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Al Khayyat SG, Conticini E, Falsetti P, Fogliame G, Gentileschi S, Baldi C, Bardelli M, Migliore A, Cantarini L, Frediani B. Intra-articular injections of biological disease-modifying anti-rheumatic drugs in inflammatory arthropathies: An up-to-date narrative review. Joint Bone Spine 2023; 90:105598. [PMID: 37271277 DOI: 10.1016/j.jbspin.2023.105598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 04/15/2023] [Accepted: 05/08/2023] [Indexed: 06/06/2023]
Abstract
INTRODUCTION Since the 1990s thebiological disease-modifying anti-rheumatic drugs (bDMARDs) have revolutionized the treatment of chronic dysimmune inflammatory arthropathies such as Rheumatoid Arthritis, Psoriatic Arthritis and Axial Spondylarthritis. Nevertheless, despite a full treatment regimen, mono- and oligoarticular persistence of the synovitis is sometimes observed. The intra-articular (IA) use of bDMARD drugs could resolve the persistent joint inflammation and result in a reduction in the degree of immunosuppression of individuals; moreover, the use of these drugs intra-articularly could be associated with a reduction in the treatment-related costs. METHODS We extensively searched via PubMed and Google Scholar articles using as keywords "etanercept", "infliximab", "adalimumab", "certolizumab", "golimumab", "tocilizumab", "ixekizumab", "secukinumab", "rituximab" each combined with "intra-articular injection". RESULTS We found and evaluated 161 papers, and then we selected 24 that were highly related to the topic of the present work. The articles examined a total of 349 patients, 85 males (M), and 168 females (F), mean age of 44.75±12.09 years old and considered 556 treated joints. Three hundred and forty-one patients were affected by Rheumatoid Arthritis, 198 by Psoriatic Arthritis, 56 by Axial Spondylarthritis, 26 by Juvenile Idiopathic Arthritis, 19 by Undifferentiated Arthritis, 1 by arthritis associated with inflammatory bowel disease and 9 patients by an unspecified inflammatory articular disorder. All patients were treated intra-articularly with a TNFα inhibitor among Adalimumab, Etanercept or Infliximab. Side effects were documented in 9 out of 349 (2.57%) treated patients and all were mild or moderate. In some cases the effectiveness of IA bDMARDs treatment was maintained for several months, however in the few published randomized controlled trials(RCTs) the corticosteroids (GCs) appeared to act better when administered intra-articularly compared to bDMARDs. CONCLUSIONS The IA use of bDMARDs seems to be weakly effective in the management of resistant synovitis and not superior to GCs injections. The treatment's main limit appears to be the poor persistence of the compound in the joint.
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Affiliation(s)
- Suhel G Al Khayyat
- Rheumatology Unit, Department of Medicine, Surgery & Neurosciences, University of Siena, 53100, Siena, Italy.
| | - Edoardo Conticini
- Rheumatology Unit, Department of Medicine, Surgery & Neurosciences, University of Siena, 53100, Siena, Italy
| | - Paolo Falsetti
- Rheumatology Unit, Department of Medicine, Surgery & Neurosciences, University of Siena, 53100, Siena, Italy
| | - Giuseppe Fogliame
- Rheumatology Unit, Department of Medicine, Surgery & Neurosciences, University of Siena, 53100, Siena, Italy
| | - Stefano Gentileschi
- Rheumatology Unit, Department of Medicine, Surgery & Neurosciences, University of Siena, 53100, Siena, Italy
| | - Caterina Baldi
- Rheumatology Unit, Department of Medicine, Surgery & Neurosciences, University of Siena, 53100, Siena, Italy
| | - Marco Bardelli
- Rheumatology Unit, Department of Medicine, Surgery & Neurosciences, University of Siena, 53100, Siena, Italy
| | - Alberto Migliore
- Unit of Rheumatology, San Pietro Fatebenefratelli Hospital, 00189 Rome, Italy
| | - Luca Cantarini
- Rheumatology Unit, Department of Medicine, Surgery & Neurosciences, University of Siena, 53100, Siena, Italy
| | - Bruno Frediani
- Rheumatology Unit, Department of Medicine, Surgery & Neurosciences, University of Siena, 53100, Siena, Italy
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Valerio MS, Edwards JB, Dolan CP, Motherwell JM, Potter BK, Dearth CL, Goldman SM. Effect of Targeted Cytokine Inhibition on Progression of Post-Traumatic Osteoarthritis Following Intra-Articular Fracture. Int J Mol Sci 2023; 24:13606. [PMID: 37686412 PMCID: PMC10487447 DOI: 10.3390/ijms241713606] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 08/24/2023] [Accepted: 08/25/2023] [Indexed: 09/10/2023] Open
Abstract
