Clinical outcomes of patients with rheumatoid arthritis after switching from infliximab to etanercept

OBJECTIVE

To assess the efficacy and monitor serious adverse events in patients with rheumatoid arthritis (RA) switching treatment from infliximab to etanercept.

METHODS

Adult patients with active RA who were discontinuing treatment with infliximab were eligible to enroll in this prospective, 12-week, open label, single-arm, observational study. Four to 10 weeks after their last infusion of infliximab, patients began treatment with etanercept (twice weekly subcutaneous injections of 25 mg). Clinical assessments using the American College of Rheumatology (ACR) criteria for improvement were performed at baseline and at Weeks 6 and 12, and serious adverse events were monitored throughout the study.

RESULTS

Twenty-five patients were enrolled, 18 of whom had discontinued infliximab because of lack of efficacy, and 22 completed 12 weeks of etanercept treatment. After 12 weeks, 14 of 22 patients (64%) achieved at least a 20% improvement in ACR criteria (ACR20), 13 (59%) experienced improvements in physical function that were considered clinically important (> or = 0.22 point decrease in overall Health Assessment Questionnaire score), and mean values of all individual components of the ACR criteria had improved. No serious adverse events were reported during the study and no patient discontinued because of lack of efficacy.

CONCLUSION

Etanercept, a soluble tumor necrosis factor (TNF) receptor, provided a well tolerated and effective treatment option for some patients even when infliximab, a monoclonal antibody to TNF, had been ineffective.

Meniscal tear and extrusion are strongly associated with progression of symptomatic knee osteoarthritis as assessed by quantitative magnetic resonance imaging

BACKGROUND

The relation between knee meniscal structural damage and cartilage degradation is plausible but not yet clearly proven.

OBJECTIVES

To quantitate the cartilage volume changes in knee osteoarthritis using magnetic resonance imaging (MRI), and determine whether meniscal alteration predicts cartilage volume loss over time.

METHODS

32 patients meeting ACR criteria for symptomatic knee osteoarthritis were studied. MRI knee acquisitions were done every six months for two years. The cartilage volumes of different knee regions were measured. Three indices of structural change in the medial and lateral menisci were evaluated--degeneration, tear, and extrusion--using a semiquantitative scale.

RESULTS

24 patients (75%) had mild to moderate or severe meniscal damage (tear or extrusion) at baseline. A highly significant difference in global cartilage volume loss was observed between severe medial meniscal tear and absence of tear (mean (SD), -10.1 (2.1)% v -5.1 (2.4)%, p = 0.002). An even greater difference was found between the medial meniscal changes and medial compartment cartilage volume loss (-14.3 (3.0)% in the presence of severe tear v -6.3 (2.7)% in the absence of tear; p<0.0001). Similarly, a major difference was found between the presence of a medial meniscal extrusion and loss of medial compartment cartilage volume (-15.4 (4.1)% in the presence of extrusion v -4.5 (1.7)% with no extrusion; p<0.001).

CONCLUSIONS

Meniscal tear and extrusion appear to be associated with progression of symptomatic knee osteoarthritis.

Adalimumab therapy in rheumatoid arthritis

Adalimumab is a recombinant human immunoglobulin G1 monoclonal antibody that is specific for human tumor necrosis factor. Based on the data presented in this article, adalimumab administered alone or in patients partially responsive to methotrexate exhibits a rapid onset of action, provides a substantial reduction in signs and symptoms, and results in an improvement in physical function and health-related quality of life. Adalimumab has been demonstrated to inhibit progression of structural joint damage in patients who have long-standing rheumatoid arthritis. Taken together, the data support adalimumab as a new therapeutic option for patients with moderate to severe rheumatoid arthritis.

Quantitative magnetic resonance imaging evaluation of knee osteoarthritis progression over two years and correlation with clinical symptoms and radiologic changes

OBJECTIVE

To evaluate the change in osteoarthritic (OA) knee cartilage volume over a two-year period with the use of magnetic resonance imaging (MRI) and to correlate the MRI changes with radiologic changes.

METHODS

Thirty-two patients with symptomatic knee OA underwent MRI of the knee at baseline and at 6, 12, 18, and 24 months. Loss of cartilage volumes were computed and contrasted with changes in clinical variables for OA and with standardized semiflexed knee radiographs at baseline at 1 and 2 years.

