The Benefit/Risk Profile of TNF-Blocking Agents: Findings of a Consensus Panel

Duration of chronic toxicity studies for biotechnology-derived pharmaceuticals: is 6 months still appropriate?

For chronic use biotechnology-derived pharmaceuticals, toxicity studies of 6 months have generally been accepted for regulatory approval. This review assessed the data for 23 approved biotechnology-derived pharmaceuticals to determine whether the studies conducted were predictive of human safety and whether there is new data from approved products indicating that longer than 6 months is necessary. This assessment involved three approaches; whether new toxicities were identified at >6 months, similarity of findings between 6 months and shorter studies and predictivity of clinical adverse events. In two cases there were apparently new findings in studies >6 months. On examination however, one of these cases was a well established risk with foreign protein administration to animals (adalimumab). For insulin aspart, the 12 month study identified tumors not seen in shorter term studies, however, determination of carcinogenic potential is not a goal of chronic toxicity studies and is addressed by separate studies. In most cases the toxicology studies were predictive of common clinical adverse reactions, but were poorly predictive of rare clinical events or some serious adverse reactions. Although specific circumstances may require a longer study, this review indicates no new data is available to refute the utility of 6 month studies to support chronic clinical dosing with biotechnology-derived pharmaceuticals.

Coccidioidomycosis pneumonia in a nonendemic area associated with infliximab

Tumor necrosis factor (TNF) inhibitors, such as infliximab, are highly effective in the management of rheumatoid arthritis; however, these agents are associated with an increased risk of infectious complications. Individuals developing coccidiomycosis pneumonia frequently acquire this while residing in endemic regions. We present a patient with rheumatoid arthritis treated with infliximab who developed acute respiratory distress syndrome (ARDS) from coccidiomycosis pneumonia while residing in a non-endemic region near the Texas-Louisiana border and was successfully treated with antifungal therapy. The source for coccidiomycosis was suspected to be from inhalation of pulverized rock dust imported from Arizona. Patients treated with TNF inhibitors may acquire coccidiomycosis infection through fomite dust exposure.

Interferon γ assay for detecting latent tuberculosis infection in rheumatoid arthritis patients during infliximab administration

In rheumatoid arthritis (RA) patients treated with infliximab (IFX), QuantiFERON-TB Gold (QFT-G), an interferon gamma assay for diagnosing tuberculosis infection, was performed to compare its effectiveness to conventional diagnostic procedures (tuberculin skin test, imaging and medical history) in diagnosing latent tuberculosis infection (LTBI). QFT-G was measured bimonthly in 14 rheumatoid arthritis patients during IFX treatment. Seven of 14 patients were confirmed as LTBI positive by at least one method. Of these, four were positive on QFT-G during the study period, and two were positive before the start of IFX administration. For two of the four QFT-G-positive patients, LTBI was diagnosed only by QFT-G. The rate of agreement between QFT-G and conventional procedures was 64.3%. A total of 5% of QFT-G tests were impossible to judge due to decreased reactions in the positive control. These results suggest that QFT-G is able to detect LTBI in RA patients overlooked by conventional methods. Conventional procedures and QFT-G should be employed in parallel, and LTBI should be assumed when one technique gives a positive result.

Potential Complications Associated with the Use of Biologic Agents for Psoriasis

The biologic agents are effective drugs to treat psoriasis. They provide physicians with additional options for patients who cannot tolerate traditional therapies or for whom traditional therapies are not sufficient. While these new TNF-alpha inhibitors and anti-T-cell agents have potential complications, they are generally safe with proper monitoring. Both physicians and patients should be aware of the risks involved with each medicine so that the correct drug is chosen to suit each patient.

