Objective: To assess current treatment in macrophage activation syndrome (MAS) worldwide and to highlight any areas of major heterogeneity of practice. Methods: A systematic literature search was performed in both EMBASE and PubMed databases. Paper screening was done by two independent teams based on agreed criteria. Data extraction was standardized following the PICO framework. A panel of experts assessed paper validity, using the Joanna Briggs Institute appraisal tools and category of evidence (CoE) according to EULAR procedure. Results: Fifty-seven papers were finally included (80% retrospective case-series), describing 1148 patients with MAS: 889 systemic juvenile idiopathic arthritis (sJIA), 137 systemic lupus erythematosus (SLE), 69 Kawasaki disease (KD) and 53 other rheumatological conditions. Fourteen and 11 studies specified data on MAS associated to SLE and KD, respectively. All papers mentioned glucocorticoids (GCs), mostly methylprednisolone and prednisolone (90%); dexamethasone was used in 7% of patients. Ciclosporin was reported in a wide range of patients according to different cohorts. Anakinra was used in 179 MAS patients, with a favourable outcome in 83% of sJIA-MAS. Etoposide was described by 11 studies, mainly as part of HLH-94/04 protocol. Emapalumab was the only medication tested in a clinical trial in 14 sJIA-MAS, with 93% of MAS remission. Ruxolitinib was the most reported Janus kinase inhibitor in MAS. Conclusion: High-dose GCs together with IL-1 and IFNγ inhibitors have shown efficacy in MAS, especially in sJIA-associated MAS. However, the global level of evidence on MAS treatment, especially in other conditions, is still poor and requires standardized studies to be confirmed.

Current treatment in macrophage activation syndrome worldwide: a systematic literature review to inform the METAPHOR project / Baldo, Francesco; Erkens, Remco G A; Mizuta, Mao; Rogani, Greta; Lucioni, Federica; Bracaglia, Claudia; Foell, Dirk; Gattorno, Marco; Jelusic, Marija; Anton, Jordi; Brogan, Paul; Canna, Scott; Chandrakasan, Shanmuganathan; Cron, Randy Q; De Benedetti, Fabrizio; Grom, Alexei; Heshin-Bekenstein, Merav; Horne, Annacarin; Khubchandani, Raju; Ozen, Seza; Quartier, Pierre; Ravelli, Angelo; Shimizu, Masaki; Schulert, Grant; Scott, Christiaan; Sinha, Rashmi; Ruperto, Nicolino; Swart, Joost F; Vastert, Sebastiaan; Minoia, Francesca; Null, Null; Aalto, Kristiina; Mendoza, Carlos Abud; Abushhaiwia, Awatif; Ailioaie, Constantin; Akikusa, Jonathan; Aksu, Guzide; Ayaz, Nuray Aktay; Al Jashmi, Ruqaiya Nasser; Al-Abrawi, Safiya; Alessio, Maria; Alexeeva, Ekaterina; Al-Mayouf, Sulaiman M; Almutairi, Abdulaziz; Alsuweiti, Muatasem; Amalia, Rizqi; Amin, Iman; Anton, Jordi; Armbrust, Wineke; Astigarraga, Itziar; Bakkaloglu, Sevcan; Bakry, Reima; Basaran, Ozge; May, Floricely Basulto; Bathia, Jigna; Battagliotti, Cristina; Belot, Alexandre; Berg, Stefan; Beutel, Karin; Bica, Blanca; Bolt, Isabel; Boyadzhiev, Martin; Boyarchuk, Oksana; Boyko, Yaryna; Bracaglia, Claudia; Breda, Luciana; Brochard, Karine; Brogan, Paul; Brunner, Jurgen; Rivas, Segundo Bujan; Calin, Aurelia; Calzada, Joan; Lovillo, Marisol Camacho; Canna, Scott; Cannizzaro, Elvira; Caorsi, Roberta; Carlomagno, Raffaella; Cattalini, Marco; Celani, Camilla; Chan, Kwai Yu