RESULTS

Progression of cartilage loss at all followup points was statistically significant (P < 0.0001), with a mean +/- SD of 3.8 +/- 5.1% for global cartilage loss and 4.3 +/- 6.5% for medial compartment cartilage loss at 6 months, 3.6 +/- 5.1% and 4.2 +/- 7.5% at 12 months, and 6.1 +/- 7.2% and 7.6 +/- 8.6% at 24 months. Discriminant function analysis identified 2 groups of patients, those who progressed slowly (<2% of global cartilage loss; n = 21) and those who progressed rapidly (>15% of global cartilage loss; n = 11) over the 2 years of study. At baseline, there was a greater proportion of women (P = 0.001), a lower range of motion (P = 0.01), a greater circumference and higher level of pain (P = 0.05) and stiffness in the study knee, and a higher body mass index in the fast progressor group compared with the slow progressor group. No statistical correlation between loss of cartilage volume and radiographic changes was seen.

CONCLUSION

Quantitative MRI can measure the progression of knee OA precisely and can help to identify patients with rapidly progressing disease. These findings indicate that MRI could be helpful in assessing the effects of treatment with structure-modifying agents in OA.

Role of adalimumab in the treatment of early rheumatoid arthritis

Adalimumab, a recent addition to the therapeutic armamentarium in rheumatoid arthritis (RA), has been evaluated in patients with early RA. The DE019 study, a double blind randomized placebo controlled trial of adalimumab given 20 mg once a week or 40 mg every other week demonstrated both clinical and radiographic efficacy. A subset analysis of patients with early disease revealed that early treatment with adalimumab may be more efficacious than therapy later in the course of disease, particularly with regard to radiographic progression. The findings support early aggressive intervention in RA.

Role of infliximab in the treatment of early rheumatoid arthritis

Data has been generated that infliximab may be more effective when initiated earlier in the course of disease. A subset analysis of the Attract trial has demonstrated better efficacy of infliximab in reducing joint damage in an early rheumatoid arthritis (RA) population. Recently a randomized double-blind controlled trial revealed that infliximab in combination with methotrexate (MTX) in an early RA population improved signs and symptoms as well as inhibition in radiographic progression compared with patients receiving infliximab or MTX alone. The possibility of withdrawing infliximab after induction of remission with a combination of infliximab and MTX has been shown in a small pilot trial. Taken together, the results support the early use of infliximab in the treatment of patients with moderate to severe disease.

Intra-articular therapy in osteoarthritis

The medical literature was reviewed from 1968-2002 using Medline and the key words "intra-articular" and "osteoarthritis" to determine the various intra-articular therapies used in the treatment of osteoarthritis. Corticosteroids and hyaluronic acid are the most frequently used intra-articular therapies in osteoarthritis. Other intra-articular substances such as orgotein, radiation synovectomy, dextrose prolotherapy, silicone, saline lavage, saline injection without lavage, analgesic agents, non-steroidal anti-inflammatory drugs, glucosamine, somatostatin, sodium pentosan polysulfate, chloroquine, mucopolysaccharide polysulfuric acid ester, lactic acid solution, and thiotepa cytostatica have been investigated as potentially therapeutic in the treatment of arthritic joints. Despite the lack of strong, convincing, and reproducible evidence that any of the intra-articular therapies significantly alters the progression of osteoarthritis, corticosteroids and hyaluronic acid are widely used in patients who have failed other therapeutic modalities for lack of efficacy or toxicity. As a practical approach for a knee with effusion, steroid injections should be considered while the presence of symptomatic "dry" knees may favour the hyaluronic acid approach. The virtual absence of serious side effects, coupled with the perceived benefits, make these approaches attractive.

Safety and efficacy of long-term intraarticular steroid injections in osteoarthritis of the knee: a randomized, double-blind, placebo-controlled trial

OBJECTIVE

To evaluate the safety and efficacy of long-term intraarticular (IA) steroid injections for knee pain related to osteoarthritis (OA).

METHODS

In a randomized, double-blind trial, 68 patients with OA of the knee received IA injections of triamcinolone acetonide 40 mg (34 patients) or saline (34 patients) into the study knee every 3 months for up to 2 years. The primary outcome variable was radiologic progression of joint space narrowing of the injected knee after 2 years. Measurements of minimum joint space width were performed by an automated computerized method on standardized fluoroscopically guided radiographs taken with the patient standing and with the knee in a semiflexed position. The clinical efficacy measure of primary interest was the pain subscale from the Western Ontario and McMaster Universities OA Index (WOMAC). Efficacy measures of secondary interest were the total score on the WOMAC, physician's global assessment, patient's global assessment, patient's assessment of pain, range of motion (ROM) of the affected knee, and 50-foot walking time. Clinical symptoms were assessed just before each injection.