Gene expression profiling of rheumatoid arthritis synovial cells treated with antirheumatic drugs

Nonbiological therapeutics are frequently used for the treatment of patients with rheumatoid arthritis (RA). Because the mechanisms of action of these therapeutics are unclear, the authors aimed to elucidate the molecular effects of typical antirheumatic drugs on the expression profile of RA-related genes expressed in activated synovial fibroblasts. For reasons of standardization and comparability, immortalized synovial fibroblasts derived from RA (RASF) and normal donors (NDSF) were treated with methotrexate, prednisolone, or diclofenac and used for gene expression profiling with oligonucleotide microarrays. The cytotoxicity of the antirheumatic drugs was tested in different concentrations by MTS tetrazolium assay. Genes that were differentially expressed in RASF compared to NDSF and reverted by treatment with antirheumatic drugs were verified by semiquantitative polymerase chain reaction and by chemiluminescent enzyme immunoassay. Treatment with methotrexate resulted in the reversion of the RA-related expression profile of genes associated with growth and apoptosis including insulin-like growth factor binding protein 3, retinoic acid induced 3, and caveolin 2 as well as in the re-expression of the cell adhesion molecule integrin alpha6. Prednisolone reverted the RA-related profile of genes that are known from inflammation and suppressed interleukins 1beta and 8. Low or high doses of diclofenac had no effect on the expression profile of genes related to RA in synovial fibroblasts. These data give the first insight into the mechanisms of action of common antirheumatic drugs used for the treatment of arthritides. Synovial fibroblasts reflect the disease-related pathophysiology and are useful tools for screening putative antirheumatic compounds.

Abatacept in the treatment of rheumatoid arthritis

Over the past decade, biological immunotherapy has revolutionised the treatment of rheumatoid arthritis (RA). The most widely used of these therapies targets tumour necrosis factor-alpha (TNF-alpha). Approximately 20% of patients fail to respond to TNF-alpha antagonism, however, and a significant number of additional patients become refractory to anti-TNF-alpha therapy over time. Thus investigators have sought to target other pathogenic elements of RA using novel biological therapies. Abatacept is the first immunotherapy directed against the process of T-cell costimulation. Abatacept has shown clinical effectiveness in RA by improving disease activity, quality of life measures and radiographic progression of disease. In this article, we review the immunology of T-cell activation and costimulation, define the role of abatacept in this process, and discuss the clinical trials that led to the approval of abatacept as the latest biological therapy in RA in the USA and Canada. We also address the role of abatacept in the greater context of biological therapy for RA.

Adalimumab alone and in combination with disease-modifying antirheumatic drugs for the treatment of rheumatoid arthritis in clinical practice: the Research in Active Rheumatoid Arthritis (ReAct) trial

OBJECTIVE

To evaluate the safety and effectiveness of adalimumab alone or in combination with standard disease-modifying antirheumatic drugs (DMARDs) for the treatment of rheumatoid arthritis (RA).

METHODS

Patients with active RA despite treatment with DMARDs or prior treatment with a tumour necrosis factor antagonist participated in a multicentre, open-label clinical study of adalimumab 40 mg every other week for 12 weeks with an optional extension phase. Patients were allowed to continue with pre-existing traditional DMARDs. Long-term safety results are reported for all patients (4210 patient-years (PYs) of adalimumab exposure). The observed effectiveness results at week 12 are reported using American College of Rheumatology (ACR) and European League Against Rheumatism (EULAR) response criteria.

RESULTS

Among the 6610 treated patients, adalimumab was generally well tolerated. Serious infections occurred in 3.1% of patients (5.5/100 PYs, including active tuberculosis, 0.5/100 PYs). Demyelinating disease (0.06%) and systemic lupus erythematosus (0.03%) were rare serious adverse events. The standardised incidence ratio of malignancy was 0.71 (95% CI 0.49 to 1.01). The standardised mortality ratio was 1.07 (95% CI 0.75 to 1.49). At week 12, 69% of patients achieved an ACR20 response, 83% a moderate, and 33% a good EULAR response. Adalimumab was effective in combination with a variety of DMARDs. The addition of adalimumab to antimalarials was comparably effective to the combination of adalimumab and methotrexate.

CONCLUSIONS

Considering the limitations of an open-label study, adalimumab alone or in combination with standard DMARDs appeared to be well tolerated and effective in 6610 difficult-to-treat patients with active RA treated in clinical practice.

