Methylprednisolone infusion therapy in rheumatoid arthritis patients. The effect on synovial fluid lymphocyte subsets and inflammatory indices

Efficacy of methylprednisolone pulse therapy in children with rheumatoid arthritis

Pulse therapy is one of the most well-known methods used in the treatment of juvenile rheumatoid arthritis. This study assessed the outcome of methylprednisolone pulse therapy, its rate of efficacy, and its associated complications in patients with juvenile rheumatoid arthritis (JRA). This cross-sectional study was performed on 120 children with JRA who attended the Pediatric Ward of Imam Khomeini Hospital from 1994 to 2004 and who had undergone around 500 cycles of methylprednisolone pulse therapies. Clinical signs, including signs of improvement, complications, or recurrence of disease, were noted. SPSS version 11.5 and paired t test were used to compare the variables prior to and after treatment. Clinical signs observed included: feeling of weakness (100%), malaise (98.3%), loss of appetite (93.3%), fever (88.3%), skin rash (28%), lymphadenopathy (18.3%), serositis (4.2%), splenomegaly (3.3%), and hepatomegaly (1.7%); however, none of these findings were present after pulse therapy. The number of swollen and tender joints, duration of morning stiffness, erythrocyte sedimentation rate, C-reactive protein, and hemoglobin levels showed significant improvement after pulse therapy. Complications of pulse therapy included tachycardia (n = 16, 13.3%), hypertension (n = 10, 8.3%), headache (n = 2, 1.7%), and flashing (n = 2, 1.7%). The mean duration of remission was 3.3 +/- 0.7 months.

Oral pulsed dexamethasone therapy in early rheumatoid arthritis: a pilot study

Pulse therapy with high-dose glucocorticoids (GCs) is widely used as "bridging therapy" for the treatment of patients with active rheumatoid arthritis (RA). Oral pulsed dexamethasone therapy has never been used for this purpose. We determined the clinical efficacy of oral pulsed dexamethasone treatment in patients with early active RA, concomitantly starting with disease-modifying anti-rheumatic drugs (DMARDs). Fourteen early RA patients, glucocorticoid-naive and with active disease for less than 1 year were included. Ten patients were treated with oral pulsed dexamethasone therapy for 4 days in a row. Of this group, four patients received 10 mg dexamethasone/day, three patients 20 mg/day, and three patients 40 mg/day. As controls, four patients were treated with intramuscular methylprednisolone injections. Disease activity (ascertained by disease activity score [DAS]) and biochemical variables were measured at base line, and biweekly thereafter for up to 4 weeks, and monthly thereafter for up to 3 months. A decrease in disease activity, similar in all subgroups, was observed. Nine of 10 patients responded favorably (decrease in DAS of >1.2) 4 weeks after the start of the study. This response was sustained in the months thereafter. One patient did not respond at all, and disease progression during treatment was observed in one patient. No side effects were reported. Only once was a decrease in cortisol level observed; this was at 2 weeks after the start of the study (0.03 micromol/L, reference value 0.18-0.70 micromol/L). Oral pulsed dexamethasone therapy seems to be effective and safe as bridging therapy in early rheumatoid arthritis. The results of the present study justify a long-term controlled trial to compare oral pulsed dexamethasone treatment (10 mg dexamethasone, once weekly for 4 weeks) with the standard GC regimes in the near future.

Power Doppler ultrasound of rheumatoid synovitis: quantification of therapeutic response

The aim of this study is to quantify power Doppler assessment of therapeutic response in rheumatoid synovitis. 13 patients (6 male, 7 female) with rheumatoid arthritis, who had an acute exacerbation of small joint synovitis in the hands, were examined with quantitative power Doppler, before and after intravenous corticosteroid treatment. All patients were examined by a single radiologist, using an ATL HDI 5000 ultrasound machine (ATL, Boswell). The images were analysed using a specially developed software package (HDI Lab), which quantifies power Doppler signal. All patients improved clinically following treatment, which was reflected in functional disability scores, and in the C-reactive protein levels and erythrocyte sedimentation rate. In all cases, there was a significant decrease in synovial vascularity as measured by the mean amplitude of signal on quantitative power Doppler. Quantitative power Doppler may allow objective assessment of treatment in small joint synovitis.

The immune suppressive effect of dexamethasone in rheumatoid arthritis is accompanied by upregulation of interleukin 10 and by differential changes in interferon gamma and interleukin 4 production

OBJECTIVES

The influence of dexamethasone on interleukin 10 (IL10) production and the type 1 (T1)/type 2 (T2) T cell balance found in rheumatoid arthritis (RA) was studied.

