Levamisole as basic treatment of rheumatoid arthritis: longterm evaluation

We evaluated longterm levamisole treatment of 201 rheumatoid patients. Fifty-nine patients in their 1st yr of treatment were not analyzed; of the remaining 142, 69 (49%) still took levamisole with benefit. Levamisole was stopped in 32 patients (22%) for inefficacy and for reversible adverse reactions in 37 (26%). Leukotoxic side-effects were the commonest cause of withdrawal (23 patients = 16%). Since June 1977, we administer levamisole on a 1 d/wk schedule (150 mg), with determination of white blood cells 10 h after intake to detect high-risk patients for agranulocytosis. With disease exacerbation during treatment or lack of response after 6 months, the drug is given on a 2nd non-consecutive day. Since June 1977, cases of agranulocytosis have not been observed. Allergic vasculitis did not occur with a 1 d/wk schedule. The absence of nephrotoxicity and hepatotoxicity is stressed. Only 4 patients (3%) were lost to follow-up. Comparison is made with longterm use of gold and D-penicillamine. We conclude that levamisole is a useful slow acting antirheumatic drug.

Determination of T lymphocyte subpopulations by monoclonal antibodies in rheumatoid arthritis. Influence of immunomodulating agents

The pathogenesis of rheumatoid arthritis is unknown, but clear abnormalities of the immune system are well documented in this disease. We therefore evaluated T cell subpopulations in patients with rheumatoid arthritis using monoclonal antibodies previously shown to react with all T cells (OKT3), with inducer/helper T cells (OKT4) and with suppressor/cytotoxic T cells (OKT8). These investigations disclosed evidence of a significant decrease in the number of OKT8+ cells/mm3 and a high inducer-helper/suppressor-cytotoxic (OKT4+/OKT8+) ratio in active rheumatoid arthritis. A modest number of patients with active arthritis were treated wit levamisole or with synthetic thymopoietin 32-36 (thymopoietin pentapeptide or TP-5). These individuals responded with ratio decreases to more normal levels. Our data support the hypothesis that monoclonal T cell antibodies may offer an important tool for the further evaluation of patients with rheumatoid arthritis and their individual response to treatment.

Influence of an oversulphated heparinoid upon hyaluronate metabolism of the human synovial cell in vivo

Glycosaminoglycans appear to affect proteoglycan metabolism of fibroblasts, human synovial cells, and chondrocytes under in vitro conditions. The influence of an oversulphated heparinoid (Arteparon) on hyaluronate metabolism of the human synovial lining cell was studied by in vivo experiments on human volunteers. A higher production of better polymerized hyaluronic acid was observed after repeated intraarticular injections of this heparinoid into the knees of 2 osteoarthritic patients. After a single injection a statistically significant rise of synovial fluid hyaluronate concentration was observed over 4 days. A higher molecular weight of this molecule was suspected in view of a significant increase of the anomalous viscosity index 2 and 4 days after intraarticular administration.

Salicylate-induced gastrointestinal bleeding: comparison between soluble buffered, enteric-coated, and intravenous administration

Serum salicylate levels and blood loss in stools were compared in 94 patients after intake of various forms of acetylsalicylate. Four different oral soluble forms, an enteric-coated variety and an intravenous form were evaluated. Analysis of the results of blood loss measurement in stools showed that salicylate users could be divided into "bleeders" and "non-bleeders". Administration of enteric-coated and intravenous forms of salicylates showed less blood less than ingestion of soluble forms. Only after administration of enteric-coated or intravenous forms of salicylates was a relationship between serum salicylate level and blood loss in stools observed in "bleeders". This suggests a similar mode of action of both these preparations on gastric mucosa. We conclude that enteric-coated forms of salicylates cause gastrointestinal bleeding by a systemic action on gastric mucosa.