Treatment of Proliferative Lupus Nephritis—A Critical Approach

OBJECTIVES

To discuss the current management of proliferative lupus nephritis (PLN), with a focus on strategies to improve long-term outcome and reduce treatment toxicity while minimizing the risk of relapse.

METHODS

The literature on treatment strategies used in systemic lupus erythematosus (SLE) and PLN from 1975 to 2006, using PubMed from the National Library of Medicine, was reviewed.

RESULTS

The high efficacy of the standard therapeutic regimen of PLN, traditionally associating cyclophosphamide (CYC) with corticosteroids (CS), has markedly ameliorated the prognosis of the disease, with more than 80% of patients achieving complete or partial remission. The ameliorated renal prognosis has positively influenced the general survival rates. Ten-year survival rates now surpass 75% and continue to improve. In view of the improved survival, the major aims of treatment now include preventing long-term organ damage and minimizing treatment toxicity, which can contribute significantly to the chronic morbidity and mortality of lupus. A number of high-quality trials have been reported, making us more confident of the value of different immunosuppressive protocols, and several novel immunosuppressive drugs are still under investigation.

CONCLUSION

Recent basic and clinical research has enormously improved our understanding of the pathogenesis of SLE and has suggested new, targeted approaches to therapy. These targeted novel therapies are expected to help the patients with PLN in the next decade.

Acute paraplegia after the initiation of anti-tumour necrosis factor-alpha therapy for Crohn's disease

Therapies aimed at inhibiting tumour necrosis factor are currently successfully administered to an increasing number of patients with autoimmune diseases. Infliximab has been approved to induce and maintain remission in Crohn's disease and fistulizing Crohn's disease. We report a case of acute-onset flaccid paraplegia after the initiation of anti-tumour necrosis factor therapy (infliximab) for Crohn's disease. Neuroimaging findings revealed an extensive longitudinal myelopathy. Two months later, no abnormal signal intensity was observed in the spinal cord and after 4 months, the patient presented improvement of motor function. A possible correlation between anti-tumour necrosis factor therapy and acute myelitis is discussed. This case highlights that patients developing new neurological symptoms while on anti-tumour necrosis factor medication should be monitored closely.

New Therapeutic Approaches for Multiple Sclerosis

Although several therapies exist for multiple sclerosis (MS), the most common inflammatory demyelinating disease of the central nervous system (CNS), there remains a large unmet clinical need for more effective immunomodulatory treatments in this category of diseases and for interventions that address their neurodegenerative component, which is currently untreated. Progress in our understanding of the immunology of MS over the past 30 years has recently synergized with novel computational methods and emerging high-throughput technologies that characterize variations in DNA, RNA, proteins, and metabolites to usher in a period of intense pathophysiologic investigation. These efforts are beginning to define subsets of patients with different forms of demyelinating disease. This partitioning of patients will prove valuable as we begin to tailor immunotherapy to the underlying pathophysiologic processes of individual patients using current therapies, emerging treatments, and rational combinations of all of these treatments. Preventing the entry of lymphocytes into the CNS and modifying the nature of the immune response are treatment approaches that work in the inflammatory component of MS but have little or no effect on neurodegeneration. Two challenges confront us: to develop cocktails of therapies that shift the immune homeostasis of patients with MS toward a healthy profile, and to identify and modulate the activity of targets within the neurodegenerative component of MS.

Clinical Applications of the Polymerase Chain Reaction: An Update

The development, in the past decade, of nucleic acid amplification and detection methods is useful in the study of the etiopathogenesis, diagnosis, and management of a variety of clinical (including rheumatologic) disorders. An association between infectious agents and rheumatic disorders has been established through such methods as polymerase chain reaction. This article describes the principles behind polymerase chain reaction-based diagnosis and updates its clinical applications. It is beyond the scope of this article, however, to describe other nucleic acid amplification methods or to include a complete list of all polymerase chain reaction assays that have been developed. Other recent reviews offer additional details.