RESULTS

At the 1-year and 2-year followup evaluations, no difference was noted between the two treatment groups with respect to loss of joint space over time. The steroid-injected knees showed a trend toward greater symptom improvement, especially at 1 year, for the WOMAC pain subscale, night pain, and ROM values (P = 0.05) compared with the saline-injected knees. Using area under the curve analyses, knee pain and stiffness were significantly improved throughout the 2-year study by repeated injections of triamcinolone acetonide, but not saline (P < 0.05).

CONCLUSION

Our findings support the long-term safety of IA steroid injections for patients with symptomatic knee OA. No deleterious effects of the long-term administration of IA steroids on the anatomical structure of the knee were noted. Moreover, long-term treatment of knee OA with repeated steroid injections appears to be clinically effective for the relief of symptoms of the disease.

Clinimetric properties of the AUSCAN Osteoarthritis Hand Index: an evaluation of reliability, validity and responsiveness

OBJECTIVE

To assess the reliability, validity and responsiveness of the Australian/Canadian (AUSCAN) Osteoarthritis Hand Index in both Likert (LK) and Visual Analogue (VA)-scaled formats.

METHODS

Two separate studies were conducted; the first addressing reliability and validity issues and the second addressing index responsiveness. In a group of 50 patients with osteoarthritis (OA) of the hand, test-retest reliability was assessed at a 1-week interval and internal consistency from single administrations of the Index. Construct validity was evaluated against several other outcome measures including the Functional Index for Hand Osteoarthritis (FIHOA), separate patient and physician global assessments, Doyle Index, grip strength, pinch grip, and Health Assessment Questionnaire. A 6-week washout retreatment design was used in a group of 44 OA hand patients to assess index responsiveness and comparative responsiveness against the FIHOA.

RESULTS

Reliability and construct validity coefficients confirm the reliability and construct validity of both the AUSCAN LK3.0 and AUSCAN VA3.0 Indices. The washout retreatment study establishes index responsiveness and suggests that the AUSCAN LK3.0 and AUSCAN VA3.0 Indices may be more responsive than the FIHOA.

CONCLUSIONS

The patient self-completed AUSCAN LK3.0 and AUSCAN VA3.0 Indices are reliable, valid and responsive and can be recommended as primary outcome measures for future hand OA clinical trials.

Dimensionality and clinical importance of pain and disability in hand osteoarthritis: Development of the Australian/Canadian (AUSCAN) Osteoarthritis Hand Index

OBJECTIVE

To develop a reliable, valid, and responsive self-administered questionnaire to probe pain, stiffness and physical disability in patients with osteoarthritis (OA) of the hand.

DESIGN

In order to assess the dimensionality of the symptomatology of hand OA, a self-administered questionnaire was developed to probe various aspects of pain (10 items), stiffness (two items), and physical function (83 items). The question inventory was generated from eight existing health status measures and an interactive process involving four rheumatologists, two physiotherapists, and an orthopaedic surgeon.

RESULTS

Face-to-face interviews were conducted with 50 OA hand patients; 39 females and 11 males with mean age 62.8 years and mean disease duration 9.4 years. Items retained were those which fulfilled specified selection criteria: prevalence > or =60% and mean importance score approximating or exceeding 2.0 Item exclusion criteria included low prevalence, gender-based, ambiguous, duplicates or similarities, alternatives, composite items, and items that were too restrictive. This process resulted in five pain, one stiffness and nine function items which have been proposed for incorporation in the AUSCAN Index.

CONCLUSIONS

Using a traditional development strategy, we have constructed a self-administered multi-dimensional outcome measure for assessing hand OA. The next stage includes reliability, validity and responsiveness testing of the 15-item questionnaire.

Current and emerging therapies for rheumatoid arthritis, with a focus on infliximab: clinical impact on joint damage and cost of care in canada

BACKGROUND

Rheumatoid arthritis (RA) is a physically debilitating disease that places an enormous burden not only on individuals and their families but also on the economy. Affecting -1% of the Canadian population, RA is characterized by pain and swelling of joints. Without effective treatment, RA results in joint destruction that often requires surgery.

OBJECTIVE

This review summarizes the effect of current and new RA treatments on joint damage, with a focus on infliximab. The health-economic repercussions and potential impact of arresting the joint destruction of RA are discussed.

METHODS

Information for inclusion in this review was identified through searches of the MEDLINE and HealthStar databases from 1995 to 2000. Search terms included rheumatoid arthritis, treatment guidelines, economics, and individual drug names.