Intra-articular fractures (IAF) result in significant and prolonged inflammation, increasing the chances of developing post-traumatic osteoarthritis (PTOA). Interleukin-one beta (IL-1β) and Tumor Necrosis Factor-alpha (TNF-α) are key inflammatory factors shown to be involved in osteochondral degradation following IAF. As such, use of targeted biologics such as Infliximab (INX), a TNF-α inhibitor, and Anakinra (ANR), an interleukin-one (IL-1) receptor antagonist (IL1RA), may protect against PTOA by damping the inflammatory response to IAF and reducing osteochondral degradation. To test this hypothesis, IAFs were induced in the hindlimb knee joints of rats treated with INX at 10 mg/kg/day, ANR at 100 g/kg/day, or saline (vehicle control) by subcutaneous infusion for a period of two weeks and healing was evaluated at 8-weeks post injury. Serum and synovial fluid (SF) were analyzed for soluble factors. In-vivo microcomputed tomography (µCT) scans assessed bone mineral density and bone morphometry measurements. Cationic CA4+ agent assessed articular cartilage composition via ex vivo µCT. Scoring according to the Osteoarthritis Research Society International (OARSI) guidelines was performed on stained histologic tibia sections at the 56-day endpoint on a 0-6 scale. Systemically, ANR reduced many pro-inflammatory cytokines and reduced osteochondral degradation markers Cross Linked C-Telopeptide Of Type II (CTXII, p < 0.05) and tartrate-resistant acid phosphatase (TRAP, p < 0.05). ANR treatment resulted in increased chemokines; macrophage-chemotractant protein-1 (MCP-1), MPC-3, macrophage inhibitory protein 2 (MIP2) with a concomitant decrease in proinflammatory interleukin-17A (IL17A) at 14 days post-injury within the SF. Microcomputed tomography (µCT) at 56 days post-injury revealed ANR Treatment decreased epiphyseal degree of anisotropy (DA) (p < 0.05) relative to saline. No differences were found with OARSI scoring but contrast-enhanced µCT revealed a reduction in glycosaminoglycan content with ANR treatment. These findings suggest targeted cytokine inhibition, specifically IL-1 signaling, as a monotherapy has minimal utility for improving IAF healing outcomes but may have utility for promoting a more permissive inflammatory environment that would allow more potent disease modifying osteoarthritis drugs to mitigate the progression of PTOA after IAF.
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Affiliation(s)
- Michael S. Valerio
- Research & Surveillance Division, DoD-VA Extremity Trauma and Amputation Center of Excellence, Bethesda, MD 20814, USA
- Department of Surgery, Walter Reed National Military Medical Center, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Jorge B. Edwards
- Department of Surgery, Walter Reed National Military Medical Center, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Connor P. Dolan
- Research & Surveillance Division, DoD-VA Extremity Trauma and Amputation Center of Excellence, Bethesda, MD 20814, USA
- Department of Surgery, Walter Reed National Military Medical Center, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Jessica M. Motherwell
- Research & Surveillance Division, DoD-VA Extremity Trauma and Amputation Center of Excellence, Bethesda, MD 20814, USA
- Department of Surgery, Walter Reed National Military Medical Center, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Benjamin K. Potter
- Department of Surgery, Walter Reed National Military Medical Center, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
- Department of Orthopaedic Surgery, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA
| | - Christopher L. Dearth
- Research & Surveillance Division, DoD-VA Extremity Trauma and Amputation Center of Excellence, Bethesda, MD 20814, USA
- Department of Surgery, Walter Reed National Military Medical Center, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Stephen M. Goldman
- Research & Surveillance Division, DoD-VA Extremity Trauma and Amputation Center of Excellence, Bethesda, MD 20814, USA
- Department of Surgery, Walter Reed National Military Medical Center, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
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Khella CM, Horvath JM, Asgarian R, Rolauffs B, Hart ML. Anti-Inflammatory Therapeutic Approaches to Prevent or Delay Post-Traumatic Osteoarthritis (PTOA) of the Knee Joint with a Focus on Sustained Delivery Approaches. Int J Mol Sci 2021; 22:8005. [PMID: 34360771 PMCID: PMC8347094 DOI: 10.3390/ijms22158005] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 07/20/2021] [Accepted: 07/22/2021] [Indexed: 12/11/2022] Open
Abstract
Inflammation plays a central role in the pathogenesis of knee PTOA after knee trauma. While a comprehensive therapy capable of preventing or delaying post-traumatic osteoarthritis (PTOA) progression after knee joint injury does not yet clinically exist, current literature suggests that certain aspects of early post-traumatic pathology of the knee joint may be prevented or delayed by anti-inflammatory therapeutic interventions. We discuss multifaceted therapeutic approaches that may be capable of effectively reducing the continuous cycle of inflammation and concomitant processes that lead to cartilage degradation as well as those that can simultaneously promote intrinsic repair processes. Within this context, we focus on early disease prevention, the optimal timeframe of treatment and possible long-lasting sustained delivery local modes of treatments that could prevent knee joint-associated PTOA symptoms. Specifically, we identify anti-inflammatory candidates that are not only anti-inflammatory but also anti-degenerative, anti-apoptotic and pro-regenerative.