Treatment of immune-mediated extraintestinal manifestations of inflammatory bowel disease with infliximab

The introduction of infliximab into clinical practice is one of the most significant advances in the care of patients who have IBD. Infliximab has become an important part of the medical armamentarium to treat extraintestinal manifestations that often are refractory to other medications and are a significant cause of morbidity in these patients. Two other TNF inhibitors recently have demonstrated efficacy in CD: certolizumab pegol and adalimumab. The Food and Drug Administration has approved adalimumab for use in RA. One predicts that these agents also may have activity in the extraintestinal manifestation for IBD. To determine whether future biologics are effective in the EIM of IBD, one may need to look no further than the vast clinical trial experience in primary chronic inflammatory diseases of the joints and skin: RA and psoriasis. For example, the Food and DRug Administration recently has approved an anti-B-cell therapy, rituximab, and a T-cell costimulation modulator, abatacept, for use in RA. It certainly will be of interest to determine whether these biologic agents demonstrate efficacy in the intestinal and EIM of IBD.

Infliximab use in luminal Crohn's disease

Infliximab has been available in the United States and Europe for more than 6 years, and its use has revolutionized the care of patients who have CD. It is used effectively for both the induction and maintenance of remission in patients who have CD and is efficacious in patients who have steroid-dependent/refractory CD and those who have fistulizing CD. Clinical trials and practice have shown infliximab to be safe, effective, and generally well tolerated. The ACCENT I and ACCENT II trials defined the best dosing and schedule regimens for its administration. With up to 30% of patients not responding to infliximab therapy, much attention has been devoted to identifying risk factors that could allow optimization of response rates. Parsi and colleagues and Arnott and colleagues demonstrated that nonsmoking and the concurrent use of immunomodulators are predictors of response to infliximab. Research has also focused on identifying biologic and immunologic markers that may correlate with response to infliximab. To date, N0D2/CARD15, anti-Saccharomyces cerevisiae antibody (ASCA), and antineutrophil cytoplasmic antibody (ANCA) have not been shown to be predictive of outcome with infliximab treatment for CD. Gene polymorphisms also are being studies with the hope that knowing the patient's genotype may help predict the course or severity of the disease, including the presence of extraintestinal manifestations, response to treatments, and susceptibility to toxicities. No single variable, however, has been consistently demonstrated to be a predictor of response to infliximab. The formation of ATIs in a small number of patients creates a clinical dilemma. ATIs have been associated with an attenuated response or loss of response to the medication over time and the development of both acute and delayed infusion reactions that occasionally are severe enough to lead to discontinuation of the medication. In such patients physicians are often left to ponder what therapy to try next. Adalimumab, a fully human monoclonal antibody used for treating rheumatologic conditions, has been investigated as an alternate treatment for patients who have CD who, after initially responding to infliximab, experience intolerance or loss of efficacy. Two studies have examined the use of adalimumab in patients who have active CD who had lost response to or developed intolerance to infliximab. In both these studies adalimumab was well tolerated and seemed to be a clinically beneficial option for such patients. Confirmation of these findings with ongoing randomized, double-blind, placebo-controlled trials is needed, however. The limits of conventional treatment for CD can be seen as a positive evolutionary force favoring the development and use of advanced therapies. The acceptance of antimetabolites began with data published a quarter-century ago and became robust in the past 5 to 10 years. Biologic therapy has become the standard of care at a far faster rate. The success seen with infliximab has broadened the acceptance of biologic therapy among professional peers, patients, and pharmaceutical developers. The lessons learned in the years since infliximab's arrival show the importance of long-term data in revealing important toxicities and best practices for maintenance. Tempered by this experience, the short cycle from concept to drug production possible with biologic therapies should bring even more advanced treatments to patients quickly while investigators work to find a cure.

Low-level laser therapy can reduce lipopolysaccharide-induced contractile force dysfunction and TNF-alpha levels in rat diaphragm muscle

Our objective was to investigate if low-level laser therapy (LLLT) could improve respiratory function and inhibit tumor necrosis factor (TNF-alpha) release into the diaphragm muscle of rats after an intravenous injection of lipopolysaccharide (LPS) (5 mg/kg). We randomly divided Wistar rats in a control group without LPS injection, and LPS groups receiving either (a) no therapy, (b) four sessions in 24 h with diode Ga-AsI-Al laser of 650 nm and a total dose of 5.2 J/cm2, or (c) an intravenous injection (1.25 mg/kg) of the TNF-alpha inhibitor chlorpromazine (CPZ). LPS injection reduced maximal force by electrical stimulation of diaphragm muscle from 24.15+/-0.87 N in controls, but the addition of LLLT partly inhibited this reduction (LPS only: 15.01+/-1.1 N vs LPS+LLLT: 18.84+/-0.73 N, P<0.05). In addition, this dose of LLLT and CPZ significantly (P<0.05 and P<0.01, respectively) reduced TNF-alpha concentrations in diaphragm muscle when compared to the untreated control group.