RESULTS

Standard initial RA drug therapy has been aimed at reducing pain and inflammation, whereas use of the more potent disease-modifying antirheumatic drugs (DMARDs) has been reserved for later stages of disease. More aggressive RA treatment involves introducing DMARDs at the earliest stage. The largest single direct cost of RA involves hospital admissions for the correction of joint deformities. Among newer therapies, the anti-tumor necrosis factor-alpha agent infliximab has been shown to arrest radiographic measures of disease progression.

CONCLUSIONS

With early and aggressive treatment involving new drugs and drug combinations, it may be possible to ameliorate the physical, social, and economic effects of RA.

Biologic agents in the treatment of rheumatoid arthritis

Advances in the understanding of the pathogenesis of rheumatoid arthritis (RA) as well as improved biotechnology has enabled selective targeting of the pathogenic elements of disease. Targeting cell recruitment through adhesion molecules has been shown to be successful in pre-clinical murine models. Results of studies of an anti-ICAM-1 monoclonal antibody and anti-sense oligonucleotides have been encouraging. An alternate approach to inhibiting recruitment has been the targeting of chemoattractant molecules ie. chemokines. Important advances have been made in cytokine directed therapy targeting TNFalpha and IL-1. TNF antagonists (anti-TNF monoclonal antibody/soluble TNF receptor Fc fusion protein) have resulted in rapid and substantial improvement in signs and symptoms of disease as well as disease modification, shown by slowing of radiological progression. IL-1 receptor antagonist protein appears to have a significant effect on radiological progression despite a modest effect on symptoms and signs. Studies using anti-inflammatory cytokines such as IL-10 are in progress. A more recent therapeutic approach has been to target T-cell activation by interfering with co-stimulatory complexes such as CD40L/CD40 and CD28/CD80 and CD86. Both pre-clinical and preliminary clinical studies in human subjects support the concept. Another approach involving T-cell receptor peptide vaccination with VB peptides over-utilized in RA synovium has shown to be beneficial. Targeting the cytokines driving T-cells in the RA synovium ie. IL-12 & IL-15 has also proven beneficial in animal studies. Recent attention has also been directed toward the invading synovial fibroblast using Fas-FasL mediated apoptosis. Pre-clinical studies in which angiogenesis and osteoclast activation are targeted have been encouraging. In conclusion, the proof of principle has been established that selective targeting of pathogenic elements of disease results in substantial improvement in signs and symptoms as well as disease progression. Improved efficacy is expected with more aggressive targeting of the pathogenic elements.

Efficacy and safety of diacerein in osteoarthritis of the knee: a double-blind, placebo-controlled trial. The Diacerein Study Group

OBJECTIVE

To evaluate the efficacy and safety of diacerein, a drug with interleukin-1beta--inhibitory activity in vitro, in patients with knee osteoarthritis (OA).

METHODS

A total of 484 patients fulfilling the American College of Rheumatology criteria for knee OA were enrolled in this 16-week, randomized, double-blind, placebo-controlled, parallel study group with 3 diacerein dosages of 50 mg/day, 100 mg/day, and 150 mg/day (administered twice daily).

RESULTS

In the intent-to-treat population, 100 mg/day diacerein (50 mg twice daily) was significantly superior (P < 0.05) to placebo using the primary criterion (visual analog scale [VAS] assessment of pain on movement). Significant improvement (P < 0.05) was also observed for the secondary criteria, which included the Western Ontario and McMaster Universities OA Index (WOMAC), the WOMAC subscores, and the VAS assessment of handicap. In patients treated with diacerein dosages of 50 mg/day and 150 mg/day, favorable but not significant results were observed for the primary criterion. The best daily dosage of diacerein, calculated from the effect on the VAS assessment of pain on movement, was 90.1 mg. In the per-protocol population, the analysis of the primary criterion showed significant dose-dependent differences (P < 0.05) between each of the 3 diacerein dosages and the placebo. No differences were observed among the 3 diacerein groups. A significantly higher incidence (P < 0.05) of adverse events (AEs), as well as a higher rate of dropoout due to AEs, was observed in patients treated with 150 mg/day diacerein versus those treated with placebo, 50 mg/day diacerein, or 100 mg/day diacerein. Mild-to-moderate transient changes in bowel habits were the most frequent AEs, increasing with the dosage.

CONCLUSION

Diacerein, a drug for the treatment of OA, was shown to be an effective treatment for symptoms in patients with knee OA. Taking into account both efficacy and safety, the optimal daily dosage of diacerein for patients with knee OA is 100 mg/day (50 mg twice daily).

