Potential antiinflammatory and immunomodulatory effects of statins in rheumatologic therapy

Rosuvastatin Enhances Alveolar Fluid Clearance in Lipopolysaccharide-Induced Acute Lung Injury by Activating the Expression of Sodium Channel and Na,K-ATPase via the PI3K/AKT/Nedd4-2 Pathway

Background

Acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) are devastating clinical conditions characterized by pulmonary epithelial damage and protein-rich fluid accumulation in the alveolar spaces. Statins are a class of HMG-CoA reductase inhibitors, which exert cholesterol-lowering and anti-inflammatory effects.

Methods

Rosuvastatin (1 mg/kg) was injected intravenously in rats 12 h before lipopolysaccharide (LPS, 10 mg/kg) administration. Eight hours later after LPS challenge, alveolar fluid clearance (AFC) was detected in rats (n = 6–8). Rosuvastatin (0.3 µmol/mL) and LPS were cultured with primary rat alveolar type II epithelial cells for 8 h.

Results

Rosuvastatin obviously improved AFC and attenuated lung-tissue damage in ALI model. Moreover, it enhanced AFC by increasing sodium channel and Na,K-ATPase protein expression. It also up-regulated P-Akt via reducing Nedd4-2 in vivo and in vitro. Furthermore, LY294002 blocked the increase in AFC in response to rosuvastatin. Rosuvastatin-induced AFC was found to be partly rely on sodium channel and Na,K-ATPase expression via the PI3K/AKT/Nedd4-2 pathway.

Conclusion

In summary, the findings of our study revealed the potential role of rosuvastatin in the management of ALI/ARDS.

Impact of diabetes, angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker use, and statin use on presentation and outcomes in patients with giant cell arteritis

AIM

Few, separate, small retrospective studies in giant cell arteritis (GCA) reported that patients: (a) with diabetes mellitus had less positive temporal artery biopsies (TAB); (b) on angiotensin-converting enzyme inhibitors (ACE-I) or angiotensin II receptor blockers (ARB) experienced fewer relapses; and (c) on statins experienced the same frequency of clinical complications and relapses as non-exposed patients. This retrospective chart review study simultaneously investigated the impact of these 3 factors on a cohort of patients followed in 2 large Canadian centers (Hamilton and Toronto, ON).

METHODS

One hundred and thirty-seven patients diagnosed with GCA between 1993 and 2015 were included in the study. Presenting symptoms, TAB results, disease complications and outcomes (relapses, duration of glucocorticoid use) were compared between exposed (diabetes/ACE/ARB/statin) and non-exposed patients, with adjustment for main potential confounding variables.

RESULTS

Temporal artery biopsies was less often positive in patients with pre-existing diabetes (relative risk 0.24; 95% CI: 0.069-0.81). Patients who developed diabetes after diagnosis had a lower relapse-free survival (adjusted hazards ratio [HR] 0.28; 95% CI: 0.095-0.84). Patients taking ARBs prior to diagnosis were more likely to successfully discontinue glucocorticoids without a flare in the following 3 months (adjusted HR 2.46; 95% CI: 1.2-5.3). Clinical complications and relapse rates did not differ between patients on statin therapy or not.

CONCLUSION

Diabetic patients with GCA were less likely to have a positive TAB, and more likely to relapse. ARB therapy prior to diagnosis showed an association with success at discontinuing glucocorticoids. Statin therapy did not alter the clinical presentation or course of GCA.

Association between statin use and incidence of relapse in anti-neutrophil cytoplasmic antibody-associated vasculitis: a single-center retrospective cohort study