A severe case of chronic infantile neurologic, cutaneous, articular syndrome treated with biologic agents

In this report we describe a case of severe chronic infantile neurologic, cutaneous, articular (CINCA) syndrome with a novel G307V cryopyrin mutation and all of the characteristic clinical and laboratory features of this autoinflammatory disease. There was no clear response to standard therapies, including human interleukin-1 (IL-1) receptor antagonist (anakinra) and soluble tumor necrosis factor receptor (etanercept). The patient finally had a partial clinical response (reduction in fever and irritability) and complete laboratory response (improved C-reactive protein and serum amyloid A levels) to humanized anti-IL-6 receptor antibody (MRA), but died from congestive heart failure and interstitial pneumonia 2 months after initiation of therapy. We serially measured the serum cytokine levels and expression of NF-kappaB activation in the patient's peripheral blood mononuclear cells before and during consecutive therapies. Pathologic examination of autopsy specimens was also performed. This case illustrates the continued difficulty in management of patients with CINCA syndrome and the complexity of the inflammatory pathways in this disorder.

Etanercept in severe active rheumatoid arthritis: first Australian experience

BACKGROUND

Etanercept reduces disease activity in adults with chronic rheumatoid arthritis (RA) who are resistant to other therapies. Medicare Australia Pharmaceutical Benefit Scheme subsidized treatment (since August 2003) restricts etanercept availability to a most drug-resistant RA population. The aim of the study was to assess the efficacy of etanercept in this unique group after 12 months of therapy.

METHODS

A prospective study of the first 50 consecutive private practice, adult RA patients whom were commenced on etanercept. The primary efficacy measures included short form 36 scores, Disease Activity Score 28, American College of Rheumatology (ACR) response improvement in per cent and the ACR individual core set components at baseline, 3 and 12 months. Analysis was by intention to treat.

RESULTS

There was significant improvement in all mean short form 36 component scores (P < 0.05) and all ACR core set component scores (P < 0.05) comparing 12 months to baseline. The disease activity score 28 also significantly fell from baseline at both 3 and 12 months (P < 0.05). The ACR 20% response significantly improved (P < 0.05) both at baseline to 3 months 92% (81.2, 96.9) and to 12 months 80% (67.0, 88.8). Serious adverse events occurred in 16%. At 12 months 88% completed treatment.

CONCLUSION

Etanercept therapy will, by 3 and 12 months, significantly improve the short form 36, disease activity score 28, ACR 20% response and core set components. Our results are similar to international studies using etanercept in efficacy and tolerance despite our cohort being more resistant to preceding drug therapy. Etanercept offers this unique active severe refractory late RA Australian population a new therapeutic option to control their disease.

Development of human–human hybridoma from anti-Her-2 peptide–producing B cells in immunized NOG mouse

OBJECTIVE

Numerous monoclonal antibodies have been developed for the purpose of medical treatments, including cancer treatment. For clinical application, the most useful are human-derived antibodies. In this study, we tried to prepare designed antigen-specific antibodies of completely human origin using immunodeficient mouse.

METHODS

Nonobese diabetic/severe combined immunodeficient/IL-2 receptor gamma null mouse (NOG) mouse was used to reconstitute the human immune system with umbilical cord blood hematopoietic stem cells (CB-NOG mouse) and to prepare human-derived Her-2-epitope-specific antibodies. Hybridoma lines were prepared by fusing the human myeloma cell line Karpas707H.