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Affiliation(s)
| | | | | | | | - Melanie L. Hart
- G.E.R.N. Center for Tissue Replacement, Regeneration & Neogenesis, Department of Orthopedics and Trauma Surgery, Faculty of Medicine, Medical Center—Albert-Ludwigs—University of Freiburg, 79085 Freiburg im Breisgau, Germany; (C.M.K.); (J.M.H.); (R.A.); (B.R.)
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Carubbi F, Zugaro L, Cipriani P, Conchiglia A, Gregori L, Danniballe C, Letizia Pistoia M, Liakouli V, Ruscitti P, Ciccia F, Triolo G, Masciocchi C, Giacomelli R. Safety and efficacy of intra-articular anti-tumor necrosis factor α agents compared to corticosteroids in a treat-to-target strategy in patients with inflammatory arthritis and monoarthritis flare. Int J Immunopathol Pharmacol 2015; 29:252-66. [PMID: 26684633 DOI: 10.1177/0394632015593220] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2014] [Accepted: 05/26/2015] [Indexed: 11/15/2022] Open
Abstract
The aim of this study was to assess safety and efficacy of ultrasonography (US)-guided intra-articular injections using tumor necrosis factor (TNF) blockers compared to corticosteroids in rheumatoid arthritis (RA) or psoriatic arthritis (PsA) patients, experiencing refractory monoarthritis despite the current systemic therapy. Eighty-two patients were randomized to receive three intra-articular injections monthly of either corticosteroid or TNF blockers. Primary endpoints were the safety and an improvement greater than 20% for visual analogic scales of involved joint pain in patients injected with anti-TNFα. Further clinical, US, and magnetic resonance imaging (MRI) evaluations were considered secondary endpoints. Intra-articular TNF blockers are a safe strategy, determining a significant reduction of patient and physician reported clinical outcomes and US/MRI scores, in RA and PsA patients, when compared to intra-articular injections of corticosteroids. US guidance excluded the possibility to inject the drug in the wrong site, maximizing local effects, reducing systemic effects, and increasing the safety of the procedure. Patients with inflammatory monoarthritis could be successfully treated with US-guided intra-articular TNF blockers that are a safe and well tolerated procedure, to achieve a longstanding clinical and radiological good clinical response and/or disease remission.
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Affiliation(s)
- Francesco Carubbi
- Department of Biotechnological and Applied Clinical Sciences, Rheumatology Unit, University of L'Aquila, L'Aquila, Italy
| | - Luigi Zugaro
- Department of Radiology, University of L'Aquila, L'Aquila, Italy
| | - Paola Cipriani
- Department of Biotechnological and Applied Clinical Sciences, Rheumatology Unit, University of L'Aquila, L'Aquila, Italy
| | | | - Lorenzo Gregori
- Department of Radiology, University of L'Aquila, L'Aquila, Italy
| | | | - Maria Letizia Pistoia
- Department of Biotechnological and Applied Clinical Sciences, Rheumatology Unit, University of L'Aquila, L'Aquila, Italy
| | - Vasiliki Liakouli
- Department of Biotechnological and Applied Clinical Sciences, Rheumatology Unit, University of L'Aquila, L'Aquila, Italy
| | - Piero Ruscitti
- Department of Biotechnological and Applied Clinical Sciences, Rheumatology Unit, University of L'Aquila, L'Aquila, Italy
| | - Francesco Ciccia
- Rheumatology Unit, Internal Medicine Department, University of Palermo, Palermo, Italy
| | - Giovanni Triolo
- Rheumatology Unit, Internal Medicine Department, University of Palermo, Palermo, Italy
| | - Carlo Masciocchi
- Department of Radiology, University of L'Aquila, L'Aquila, Italy
| | - Roberto Giacomelli
- Department of Biotechnological and Applied Clinical Sciences, Rheumatology Unit, University of L'Aquila, L'Aquila, Italy
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Intra-articular etanercept treatment in inflammatory arthritis: A randomized double-blind placebo-controlled proof of mechanism clinical trial validating TNF as a potential therapeutic target for local treatment. Joint Bone Spine 2015; 82:338-44. [DOI: 10.1016/j.jbspin.2015.03.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2014] [Accepted: 03/03/2015] [Indexed: 12/31/2022]