Several studies have shown the efficacy of statins for some autoimmune disorders caused by anti-inflammatory and immunomodulatory reactions. However, little information is available about the impact of statins on relapse in antineutrophil cytoplasmic antibody-associated vasculitis (AAV). We performed the first investigation examining whether statin use has an effect on suppressing the first relapse of AAV in Japanese patients with AAV. This single-center retrospective cohort study included 98 consecutive patients with newly diagnosed AAV from Aichi Medical University Hospital, Japan between March 2009 and December 2017. Time to first relapse from the first remission was compared between 36 patients in the statin group and 62 patients in the non-statin group using multivariate Cox proportional hazard models, which were adjusted for clinically relevant factors. During the follow-up period (median, 24 months; interquartile range, 9-50 months), 35 (97.2%) patients in the statin group achieved remission, whereas 56 (90.3%) patients achieved remission in the non-statin group (P = 0.201). After achieving the first remission, 9 (25.7%) patients in the statin group and 29 (51.8%) patients in the non-statin group had at least one relapse. Multivariate Cox proportional hazard models revealed that statin use was significantly associated with a lower incidence of relapse compared with non-statin use (multivariate-adjusted hazard ratio = 0.41, 95% confidence interval: 0.18-0.92; P = 0.031). Patients with statin use were associated with a lower incidence of relapse in AAV. Our results should be assessed in well-designed randomized controlled trials.

Transdermal delivery of fluvastatin sodium via tailored spanlastic nanovesicles: mitigated Freund's adjuvant-induced rheumatoid arthritis in rats through suppressing p38 MAPK signaling pathway

The current study aimed to encapsulate fluvastatin sodium (FVS), a member of the statins family possessing pleiotropic effects in rheumatoid arthritis (RA), into spanlastic nanovesicles (SNVs) for transdermal delivery. This novel delivery could surmount FVS associated oral encumbrances such as apparent first-pass effect, poor bioavailability and short elimination half-life, hence, accomplishing platform for management of RA. To consummate this objective, FVS-loaded SNVs were elaborated by thin film hydration method, utilizing either Span 60 or Span 80, together with Tween 80 or Brij 35 as an edge activator according to full factorial design (2⁴). Applying Design-Expert^® software, the influence of formulation variables on SNVs physicochemical properties and the optimized formulation selection were explored. Additionally, the pharmacokinetic studies were scrutinized in rats. Furthermore, in Freund's adjuvant-induced arthritis, rheumatoid markers, TNF-α, IL-10, p38 MAPK, and antioxidant parameters were measured. The optimum SNVs were nano-scaled spherical vesicles (201.54 ± 9.16 nm), having reasonable entrapment efficiency (71.28 ± 2.05%), appropriate release over 8 h (89.45 ± 3.64%) and adequate permeation characteristics across the skin (402.55 ± 27.48 µg/cm²). The pharmacokinetic study disclosed ameliorated bioavailability of the optimum SNVs gel by 2.79- and 4.59-fold as compared to the oral solution as well as the traditional gel, respectively. Moreover, it elicited a significant suppression of p38 MAPK expression and also significant improvement of all other measured biomarkers. Concisely, the foregoing findings proposed that SNVs can be auspicious for augmenting FVS transdermal delivery for management of RA.

Statins improve the long-term prognosis in patients who have survived sepsis: A nationwide cohort study in Taiwan (STROBE complaint)

Most patients diagnosed with sepsis died during their first episode, with the long-term survival rate upon post-sepsis discharge being low. Major adverse cardiovascular events and recurrent infections were regarded as the major causes of death. No definite medications had proven to be effective in improving the long-term prognosis. We aimed to examine the benefits of statins on the long-term prognosis of patients who had survived sepsis.Between 1999 and 2013, a total of 220,082 patients who had been hospitalized due to the first episode of sepsis were included, with 134,448 (61.09%) of them surviving to discharge. The surviving patients who were subsequently prescribed statins at a concentration of more than 30 cumulative Defined Daily Doses (cDDDs) during post-sepsis discharge were defined as the users of statin.After a propensity score matching ratio of 1:5, a total of 7356 and 36,780 surviving patients were retrieved for the study (statin users) and comparison cohort (nonstatin users), respectively. The main outcome was to determine the long-term survival rate during post-sepsis discharge.HR with 95% CI was calculated using the Cox regression model to evaluate the effectiveness of statins, with further stratification analyses according to cDDDs.The users of statins had an adjusted HR of 0.29 (95% CI, 0.27-0.31) in their long-term mortality rate when compared with the comparison cohort. For the users of statins with cDDDs of 30-180, 180-365, and >365, the adjusted HRs were 0.32, 0.22, and 0.16, respectively, (95% CI, 0.30-0.34, 0.19-0.26, and 0.12-0.23, respectively), as compared with the nonstatins users (defined as the use of statins <30 cDDDs during post-sepsis discharge), with the P for trend <.0001. In the sensitivity analysis, after excluding the surviving patients who had died between 3 and 6 months after post-sepsis discharge, the adjusted HR for the users of statins remained significant (0.35, 95% CI 0.32-0.37 and 0.42, 95% CI 0.39-0.45, respectively).Statins may have the potential to decrease the long-term mortality of patients who have survived sepsis. However, more evidence, including clinical and laboratory data, is necessary in order to confirm the results of this observational cohort study.Trial registration: CMUH104-REC2-115.