RESULTS

Serum of immunized NOG mouse contained human-derived immunoglobulin M (IgM) antibodies specific for a short peptide sequence of 20 amino acids, including the epitope peptide of apoptotic Her-2 antibody CH401. Hybridoma lines were successfully prepared with spleen B cells obtained from the immunized CB-NOG mouse. One of these cell lines produced human IgM against the epitope peptide that can recognize surface Her-2 molecule.

CONCLUSION

We could produce human-derived IgM antibody against Her-2 epitope peptide in CB-NOG mouse, succeeding in generation of human hybridoma-secreting IgM against a given peptide.

Treatment of rheumatoid arthritis with rituximab: An update and possible indications

Based on new biologic and clinical insights, the number of drugs blocking different biologic targets in rheumatoid arthritis (RA) [e.g., tumor necrosis factor alpha (TNFalpha), CTLA4, interleukin (IL)-1, IL-6, IL-15, IL-18, B lymphocyte stimulator (BLyS), CD20] has increased considerably over the last decade. Rituximab, a chimeric monoclonal antibody that was developed for the treatment of B-cell lymphomas, has been used in different autoimmune diseases where B-cells are thought to play a pivotal role. However, blinded randomised controlled trials have been completed only for RA so far, indicating the clear efficacy of B-cell blockade in RA and highlighting the pathogenetic B-cell in rheumatoid synovitis. The use of rituximab in RA is herein updated, from early preliminary studies to more recent presentations in International Conferences. Key clinical and biologic issues are discussed, i.e., efficacy and safety of rituximab, role of concomitant therapies, use in the long term and retreatment strategies, differences with anti-TNFalpha therapy. The possible indications in RA are finally discussed, also on the ground of personal experience with rituximab in RA and other rheumatic diseases associated with B-cell lymphoproliferation. Further clinical research should go hand in hand with laboratory research, and tissue studies are now needed.

Biologic therapies for inflammatory eye disease

The era of biologic medical therapies provides new options for patients with treatment-resistant inflammatory eye disease. In this review, the authors summarize current published experience in a rapidly progressing clinical field, including the use of biologics, such as the tumour necrosis factor blockers, daclizumab and rituximab, and related agents, interferons and intravenous immunoglobulin, for the treatment of uveitis, scleritis and orbital inflammation. Reports of dramatic recoveries in patients with recalcitrant ocular inflammation who have received such therapies must be balanced against the high cost of biologics and the potential for serious, and at times unanticipated, complications of this treatment.

Pulmonary infectious complications associated with anti-TNFalpha therapy (infliximab) for rheumatoid arthritis

Two patients with rheumatoid arthritis (RA) that developed serious infectious complications following anti-TNFalpha therapy (infliximab) are reported. Patient 1 developed tuberculosis with high fever, refractory diarrhea and mediastinal lymphadenopathy. Trans-bronchial needle biopsy was useful to confirm the diagnosis. Patient 2 showed sudden onset of dyspnea with diffuse bilateral lung infiltration caused by pneumocystis jiroveci pneumonia and the diagnosis was confirmed by broncho-alveolar lavage. Physicians should be alerted to infectious complications with atypical presentation and rapid progression in infliximab-treated patients. Invasive diagnostic procedures including fiber-optic bronchoscopy may be necessary early in the course for such cases.

Early Rheumatoid Arthritis

The treatment of rheumatoid arthritis (RA) has changed dramatically in the past decade as advancements in the understanding of the pathobiology of the disease have led to novel therapeutic agents. The recognition that early diagnosis and treatment leads to improvements in morbidity and mortality has altered the therapeutic strategy such that early therapy is now considered the standard of care. This review focuses on the challenges in making the diagnosis of early RA, including a broad differential diagnosis for inflammatory polyarthritis, poor performance of the standard classification criteria, difficulty in clinical assessment of synovitis, absence of absolute laboratory tests, inability of conventional radiography to detect bony changes early, and barriers to rheumatology care. Additionally, the pathogenesis of RA is highlighted, with particular emphasis on cytokine biology as it relates to therapeutic regimens. Relevant clinical trials in early RA are reviewed and discussed, including trials of combination disease-modifying antirheumatic drugs and biological therapy. The role of induction therapy as a novel therapeutic approach is highlighted. The search for predictors of response is reviewed and the external validity of the trials is analysed. Finally, the trials in early RA therapy suggest that swift intervention with combinations of medications is required for patients with severe RA. However, further research is needed to determine which regimen is appropriate for the individual patient with RA.

