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Alotaibi A, Albarrak D, Alammari Y. The Efficacy and Safety of Biologics in Treating Ankylosing Spondylitis and Their Impact on Quality of Life and Comorbidities: A Literature Review. Cureus 2024; 16:e55459. [PMID: 38571822 PMCID: PMC10988185 DOI: 10.7759/cureus.55459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/22/2024] [Indexed: 04/05/2024] Open
Abstract
Ankylosing spondylitis (AS) is a chronic inflammatory arthritis that affects the axial skeleton, causing intense pain, progressive joint destruction, and a gradual reduction in physical function. Additionally, AS can result in extra-musculoskeletal manifestations including inflammatory bowel disease (IBD), psoriasis, and acute anterior uveitis (AAU) affecting patients' quality of life (QoL). Furthermore, AS association with neurological and cardiovascular events has been documented. With the advent of biologics, treating AS has dramatically changed due to their high efficacy and tolerable safety. Nevertheless, there are differences in traits, including rapidity of onset, long-term efficacy, safety profile, and influence on comorbidities. A better understanding of such traits enables clinicians to make the best decision for each patient, increasing persistence, extending medication survival, enhancing patient satisfaction, and reducing the disease effect of AS. A review of the literature published in English in PubMed and Google Scholar databases from 2010 to 2023 was conducted. All relevant results fitting the scope of the topic were included. In this article, we emphasize biologics' efficacy and safety profile in patients with AS. In addition, we discuss the impact of biologics on comorbidities and health-related quality of life (HRQoL).
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Affiliation(s)
| | - Danah Albarrak
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, SAU
| | - Yousef Alammari
- College of Medicine, Imam Mohammad Ibn Saud Islamic University, Riyadh, SAU
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2
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Hornick MG, Olson ME, Jadhav AL. SARS-CoV-2 Psychiatric Sequelae: A Review of Neuroendocrine Mechanisms and Therapeutic Strategies. Int J Neuropsychopharmacol 2022; 25:1-12. [PMID: 34648616 PMCID: PMC8524640 DOI: 10.1093/ijnp/pyab069] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 09/07/2021] [Accepted: 10/12/2021] [Indexed: 12/15/2022] Open
Abstract
From the earliest days of the coronavirus disease 2019 (COVID-19) pandemic, there have been reports of significant neurological and psychological symptoms following Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection. This narrative review is designed to examine the potential psychoneuroendocrine pathogenic mechanisms by which SARS-CoV-2 elicits psychiatric sequelae as well as to posit potential pharmacologic strategies to address and reverse these pathologies. Following a brief overview of neurological and psychological sequelae from previous viral pandemics, we address mechanisms by which SARS-CoV-2 could enter or otherwise elicit changes in the CNS. We then examine the hypothesis that COVID-19-induced psychiatric disorders result from challenges to the neuroendocrine system, in particular the hypothalamic-pituitary-adrenal stress axis and monoamine synthesis, physiological mechanisms that are only further enhanced by the pandemic-induced social environment of fear, isolation, and socioeconomic pressure. Finally, we evaluate several FDA-approved therapeutics in the context of COVID-19-induced psychoneuroendocrine disorders.
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Affiliation(s)
- Mary G Hornick
- Roosevelt University, College of Science, Health and Pharmacy, Schaumburg, Illinois, USA
| | - Margaret E Olson
- Roosevelt University, College of Science, Health and Pharmacy, Schaumburg, Illinois, USA
| | - Arun L Jadhav
- Roosevelt University, College of Science, Health and Pharmacy, Schaumburg, Illinois, USA
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Poutoglidou F, Pourzitaki C, Manthou ME, Malliou F, Saitis A, Tsimoulas I, Panagiotopoulos S, Kouvelas D. Effects of long-term infliximab and tocilizumab treatment on anxiety-like behavior and cognitive function in naive rats. Pharmacol Rep 2021; 74:84-95. [PMID: 34569017 DOI: 10.1007/s43440-021-00328-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 09/16/2021] [Accepted: 09/16/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Circulating cytokines have been proposed to be implicated in the development of mood disorders and cognitive impairment. This study aims to examine the effect of chronic treatment with infliximab, a tumor necrosis factor-alpha (TNF-alpha) inhibitor, and tocilizumab, an antibody against interleukin-6 (IL-6) receptor on anxiety-like behavior and cognitive function. METHODS Twenty-eight male, Wistar rats were randomly allocated into negative control, vehicle, infliximab and tocilizumab groups. After 8 weeks of intraperitoneal drug administration, rats performed the elevated-plus maze, the elevated-zero maze, the olfactory social memory and the passive avoidance tests. Brain sections at the level of the hippocampus, the amygdala and the prefrontal cortex were histologically examined. Finally, hippocampal and amygdaloid brain-derived neurotrophic factor (BDNF) expression was determined by reverse transcription-quantitative polymerase chain reaction (RT-qPCR). RESULTS Infliximab group exhibited a significantly higher number of entries and time spent into the open arms of the mazes, showing a lower level of anxiety. In the olfactory social memory test, tocilizumab significantly increased the ratio of interaction. Both infliximab- and tocilizumab-treated animals had a significantly lower latency time in the passive avoidance test that suggests an improved memory. Histological examination revealed similar morphology and neuronal density between groups. BDNF expression levels were significantly increased in the groups receiving anti-cytokine treatment. CONCLUSIONS Our findings suggest that long-term peripheral TNF-alpha and IL-6 inhibition improves anxiety and cognitive function in rats and leads to an increased BDNF expression in the brain.