The incidence of cancer associated with the treatment of rheumatoid arthritis

OBJECTIVES

The treatment of rheumatoid arthritis (RA) targets inflammation either by inhibiting the activation of immune cells or their clonal expansion. We evaluated the available evidence concerning the risk of cancer associated with RA treatment.

METHOD

Articles published between 1966 and 1998 reporting the incidence of cancer in RA patients were reviewed.

RESULTS

Large follow-up studies suggest the relative risk (RR) of lymphomas associated with RA is about twofold higher than in the general population. A role for azathioprine in the development of lymphomas and a role for cyclophosphamide in cancers, particularly bladder cancer, has been suggested. However, no studies have shown that methotrexate increases the risk of cancer in RA patients. Studies that showed an increased risk of cancer associated with gold or cyclosporine therapy in RA patients are inconclusive as they have used cancer incidence in the general population as the reference. One study measured the RR of cancer in a group of cyclosporine-treated RA patients (1.6 year on average) using RA patients as a control and found no enhanced risk.

CONCLUSIONS

Although evidence suggests an increased risk of specific cancers associated with the use of some treatments, this may be outweighed by the potential benefit of therapy, especially in patients with severe disease.

Pharmacologic therapy of osteoarthritis

This article presents a brief review of the most current therapies that are used for the relief of the symptoms related to osteoarthritis. The agents used either systematically or locally are described, providing the rationale for their usage in the treatment of osteoarthritis. Moreover, new therapies that have reached clinical evaluations and that can possibly reduce or stop the progression of the disease--namely the inhibitors of metalloproteases--are presented. Overall, it is obvious that significant progress has been made toward the development of new therapeutic agents to reduce the symptoms as well as the structural changes of the disease.

Miliary tuberculosis presenting as tenosynovitis in a case of rheumatoid arthritis

A 77-year-old woman with a seropositive nodular rheumatoid arthritis and vasculitis, who was treated with high doses of corticosteroids and intravenous cyclophosphamide, developed miliary tuberculosis that was heralded by a tenosynovitis in her right wrist. A 1-year course of anti-tuberculous therapy resulted in complete resolution of the tenosynovitis and disseminated infection.

Serum keratan sulfate levels in rheumatoid arthritis: inverse correlation with radiographic staging

OBJECTIVE

To correlate the serum levels of keratan sulfate (KS) in patients with rheumatoid arthritis (RA) with different clinical and radiographic variables.

METHODS

Serum KS levels were measured in 85 patients with RA and 41 age matched controls. Patients with RA were classified according to their disease activity, the presence of rheumatoid factor, the medication prescribed, and to the severity of the joint radiographic changes.

RESULTS

Patients with RA had significantly (p < 0.02) higher levels of serum KS compared to the healthy controls. More significantly, there was an inverse correlation of the serum KS levels with the disease activity (p = 0.02) and the severity of the radiographic changes (p = 0.012).

CONCLUSIONS

Serum KS levels appear to correlate with the severity of articular cartilage damage in RA.

Comparison of amitriptyline, cyclobenzaprine, and placebo in the treatment of fibromyalgia. A randomized, double-blind clinical trial

OBJECTIVE

To compare the relative efficacy and tolerability of amitriptyline, cyclobenzaprine, and placebo in the treatment of fibromyalgia, and to identify predictors of response to amitriptyline and cyclobenzaprine.

METHODS

Two hundred eight patients who fulfilled the American College of Rheumatology criteria for the classification of fibromyalgia were entered into a 6-month prospective, double-blind, multicenter trial and were randomized to 1 of 3 treatment groups: amitriptyline, cyclobenzaprine, or placebo.

RESULTS

After 1 month, 21%, 12%, and 0% of the amitriptyline, cyclobenzaprine, and placebo patients, respectively, had significant clinical improvement (amitriptyline versus placebo P = 0.002, cyclobenzaprine versus placebo P = 0.02, amitriptyline versus cyclobenzaprine P not significant). These percentages increased to 36%, 33%, and 19%, respectively, at the 6-month assessment (P not significant). The nature and frequency of side effects reported by patients treated with amitriptyline and those reported by patients treated with cyclobenzaprine were similar. A normal Minnesota Multiphasic Personality Inventory (MMPI) profile at baseline was predictive of clinical improvement at the 1-month evaluation (odds ratio 3.3, 95% confidence interval 1.2-9.0). However, neither the MMPI profile nor any of the demographic, clinical, or functional parameters evaluated at baseline predicted long-term response.

CONCLUSION

Our data confirm the short-term efficacy of amitriptyline and cyclobenzaprine in a small percentage of patients with fibromyalgia. Long-term efficacy could not be demonstrated because of a higher-than-expected placebo response. Predictors of response to these drugs could not be determined.