Statins reduce relapse rate in Takayasu arteritis

BACKGROUND

To investigate the effect of statins on relapse of Takayasu arteritis (TAK), which frequently occurs after achievement of remission.

METHODS

We conducted a retrospective study on TAK patients with active disease, diagnosed between 2012 and 2017. Relapse was defined as recurrence of active disease after achieving remission. Demographic and clinical parameters of patients who experienced relapse were compared to those who did not. To identify factors associated with relapse, significant factors identified in this comparison were included in a multivariate Cox regression analysis. Inverse probability of treatment weighting (IPTW)-adjusted analysis was used to evaluate the influence of statins on relapse.

RESULTS

Of the total 74 TAK patients, 40 (54.1%) patients received statins, whereas 34 (45.9%) patients did not. Relapse was observed in 36 (48.6%) patients of the total 74 TAK patients. Compared with patients who did not experience relapse, patients who experienced relapse were younger (44.5 ± 13.5 years vs 34.1 ± 12.6 years, p = 0.001), had lower prevalence of hypertension (63.2% vs 38.9%, p = 0.037), more commonly had carotidynia (7.9% vs 27.8%, p = 0.025), had higher LDL-cholesterol (84.8 ± 18.8 mg/dl vs 100.5 ± 26.1 mg/dl, p = 0.010), and were less commonly taking statins (71.1% vs 36.1%, p = 0.003). The use of statins was significant in multivariate Cox regression analysis (adjusted hazard ratio 0.260, 95% confidence interval 0.120-0.563, p = 0.001). Furthermore, IPTW-adjusted analysis confirmed that statin use was associated with a lower risk of relapse (IPTW-adjusted hazard ratio 0.153, 95% confidence interval 0.038-0.616, p = 0.008).

CONCLUSION

In TAK, statins can be beneficial in reducing relapse rate after achieving remission.

Effect of statins on toll-like receptors: a new insight to pleiotropic effects

The toll-like receptors (TLRs) are a class of transmembrane-spanning receptors that are sentinels of both innate and adaptive immunity. Statins (3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors) are the most commonly prescribed therapeutic agents for treating hypercholesterolemia globally. However, statin therapy appears to have pleiotropic effects including attenuation of chronic low-grade inflammation and modulation of TLR activity. Statins through abolition of TLR4 expression and regulation of the TLR4/Myd88/NF-κB signaling pathway may slow the progression of atherosclerosis and other inflammatory diseases. In this review, we have focused on the impact and mechanism of action of statins on cardiovascular and non-cardiovascular diseases.

Simvastatin Inhibits Toll-like Receptor 8 (TLR8) Signaling in Primary Human Monocytes and Spontaneous Tumor Necrosis Factor Production from Rheumatoid Synovial Membrane Cultures

Simvastatin has been shown to have antiinflammatory effects that are independent of its serum cholesterol lowering action, but the mechanisms by which these antiinflammatory effects are mediated have not been elucidated. To explore the mechanism involved, the effect of simvastatin on toll-like receptor (TLR) signaling in primary human monocytes was investigated. A short pretreatment with simvastatin dose-dependently inhibited the production of tumor necrosis factor (TNF)-α in response to TLR8 activation (but not TLR2, -4 or -5). Statins are known inhibitors of the cholesterol biosynthetic pathway, but, intriguingly, TLR8 inhibition could not be reversed by addition of mevalonate or geranylgeranyl pyrophosphate, downstream products of cholesterol biosynthesis. TLR8 signaling was examined in HEK 293 cells stably expressing TLR8, where simvastatin inhibited I kappa B kinase (IKK)α/β phosphorylation and subsequent nuclear factor (NF)-κB activation without affecting the pathway to activating protein-1 (AP-1). Because simvastatin has been reported to have antiinflammatory effects in RA patients and TLR8 signaling contributes to TNF production in human RA synovial tissue in culture, simvastatin was tested in these cultures. Simvastatin significantly inhibited the spontaneous release of TNF in this model, which was not reversed by mevalonate. Together, these results demonstrate a hitherto unrecognized mechanism of simvastatin inhibition of TLR8 signaling that may in part explain its beneficial antiinflammatory effects.