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Affiliation(s)
- Frideriki Poutoglidou
- Department of Clinical Pharmacology, Faculty of Medicine, School of Health Sciences, Aristotle University of Thessaloniki, 54124, Thessaloníki, Greece. .,Department of Clinical Pharmacology, School of Health Sciences, Aristotle University of Thessaloniki, PO Box 1532, 54006, Thessaloníki, Greece.
| | - Chryssa Pourzitaki
- Department of Clinical Pharmacology, Faculty of Medicine, School of Health Sciences, Aristotle University of Thessaloniki, 54124, Thessaloníki, Greece
| | - Maria Eleni Manthou
- Laboratory of Histology and Embryology, Medical School, Aristotle University of Thessaloniki, University Campus, 54124, Thessaloníki, Greece
| | - Foteini Malliou
- Department of Clinical Pharmacology, Faculty of Medicine, School of Health Sciences, Aristotle University of Thessaloniki, 54124, Thessaloníki, Greece
| | - Athanasios Saitis
- Department of Clinical Pharmacology, Faculty of Medicine, School of Health Sciences, Aristotle University of Thessaloniki, 54124, Thessaloníki, Greece
| | - Ioannis Tsimoulas
- Department of Clinical Pharmacology, Faculty of Medicine, School of Health Sciences, Aristotle University of Thessaloniki, 54124, Thessaloníki, Greece
| | - Spyridon Panagiotopoulos
- Department of Clinical Pharmacology, Faculty of Medicine, School of Health Sciences, Aristotle University of Thessaloniki, 54124, Thessaloníki, Greece
| | - Dimitrios Kouvelas
- Department of Clinical Pharmacology, Faculty of Medicine, School of Health Sciences, Aristotle University of Thessaloniki, 54124, Thessaloníki, Greece
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Benefit of Biological Drugs for Quality of Life in Patients with Ankylosing Spondylitis: A Systematic Review and Meta-Analysis of Clinical Trials. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2020; 1335:63-78. [PMID: 33378002 DOI: 10.1007/5584_2020_611] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Ankylosing spondylitis (AS) is a chronic inflammatory rheumatic disease involving the axial skeleton, peripheral joints, and extra-articular manifestations like psoriasis, inflammatory bowel disease, or uveitis. A deterioration of quality of life (QoL) affects the disease management and therapeutic decision-making. This meta-analysis focused on the influence of biological drugs on the QoL in SA compared to the effects of other therapeutic modalities. We searched the databases of MedLine, Academic Search Ultimate, CINAHL Complete, and Health Source - Nursing/Academic Edition for articles related to AS treatment using the terms "ankylosing spondylitis" OR "rheumatoid spondylitis" OR "spondylitis" AND "quality of life" OR "patient-reported outcomes" OR "well-being" OR "health-related quality of life" OR "biological treatment". The search came up with 10 English-language articles published between 2010 and 2020. Patients were evaluated with the following indexes and questionnaires: Assessment of Spondyloarthritis International Society (ASAS), Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), Ankylosing Spondylitis Quality of Life (ASQoL), 36-Item Short-Form Health Survey (SF-36), Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F), and the Bath Ankylosing Spondylitis Functional Index (BASFI), and Bath Ankylosing Spondylitis Functional (BASFI) Indexes. We found that the QoL, assessed with the ASQoL, improved significantly better in patients treated with biological drugs when compared to those treated with other standard therapies or placebo at a 4-month follow-up. However, improvements in other disease characteristics could not be differentiated based on the therapy modality. The finding that biological drugs are superior in improving the QoL should strengthen the recommendations for their use in patients with AS.