Winnie; Chandra, Sharat; Chandrakasan, Shanmuganathan; Chang, Chong U; Chasnyk, Vyacheslav; Chyzheuskaya, Iryna; Ciurtin, Coziana; Garulo, Daniel Clemente; Cochino, Alexis-Virgil; Consolaro, Alessandro; Consolini, Rita; Cron, Randy; Da Silva, Carlos Henrique M; De Benedetti, Fabrizio; De Cunto, Carmen; De Matteis, Arianna; De Somer, Lien; Dedeoglu, Fatma; Deepakbabu, Chellapandian; Del Giudice, Emanuela; Maldonado, Adriana Soraya Diaz; Dolezalova, Pavla; Dressler, Frank; Dzhus, Marta; El Miedany, Yasser; El-Ghoneimy, Dalia; Emminger, Wolfgang; Enciso, Sandra; Estmann, Anne; Etayari, Hala; Fair, Danielle; Fasshauer, Maria; Fassi, Daniel; Faugier, Enrique; Federici, Silvia; Feldman, Brian; Filocamo, Giovanni; Flato, Berit; Fluchel, Mark; Foell, Dirk; Fotis, Lampros; Frkovic, Marijan; Fuhlbrigge, Robert; Gaggiano, Carla; Gagro, Alenka; Gallizzi, Romina; Cunha, Ana Luiza Garcia; Garcia-Rodriguez, Fernando; García-Rodríguez, Fernando; Gattorno, Marco; Girschick, Hermann; Glerup, Mia; Grebenkina, Lyudmila; Guha, Suparna; Suarez, Raul Gutierrez; Ramirez, Jaime Guzman; Hadef, Djohra; Saied, Mohamad Hamad; Hashad, Soad; Hashkes, Philip (Pinchas); Hasle, Henrik; Hays, Julia Allyson; Held, Martina; Henter, Jan-Inge; Herrera, Cristina N; Heshin-Bekenstein, Merav; Ho, Assunta Chi Hang; Horne, Anna Carin; Horneff, Gerd; Huang, Jing-Long; Hufnagel, Markus; Ilisson, Jaanika; Islam, Mohammad Imnul; Ivanova, Viktoriia; Izawa, Kazushi; Janda, Ales; Jelusic, Marija; Jeong, Daechul; Jesudas, Rohith; Jindal, Ankur; Mendiola, Karla Vanessa Jiron; Oliveira, Sheila K; Kahn, Robin; Kaposzta, Rita; Kasapcopur, Ozgur; Katsicas, Maria Martha; Kavirayani, Akhila; Keenan, Camille; Khaosut, Parichat; Khawaja, Khulood; Khedr, Waleed Ahmed Salaheldeen Hassan; Khubchandani, Raju; Kobusinska, Katarzyna; Koker, Oya; Koné-Paut, Isabelle; Kostik, Mikhail; Kuemmerle-Deschner, Jasmin; Kumar, Ashish; La Rosée, Paul; Ramirez, Mabel Aurora Ladino; Lazar, Calin; Lee, Chongwei; Lehmann, Hartwig; Lehmberg, Kai; Li, Caifeng; Li, Xiaoqing; Licciardi, Francesco; Lima, Joana; Lorenz, Zoref; Lotfy, Hala; Lovell, Daniel J; Lu, Meiping; Lukjanoviča, Kristīne; Maggio, Maria Cristina; Magni-Manzoni, Silvia; Maher, Sheren Esam Maher; Majeed, Mahmoud; Maritsi, Despoina; Marsh, Rebecca; Martini, Giorgia; Masmas, Tania Nicole; Mastrolia, Maria Vincenza; Mauro, Angela; Mehregan, Fatemeh Feresteh; Mejbri, Manel; Melki, Isabelle; Miettunen, Paivi; Miniaci, Angela; Minoia, Francesca; Mizuta, Mao; Mondal, Rakesh; Montin, Davide; Ayala, Zoilo Morel; Angarita, Juan Manuel Mosquera; Mukusheva, Zaure; Myrup, Charlotte; Nakhutsrishvili, Eka; Naqvi, Ahmed; Narazaki, Hidehiko; Nascimento, Joao; Navarrete, Carmen; Nordal, Ellen Berit; Ogbu, Ekemini A; Ogunjimi, Benson; Okong'O, Lawrence Owino; Oliveira-Ramos, Filipa; Omenetti, Alessia; Opoka-Winiarska, Violetta; Orlando, Francesca; Cicek, Sumeyra Ozdemir; Ozen, Seza; Pain, Clare; Pal, Priyankar; Fontana, Natalia Palmou; Papadopoulou, Charalampia; Pardeo, Manuela; Petrovic, Gordana; Picarelli, Mercedes; Pilania, Rakesh Kumar; Pilkington, Clarissa; Del Carmen Pinedo, Maria; Pratsidou-Gertsi, Polyxeni; Pruunsild, Chris; Quarmyne, Maa-Ohui; Quartier, Pierre; Karami, Seyed Reza Raees; Ramme, Kim; Ravelli, Angelo; Razanamahery, Jerome; Rebane, Katariina; Remesal, Agustin; Retornaz, Karine; Rigante, Donato; Rocco, Joseph; Fonseca, Adriana