METHODS

Peripheral blood mononuclear cells (PB MNC) were isolated from 14 RA patients both before and 7 and 42 days after high dose dexamethasone pulse therapy. The ex vivo production of IL10, interferon gamma (IFN gamma) (T1 cell), and IL4 (T2 cell) by PB MNCs was assessed, along with parameters of disease activity (erythrocyte sedimentation rate, C reactive protein, Visual Analogue Scale, Thompson joint score). In addition, the in vitro effect of dexamethasone (0.02, 0.2, and 2 microM) on PB MNC IL10, IFN gamma, and IL4 production was studied.

RESULTS

Dexamethasone pulse therapy resulted in a rapid and sustained decrease in RA disease activity. IL10 production increased after dexamethasone treatment and this was sustained for at least six weeks. A transient strong decrease in IFN gamma was seen shortly after corticosteroid treatment, while IL4 only decreased slightly. This led to an increased IL-4/IFN gamma ratio. In vitro, IL10 production was not detectable, IFN gamma and IL4 decreased, but the effect was more pronounced for IFN gamma than for IL4, which again resulted in an increased IL4/IFN gamma ratio.

CONCLUSION

Dexamethasone therapy in RA patients leads to a rapid, clinically beneficial effect. The upregulation of IL10 production may be involved in the prolonged clinical benefit. The strong immunosuppressive effect is most evident in the decrease in IFN gamma, and is therefore accompanied by a relative shift towards T2 cell activity. In vitro evaluation showed that this shift in T cell balance was a direct effect of dexamethasone and thus independent of the hypothalamic-pituitary-adrenal axis.

Leukocyte infiltration in synovial tissue from the shoulder of patients with polymyalgia rheumatica. Quantitative analysis and influence of corticosteroid treatment

OBJECTIVE

To investigate the immunologic features of synovitis in patients with polymyalgia rheumatica (PMR) and to assess the modifications induced by corticosteroids.

METHODS

Arthroscopic biopsies of shoulder synovium were obtained from 12 patients with untreated PMR and from 7 patients with PMR that had been treated. Immunohistochemistry was performed on frozen sections utilizing a panel of monoclonal antibodies and computerized image analysis.

RESULTS

Synovitis was present in 10 of 12 (83%) untreated patients and in only 2 of 7 (29%) treated patients. The synovitis was characterized by vascular proliferation and leukocyte infiltration. Infiltrating cells consisted predominantly of macrophages and T Lymphocytes. Almost all T lymphocytes were CD45RO positive. A few neutrophils, but no B cells, natural killer cells, or gamma/delta T cells were found. Intense expression of HLA class II antigens (DR moreso than DP moreso than DQ) was found in the lining layer cells as well as in macrophages and lymphocytes. DR, but not DP or DQ, was expressed by the endothelium of a few vessels. Class II antigen expression correlated with the number of macrophages and lymphocytes. Macrophage infiltration of arteriole walls was observed in 1 untreated patient without giant cell arteritis (GCA). In untreated patients, there was a positive correlation between the percentage of infiltrating T cells and the duration of disease. Steroid therapy was associated with a significant reduction in the number of blood vessels and of HLA class II expression. One treated patient who no longer had symptoms of PMR still had active synovitis: a relapse occurred 4 months after the biopsy.

CONCLUSION

Our findings support the hypothesis that synovitis is a major cause of the musculoskeletal symptoms of PMR. There are immunologic similarities with the vascular inflammation observed in GCA. Corticosteroids act on both the vascular and cellular components of synovitis.

Properties of four acute phase proteins: C-reactive protein, serum amyloid A protein, alpha 1-acid glycoprotein, and fibrinogen

Four plasma proteins, referred to as positive acute phase proteins because of increases in concentration following inflammatory stimuli, are reviewed: C-reactive protein (CRP), serum amyloid A protein (SAA), alpha 1-acid glycoprotein (AAG), and fibrinogen. The CRP and SAA may increase in concentration as much as 1000-fold, the AAG and fibrinogen approximately twofold to fourfold. All are synthesized mainly in the liver, but each may be produced in a number of extrahepatic sites. The role of cytokines in induction of the acute phase proteins is discussed, particularly the multiple functional capabilities of interleukin-6 (IL-6). Other cytokines that regulate acute phase gene expression and protein synthesis include IL-1, tumor necrosis factor alpha, interferon gamma, as well as other stimulatory factors and cofactors. The physicochemical characteristics of each protein are reviewed together with the molecular biology. For each protein, the known biological effects are detailed. The following functions for CRP have been described: reaction with cell surface receptors resulting in opsonization, enhanced phagocytosis, and passive protection; activation of the classical complement pathway; scavenger for chromatin fragments; inhibition of growth and/or metastases of tumor cells; modulation of polymorphonuclear function; and a few additional diverse activities. The role of plasma SAA is described as a precursor of protein AA in secondary amyloidosis; other functions are speculative. AAG may play an immunoregulatory role as well as a role in binding a number of diverse drugs. In addition to clot formation, new data are described for binding of fibrinogen and fibrin to complement receptor type 3. Finally, the concentration of each protein is discussed in a wide variety of noninfectious and infectious disease states, particularly in connective tissue diseases. The quantification of the proteins during the course of various acute and chronic inflammatory disorders is useful in diagnosis, therapy, and in some cases, prognosis.