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Webers C, Stolwijk C, Schiepers O, Schoonbrood T, van Tubergen A, Landewé R, van der Heijde D, Boonen A. Infliximab treatment reduces depressive symptoms in patients with ankylosing spondylitis: an ancillary study to a randomized controlled trial (ASSERT). Arthritis Res Ther 2020; 22:225. [PMID: 32993799 PMCID: PMC7523309 DOI: 10.1186/s13075-020-02305-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Accepted: 08/25/2020] [Indexed: 12/12/2022] Open
Abstract
Background Patients with ankylosing spondylitis (AS) are at increased risk of depression. This increased risk has been hypothesized to be solely secondary due to AS-related symptoms, or additionally due to a common inflammatory pathway. From a clinical perspective, it is important to know whether treatment with tumor necrosis factor alpha inhibitors reduces depressive symptoms, while from a pathophysiological point of view, it would be insightful to understand whether such an effect would be a direct result of reduced inflammation, the result of reduced AS-related symptoms, or both. The objective of this study was to evaluate the effect of infliximab on depressive symptoms in patients with AS in a randomized-controlled trial setting. Methods Data were retrieved from a subgroup of patients from the AS Study for the Evaluation of Recombinant Infliximab Therapy (ASSERT). Patients were randomly allocated to infliximab (n = 16) or placebo (n = 7) until week 24, after which all received infliximab until week 54. Associations between treatment group and depressive symptoms, measured with the Center for Epidemiological Studies Depression scale (CES-D, range 0–60 (best-worst)) at baseline and over time, were explored with generalized estimating equations (GEE). Results Mean CES-D score at baseline was 15.5 (SD 9.3) in the infliximab group and 17.3 (SD 5.7) in the placebo group. Twelve patients (52%) had a CES-D score > 16, suggestive for clinical depression. After 24 weeks, mean CES-D had decreased to 9.5 (SD 11.4) in the infliximab group, but was 18.0 (SD 6.9) in the placebo group. GEE revealed larger improvements in depressive symptoms (B = − 6.63, 95%CI − 13.35 to 0.09) and odds of possible depression (OR = 0.02, 95%CI 0.00 to 0.72) in the infliximab group, compared to the placebo group. Both associations largely disappeared when adjusted for self-reported disease activity and/or physical function. Additional adjustment for C-reactive protein (CRP) did not change results. Conclusions Depressive symptoms are common in patients with AS and active disease. Infliximab improves these depressive symptoms in AS when compared to placebo by improving disease symptoms. We did not find an indication for a direct link between CRP-mediated inflammation and depressive symptoms. Trial registration Trial registration (ASSERT): NCT00207701. Registered on September 21, 2005 (retrospectively registered).
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Affiliation(s)
- Casper Webers
- Department of Internal Medicine, Division of Rheumatology, Maastricht University Medical Centre, PO Box 5800, Maastricht, 6202 AZ, The Netherlands. .,Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, the Netherlands.