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Curtis EM, Marks JL. Optimal dose of etanercept in the treatment of rheumatoid arthritis. Open Access Rheumatol 2014; 6:27-38. [PMID: 27790032 PMCID: PMC5045112 DOI: 10.2147/oarrr.s41409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Etanercept (ETN) is one of a number of biological therapies targeting the proinflammatory cytokine tumor necrosis factor-alpha that have demonstrated efficacy in the management of rheumatoid arthritis (RA). As experience has grown, a number of different treatment strategies have been investigated to ascertain the optimal conditions for use of ETN in RA and maximize the clinical gains from therapy. These have included the use of higher- and lower-dose treatment regimens, ETN as a monotherapy or in combination with other nonbiologic disease-modifying antirheumatic drugs, the use of ETN in very early clinical disease, and intraarticular ETN administration for resistant synovitis. Recent trials have focused on phased dose reduction or withdrawal of ETN in patients achieving low disease activity states or clinical remission. This review summarizes existing data regarding the optimal timing of ETN initiation and dosing regimens and also evaluates more recent evidence regarding dose-reduction strategies that offer the possibility of biologic-free remission in RA.
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Affiliation(s)
- Elizabeth Mary Curtis
- Department of Rheumatology, University Hospital Southampton, Southampton, Hampshire, UK
| | - Jonathan Lewis Marks
- Department of Rheumatology, University Hospital Southampton, Southampton, Hampshire, UK
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Nissen MJ, Boucher A, Brulhart L, Menetrey J, Gabay C. Efficacy of intra-articular bevacizumab for relapsing diffuse-type giant cell tumour. Ann Rheum Dis 2014; 73:947-8. [PMID: 24401993 DOI: 10.1136/annrheumdis-2013-204589] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- M J Nissen
- Division of Rheumatology, Geneva University Hospital, , Geneva, Switzerland
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8
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Fiocco U, Sfriso P, Oliviero F, Lunardi F, Calabrese F, Scagliori E, Cozzi L, Di Maggio A, Nardacchione R, Molena B, Felicetti M, Gazzola K, Stramare R, Rubaltelli L, Accordi B, Costa L, Roux-Lombard P, Punzi L, Dayer JM. Blockade of intra-articular TNF in peripheral spondyloarthritis: Its relevance to clinical scores, quantitative imaging and synovial fluid and synovial tissue biomarkers. Joint Bone Spine 2013; 80:165-70. [DOI: 10.1016/j.jbspin.2012.06.016] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2012] [Accepted: 06/27/2012] [Indexed: 11/16/2022]
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9
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Stoll ML, Morlandt ABP, Teerawattanapong S, Young D, Waite PD, Cron RQ. Safety and efficacy of intra-articular infliximab therapy for treatment-resistant temporomandibular joint arthritis in children: a retrospective study. Rheumatology (Oxford) 2012; 52:554-9. [PMID: 23221325 DOI: 10.1093/rheumatology/kes318] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE TM joint (TMJ) arthritis occurs in up to 80% of children with JIA and can result in substantial deformity. TMJ arthritis can be refractory to systemic immunosuppressive therapy and IA CS injections (IACIs). Multiple studies have shown the benefit of IA infliximab injections (IAIIs) in several different joints, so we used intra-articular infliximab injections (IAIIs) in JIA patients with TMJ arthritis refractory to IACIs. The objective of the study was to test the safety and efficacy of IAII therapy for TMJ arthritis. METHODS Retrospective chart review was performed for all children with JIA treated at a single centre who received one or more IAIIs. Outcomes assessed were safety of the injections as well as efficacy as evidenced by maximal incisal opening (MIO) and MRI findings. RESULTS Twenty-four children underwent bilateral IAIIs, all of whom had at least one follow-up visit after the final injection. All 24 tolerated the injections without any adverse events. MIOs were unchanged in patients before and after IAII. Findings of acute synovitis were present in 30/46 (65%) TMJs at baseline, 44/48 (92%) following completion of the IACI and 42/48 (88%) following completion of the IAII; findings of chronic synovitis at the three time points were 12/46 (26%), 29/48 (60%) and 38/48 (79%). Resolution of the arthritis was observed in six TMJs. CONCLUSION IAII was safe and it reversed the progression of TMJ arthritis in some patients with refractory disease. Future studies will evaluate the efficacy of infliximab vs CS injections as initial therapy for TMJ arthritis.