Rodrigues; Lozano, Ana Luisa Rodriguez; Rodriguez-Aguayo, Sandra; Rojas, Jorge; Rossano, Martina; Ryhanen, Samppa; Magalhaes, Claudia Saad; Sadeghi, Payman; Sag, Erdal; Davila, Blachy Javier Saldana; Salehzadeh, Farhad; Sánchez-Manubens, Judith; Sawhney, Sujata; Schulert, Grant; Schvartz, Adrien; Selcuk, Yuksel; Mulaosmanovic, Velma Selmanovic; Sen, Ethan; Sener, Seher; Mohite, Rachna Shanbhag; Sharma, Avinash; Shehata, Rawia Salama; Shimizu, Masaki; Simonini, Gabriele; Singh, Surjit; Smerla, Roubini; Šnipaitienė, Aušra; Sobh, Ali; Sozeri, Betul; Sparchez, Mihaela; Sršen, Saša; Stanevicha, Valda; Swart, Joost; Sztajnbok, Flavio; Tangcheewinsirikul, Sirikarn; Temelkova, Katya; Tenbrock, Klaus; Toplak, Natasa; Torno, Lilibeth; Trevisan, Matteo; Tsinti, Maria; Tsitsami, Elena; Twilt, Marinka; Van Den Berg, J Merlijn; Van Laar, Jan A M; Rincon, Camilo Andres Vargas; Varnier, Giulia Camilla; Vastert, Sebastiaan; Cornejo, Gabriel Vega; Verdoni, Lucio; Viola, Diego Oscar; Vojinovic, Jelena; Vyzhga, Yulia; Wahlin, Bjorn; Wakiguchi, Hiroyuki; Weiser, Peter; Wiesik-Szewczyk, Ewa; Yamazaki, Kazuko; Yasumura, Junko; Yin, Wei; Zeng, Huasong; Zhang, Wei; Ziaee, Vahid; Ziv, Amit; Zuber, Zbigniew. - In: RHEUMATOLOGY. - ISSN 1462-0324. - 64:1(2025), pp. 32-44. [10.1093/rheumatology/keae391]

Current treatment in macrophage activation syndrome worldwide: a systematic literature review to inform the METAPHOR project

Bracaglia, Claudia;Bracaglia, Claudia;Celani, Camilla;Chandra, Sharat;Del Giudice, Emanuela;Martini, Giorgia;
2025

Abstract

Objective: To assess current treatment in macrophage activation syndrome (MAS) worldwide and to highlight any areas of major heterogeneity of practice. Methods: A systematic literature search was performed in both EMBASE and PubMed databases. Paper screening was done by two independent teams based on agreed criteria. Data extraction was standardized following the PICO framework. A panel of experts assessed paper validity, using the Joanna Briggs Institute appraisal tools and category of evidence (CoE) according to EULAR procedure. Results: Fifty-seven papers were finally included (80% retrospective case-series), describing 1148 patients with MAS: 889 systemic juvenile idiopathic arthritis (sJIA), 137 systemic lupus erythematosus (SLE), 69 Kawasaki disease (KD) and 53 other rheumatological conditions. Fourteen and 11 studies specified data on MAS associated to SLE and KD, respectively. All papers mentioned glucocorticoids (GCs), mostly methylprednisolone and prednisolone (90%); dexamethasone was used in 7% of patients. Ciclosporin was reported in a wide range of patients according to different cohorts. Anakinra was used in 179 MAS patients, with a favourable outcome in 83% of sJIA-MAS. Etoposide was described by 11 studies, mainly as part of HLH-94/04 protocol. Emapalumab was the only medication tested in a clinical trial in 14 sJIA-MAS, with 93% of MAS remission. Ruxolitinib was the most reported Janus kinase inhibitor in MAS. Conclusion: High-dose GCs together with IL-1 and IFNγ inhibitors have shown efficacy in MAS, especially in sJIA-associated MAS. However, the global level of evidence on MAS treatment, especially in other conditions, is still poor and requires standardized studies to be confirmed.