| | - Carmen Stolwijk
- Department of Internal Medicine, Erasmus Medical Centre, Rotterdam, the Netherlands
| | - Olga Schiepers
- Department of Psychiatry and Neuropsychology, School for Mental Health and Neuroscience (MHeNs), Maastricht University, Maastricht, the Netherlands
| | - Thea Schoonbrood
- Department of Internal Medicine, Division of Rheumatology, Maastricht University Medical Centre, PO Box 5800, Maastricht, 6202 AZ, The Netherlands
| | - Astrid van Tubergen
- Department of Internal Medicine, Division of Rheumatology, Maastricht University Medical Centre, PO Box 5800, Maastricht, 6202 AZ, The Netherlands.,Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, the Netherlands
| | - Robert Landewé
- Department of Clinical Immunology & Rheumatology, Amsterdam Rheumatology Centre, University of Amsterdam, Amsterdam, the Netherlands.,Department of Rheumatology, Zuyderland Medical Centre, Heerlen, the Netherlands
| | | | - Annelies Boonen
- Department of Internal Medicine, Division of Rheumatology, Maastricht University Medical Centre, PO Box 5800, Maastricht, 6202 AZ, The Netherlands.,Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, the Netherlands
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Hwang MC, Lee MJ, Gensler LS, Ward MM, Brown MA, Eisen S, Learch TJ, Tahanan A, Rahbar MH, Ishimori ML, Weisman MH, Reveille JD. Longitudinal associations between depressive symptoms and clinical factors in ankylosing spondylitis patients: analysis from an observational cohort. Rheumatol Int 2020; 40:1053-1061. [PMID: 32166439 DOI: 10.1007/s00296-020-04544-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Accepted: 02/28/2020] [Indexed: 12/17/2022]
Abstract
OBJECTIVES Although cross-sectional studies have shown that ankylosing spondylitis-specific factors correlate with depressive symptom severity, the association of these factors over time is unresolved. We examined the demographic and clinical factors associated with longitudinal depressive symptom severity in AS patients. METHODS We analyzed sociodemographic, clinical, behavioral and medication data from 991 patients from the Prospective Study of Outcomes in Ankylosing spondylitis cohort, and measured depression severity with the Center for Epidemiological Studies Depression (CES-D) Scale administered at approximately 6-month visit intervals. Multivariable longitudinal negative binomial regression models were conducted using generalized estimating equation modeling to assess the demographic, clinical, and medication-related factors associated with depression severity by CES-D scores over time. RESULTS The median baseline CES-D score (possible range 0-60) was 10.0 (interquartile range = 5, 17). In longitudinal multivariable analyses, higher CES-D scores were associated with longitudinal smoking, greater functional impairment, greater disease activity, self-reported depression, and poor global health scores. Marital status (e.g., being married) was associated with lower CES-D. Adjusted mean CES-D scores in our model decreased over time, with a significant interaction between time and gender observed. CONCLUSION This study identified longitudinal clinical factors such as greater disease activity, greater functional impairment, and poor global health to be associated with longitudinal depression severity. These factors are potentially modifiable and may help manage depressive symptoms in AS.
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Affiliation(s)
- Mark C Hwang
- Division of Rheumatology, Department of Internal Medicine, McGovern Medical School, University of Texas Health Science Center at Houston, 6431 Fannin MSB 5.270, Houston, TX, 77030, USA.
| | - Min Jae Lee
- Division of Clinical and Translational Sciences, Department of Internal Medicine, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Lianne S Gensler
- Division of Rheumatology, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Michael M Ward
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health Bethesda, Bethesda, MD, USA
| | - Matthew A Brown
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Translational Research Institute, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Seth Eisen
- Department of Medicine, Division of Rheumatology, Washington University at St. Louis, St. Louis, MO, USA
| | - Thomas J Learch
- Division of Rheumatology, Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - Amirali Tahanan
- Division of Clinical and Translational Sciences, Department of Internal Medicine, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Mohammad H Rahbar
- Division of Clinical and Translational Sciences, Department of Internal Medicine, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Mariko L Ishimori
- Division of Rheumatology, Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - Michael H Weisman
- Division of Rheumatology, Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - John D Reveille
- Division of Rheumatology, Department of Internal Medicine, McGovern Medical School, University of Texas Health Science Center at Houston, 6431 Fannin MSB 5.270, Houston, TX, 77030, USA
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Fatigue and contributing factors in Chinese patients with ankylosing spondylitis. Clin Rheumatol 2020; 39:2337-2344. [PMID: 32133565 DOI: 10.1007/s10067-020-04976-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Revised: 12/25/2019] [Accepted: 02/07/2020] [Indexed: 01/26/2023]
Abstract
OBJECTIVES Fatigue is a common symptom in patients with ankylosing spondylitis (AS). However, fatigue of AS patients has not been well elucidated in China. This study aimed to evaluate the predictors of fatigue and the effects of fatigue on health-related quality of life among patients with AS. METHOD A total of 150 AS patients were involved in the study. A series of questionnaires included the following: Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), Bath Ankylosing Spondylitis Metrology Index (BASMI), Bath Ankylosing Spondylitis Functional Index (BASFI), the 10-cm Visual Analog Scale (VAS), the Self-Rating Anxiety Scale (SAS), the Self-Rating Depression Scale (SDS), the Pittsburgh Sleep Quality Index (PSQI), the Health Assessment Questionnaire-Disability Index (HAQ-DI), the Short Form 36 Health Survey (SF-36), and the Fatigue Severity Scale (FSS). Independent samples t test, Mann-Whitney U test, chi-square analysis, Pearson/Spearman correlation, and binary logistic regression were used to analyze the data. RESULTS The results demonstrated that 48.7% individuals with AS suffered from fatigue. Binary logistic regression indicated that waist-to-hip ratio, BASDAI, and sleep disturbance were independent predictors of fatigue in AS patients. Meanwhile, severe fatigue led to lower quality of life. CONCLUSION These findings suggested that medical personnel should pay more attention to AS patients with fatigue and take effective measures to relieve fatigue. Key Points • Incidence of fatigue in AS patients is 48.7% according to this cross-sectional study. • The occurrence of fatigue was associated with higher WHR, higher BASDAI, and sleep disturbance. • We also found that the occurrence of fatigue significantly reduced the quality of life in AS patients both physically and psychologically.