Is statin exposure associated with occurrence or better outcome in giant cell arteritis? Results from a French population-based study

OBJECTIVE

To investigate the potential association between statin use and giant cell arteritis (GCA) course.

METHODS

Using the French National Health Insurance system, we included patients with incident GCA from the Midi-Pyrenees region, southern France, from January 2005 to December 2008 and randomly selected 6 controls matched by age, sex, and date of diagnosis. Statin exposure was compared between patients with GCA and their controls before GCA occurrence with a logistic regression. Influence of statin exposure on prednisone requirements during GCA course was explored with a Cox model, considering statin exposure as a time-varying variable.

RESULTS

The cohort included 103 patients (80 women, mean age 74.8 ± 9 yrs, mean followup 48.9 ± 14.8 mos), compared to 606 controls. Statin exposure (27.2% of patients with GCA and 23.4% of controls) was not associated with GCA occurrence (adjusted OR 1.2, 95% CI 0.76-1.96; p = 0.41). Diabetes mellitus was significantly associated to GCA occurrence (adjusted OR 0.38, 95% CI 0.11-0.72; p = 0.008). After diagnosis, exposure to statins up to 20 months was associated with maintenance while taking low prednisone doses (p = 0.01).

CONCLUSION

Statin exposure was not associated with GCA occurrence in the general population. However, exposure to statins up to 20 months may favor a quicker corticosteroid tapering. Based on those results, statin effect on GCA course should not be definitively ruled out.

Effect of statin therapy on mortality from infection and sepsis: a meta-analysis of randomized and observational studies

INTRODUCTION

Observational data have suggested that statin therapy may reduce mortality in patients with infection and sepsis; however, results from randomized studies are contradictory and do not support the use of statins in this context. Here, we performed a meta-analysis to investigate the effects of statin therapy on mortality from infection and sepsis.

METHODS

We searched electronic databases (PubMed and Embase) for articles published before November 2013. Randomized or observational studies reporting the effects of statin therapy on mortality in patients with infection or sepsis were eligible. Randomized and observational studies were separately pooled with relative risks (RRs) and random-effects models.

RESULTS

We examined 5 randomized controlled trials with 867 patients and 27 observational studies with 337,648 patients. Among the randomized controlled trials, statins did not significantly decrease in-hospital mortality (RR, 0.98; 95% confidence interval (CI), 0.73 to 1.33) or 28-day mortality (RR, 0.93; 95% CI, 0.46 to 1.89). However, observational studies indicated that statins were associated with a significant decrease in mortality with adjusted data (RR, 0.65; 95% CI, 0.57 to 0.75) or unadjusted data (RR, 0.74; 95% CI, 0.59 to 0.94).

CONCLUSIONS

Limited evidence suggests that statins may not be associated with a significant reduction in mortality from infection and sepsis. Although meta-analysis from observational studies showed that the use of statins was associated with a survival advantage, these outcomes were limited by high heterogeneity and possible bias in the data. Therefore, we should be cautious about the use of statins in infection and sepsis.

Diagnosis, prevention, and management of statin adverse effects and intolerance: proceedings of a Canadian Working Group Consensus Conference

While the proportion of patients with significant statin-associated adverse effects or intolerance is very low, the increasing use and broadening indications have led to a significant absolute number of such patients commonly referred to tertiary care facilities and specialists. This report provides a comprehensive overview of the evidence pertaining to a broad variety of statin-associated adverse effects followed by a consensus approach for the prevention, assessment, diagnosis, and management. The overview is intended both to provide clarification of the untoward effects of statins and to impart confidence in managing the most common issues in a fashion that avoids excessive ancillary testing and/or subspecialty referral except when truly necessary. The ultimate goal is to ensure that patients who warrant cardiovascular risk reduction can be treated optimally, safely, and confidently with statin medications or alternatives when warranted.