Short term variation of human immunoglobulin levels with an estimation of the day to day physiological variability

In this work serum Ig levels were determined daily for 14 days in 12 subjects, every two days for 14 days in 19 subjects, every week for 1 month in 11 subjects and fortnightly in 11 subjects for 6 months. The serum IgG, IgM and IgA levels were quantitated by the linear plate method. The day-to-day reproducibility of the technique was checked for a period of one months on seven different samples. The mean coefficient of variation in the reproducibility experiments was found to be 4.8% for IgG, 8.2% for IgM and 5.2% for IgA. Since the observed variation in all groups of subjects was found to be higher than the methodological variation, it appears that physiological variability occurs in the serum Ig levels of an individual. No difference was found between the physiological variances of IgG, IgM and IgA observed in the group with daily analysis and those with determinations every two days. The physiological variations increase when longer periods are considered between consecutive determinations, but the variability of IgG and IgA in the group with fortnightly determinations is less important than that observed in the group with weekly analyses. Some evidence is presented indicating a periodic fluctuation of serum IgG and IgA levels with an amplitude of nearly 20% and with a recurrence rate of two weeks.

[HL-A and chronic juvenile polyarthritis]

The authors determined the HLA groups in 1000 blood donors, in 62 subjects suffering from ankylosing spondylarthritis, and in 32 subjects suffering from chronic juvenile polyarthritis. The results confirm those of other authors as regards the occurrence of W27 antigen in ankylosing spondylarthritis. The examination of the subjects suffering from chronic juvenile polyarthritis made it possible to subdivide this population into 4 groups: (1) Chronic juvenile polyarthritis evolving towards ankylosing spondylarthritis; (2) Chronic juvenile polyarthritis with sacroilitis; (3) Chronic juvenile polyarthritis without sacroiliac involvement; and (4) Rhematoid juvenile polyarthritis. They showed that the presence of W27 antigen was very high in groups (1) and (2) and very low in groups (3) and (4). Determination of the presence of W27 antigen makes it possible to place the patient in one of these groups and the future will show whether this classification is of any therapeutic consequence.

HLA and juvenile chronic polyarthritis

HLA antigen have been identified in patients with juvenile chronic polyarthritis (J.C.P.) (n = 35). In J.C.P. the incidence of antigen B27 (57%) was found to be higher than in a normal population (n = 1,000). On recent evaluation of the clinical status, serology and x-rays, the patients with juvenile chronic polyarthritis who has been followed up many years, could be subdivided into four groups: Group 1: J.C.P. evolving to ankylosing spondylitis (n = 3); Group 2: J.C.P. with sacroiliitis (n = 17); Group 3: J.C.P. without sacroiliitis (n = 9); Group 4: juvenile rheumatoid arthritis characterised by a positive serology (n = 6). Groups 1 and 2 were characterized by a high incidence of antigen B27 (19/20). Only one subject of groups 3 and 4 had antigen B27. Sex distribution in groups 1 and 2 was found to be similar to that found in ankylosing spondylitis in adults and sex distribution in groups 3 and 4 was found to be similar to that found in rheumatoid arthritis in adults. It is concluded that if B27 positive develop juvenile chronic polyarthritis they have a high risk of developing sacroiliitis and acute uveitis. The authors propose to give the name Still's disease to the total group of children presenting initial symptoms corresponding to the criteria of Ansell & Bywaters (1959). Follow-up of the cases permitted their further classification as juvenile ankylosing spondylitis, as juvenile chronic polyarthritis with or without sacroiliitis or as juvenile rheumatoid arthritis.

Avascular necrosis and its relation to lipid and purine metabolism

Serum uric acid, triglycerides, cholesterol, and lipoprotein levels were determined in 35 patients with primary avascular necrosis of the femoral head. The results were compared with a control group and a group of gouty patients. Frequency distribution of the data in the three groups was found to be of the log normal type, and the statistical calculations were performed after log transformation of the serum values. Compared to the control group, a significant increase in the levels of triglycerides, cholesterol, pre-beta-lipoprotein, and uric acid were found in the patients with avascular necrosis. No significant difference was observed between lipid and lipoprotein levels in gout and avascular necrosis, although the serum uric acid was higher in the gouty patients. In contrast to the findings in gout, the uric acid levels did not correlate with the lipid or lipoprotein fractions in patients with avascular necrosis. There were no statistical differences between lipid, lipoprotein and uric acid levels in patients with avascular necrosis receiving corticosteroids or using alcohol, as compared with those not taking these drugs. It is concluded that avascular necrosis of bone complicating longterm use of steroids or alcohol is not induced directly by the two drugs, but that the initiating event may lie in lipid disturbances.