High-dose, pulse intravenous methylprednisolone enhances Fc gamma receptor-mediated mononuclear phagocyte function in systemic lupus erythematosus

The benefit of high-dose, pulse intravenous methylprednisolone (IVMP) for some patients with active lupus nephritis would appear paradoxical, since active nephritis is associated with profound abnormalities in Fc gamma receptor function, and several studies have demonstrated that glucocorticoids decrease monocyte Fc gamma receptor expression and phagocytic function. To resolve this paradox, we investigated the possibility that pulse IVMP might enhance monocyte Fc gamma receptor function in patients with systemic lupus erythematosus (SLE). Circulating immune complex (CIC) levels, Fc gamma receptor-mediated clearance, and Fc gamma receptor-dependent monocyte function were analyzed in 23 SLE patients before and after pulse IVMP (1 gm daily for 3 days). A biphasic response in CIC levels, determined by a staphylococcal protein A binding assay, was observed. Initially, CIC levels increased within 2-4 hours after the first dose of pulse IVMP and then decreased by 50% within 24-48 hours after the completion of therapy. Fc gamma receptor-mediated binding and phagocytosis of IgG-sensitized erythrocytes (EA) by monocytes in vitro were significantly enhanced 24 hours after the final dose of pulse IVMP (pre-IVMP versus post-IVMP 43 +/- 14% versus 53 +/- 12% EA rosettes, P less than 0.01; 3.00 +/- 1.04 versus 3.99 +/- 1.30 EA ingested/monocyte, P less than 0.01). In contrast, there was no change in the phagocytosis of an Fc gamma receptor-independent probe, neuraminidase-treated erythrocytes.(ABSTRACT TRUNCATED AT 250 WORDS)

Pulse steroid therapy in rheumatoid arthritis: can equivalent doses of oral prednisolone give similar clinical results to intravenous methylprednisolone?

Pulse methylprednisolone therapy has dramatic effects on clinical and immunological parameters of disease activity in patients with rheumatoid arthritis. Previous studies of this treatment have all used the intravenous route and methylprednisolone succinate. This study addresses the question of whether oral prednisolone in equivalent doses can substitute for intravenous methylprednisolone in pulse therapy in a double blind parallel study. It is shown that oral prednisolone has clinical and immunological effects equivalent to those of intravenous methylprednisolone, making it possible to administer pulse therapy to patients with rheumatoid arthritis as outpatients without the inconvenience and inherent dangers of intravenous administration.

'Pulsed' immunosuppressive therapy in the treatment of immunologically induced corneal and scleral disease

'Pulsed' immunosuppressive therapy, using methylprednisolone with or without cyclophosphamide, has effectively controlled severe destructive corneal and scleral disease that had been unresponsive to oral steroids. Thirty-seven patients have been treated in this manner and the results, complications and possible mechanism of action are discussed.

Prospects in the immunological treatments of rheumatoid arthritis

Different trends in the therapeutic immunomodulation of rheumatoid arthritis (RA) have been developed since a few years. Early treatment and/or combined treatments using 2 or 3 classical remission inducing drugs could improve the clinical results. Diet and especially eicosapentanoic acid could influence the clinical signs of RA. Among the non specific immunodepressive agents, methotrexate is of major interest. Immunodepressive agents partly selective of a lymphocyte subpopulation: cyclosporin A, total lymphoid irradiation, act on CD4 cells. Some experimental immunomodulating drugs are under study: type II interferon, thymic hormones, immunoglobulins of placental origin. The specific immunotherapy of RA is still experimental and only used in animal with very promising results. Anticlass II HLA monoclonal or polyclonal antibodies could be one of the major treatments of autoimmune diseases within a few years. The treatment of RA by anti-idiotype antibodies remains, at this moment, theoretical.

Fibromyalgia. 2. Management guidelines and research findings

Treatment of fibromyalgia includes various forms of therapy--physical, behavioral, psychological, and pharmacologic. No drug therapy has proved uniformly successful, but some drugs provide temporary relief from pain. After an initial therapy program has been established, patients can assume the major responsibility for management. Research studies aimed at defining the cause of fibromyalgia have linked it to sleep disorders, neurogenic mediators, immune mechanisms, muscle disease, and psychological disturbances.