Conservative treatments for rheumatoid arthritis in the foot and ankle

Rheumatoid arthritis (RA) is a systemic inflammatory disease that attacks peripheral joints, causing their destruction. Several pharmacologic therapies and physical modalities are available for its treatment. Because of the progressive nature of RA, complementary and alternative medicine therapy in conjunction with conventional medicine is administered to patients with RA. This article discusses the presence of undiagnosed RA in the foot and ankle and reviews the concurrent nonoperative measures in treatment, including pharmacologic and physical modalities.

Atorvastatin enhances interleukin-10 levels and improves cardiac function in rats after acute myocardial infarction

LV (left ventricular) remodelling is the basic mechanism of HF (heart failure) following MI (myocardial infarction). Although there is evidence that pro-inflammatory cytokines [including TNF-alpha (tumour necrosis factor-alpha) and IL-6 (interleukin-6)] are involved in the remodelling process, only little is known about the role of anti-inflammatory cytokines, such as IL-10. As accumulating evidence has revealed that statins possess anti-inflammatory properties, the aim of the present study was to elucidate the effect of atorvastatin on the modulation of the anti-inflammatory cytokine IL-10 and its effect on LV function in rats with HF subsequent to MI. Rats with MI, induced by permanent LAD (left anterior descending) branch coronary artery ligation, were treated for 4 weeks with atorvastatin (10 mg x kg(-1) of body weight x day(-1) via oral gavage) starting on the first day after induction of MI. Cardiac function was assessed by echocardiography and cardiac catheterization 4 weeks after MI induction. Membrane-bound and soluble fractions of TNF-alpha, IL-6 and IL-10 protein, the TNF-alpha/IL-10 ratio, serum levels of MCP-1 (monocyte chemoattractant protein-1) as well as myocardial macrophage infiltration were analysed. Treatment with atorvastatin significantly improved post-MI LV function (fractional shortening, +120%; dP/dt(max), +147%; and LV end-diastolic pressure, -27%). Furthermore atorvastatin treatment markedly decreased the levels of TNF-alpha, IL-6 and MCP-1, reduced myocardial infiltration of macrophages and significantly increased myocardial and serum levels of the anti-inflammatory cytokine IL-10. Thus the balance between pro-inflammatory and anti-inflammatory cytokines was shifted in the anti-inflammatory direction, as shown by a significantly decreased TNF-alpha/IL-10 ratio. Atorvastatin ameliorated early LV remodelling and improved LV function in rats with HF subsequent to MI. Our study suggests that the modulation of the balance between pro- and anti-inflammatory cytokines towards the anti-inflammatory cytokine IL-10 is one salutary mechanism underlying how atorvastatin influences post-MI remodelling and thus improves LV function.

Statin therapy does not seem to benefit giant cell arteritis

OBJECTIVE

Since statins interfere with a variety of immune-inflammatory pathways shared by atherosclerosis and giant cell arteritis (GCA), they might be potentially useful as adjunctive therapy to glucocorticosteroids in GCA. Our aim was to examine whether concomitant use of statins had any potential benefit in GCA.

METHODS

Retrospective follow-up study of an unselected population of 121 patients with GCA. A comparative analysis between patients with and without statin therapy was performed.

RESULTS

At the time of the GCA diagnosis, 30 patients (25%) had already been receiving statins and continued taking them during the corticosteroid treatment. No statistically significant reduction in the incidence of severe ischemic complications (including visual manifestations, jaw claudication, cerebrovascular accidents, ischemic heart disease, and limb claudication due to large artery stenosis) was observed in this group compared with the remaining patients. When we analyzed follow-up data, we found no significant differences between groups in terms of frequency of relapses, incidence of aortitis, and percentage of patients recovered from GCA. The duration of therapy and corticosteroids requirements among patients in permanent remission was similar in both groups.

CONCLUSION

We did not observe a significant benefit derived from the use of statins at low to moderate doses in the incidence of severe ischemia or the disease outcome.