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Brenner P, Citarella A, Wingård L, Sundström A. Use of antidepressants and benzodiazepine-related hypnotics before and after initiation of TNF-α inhibitors or non-biological systemic treatment in patients with rheumatoid arthritis, psoriatic arthritis or ankylosing spondylitis. BMC Rheumatol 2020; 4:9. [PMID: 32072134 PMCID: PMC7014636 DOI: 10.1186/s41927-019-0106-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Accepted: 11/18/2019] [Indexed: 12/27/2022] Open
Abstract
Background Rheumatoid arthritis (RA), psoriatic arthritis (PsA) and ankylosing spondylitis (AS) are autoimmune disorders associated with an increased risk for depression, anxiety and sleeping problems. The objective of this study was to analyze use of antidepressants and benzodiazepine-related hypnotics (BRH) in Sweden before and after first time treatment with anti-TNF and non-biological systemic (NBS) treatments among patients with the above diagnoses, and to correlate such use with that of randomly selected population controls. Methods Patients and dispensed drugs were identified in nationwide Swedish healthcare registers. Proportions of subjects filling prescriptions of antidepressants and BRH from 2 years before start of treatment (index-date), and 2 years after index date were assessed. Using the period -6 months to index-date as reference, prevalence rate ratios were computed for 6 months' intervals before and after index. For up to ten randomly selected population controls per patient, the same measures were calculated. Results A total of 6256 patients started anti-TNF treatment, and 13,241 NBS treatment. The mean age at index was 52.0 for the anti-TNF group and 56.1 for NBS. Use of antidepressants and BRH was similar in both treatment groups (10.4-12.8%), significantly more common than in the controls (6.6 to 7.6%). For all patients, proportions filling prescriptions for antidepressants and BRH decreased directly or soon after the index; no such changes were seen in the controls, who all showed a slow but steady increase in use over time. Starters of anti-TNF treatment did not show clearer decreases in use of psychotropics than those initiating NBS. Conclusions Decreased rates of dispensed psychotropic drugs after the time of anti-TNF and NBS treatment initiation were seen among patients with autoimmune disorders but not population controls. This may correspond to treatment effects of anti-TNF and NBS also on psychiatric symptoms among these patients.
