatic drugs. They demonstrate an acceptable safety profile. Their survival rate is high in the first years of treatment, while after the fifth year it decreases considerably.

Coping with health-stressors and defence styles associated with health-related quality of life in patients with systemic lupus erythematosus.

This study aimed to assess the association of coping with health-stressors and defence styles with health-related quality of life (HRQOL) in systemic lupus erythematosus (SLE). In 56 SLE patients we assessed disease activity (SLEDAI), functional limitations (HAQ), psychological distress (SCL-90-R), defence styles (Defence Style Questionnaire), hostility (HDHQ), coping with health-stressors (Sense of Coherence scale) and HRQOL (WHOQOL-BREF). Two hundred and eight rheumatologic patients (168 with rheumatoid arthritis [RA] and 40 with primary Sjögren's syndrome [SS]) served as disease controls. SLE patients' HRQOL was similar to that of patients with RA and primary SS after adjusting for demographic and disease variables. Psychological distress was significantly associated with most aspects of HRQOL, but sense of coherence mediated the relationship of psychological distress with Physical HRQOL; this mediation effect was unique to SLE, as mediation analyses showed. Maladaptive action defence style was also significantly associated with Environment HRQOL independently of psychological distress (p < 0.024). These findings indicate that, apart from the early assessment and treatment of psychological distress, clinicians and consultation-liaison psychiatrists should bear in mind the SLE patients' psychological resources and coping capacities to deal with the stress of the disease, since such traits, although usually underestimated, are strongly independently associated with HRQOL.

The psychological defensive profile of primary Sjögren's syndrome patients and its relationship to health-related quality of life.

OBJECTIVES: We aimed to assess the defensive profile of primary Sjögren's syndrome (SS) patients and to investigate the independent associations of psychological distress and personality variables with health-related quality of life (HRQOL). METHODS: In 40 primary SS patients we assessed psychological distress (SCL-90-R), ego defense mechanisms (Defense Style Questionnaire), hostility features (HDHQ) and HRQOL (WHOQOL-BREF). Fifty-six patients with Systemic Lupus Erythematosous (SLE) and 80 healthy participants matched for age and sex served as controls. RESULTS: Primary SS patients presented higher rates of general psychological distress compared to SLE and healthy participants. Symptoms of somatisation were more prominent in SS than SLE or healthy controls. SS patients presented less use of humour defense and more help-rejecting complains and delusional guilt hostility, compared to controls. Primary SS patients' HRQOL was more impaired than healthy participants and comparable to SLE. Psychological distress was a constant independent correlate of SS patients' HRQOL, while less use of humour (p<0.001) and higher rates of delusional guilt (p=0.032) were also significantly associated with Physical HRQOL independently of psychological distress; more use of schizoid fantasy was also independently associated with impaired Environment HRQOL (p=0.005). CONCLUSIONS: Primary SS patients exhibit several specific psychological difficulties in adaptation to life stressors, and clinicians and consultation-liaison psychiatrists, apart from the early assessment and treatment of psychological distress and somatisation symptoms, should consider the patients' underlying defensive profile and coping capacities, since such personality traits, although usually underestimated, are also independently associated with the disease outcome.

Obesity, adipose tissue and rheumatoid arthritis: coincidence or more complex relationship?

In the last two decades we have witnessed a boost in scientific interest and knowledge of adipose tissue biology to such an extent that it was promoted to an active endocrine organ. Adipose tissue is not just related to body weight and appetite regulation. It is also implicated in obesity, a low-grade inflammatory state, as well as inflammatory conditions including rheumatoid arthritis (RA), an autoimmune disease where anti- and pro-inflammatory cytokine balance is critical. All major adipose derived products, simply termed adipokines, like leptin, adiponectin, visfatin and resistin, reportedly participate in inflammation and immunity. In this review we explore in depth the relationship between adipose tissue and RA, with focus on possible mechanisms, beyond observations about circulating or synovial levels, and special reference to future perspectives and clinical implications.

Outcome of refractory to conventional and/or biologic treatment adult Still's disease following canakinumab treatment: Countrywide data in 50 patients.

OBJECTIVE: To assess the efficacy and safety of the IL-1b inhibitor canakinumab in all adults with refractory Still's disease identified from the National Organization For Medicines for off-label drug use. METHODS: In a retrospective longitudinal multicenter cohort of 50 patients (median age 39 years) with active Still's disease despite treatment with corticosteroids (n = 11), conventional and synthetic (n = 34) and/or biologic disease modifying anti-rheumatic drugs (n = 30), we assessed the efficacy of canakinumab 150-300 mg administered every 4 (n = 47) or 8 weeks (n = 3) as combination therapy or monotherapy (n = 7) during a median follow-up of 27 (3-84) months. RESULTS: Α complete response was initially observed in 78% of patients within 3 months (median), irrespective of age at disease onset. A partial response was evident in 20%. One patient had resistant disease. Treatment de-escalation was attempted in 15 of 39 complete responders and a complete drug discontinuation in 21 patients for 8 months (median). Eleven patients (22%) relapsed during treatment, one during de-escalation process, and 11 after treatment discontinuation. Overall, 9 of 11 relapses were successfully treated with canakinumab treatment intensification or re-introduction. At last visit, 18% of patients were off treatment due to remission and 26% due to disease activity. Canakinumab had a significant corticosteroid sparing effect allowing weaning in 21 of 41 cases. Infections (20%, severe 4%) and leucopenia (6%) led to treatment cessation in one patient. CONCLUSION: High rates of sustained remission were observed in this, largest so far, real-life cohort of adult patients with refractory Still's disease treated with canakinumab.