2025
haemophagocytic lymphohistiocytosis; haemophagocytic syndromes; macrophage activation syndrome; treatment
01 Pubblicazione su rivista::01a Articolo in rivista
Current treatment in macrophage activation syndrome worldwide: a systematic literature review to inform the METAPHOR project / Baldo, Francesco; Erkens, Remco G A; Mizuta, Mao; Rogani, Greta; Lucioni, Federica; Bracaglia, Claudia; Foell, Dirk; Gattorno, Marco; Jelusic, Marija; Anton, Jordi; Brogan, Paul; Canna, Scott; Chandrakasan, Shanmuganathan; Cron, Randy Q; De Benedetti, Fabrizio; Grom, Alexei; Heshin-Bekenstein, Merav; Horne, Annacarin; Khubchandani, Raju; Ozen, Seza; Quartier, Pierre; Ravelli, Angelo; Shimizu, Masaki; Schulert, Grant; Scott, Christiaan; Sinha, Rashmi; Ruperto, Nicolino; Swart, Joost F; Vastert, Sebastiaan; Minoia, Francesca; Null, Null; Aalto, Kristiina; Mendoza, Carlos Abud; Abushhaiwia, Awatif; Ailioaie, Constantin; Akikusa, Jonathan; Aksu, Guzide; Ayaz, Nuray Aktay; Al Jashmi, Ruqaiya Nasser; Al-Abrawi, Safiya; Alessio, Maria; Alexeeva, Ekaterina; Al-Mayouf, Sulaiman M; Almutairi, Abdulaziz; Alsuweiti, Muatasem; Amalia, Rizqi; Amin, Iman; Anton, Jordi; Armbrust, Wineke; Astigarraga, Itziar; Bakkaloglu, Sevcan; Bakry, Reima; Basaran, Ozge; May, Floricely Basulto; Bathia, Jigna; Battagliotti, Cristina; Belot, Alexandre; Berg, Stefan; Beutel, Karin; Bica, Blanca; Bolt, Isabel; Boyadzhiev, Martin; Boyarchuk, Oksana; Boyko, Yaryna; Bracaglia, Claudia; Breda, Luciana; Brochard, Karine; Brogan, Paul; Brunner, Jurgen; Rivas, Segundo Bujan; Calin, Aurelia; Calzada, Joan; Lovillo, Marisol Camacho; Canna, Scott; Cannizzaro, Elvira; Caorsi, Roberta; Carlomagno, Raffaella; Cattalini, Marco; Celani, Camilla; Chan, Kwai Yu Winnie; Chandra, Sharat; Chandrakasan, Shanmuganathan; Chang, Chong U; Chasnyk, Vyacheslav; Chyzheuskaya, Iryna; Ciurtin, Coziana; Garulo, Daniel Clemente; Cochino, Alexis-Virgil; Consolaro, Alessandro; Consolini, Rita; Cron, Randy; Da Silva, Carlos Henrique M; De Benedetti, Fabrizio; De Cunto, Carmen; De Matteis, Arianna; De Somer, Lien; Dedeoglu, Fatma; Deepakbabu, Chellapandian; Del Giudice, Emanuela; Maldonado, Adriana Soraya Diaz; Dolezalova, Pavla; Dressler, Frank; Dzhus, Marta; El Miedany, Yasser; El-Ghoneimy, Dalia; Emminger, Wolfgang; Enciso, Sandra; Estmann, Anne; Etayari, Hala; Fair, Danielle; Fasshauer, Maria; Fassi, Daniel; Faugier, Enrique; Federici, Silvia; Feldman, Brian; Filocamo, Giovanni; Flato, Berit; Fluchel, Mark; Foell, Dirk; Fotis, Lampros; Frkovic, Marijan; Fuhlbrigge, Robert; Gaggiano, Carla; Gagro, Alenka; Gallizzi, Romina; Cunha, Ana Luiza Garcia; Garcia-Rodriguez, Fernando; García-Rodríguez, Fernando; Gattorno, Marco; Girschick, Hermann; Glerup, Mia; Grebenkina, Lyudmila; Guha, Suparna; Suarez, Raul Gutierrez; Ramirez, Jaime Guzman; Hadef, Djohra; Saied, Mohamad Hamad; Hashad, Soad; Hashkes, Philip (Pinchas); Hasle, Henrik; Hays, Julia Allyson; Held, Martina; Henter, Jan-Inge; Herrera, Cristina N; Heshin-Bekenstein, Merav; Ho, Assunta Chi Hang; Horne, Anna Carin; Horneff, Gerd; Huang, Jing-Long; Hufnagel, Markus; Ilisson, Jaanika; Islam, Mohammad Imnul; Ivanova, Viktoriia; Izawa, Kazushi; Janda, Ales; Jelusic, Marija; Jeong, Daechul; Jesudas, Rohith; Jindal, Ankur; Mendiola, Karla