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Affiliation(s)
- Philip Brenner
- Department of Medicine Solna, Centre for Pharmacoepidemiology, Karolinska Institutet, SE-171 76 Stockholm, Sweden
| | - Anna Citarella
- Department of Medicine Solna, Centre for Pharmacoepidemiology, Karolinska Institutet, SE-171 76 Stockholm, Sweden
| | - Louise Wingård
- Department of Medicine Solna, Centre for Pharmacoepidemiology, Karolinska Institutet, SE-171 76 Stockholm, Sweden
| | - Anders Sundström
- Department of Medicine Solna, Centre for Pharmacoepidemiology, Karolinska Institutet, SE-171 76 Stockholm, Sweden
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Milutinovic S, Veljkovic K, Zlatanovic M, Radunovic G, Damjanov N. Depression/anxiety symptoms in axial spondyloarthritis and psoriatic arthritis patients in Serbia: a pilot study. Rheumatol Int 2019; 39:1595-1605. [PMID: 31309294 DOI: 10.1007/s00296-019-04376-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Accepted: 07/09/2019] [Indexed: 12/24/2022]
Abstract
To assess prevalence and change of depression/anxiety symptoms in spondyloarthritis patients and feasibility of depression/anxiety questionnaires. 43 Patients with axial spondyloarthritis (axSpA) and 27 patients with psoriatic arthritis (PsA) were consecutively recruited. There were 34 patients on biologics and 36 patients on nonbiologics. Patients were not previously treated for depression. The demographic variables, pain, patient global assessment, laboratory, clinical findings, diseases activity scores, Beck Depression Inventory (BDI) and Depression Anxiety and Stress Scale-short version (DASS-21) were collected. The study visits were at the beginning, after 1 month, after 3 and after 6 months. In axSpA and PsA patients on biologics, BDI and DASS-21 were significantly lower compared to nonbiologics group during time. The axSpA patients on biologics had significantly lower BDI and depression severity by BDI at each time point and lower DASS-21 after 1, 3 and 6 months. BDI in PsA patients who received biological therapy was significantly lower after 3 and 6 months. In biologics groups, BDI significantly decreased after 3 months in axSpA patients and after 1 month in PsA patients. In axSpA patients, there was a medium correlation between BDI and axial pain, patient global assessment and disease activity scores. The biological therapy significantly affected the depression/anxiety symptoms in axSpA and PsA during time. BDI moderately correlated with pain and disease activity in axSpA. BDI and DASS-21 are easy to use in daily practice.
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Affiliation(s)
- Sanja Milutinovic
- Institute of Rheumatology, University of Belgrade Medical School, Belgrade, Serbia
| | - Kristina Veljkovic
- Department of Probability and Statistics, Faculty of Mathematics, University of Belgrade, Belgrade, Serbia.
| | - Maja Zlatanovic
- Institute of Rheumatology, University of Belgrade Medical School, Belgrade, Serbia
| | - Goran Radunovic
- Institute of Rheumatology, University of Belgrade Medical School, Belgrade, Serbia
| | - Nemanja Damjanov
- Institute of Rheumatology, University of Belgrade Medical School, Belgrade, Serbia
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Vancassel S, Capuron L, Castanon N. Brain Kynurenine and BH4 Pathways: Relevance to the Pathophysiology and Treatment of Inflammation-Driven Depressive Symptoms. Front Neurosci 2018; 12:499. [PMID: 30140200 PMCID: PMC6095005 DOI: 10.3389/fnins.2018.00499] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Accepted: 07/03/2018] [Indexed: 12/13/2022] Open
Abstract
The prevalence of depressive disorders is growing worldwide, notably due to stagnation in the development of drugs with greater antidepressant efficacy, the continuous large proportion of patients who do not respond to conventional antidepressants, and the increasing rate of chronic medical conditions associated with an increased vulnerability to depressive comorbidities. Accordingly, better knowledge on the pathophysiology of depression and mechanisms underlying depressive comorbidities in chronic medical conditions appears urgently needed, in order to help in the development of targeted therapeutic strategies. In this review, we present evidence pointing to inflammatory processes as key players in the pathophysiology and treatment of depressive symptoms. In particular, we report preclinical and clinical findings showing that inflammation-driven alterations in specific metabolic pathways, namely kynurenine and tetrahydrobiopterin (BH4) pathways, leads to substantial alterations in the metabolism of serotonin, glutamate and dopamine that are likely to contribute to the development of key depressive symptom dimensions. Accordingly, anti-inflammatory interventions targeting kynurenine and BH4 pathways may be effective as novel treatment or as adjuvants of conventional medications rather directed to monoamines, notably when depressive symptomatology and inflammation are comorbid in treated patients. This notion is discussed in the light of recent findings illustrating the tight interactions between known antidepressant drugs and inflammatory processes, as well as their therapeutic implications. Altogether, this review provides valuable findings for moving toward more adapted and personalized therapeutic strategies to treat inflammation-related depressive symptoms.