Atypical CD8+ Cutaneous T-Cell Lymphoma After Immunomodulatory Therapy

Systemic immunomodulatory agents have recently been approved for the treatment of rheumatoid arthritis and psoriasis. Although lymphomas are known to emerge in the setting of immunosuppressive therapy, it has not been well described or established for the newer biologic immune response modifiers. Herein, we describe 2 patients who developed unusual CD8+ cutaneous lymphoproliferative disorders after treatment with efalizumab and infliximab. The mechanisms and occurrence of lymphoma after immune response modifiers are discussed.

Infliximab treatment does not induce organ-specific or nonorgan-specific autoantibodies other than antinuclear and anti-double-stranded DNA autoantibodies in Crohn's disease

BACKGROUND

Treatment of Crohn's disease (CD) by infliximab has been associated with the induction of antinuclear (ANA) and anti-double stranded DNA (dsDNA) autoantibodies. As yet, little is known about the effect of the humoral response induced by infliximab on the production of other organ-specific or nonorgan-specific autoantibodies.

METHODS

Thirty-five patients with CD treated with repeated infusions of infliximab were prospectively studied. Thirty-two patients with CD who had never received infliximab served as controls. A large panel of autoantibodies directed against phospholipid, beta2-glycoprotein I, mitochondria, smooth muscle, liver--kidney microsomes, filaggrin, thyroid, adrenals, and rheumatoid factor was tested along with ANA and anti-dsDNA autoantibodies during 1 year of intermittent treatment with infliximab. Autoantibodies were detected using the appropriate methods (i.e., indirect immunofluorescence, a radioimmunological technique, and ELISA assays).

RESULTS

Induction of ANA and anti-dsDNA autoantibodies was observed in 53% and 35% of infliximab-treated patients with CD, respectively. Overall, no other organ-specific or nonorgan-specific autoantibodies were detected during follow-up. A single patient who developed ANA and anti-dsDNA autoantibodies showed clinical features consistent with drug-induced lupus, which quickly resolved after discontinuation of infliximab. The other patients with CD receiving infliximab did not develop any clinical symptoms of autoimmunity.

CONCLUSIONS

The humoral response induced by infliximab was restricted to ANA and anti-dsDNA autoantibodies, which persist for up to 1 year of follow-up. We confirmed the significant prevalence of such autoantibodies induced by infliximab in CD, but they are not generally associated with clinical signs of autoimmunity.

Update of tnf-alpha antagonists and cardiovascular disease in rheumatoid arthritis

Tumor necrosis factor-alpha (TNF-alpha) antagonists were unexpectedly found to have no beneficial effects in moderate-to-severe heart failure in two large randomized clinical trials. In certain doses, the agents were found to be harmful. These results have important implications for rheumatoid arthritis (RA). Patients with the disease have an increased risk for developing cardiovascular co-morbidity, including heart failure. Because of the beneficial effect of the TNF-alpha antagonists in the management of RA, these agents have gained widespread use. Rheumatologists and other physicians who provide care for RA are thus likely to encounter candidates for anti-TNF-alpha therapy who have overt or subclinical heart failure. Although data are currently not sufficient to support evidence-based recommendations, it is possible to make reasonable suggestions to guide clinical practice.

The therapeutic potential of RNA interference

In recent years, we have witnessed the discovery of a new mechanism of gene regulation called RNA interference (RNAi), which has revitalized interest in the development of nucleic acid‐based technologies for therapeutic gene suppression. This review focuses on the potential therapeutic use of RNAi, discussing the theoretical advantages of RNAi‐based therapeutics over previous technologies as well as the challenges involved in developing RNAi for clinical use. Also reviewed, are the in vivo proof‐of principle experiments that provide the preclinical justification for the continued development of RNAi‐based therapeutics.