Drug abuse as a risk factor of multiple sclerosis: case-control analysis and a study of heterogeneity

The etiology of multiple sclerosis (MS) remains unknown despite considerable research involving a number of disciplines for many decades. Cluster analysis was used to disentangle the possible heterogeneity of MS, based on clinical characteristics of 108 subjects. Further on, a case-control study was conducted within each subgroup found with the cluster analysis, to test with more validity environmental risk factors, such as alcohol, tobacco, medication and drug abuse. The controls with a rheumatoid arthritis condition were matched to the cases on age, gender and same postdiagnostic period and were recruited from the same hospital. Three main groups of MS subjects were obtained from the cluster analysis, distinguished by the gender, the presence or not of family history and the degree of severity of their physical disability. The results showed that drug abuse was the only risk factor with a statistically significant odds ratio for overall and for the unique female group without familial history of MS.

Synovial membrane histology and immunopathology in rheumatoid arthritis and osteoarthritis. In vivo effects of antirheumatic drugs

We examined the histologic and immunopathologic features of the synovial membrane of 18 patients with rheumatoid arthritis (RA) and 12 patients with osteoarthritis (OA) who had undergone total knee arthroplasty. Patients were classified into 5 groups according to therapeutic regimen and disease: RA treated with nonsteroidal antiinflammatory drugs (NSAIDs), RA treated with NSAIDs and prednisone, RA treated with NSAIDs and methotrexate (MTX), OA treated with analgesics, and OA treated with NSAIDs. There were no significant between-group differences in the percentages or the distribution pattern of the infiltrating T cell subsets (CD4, CD8), HLA-DR, or interleukin-2 receptor-bearing cells. However, inflammatory indices, which included the thickness of the lining cell layer and the density of the mononuclear cell infiltrate, were significantly higher in the RA patients treated with prednisone and those treated with MTX (P less than 0.05). Similarly, fibrosis was markedly reduced in these 2 groups. The RA patients treated with NSAIDs alone and the 2 groups of patients with OA demonstrated similar profiles. These data suggest that prednisone and MTX may inhibit the development of fibrosis without altering the subsets of the inflammatory cell population. This observation raises the possibility that the action of these 2 drugs may be partly mediated by the suppression of inflammatory mediators that are responsible for fibroblast activation.

Clinical evaluation of a new controlled-release formulation of naproxen in osteoarthritis and rheumatoid arthritis. Canadian Multicentre Study Group

A two-part multi-centre study was carried out to assess the efficacy and tolerability of a new controlled-release (CR) naproxen tablet in the treatment of osteoarthritis and rheumatoid arthritis. Patients already receiving naproxen on a regular basis were first enrolled in a 6-week randomized double-blind trial comparing the controlled-release tablet (750 mg or 1000 mg once-a-day) to the standard marketed tablet (375 mg or 500 mg twice-a-day). At the end of this phase, patients in both treatment groups were eligible to enter the long-term phase involving 28 weeks of open-label treatment with controlled-release naproxen at the previously established dose level (750 mg or 1000 mg once-a-day). A total of 404 patients entered the initial double-blind phase, 320 of whom continued into the open-label phase. Twenty-nine (14%) naproxen patients and 23 (11%) naproxen CR patients were withdrawn prematurely from the double-blind phase, 87 (27%) patients from the open-label phase. Parameters of efficacy and tolerability were evaluated at base-line, during the double-blind phase (after 3 and 6 weeks of treatment), and during the open-label phase (after 20 and 34 weeks of treatment). The entire study population showed significant improvements in overall disease activity and severity of pain, but with no statistically or clinically significant differences between the two treatment groups; nor were there significant differences among treatments in incidence of adverse events. The patients treated with naproxen CR for an additional 28 weeks showed either no change or continued improvement in arthritic symptoms and no signs of toxicity. It was concluded that, in osteoarthritis and rheumatoid arthritis patients, once-a-day controlled-release naproxen tablets can be substituted for standard naproxen tablets without loss of efficacy or tolerability.

