Efficacy of methotrexate in reducing the risk of bone erosion in patients with rheumatoid arthritis: a systematic review of randomized controlled trials

Early prediction of bone destruction in rheumatoid arthritis through machine learning analysis of plasma metabolites

BACKGROUND

To develop a predictive model for bone destruction in patients with rheumatoid arthritis (RA), based on the characteristics of plasma metabolites and common clinical indicators.

METHODS

The cohort comprised 60 patients with RA, with baseline metabolite features identified using the liquid chromatograph-mass spectrometer system. Radiographic outcomes were assessed using the van der Heijde-modified total Sharp score (mTSS) following a one-year follow-up period to quantify bone destruction. The longitudinal association between metabolites and radiographic progression was analyzed using several machine learning algorithms, and the significance of core metabolites was calculated. A new model incorporating metabolites and clinical indicators was created to evaluate its predictive performance for radiographic progression; the model was compared with other prediction models.

RESULTS

The median increase in mTSS was 3.50. Of the 774 detected metabolites, 77 differed between patients with different outcomes. Core metabolites identified using the Gaussian Naive Bayes algorithm included mangiferic acid, O-acetyl-L-carnitine, 5,8,11-eicosatrienoic acid, and 16-methylheptadecanoic acid. A standardized bone erosion risk score (BERS) was developed based on these core metabolite features for assessing the radiographic progression outcome. Individuals with a high BERS exhibited a lower risk of rapid radiographic progression than those with a lower score (OR = 0.01, 95% CI = 0.01-0.03, P = 0.003). The "China-Japan Friendship Hospital-BERS Model" (CjBM), combining BERS with clinical features (methotrexate and C-reactive protein), produced an area under the receiver operating characteristic curve of 0.800. Moreover, compared with the reported models, the CjBM showed near statistical significance in identifying rapid radiographic progression; adding BERS can improve the discrimination of the original reported model (PDeLong=0.035).

CONCLUSIONS

The CjBM was developed for early prediction of bone destruction in patients with RA, and the evaluation of BERS emphasizes the significance of metabolite features.

AMPD1 and MTHFR genes are not associated with calcium levels in rheumatoid arthritis patients with methotrexate therapy in Indonesia

Rheumatoid Arthritis (RA) is a chronic and progressive autoimmune disease that affects synovial tissues has greater risk of developing secondary osteoporosis (OP). In particular, polymorphisms in Adenosine Monophosphate Deaminase 1 (AMPD1) and Methylenetetrahydrofolate Reductase (MTHFR) affect the outcome of methotrexate (MTX) treatment in patients with RA. Therefore, this study aimed to determine the association of AMPD1 rs17602729, MTHFR C677T, and MTHFR A1298C polymorphisms with MTX activity in RA patients. A retrospective design was adopted to collect data from medical records and blood samples of 99 patients experiencing outpatient care at a referral hospital in Bandung. The inclusion criteria were patients diagnosed with RA, aged 18-59 years, and receiving MTX therapy for ≥ 6 months. DNA was isolated and then amplified using Polymerase Chain Reaction (PCR), and genotyping was performed with Sanger sequencing. The kinetic photometric method was used to measure the levels of calcium in the samples. The results showed that there is no significant association between the MTHFR C677T genotype variant or allele with calcium levels, as indicated by p-values of 0.177 and 0.174, respectively. The association between the MTHFR A1298C genotype variant or alleles with calcium levels was also not significant (p = 0.206 and p = 0.090, respectively). However, most patients had normal calcium levels (76 patients; 77.6%) with the MTHFR C677T genotype variant CC and the MTHFR A1298C genotype variant AA (84 patients; 84.9%). AMPD1 rs17602729 in all patients had a CC genotype with normal calcium levels. The results suggested that there was no significant association between the genetic variation of AMPD1 rs17602729, MTHFR C677T, and MTHFR A1298C with serum calcium levels in patients with RA receiving MTX therapy.

Therapeutic potential of antibody-drug conjugates possessing bifunctional anti-inflammatory action in the pathogenies of rheumatoid arthritis

In an age where there is a remarkable upsurge in developing precision medicines, antibody-drug conjugates (ADCs) have emerged as a progressive therapeutic strategy. ADCs typically consist of monoclonal antibodies (mAb) conjugated to the cytotoxic payloads by utilizing a linker, combining the benefits of definitive target specificity of mAbs and potent killing impact of payload to achieve precise and efficient elimination of target cells. In addition to their well-established role in oncology, ADCs are currently demonstrating encouraging potential in addressing the unmet requirements in the treatment of autoimmune conditions such as rheumatoid arthritis (RA). Prevalent long-term autoimmune disease RA costs billions of dollars annually but still, there is a lack of precision-targeted therapeutics with minimal side effects. This review provides an overview of the RA pathogenesis, pre-existing therapies, and their limitations, the introduction of ADCs in RA treatment, the mechanism of ADCs, and a summary of ADCs in preclinical and clinical trials. Based on the literature we also propose a strategy in ADC synthesis, which may increase the efficiency in targeting multifactorial diseases like RA. We propose to utilize DMARDs (Disease-modifying anti-rheumatic drugs), the first-line treatment for RA, as a payload for ADC synthesis. DMARDs are the only class of medication that limits the disease progression, but their efficacy is limited due to off-target toxicities. Hence, utilizing them as payload will help to deliver them directly at the targeted site, reducing their off-target toxicity, which in turn will increase their efficiency in targeting disease. Also, as mAbs are not sufficient to achieve remission, they are given in combinations with DMARDs. Hence, synthesizing ADCs may reduce the multiple and higher dosages given to patients, which in turn may enhance patient compliance.