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Affiliation(s)
- Sylvie Vancassel
- UMR 1286, Laboratory of Nutrition and Integrative Neurobiology (NutriNeuro), INRA, Bordeaux, France
- UMR 1286, Laboratory of Nutrition and Integrative Neurobiology (NutriNeuro), Bordeaux University, Bordeaux, France
| | - Lucile Capuron
- UMR 1286, Laboratory of Nutrition and Integrative Neurobiology (NutriNeuro), INRA, Bordeaux, France
- UMR 1286, Laboratory of Nutrition and Integrative Neurobiology (NutriNeuro), Bordeaux University, Bordeaux, France
| | - Nathalie Castanon
- UMR 1286, Laboratory of Nutrition and Integrative Neurobiology (NutriNeuro), INRA, Bordeaux, France
- UMR 1286, Laboratory of Nutrition and Integrative Neurobiology (NutriNeuro), Bordeaux University, Bordeaux, France
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Pehlivan Y, Orucoglu N, Pehlivan S, Kimyon G, Zengin O, Kucuk A, Sahin A, Tomas N, Oksuz MF, Kisacik B, Akar S, Onat AM, Dalkilic E. Patients' concerns regarding biological agents in rheumatology. Int J Rheum Dis 2018; 21:1219-1226. [PMID: 29879318 DOI: 10.1111/1756-185x.13319] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The potential side effects of biological agents may increase the anxiety levels of patients and influence not only their desire to use these therapies but also their concordance to treatment. This study aimed to determine the level and prevalence of drug-related concern in patients treated with biological agents and to acquire additional information regarding the related causes. MATERIALS AND METHODS A total of 1134 patients who were using biological agents for at least 3 months with a diagnosis of rheumatic diseases were enrolled. General anxiety levels were evaluated using the State-Trait Anxiety Inventory (STAI). RESULTS The most common cause for drug-related concerns was the potential side effects of the drugs (59.5%). Among the potential side effects, cancer risk was the most common cause for concern (40.1%), followed by the risk of tuberculosis activation (30.7%). Anxiety levels were higher in patients who experienced side effects than in other patients, and this difference was statistically significant (P < 0.05). STAI trait and state scores were moderately correlated with anxiety levels related to the drug (P < 0.001). CONCLUSION Anxiety related to biological agents may significantly affect the patients' anxiety levels. Awareness regarding the patients' concerns and expectations related to the drug is important to ensure drug adherence and concordance to treatment.
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Affiliation(s)
- Yavuz Pehlivan
- Department of Rheumatology, School of Medicine, Uludag University, Bursa, Turkey
| | - Nurdan Orucoglu
- Department of Rheumatology, School of Medicine, Uludag University, Bursa, Turkey
| | - Seda Pehlivan
- Department of Nursing, Health Science Faculty, Uludag University, Bursa, Turkey
| | - Gezmis Kimyon
- Department of Rheumatology, School of Medicine, Gaziantep University, Gaziantep, Turkey
| | - Orhan Zengin
- Department of Rheumatology, School of Medicine, Gaziantep University, Gaziantep, Turkey
| | - Adem Kucuk
- Department of Rheumatology, Meram School of Medicine, Necmettin Erbakan University, Konya, Turkey
| | - Ali Sahin
- Department of Rheumatology, School of Medicine, Cumhuriyet University, Sivas, Turkey
| | - Nazmiye Tomas
- Department of Rheumatology, School of Medicine, İzmir Katip Celebi University, İzmir, Turkey
| | - Mustafa Ferhat Oksuz
- Department of Rheumatology, School of Medicine, Uludag University, Bursa, Turkey
| | - Bunyamin Kisacik
- Department of Rheumatology, School of Medicine, Gaziantep University, Gaziantep, Turkey
| | - Servet Akar
- Department of Rheumatology, School of Medicine, İzmir Katip Celebi University, İzmir, Turkey
| | - Ahmet Mesut Onat
- Department of Rheumatology, School of Medicine, Gaziantep University, Gaziantep, Turkey
| | - Ediz Dalkilic
- Department of Rheumatology, School of Medicine, Uludag University, Bursa, Turkey
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12
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Abstract
Abstract
Axial spondyloarthritis (SpA) is a spectrum of chronic inflammatory rheumatologic diseases commonly presenting with symptoms of inflammatory back pain, peripheral joint pain, and fatigue. When compared to the general population, patients with SpA have higher prevalence of depression and anxiety symptoms. Poor psychological status is associated with worse disease activity, poorer functional status, poor treatment adherence, and unhealthy lifestyle choices such as cigarette smoking. The Chinese-bilingual Hospital Anxiety and Depression Scale (HADS) is a validated tool to screen depression and anxiety in patients with axial SpA. The cytokine theory of depression may explain emerging evidence on the mutually beneficial effects of antidepressants on disease outcomes and anti-tumor necrosis factor α (TNFα) therapy on psychological status.