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Affiliation(s)
- Matthew L Stoll
- Department of Pediatrics, University of Alabama at Birmingham, 1600 7th Avenue South/Suite 210 N, Birmingham, AL 35233-1711, USA.
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Stepensky D. Local versus systemic anti-tumour necrosis factor-α effects of adalimumab in rheumatoid arthritis: pharmacokinetic modelling analysis of interaction between a soluble target and a drug. Clin Pharmacokinet 2012; 51:443-55. [PMID: 22540283 DOI: 10.2165/11599970-000000000-00000] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND AND OBJECTIVE The pharmacokinetic models that are applied to describe the disposition of therapeutic antibodies assume that the interaction between an antibody and its target takes place in the central compartment. However, an increasing number of therapeutic antibodies are directed towards soluble/mobile targets. A flawed conclusion can be reached if the pharmacokinetic and pharmacodynamic analysis assumes that the interaction between the therapeutic antibody and its target takes place in the central compartment. The objective of this study was to assess the relative importance of local versus systemic interactions between adalimumab and tumour necrosis factor (TNF)-α in rheumatoid arthritis (RA), identify localization of the site of adalimumab action and assess the efficacy of local (intra-articular) versus systemic adalimumab administration for treatment of RA. METHODS The clinical and preclinical data on adalimumab and TNFα disposition were analysed using a pharmacokinetic modelling and simulation approach. The disposition of adalimumab and TNFα and the interaction between them at the individual compartments (the synovial fluid of the affected joints, central and peripheral compartments) following different routes of adalimumab administration were studied. RESULTS Outcomes of modelling and simulation using the pharmacokinetic model developed indicate that adalimumab can efficiently permeate from the diseased joints to the central circulation in RA patients. Permeability of TNFα, which is excessively secreted in the joints, is even higher than that of adalimumab. As a result, subcutaneous, intravenous and intra-articular administration of the clinically used dose of adalimumab (40 mg) exert similar effects on the time course of TNFα concentrations at different locations in the body and efficiently deplete the TNFα in all of the compartments for a prolonged period of time (8-10 weeks). At this dose, adalimumab exhibits predominantly systemic anti-TNFα effects at the central and peripheral compartments (∼93% of the overall effect) and the contribution of the local effects in the rheumatic joints is ∼7% for all of the studied routes, including the local intra-articular injections. The major pathway of TNFα elimination from the synovial fluid (∼77% for subcutaneous administration, and ∼72% for intravenous and intra-articular administration of adalimumab 40 mg) is interaction with adalimumab, which reaches the joints following local or systemic administration. CONCLUSIONS The kinetics of adalimumab permeation to the synovial fluid (0.00422 L/h clearance of permeation) versus the rate of TNFα turnover in the affected joints (1.84 pmol/h synthesis rate and 0.877 h(-1) degradation rate constant) are apparently the major parameters that determine the time course of TNFα concentrations in the synovial fluid and the TNFα-neutralizing effects of adalimumab in RA patients. Outcomes of this study suggest that intra-articular administration of adalimumab is not preferable to subcutaneous or intravenous treatment. Local and systemic permeability, turnover and interactions between the drug and the target should be taken into account for optimization of the use of drugs acting on soluble targets (growth factors, interferons, interleukins, immunoglobulins, etc.).
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Affiliation(s)
- David Stepensky
- Department of Pharmacology and School of Pharmacy, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel.