Vanessa Jiron; Oliveira, Sheila K; Kahn, Robin; Kaposzta, Rita; Kasapcopur, Ozgur; Katsicas, Maria Martha; Kavirayani, Akhila; Keenan, Camille; Khaosut, Parichat; Khawaja, Khulood; Khedr, Waleed Ahmed Salaheldeen Hassan; Khubchandani, Raju; Kobusinska, Katarzyna; Koker, Oya; Koné-Paut, Isabelle; Kostik, Mikhail; Kuemmerle-Deschner, Jasmin; Kumar, Ashish; La Rosée, Paul; Ramirez, Mabel Aurora Ladino; Lazar, Calin; Lee, Chongwei; Lehmann, Hartwig; Lehmberg, Kai; Li, Caifeng; Li, Xiaoqing; Licciardi, Francesco; Lima, Joana; Lorenz, Zoref; Lotfy, Hala; Lovell, Daniel J; Lu, Meiping; Lukjanoviča, Kristīne; Maggio, Maria Cristina; Magni-Manzoni, Silvia; Maher, Sheren Esam Maher; Majeed, Mahmoud; Maritsi, Despoina; Marsh, Rebecca; Martini, Giorgia; Masmas, Tania Nicole; Mastrolia, Maria Vincenza; Mauro, Angela; Mehregan, Fatemeh Feresteh; Mejbri, Manel; Melki, Isabelle; Miettunen, Paivi; Miniaci, Angela; Minoia, Francesca; Mizuta, Mao; Mondal, Rakesh; Montin, Davide; Ayala, Zoilo Morel; Angarita, Juan Manuel Mosquera; Mukusheva, Zaure; Myrup, Charlotte; Nakhutsrishvili, Eka; Naqvi, Ahmed; Narazaki, Hidehiko; Nascimento, Joao; Navarrete, Carmen; Nordal, Ellen Berit; Ogbu, Ekemini A; Ogunjimi, Benson; Okong'O, Lawrence Owino; Oliveira-Ramos, Filipa; Omenetti, Alessia; Opoka-Winiarska, Violetta; Orlando, Francesca; Cicek, Sumeyra Ozdemir; Ozen, Seza; Pain, Clare; Pal, Priyankar; Fontana, Natalia Palmou; Papadopoulou, Charalampia; Pardeo, Manuela; Petrovic, Gordana; Picarelli, Mercedes; Pilania, Rakesh Kumar; Pilkington, Clarissa; Del Carmen Pinedo, Maria; Pratsidou-Gertsi, Polyxeni; Pruunsild, Chris; Quarmyne, Maa-Ohui; Quartier, Pierre; Karami, Seyed Reza Raees; Ramme, Kim; Ravelli, Angelo; Razanamahery, Jerome; Rebane, Katariina; Remesal, Agustin; Retornaz, Karine; Rigante, Donato; Rocco, Joseph; Fonseca, Adriana Rodrigues; Lozano, Ana Luisa Rodriguez; Rodriguez-Aguayo, Sandra; Rojas, Jorge; Rossano, Martina; Ryhanen, Samppa; Magalhaes, Claudia Saad; Sadeghi, Payman; Sag, Erdal; Davila, Blachy Javier Saldana; Salehzadeh, Farhad; Sánchez-Manubens, Judith; Sawhney, Sujata; Schulert, Grant; Schvartz, Adrien; Selcuk, Yuksel; Mulaosmanovic, Velma Selmanovic; Sen, Ethan; Sener, Seher; Mohite, Rachna Shanbhag; Sharma, Avinash; Shehata, Rawia Salama; Shimizu, Masaki; Simonini, Gabriele; Singh, Surjit; Smerla, Roubini; Šnipaitienė, Aušra; Sobh, Ali; Sozeri, Betul; Sparchez, Mihaela; Sršen, Saša; Stanevicha, Valda; Swart, Joost; Sztajnbok, Flavio; Tangcheewinsirikul, Sirikarn; Temelkova, Katya; Tenbrock, Klaus; Toplak, Natasa; Torno, Lilibeth; Trevisan, Matteo; Tsinti, Maria; Tsitsami, Elena; Twilt, Marinka; Van Den Berg, J Merlijn; Van Laar, Jan A M; Rincon, Camilo Andres Vargas; Varnier, Giulia Camilla; Vastert, Sebastiaan; Cornejo, Gabriel Vega; Verdoni, Lucio; Viola, Diego Oscar; Vojinovic, Jelena; Vyzhga, Yulia; Wahlin, Bjorn; Wakiguchi, Hiroyuki; Weiser, Peter; Wiesik-Szewczyk, Ewa; Yamazaki, Kazuko; Yasumura, Junko; Yin, Wei; Zeng, Huasong; Zhang, Wei; Ziaee, Vahid; Ziv, Amit; Zuber, Zbigniew. - In: RHEUMATOLOGY. - ISSN 1462-0324. - 64:1(2025), pp. 32-44. [10.1093/rheumatology/keae391]
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