Mannose-mediated nanodelivery of methotrexate to macrophages augments rheumatoid arthritis therapy

Rheumatoid arthritis (RA) is a chronic autoimmune disease that gravely jeopardizes the quality of life of numerous people. Methotrexate (MTX) is a disease-modifying anti-rheumatic drug commonly used in clinics; however, it suffers from slow onset, moderate efficacy, and adverse reactions such as renal dysfunction, myelosuppression, and bone erosion after long-term treatment. Here, we explored macrophage targeted delivery of MTX using mannose-installed chimaeric polymersomes (Man-PMTX) as an advanced treatment for RA. Man-PMTX exhibited high (∼18 wt%) and robust loading of MTX, uniform size of 51-55 nm, minimal hemolytic activity, and glutathione-actuated drug release property. Man-PMTX showed better uptake by activated macrophages than PMTX, and more repolarization of bone marrow-derived macrophages (BMDMs) to anti-inflammatory M2 type macrophages and less secretion of TNF-α and IL-1β compared with free MTX and PMTX. In vivo studies revealed that Man-PMTX showed significantly higher accumulation in inflammatory joints than in healthy joints and effectively treated RA by relieving inflammation, repolarizing macrophages from M1 type to M2 type, and mitigating proinflammatory cytokines. Accordingly, Man-PMTX effectively protected the synovium and bone from damage. Mannose-mediated nanodelivery of methotrexate to macrophages appears to be an attractive strategy to augment rheumatoid arthritis therapy.

Methotrexate related cutaneous adverse drug reactions: a systematic literature review

OBJECTIVES

Recently, there is an increased number of reports being published on Methotrexate (MTX) related cutaneous manifestations. We aimed to identify and critically appraise descriptive studies describing the MTX related skin manifestations, treatment approach, and their outcomes.

METHODOLOGY

An extensive literature search was performed in the PubMed, Embase, and Scopus databases from inception to April 2021 without any restrictions along with the bibliographic search of included studies, grey literature search, and a snowball search was performed in Google and Google Scholar to identify the relevant literature. Descriptive studies reporting MTX related cutaneous manifestations were considered for the review. The study selection, data extraction, and quality assessment were conducted by two independent reviewers and any disagreements were settled by consensus with the third reviewer.

RESULTS

31 out of 8,365 descriptive studies including 38 patients (22 females and 16 males) aged between 12 and 78 years prescribed for the management of rheumatoid arthritis, ankylosing spondylitis, and psoriasis were included in this review. Toxic epidermal necrolysis (TEN), papular eruption, vasculitis, erosions of psoriasis, ulcerated psoriatic plaques, local reactions, keratinocyte dystrophy, erythema multiforme, drug rash with eosinophilia and systemic symptoms, Steven Johnson syndrome and photosensitive dermatitis were the majority of MTX induced cutaneous reactions. Immediate withdrawal of MTX, providing appropriate care with anti-inflammatory, topical steroids, and supplementation with folic acid were reported to be effective for the management of the MTX related cutaneous manifestations.

CONCLUSIONS

Clinicians and healthcare professionals should be aware of possible acute cutaneous drug reactions induced by MTX to avoid further consequences and fatal conditions. Immediate withdrawal of MTX and supportive care were reported as an efficacious therapeutic management of acute cutaneous drug reactions.

PROSPERO REGISTRATION NUMBER

CRD42020220038.

Bone Metabolism and RANKL/OPG Ratio in Rheumatoid Arthritis Women Treated with TNF-α Inhibitors

The aim of this study was to evaluate the effect of anti-tumor necrosis factor α (anti-TNF-α) therapy in combination with methotrexate on bone remodeling and osteoclastogenesis in female patients with RA. Serum levels of bone turnover markers (i.e., C- and N-terminal propeptides of type I procollagen (PICP and PINP), C- and N-terminal cross-linking telopeptides of type I collagen (CTX-I and NTX-I), and soluble receptor activator of nuclear factor κB ligand (sRANKL) and osteoprotegerin (OPG)) were determined by immunoassay at baseline and 15 months after initiation of treatment. Bone mineral density was measured by dual-energy x-ray absorptiometry. We found a significant decrease in serum PINP levels, a biomarker of bone formation, and higher levels of CTX-I and sRANKL indicative of increased bone resorption in RA patients prior to TNFαI treatment compared to the controls. Anti-TNF-α therapy was effective in improving bone metabolism in RA patients as reflected in a decrease in CTX-I (at least partially due to the RANKL/OPG reduction) and a concomitant increase in PINP levels. The bone metabolism changes were independent of the type of TNFαI used. PINP and CTX-I were found to be useful markers of bone metabolism, which may prove the effectiveness of TNF-α therapy earlier than the bone density assessment.