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“Are there any evidences for using the intra-articular TNF-α blockade in resistant arthritis?”. Joint Bone Spine 2011; 78:331-4. [DOI: 10.1016/j.jbspin.2011.01.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2010] [Accepted: 01/06/2011] [Indexed: 12/31/2022]
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Singh JA, Wells GA, Christensen R, Tanjong Ghogomu E, Maxwell LJ, MacDonald JK, Filippini G, Skoetz N, Francis DK, Lopes LC, Guyatt GH, Schmitt J, La Mantia L, Weberschock T, Roos JF, Siebert H, Hershan S, Cameron C, Lunn MPT, Tugwell P, Buchbinder R. Adverse effects of biologics: a network meta-analysis and Cochrane overview. Cochrane Database Syst Rev 2011; 2011:CD008794. [PMID: 21328309 PMCID: PMC7173749 DOI: 10.1002/14651858.cd008794.pub2] [Citation(s) in RCA: 352] [Impact Index Per Article: 27.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Biologics are used for the treatment of rheumatoid arthritis and many other conditions. While the efficacy of biologics has been established, there is uncertainty regarding the adverse effects of this treatment. Since serious risks such as tuberculosis (TB) reactivation, serious infections, and lymphomas may be common to the biologics but occur in small numbers across the various indications, we planned to combine the results from biologics used in many conditions to obtain the much needed risk estimates. OBJECTIVES To compare the adverse effects of tumor necrosis factor blocker (etanercept, adalimumab, infliximab, golimumab, certolizumab), interleukin (IL)-1 antagonist (anakinra), IL-6 antagonist (tocilizumab), anti-CD28 (abatacept), and anti-B cell (rituximab) therapy in patients with any disease condition except human immunodeficiency disease (HIV/AIDS). METHODS Randomized controlled trials (RCTs), controlled clinical trials (CCTs) and open-label extension (OLE) studies that studied one of the nine biologics for use in any indication (with the exception of HIV/AIDS) and that reported our pre-specified adverse outcomes were considered for inclusion. We searched The Cochrane Library, MEDLINE, and EMBASE (to January 2010). Identifying search results and data extraction were performed independently and in duplicate. For the network meta-analysis, we performed mixed-effects logistic regression using an arm-based, random-effects model within an empirical Bayes framework. MAIN RESULTS We included 163 RCTs with 50,010 participants and 46 extension studies with 11,954 participants. The median duration of RCTs was six months and 13 months for OLEs. Data were limited for tuberculosis (TB) reactivation, lymphoma, and congestive heart failure. Adjusted for dose, biologics as a group were associated with a statistically significant higher rate of total adverse events (odds ratio (OR) 1.19, 95% CI 1.09 to 1.30; number needed to treat to harm (NNTH) = 30, 95% CI 21 to 60) and withdrawals due to adverse events (OR 1.32, 95% CI 1.06 to 1.64; NNTH = 37, 95% CI 19 to 190) and an increased risk of TB reactivation (OR 4.68, 95% CI 1.18 to 18.60; NNTH = 681, 95% CI 143 to 14706) compared to control.The rate of serious adverse events, serious infections, lymphoma, and congestive heart failure were not statistically significantly different between biologics and control treatment. Certolizumab pegol was associated with significantly higher risk of serious infections compared to control treatment (OR 3.51, 95% CI 1.59 to 7.79; NNTH = 17, 95% CI 7 to 68). Infliximab was associated with significantly higher risk of withdrawals due to adverse events compared to control (OR 2.04, 95% CI 1.43 to 2.91; NNTH = 12, 95% CI 8 to 28). Indirect comparisons revealed that abatacept and anakinra were associated with a significantly lower risk of serious adverse events compared to most other biologics. Although the overall numbers are relatively small, certolizumab pegol was associated with significantly higher odds of serious infections compared to etanercept, adalimumab, abatacept, anakinra, golimumab, infliximab, and rituximab; abatacept was significantly less likely than infliximab and tocilizumab to be associated with serious infections. Abatacept, adalimumab, etanercept and golimumab were significantly less likely than infliximab to result in withdrawals due to adverse events. AUTHORS' CONCLUSIONS Overall, in the short term biologics were associated with significantly higher rates of total adverse events, withdrawals due to adverse events and TB reactivation. Some biologics had a statistically higher association with certain adverse outcomes compared to control, but there was no consistency across the outcomes so caution is needed in interpreting these results.There is an urgent need for more research regarding the long-term safety of biologics and the comparative safety of different biologics. National and international registries and other types of large databases are relevant sources for providing complementary evidence regarding the short- and longer-term safety of biologics.