Dose-dependent suppression by the synthetic retinoid, 4-hydroxyphenyl retinamide, of streptococcal cell wall-induced arthritis in rats

We studied the effects of oral administration of the retinoid, 4-hydroxyphenyl retinamide (4-HPR), on group A streptococcal cell wall-induced polyarthritis in the rat, a model characterized initially by exudative inflammation of peripheral joints followed by chronic proliferative/erosive synovitis. Experimental arthritis was induced in female LEW/N rats by i.p. injection of streptococcal cell walls in saline (15 micrograms/g body weight). Depending upon the experiment, continuous daily oral administration of the retinoid was begun either 14 days prior to induction of the disease, at the time of cell wall administration and/or 11 days and 31 days after cell wall injection. Dosage was either 1 or 2 mmol 4-HPR/kg of chow. During the course of the disease, severity of clinical illness was assessed by determination of clinical severity index, by histological or radiologic examination, and by measurement of production in vitro of collagenase and prostaglandin E2 by excised synovial tissue. In rats fed the retinoid prior to cell wall injection, both the acute and the chronic responses were suppressed. In rats given the retinoid at the time of cell wall injection, the acute inflammatory response was only partially suppressed on the diet containing 2 mmol 4-HPR/kg chow, but the chronic disease was impressively inhibited in a dose dependent manner. Similarly, in animals with established disease, the drug was also effective; however, the more advanced the illness, the less effective the drug. Clinical observations were paralleled by the histological, radiographical and biochemical analyses. Treated animals showed far less synovial proliferation and joint destruction, and synovial tissues taken from these rats produced lesser amounts of collagenase and prostaglandin E2. No significant toxicity of the retinoid was noted. We conclude that oral administration of 4-HPR suppresses, in a dose and time dependent manner, both the acute and chronic stages of streptococcal cell wall-induced arthritis in rats without apparent significant toxicity. Our data suggest that studies of the effects of this retinoid on patients with chronic inflammatory synovitis are warranted.

NIH conference. Rheumatoid arthritis: evolving concepts of pathogenesis and treatment

Rheumatoid arthritis is a chronic inflammatory synovitis that primarily involves peripheral diarthrodial joints. Immunohistologic analysis of diseased synovium has shown a spectrum of abnormalities that resemble various stages of a cell-mediated, or delayed-type, immune reaction. The infiltrating mononuclear cells produce various factors that modulate adjacent tissues and appear to produce the characteristic destructive features of the disorder. Our understanding of the mechanisms of action of various therapeutic modes also indicates that the disease is primarily mediated by activated mononuclear cells. All effective therapies have been shown to affect either mononuclear cell function or the rates of production or elimination of these cells. The disorder likely represents the pathologic expression of a genetically controlled host immune response to an undefined causative stimulus. The stimulus could be an infectious agent(s), a product(s) derived from an infectious agent(s), a constituent(s) of synovial or connective tissue, or a combination of these.

Immune function in severe, active rheumatoid arthritis: a relationship between peripheral blood mononuclear cell proliferation to soluble antigens and mononuclear cell subset profiles

We have previously reported that patients with active rheumatoid arthritis and depressed in vitro peripheral blood mononuclear cell proliferation to soluble recall antigens (anergic subgroup) improve clinically after repeated short-term leukapheresis, whereas patients with normal responses (nonanergic subgroup) do not. This observation prompted us to examine the mononuclear cell subset profiles in the peripheral blood of anergic and nonanergic seropositive rheumatoid arthritis patients with severe, active, clinically similar disease not taking long-acting anti-rheumatic drugs. In the present study, 42 patients were categorized as anergic (n = 14) or nonanergic (n = 28) on the basis of in vitro peripheral blood mononuclear cell proliferation to soluble recall antigens. The anergic patients had a decreased frequency of OKT4+ mononuclear cells (p less than 0.01), and an increased frequency of OKT8+ cells (p less than 0.02), with a lower OKT4+ :OKT8+ ratio (p less than 0.01) than the nonanergic patients. Anergic patients also had a higher frequency of HLA-DR+ mononuclear cells and HLA-DR+ T cells (p less than 0.001). About 50% of the OKT8+ cells were HLA-DR+, whereas only about 20% of the OKT4+ population expressed HLA-DR antigens. These data suggest that the decreased lymphocyte function described in the anergic patient subgroup is associated with characteristic peripheral blood mononuclear cell subset profiles. Moreover, when considered in the context of other data indicating that anergic patients have characteristic synovial immunopathologic abnormalities, these data provide insight into potential pathogenic mechanisms of this disorder.