The role of microRNA-146a (miR-146a) and its target IL-1R-associated kinase (IRAK1) in psoriatic arthritis susceptibility.

MicroRNAs have shown different expression patterns in immune diseases. The present study explores the association of miRNA-146a variant rs2910164 and of two IRAK1 (target of miR-146a) polymorphisms rs3027898 and rs1059703 with psoriasic arthritis (PsA). Twenty-nine PsA and 66 controls were enrolled in the study. To study if the statistical significant differences between patients with PsA and controls are independent to psoriasis, we expanded the study in 49 patients with ankylosing spondylitis (AS). Strong statistical significant difference was observed in IRAK1 rs3027898 polymorphism distribution between patients with PsA and controls (P = 0.003), as between patients with AS and controls (P < 0.001). Marginally significant difference was observed in distribution of IRAK1 rs1059703 genotypes between patients with PsA and controls (P = 0.058), but no difference was observed in miRNA-146a rs2910164 distribution (P = 0.394). This is the first study that addresses IRAK1 rs3027898 polymorphism association with PsA susceptibility, but further studies could help to understand the extent of the proposed association.

Leptin and adiponectin levels in patients with ankylosing spondylitis. The effect of infliximab treatment.

BACKGROUND: Adipose tissue-derived leptin and adiponectin control hunger, energy expenditure, insulin sensitivity, endothelial function, reproduction and immunity and are thought to play a role in autoimmune diseases. However, their role in ankylosing spondylitis (AS) is not clearly defined. Tumour necrosis factor ΤNF-α is a potential modulator of adipocytokines. The effect of longterm anti-TNF-α treatment on plasma levels of leptin and adiponectin has not been assessed so far. OBJECTIVES: To assess the effect of a 6-month anti-TNF-α treatment on serum leptin and adiponectin levels in AS patients. METHODS: Thirty men with AS were included in the study. Thirty age- and weight-matched men served as controls. Clinical and biochemical parameters were assessed and serum levels of leptin and adiponectin were measured with enzyme immunoassay methods prior to and after the 6-month treatment with infliximab. RESULTS: Mean age and disease duration of AS patients were 40.6±13.7 and 13.4±8.4 years, respectively. At baseline, AS patients exhibited significantly higher adiponectin (15.4±8.3 vs. 8.6±4.2 µg/ml, p<0.05), but no difference in leptin levels (7.2±2.9 vs. 8.9±6.4 ng/ml, p=NS). Adipocytokines did not correlate with any disease parameter. Body weight of the patients did not change significantly over the 6-month period. Serum levels of leptin and adiponectin did not change significantly after the 6-month treatment. CONCLUSIONS: Adiponectin levels were significantly higher in AS patients compared with controls. Infliximab treatment did not change serum levels of leptin and adiponectin suggesting that the anti-TNF-α treatment may not modulate significantly their levels.

Treatment modalities and drug survival in a systemic sclerosis real-life patient cohort.

BACKGROUND: European data indicate that systemic sclerosis (SSc)-related death rates are increasing, thus raising concerns about SSc's optimal management. Herein, we describe current treatment modalities and drug survival in a real-life SSc cohort. METHODS: Details on immunosuppressive/antiproliferative (methotrexate, mycophenolate, cyclophosphamide, azathioprine, rituximab, tocilizumab) and vasoactive agent [(endothelin receptor antagonists (ERAs), sildenafil, iloprost, and calcium channel blockers (CCB)] administration during the disease course (11.8 ± 8.4 years, mean + SD) of 497 consecutive patients examined between 2016 and 2018 were retrospectively recorded. Drug survival was assessed by Kaplan-Meier analysis. RESULTS: Methotrexate was the most frequently administered immunosuppressive/antiproliferative agent (53% of patients), followed by cyclophosphamide (26%), mycophenolate (12%), and azathioprine (11%). Regarding vasoactive agents, CCB had been ever administered in 68%, ERAs in 38%, iloprost in 7%, and sildenafil in 7% of patients; 23% of patients with pulmonary fibrosis had never received immunosuppressive/antiproliferative agents, 33% of those with digital ulcers had never received ERAs, iloprost, or sildenafil, whereas 19% of all patients had never received either immunosuppressive/antiproliferative or other than CCB vasoactive agents. Survival rates of methotrexate, cyclophosphamide, and mycophenolate differed significantly, being 84/75%, 59/43%, and 74/63% at 12/24 months, respectively, with inefficacy being the most frequent discontinuation cause. Conversely, CCB, ERAs, and sildenafil had high and comparable retention rates of 97/91%, 88/86%, and 80/80%, respectively. CONCLUSIONS: Existing therapeutic limitations indicate that more evidence-based treatment is warranted for successful management of SSc. Vasculopathy seems to be managed more rigorously, but the low retention rates of immunosuppressive/antiproliferative drugs suggest that effective and targeted disease-modifying agents are warranted.