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Affiliation(s)
- Jasvinder A Singh
- Birmingham VA Medical CenterDepartment of MedicineFaculty Office Tower 805B510 20th Street SouthBirminghamALUSA35294
| | - George A Wells
- University of OttawaDepartment of Epidemiology and Community MedicineRoom H128140 Ruskin StreetOttawaONCanadaK1Y 4W7
| | - Robin Christensen
- Copenhagen University Hospital, Bispebjerg og FrederiksbergMusculoskeletal Statistics Unit, The Parker InstituteNordre Fasanvej 57CopenhagenDenmarkDK‐2000
| | | | - Lara J Maxwell
- Ottawa Hospital Research Institute (OHRI), The Ottawa Hospital ‐ General CampusCentre for Practice‐Changing Research (CPCR)501 Smyth Road, Box 711OttawaONCanadaK1H 8L6
| | - John K MacDonald
- Robarts Clinical TrialsCochrane IBD Group100 Dundas Street, Suite 200LondonONCanadaN6A 5B6
| | - Graziella Filippini
- Fondazione I.R.C.C.S. Istituto Neurologico Carlo BestaScientific Directionvia Celoria, 11MilanoItaly20133
| | - Nicole Skoetz
- University Hospital of CologneCochrane Haematological Malignancies Group, Department I of Internal MedicineKerpener Str. 62CologneGermany50937
| | - Damian K Francis
- University of West IndiesEpidemiology Research UnitMona Kingston 7Jamaica
| | - Luciane C Lopes
- University of Sorocaba, São PauloSciences of Pharmaceutical ProgramRodovia Raposo Tavares, s/nSorocabaSão PauloBrazilCEP 18023‐000
| | - Gordon H Guyatt
- McMaster UniversityDepartment of Clinical Epidemiology and Biostatistics1200 Main Street WestHamiltonONCanadaL8N 3Z5
| | - Jochen Schmitt
- Faculty of Medicine Carl Gustav Carus, Technischen Universität (TU) DresdenCenter for Evidence‐Based HealthcareFetscherstr. 74DresdenGermany01307
| | - Loredana La Mantia
- I.R.C.C.S. Santa Maria Nascente ‐ Fondazione Don GnocchiUnit of Neurorehabilitation ‐ Multiple Sclerosis CenterVia Capecelatro, 66MilanoItaly20148
| | - Tobias Weberschock
- Goethe UniversityEvidence‐Based Medicine Frankfurt, Institute of General PracticeTheodor Stern Kai 7FrankfurtGermany60590
- J.W. Goethe‐University HospitalDepartment of Dermatology, Venereology, and AllergologyTheodor‐Stern‐Kai 7FrankfurtGermany60590
| | - Juliana F Roos
- Dubai Pharmacy CollegeDept of Clinical Pharmacy & Pharmacy PracticePo Box 19099AlMuhaisanah 1, Al mizharDubaiUnited Arab Emirates
| | - Hendrik Siebert
- University Hospital CologneCochrane Haematological Malignancies GroupKerpener Strasse 62CologneGermany50924
| | - Sarah Hershan
- Department of Epidemiology and Preventive Medicine, Monash UniversityMonash Department of Clinical Epidemiology at Cabrini HospitalSuite 41, Cabrini Medical Centre183 Wattletree RoadMalvernVictoriaAustralia3144
| | - Chris Cameron
- University of OttawaDepartment of Epidemiology and Community MedicineRoom H128140 Ruskin StreetOttawaONCanadaK1Y 4W7
| | - Michael PT Lunn
- National Hospital for Neurology and NeurosurgeryDepartment of Neurology and MRC Centre for Neuromuscular DiseasesQueen SquareLondonUKWC1N 3BG
| | - Peter Tugwell
- Faculty of Medicine, University of OttawaDepartment of MedicineOttawaONCanadaK1H 8M5
- Clinical Epidemiology ProgramOttawa Hospital Research InstituteOttawaONCanadaK1Y 4E9
- Faculty of Medicine, University of OttawaDepartment of Epidemiology and Community MedicineOttawaONCanadaK1H 8M5
| | - Rachelle Buchbinder
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash UniversityMonash Department of Clinical Epidemiology, Cabrini HospitalSuite 41, Cabrini Medical Centre183 Wattletree RoadMalvernVictoriaAustralia3144
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Fiocco U, Sfriso P, Oliviero F, Roux-Lombard P, Scagliori E, Cozzi L, Lunardi F, Calabrese F, Vezzù M, Dainese S, Molena B, Scanu A, Nardacchione R, Rubaltelli L, Dayer JM, Punzi L. Synovial effusion and synovial fluid biomarkers in psoriatic arthritis to assess intraarticular tumor necrosis factor-α blockade in the knee joint. Arthritis Res Ther 2010; 12:R148. [PMID: 20642840 PMCID: PMC2945042 DOI: 10.1186/ar3090] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2009] [Revised: 05/17/2010] [Accepted: 07/19/2010] [Indexed: 12/16/2022] Open
Abstract