Immune function in severe, active rheumatoid arthritis: a relationship between peripheral blood mononuclear cell proliferation to soluble antigens and mononuclear cell subset profiles

We have previously reported that patients with active rheumatoid arthritis and depressed in vitro peripheral blood mononuclear cell proliferation to soluble recall antigens (anergic subgroup) improve clinically after repeated short-term leukapheresis, whereas patients with normal responses (nonanergic subgroup) do not. This observation prompted us to examine the mononuclear cell subset profiles in the peripheral blood of anergic and nonanergic seropositive rheumatoid arthritis patients with severe, active, clinically similar disease not taking long-acting anti-rheumatic drugs. In the present study, 42 patients were categorized as anergic (n = 14) or nonanergic (n = 28) on the basis of in vitro peripheral blood mononuclear cell proliferation to soluble recall antigens. The anergic patients had a decreased frequency of OKT4+ mononuclear cells (p less than 0.01), and an increased frequency of OKT8+ cells (p less than 0.02), with a lower OKT4+ :OKT8+ ratio (p less than 0.01) than the nonanergic patients. Anergic patients also had a higher frequency of HLA-DR+ mononuclear cells and HLA-DR+ T cells (p less than 0.001). About 50% of the OKT8+ cells were HLA-DR+, whereas only about 20% of the OKT4+ population expressed HLA-DR antigens. These data suggest that the decreased lymphocyte function described in the anergic patient subgroup is associated with characteristic peripheral blood mononuclear cell subset profiles. Moreover, when considered in the context of other data indicating that anergic patients have characteristic synovial immunopathologic abnormalities, these data provide insight into potential pathogenic mechanisms of this disorder.

Isolation of human mononuclear cell subsets by counterflow centrifugal elutriation (CCE). I. Characterization of B-lymphocyte-, T-lymphocyte-, and monocyte-enriched fractions by flow cytometric analysis

Rapid separation of large numbers of human peripheral blood mononuclear cells into fractions enriched for B lymphocytes, T lymphocytes, or monocytes was accomplished by counterflow centrifugal elutriation (CCE). The first fraction contained 98% of the platelets. Ten additional fractions containing subpopulations of mononuclear cells were collected by sequential increases in the flow rate while maintaining a constant centrifuge speed. Analysis of the fractions using monoclonal antibodies revealed that fraction 2, which was free of esterase-positive monocytes, was highly enriched for B cells. T lymphocytes (OKT3+) were the predominant cell type found in fraction 4. No enrichment for T-lymphocyte-helper (OKT4+) or -suppressor (OKT8+) subpopulations was observed in the lymphocyte containing fractions. Three fractions (7-9), highly enriched for esterase-positive cells, were predominantly OKM1+ monocytes with no evidence of selective separation of monocyte subpopulations. Thus, cell fractions enriched for B cells, T cells, and monocytes could be obtained, by utilizing CCE, in large enough quantities to enable analysis of their functional properties. Of particular interest was the ability to separate small, resting B lymphocytes from monocytes.

Leukapheresis and pathogenetic mechanisms in rheumatoid arthritis

Rheumatoid Arthritis is a chronic, usually progressive inflammatory disorder of joints in which the immune system plays a central role in the pathogenesis. In its classic form, the synovial tissues from severely affected joints are densely infiltrated with HLA-DR bearing T-lymphocytes (primarily OKT4+/Leu3+ subset) and macrophage-like cells. Moreover, these tissues, as demonstrated by ex vivo culture, spontaneously produce high levels of a multitude of inflammatory mediators, such as collagenase, PGE2, interleukin 1 and fibroblast activating factors, indicating that the cells infiltrating the synovium are "activated". The action of these various inflammatory mediators on different target substances or cells (collagen, fibroblasts, chondrocytes, osteoclasts, etc.) most likely produce the characteristic pattern of joint pathology. Recent data indicate that this classic form of synovitis tends to be associated with peripheral anergy and other qualitative and quantitative abnormalities in the peripheral blood mononuclear cells. Repeated leukapheresis can induce substantial, although transient, clinical improvement in patients with these classic features, probably as a consequence of disrupting T-lymphocyte traffic. Rheumatoid synovitis, however, is highly heterogeneous, but can be categorized into subsets. For example, a subset of patients with highly active clinical rheumatoid arthritis exists which do not exhibit the classic features of disease. Synovial tissues from this patient subset are sparsely infiltrated by T-lymphocytes but contain mainly macrophages and fibroblasts, as well as prominent lining layer fibrin deposition.(ABSTRACT TRUNCATED AT 250 WORDS)

Simultaneous multifocal sarcomatous degeneration in Paget's disease of bone. A hypothesis

Multisite pagetic sarcoma was present in three of 18 patients with pagetic sarcomas treated during a 12-year period at two centers. A hypothesis of multifocal origin of the tumor is supported by the sarcoma arising only in pagetic bone, the infrequency of metastases to bone, evidence of multiple sites at presentation, and the rarity of new lesions developing in bone under observation. Survival was shorter with multisite disease than with other pagetic sarcomas.