INTRODUCTION The purpose of this study was the evaluation of synovial effusion (SE), synovial fluid (SF) and synovial tissue (ST) biomarkers in relation to disease activity indexes to assess the response to intraarticular (IA) tumor necrosis factor (TNF)-α blockers in psoriatic arthritis (PsA). METHODS Systemic and local disease activity indexes (disease activity score (DAS); the Ritchie articular index (mRAI), erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP); Thompson articular (THOMP) and joint articular (KJAI)-Index ) and ST samples were assessed at baseline, throughout treatment, and during the follow-up in 14 patients affected with PsA who underwent IA injections (0.5 ml to 12.5 mg) in the knee joint of etanercept (E) or placebo (P) once every two weeks for a 10-week period. Total SF white blood cell (WBC) counts (WBC/μl) and SF cytokine/chemokine (CK/CCK) levels were measured before IA-E at baseline, after IA-E, and as long as there were adequate amounts of SF for knee aspiration (post). Characterization of synovial mononuclear cell infiltration and synovial vessels was carried out in 8 out of 14 knees by staining serial sections of synovial tissue biopsies for CD45, CD3, CD68, CD31 and CD105. RESULTS At baseline, CRP and/or ESR were significantly correlated with SF-CK (interleukin- (IL-)1β, IL-1Ra, IL-6, IL-8) and CCK (CCL3). Post-IA injections, there was a decrease in SE in the knees in which aspiration following IA-E injection was possible as well as a significant reduction in SF WBC/μl and in SF-CK (IL-1β, IL-1Ra, IL-6 and IL-22). Pre- and post-IA-E injections, there were significant correlations between ST markers and SF-CK (IL-1β with CD45; IL-1β and IL-6 with CD31) and between SF-CCK (CCL4 and CCL3 with CD3). At the end of the study, there was a significant reduction in disease activity indexes (CRP, DAS, RAI, THOMP, KJAI) as well as in the ST markers (CD45; CD3). CONCLUSIONS Synovial effusion regression is a reliable indicator of the response to IA TNF-α blockers in PsA patients as it is confirmed by the correlation between SF biomarkers to disease activity and synovial tissue inflammation.
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Affiliation(s)
- Ugo Fiocco
- Department of Clinical and Experimental Medicine, University of Padova, Via Giustiniani 2, Padova, 35128, Italy
| | - Paolo Sfriso
- Department of Clinical and Experimental Medicine, University of Padova, Via Giustiniani 2, Padova, 35128, Italy
| | - Francesca Oliviero
- Department of Clinical and Experimental Medicine, University of Padova, Via Giustiniani 2, Padova, 35128, Italy
| | - Pascale Roux-Lombard
- Immunology and Allergy Division, Geneva University Hospitals and University of Geneva, Rue Gabrielle Perret-Gentil 4, Geneva, CH-1211, Switzerland
| | - Elena Scagliori
- Department of Diagnostic Sciences and Special Therapies, University of Padova, Via Giustiniani 2, Padova, 35128, Italy
| | - Luisella Cozzi
- Department of Clinical and Experimental Medicine, University of Padova, Via Giustiniani 2, Padova, 35128, Italy
| | - Francesca Lunardi
- Department of Diagnostic Sciences and Special Therapies, University of Padova, Via Giustiniani 2, Padova, 35128, Italy
| | - Fiorella Calabrese
- Department of Diagnostic Sciences and Special Therapies, University of Padova, Via Giustiniani 2, Padova, 35128, Italy
| | - Maristella Vezzù
- Department of Clinical and Experimental Medicine, University of Padova, Via Giustiniani 2, Padova, 35128, Italy
| | - Serena Dainese
- Department of Clinical and Experimental Medicine, University of Padova, Via Giustiniani 2, Padova, 35128, Italy
| | - Beatrice Molena
- Department of Clinical and Experimental Medicine, University of Padova, Via Giustiniani 2, Padova, 35128, Italy
| | - Anna Scanu
- Department of Clinical and Experimental Medicine, University of Padova, Via Giustiniani 2, Padova, 35128, Italy
| | - Roberto Nardacchione
- Department of Orthopedics, Leonardo Foundation, Abano Terme General Hospital, Piazza Cristoforo Colombo 1, Abano Terme (PD), 35031, Italy
| | - Leopoldo Rubaltelli
- Department of Diagnostic Sciences and Special Therapies, University of Padova, Via Giustiniani 2, Padova, 35128, Italy
| | - Jean Michel Dayer
- Faculty of Medicine, CMU 1, rue Michel-Servet, Geneva, CH-1211, Switzerland
| | - Leonardo Punzi
- Department of Clinical and Experimental Medicine, University of Padova, Via Giustiniani 2, Padova, 35128, Italy
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Drosos AA. Efficacy of intraarticular infliximab administration in patients with recurrent gonarthritis: Comment on the article by van der Bijl et al. Arthritis Care Res (Hoboken) 2010; 62:291; author reply 291-2. [DOI: 10.1002/acr.20081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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In brief. Nat Rev Rheumatol 2009. [DOI: 10.1038/nrrheum.2009.160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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