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13
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Meesters JJL, Bergman S, Haglund E, Jacobsson LTH, Petersson IF, Bremander A. Prognostic factors for change in self-reported anxiety and depression in spondyloarthritis patients: data from the population-based SpAScania cohort from southern Sweden. Scand J Rheumatol 2017; 47:185-193. [DOI: 10.1080/03009742.2017.1350744] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- JJL Meesters
- ERC Syd, Skåne University Hospital, Lund, Sweden
- Department of Orthopaedics, Rehabilitation and Physical Therapy, Leiden University Medical Center, Leiden, The Netherlands
- Research and Development, Sophia Rehabilitation Center, The Hague, The Netherlands
| | - S Bergman
- Section of Rheumatology, Department of Clinical Sciences, Lund, Lund University, Lund, Sweden
- Primary Health Care Unit, Institute of Medicine, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Spenshult Research and Development Center, Halmstad, Sweden
| | - E Haglund
- Spenshult Research and Development Center, Halmstad, Sweden
- School of Business, Engineering and Science, Halmstad University, Halmstad, Sweden
| | - LTH Jacobsson
- Department of Rheumatology and Inflammation Research, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - IF Petersson
- Section of Orthopedics, Department of Clinical Sciences, University of Lund, Lund, Sweden
| | - A Bremander
- Section of Rheumatology, Department of Clinical Sciences, Lund, Lund University, Lund, Sweden
- Spenshult Research and Development Center, Halmstad, Sweden
- School of Business, Engineering and Science, Halmstad University, Halmstad, Sweden
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14
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Bortolato B, Carvalho AF, Soczynska JK, Perini GI, McIntyre RS. The Involvement of TNF-α in Cognitive Dysfunction Associated with Major Depressive Disorder: An Opportunity for Domain Specific Treatments. Curr Neuropharmacol 2016; 13:558-76. [PMID: 26467407 PMCID: PMC4761629 DOI: 10.2174/1570159x13666150630171433] [Citation(s) in RCA: 93] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2014] [Revised: 12/05/2014] [Accepted: 12/08/2014] [Indexed: 12/31/2022] Open
Abstract
Major depressive disorder is a highly prevalent, chronic and recurring disorder, associated
with substantial impairment in cognitive and interpersonal functions. Accumulating evidence suggests
that inflammatory processes play an important role in the etio-pathogenesis, phenomenology,
comorbidity and treatment of MDD. Suboptimal remission rates and the persistence of cognitive
deficits contribute to functional impairment in MDD inviting the need for the development of mechanistically novel and
domain specific treatment approaches. The MEDLINE/ Pubmed database was searched from inception to February, 9th,
2014 with combinations of the following search terms: ‘TNF-alpha’, ‘depression’, ‘infliximab’, ‘etanercept’, ‘adalimumab’, ‘golimumab’and ‘certolizumab’. Preclinical and clinical evidence linking TNF-α to MDD pathophysiology were
reviewed as well as the current status of TNF-α modulators as novel agents for the treatment of MDD. Experimental
models and clinical studies provide encouraging preliminary evidence for the efficacy of TNF-α antagonists in mitigating
depressive symptoms and improving cognitive deficits. Further studies are warranted to confirm these data in larger
randomized controlled trials in primary psychiatric populations. Translational research provides a promising perspective
that may aid the development and/or repurposing of mechanism-based treatments for depressive symptoms and cognitive
impairment in MDD.
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Affiliation(s)
| | | | | | | | - Roger S McIntyre
- Department of Psychiatry and Pharmacology, University of Toronto, Mood Disorders Psychopharmacology Unit, University Health Network, University of Toronto, 399 Bathurst Street, Toronto, ON, Canada M5T2S8
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15
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Ma K, Zhang H, Baloch Z. Pathogenetic and Therapeutic Applications of Tumor Necrosis Factor-α (TNF-α) in Major Depressive Disorder: A Systematic Review. Int J Mol Sci 2016; 17:ijms17050733. [PMID: 27187381 PMCID: PMC4881555 DOI: 10.3390/ijms17050733] [Citation(s) in RCA: 117] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Revised: 04/29/2016] [Accepted: 05/06/2016] [Indexed: 02/07/2023] Open
Abstract
Major depressive disorder (MDD) is characterized by mood, vegetative, cognitive, and even psychotic symptoms and signs that can cause substantial impairments in quality of life and functioning. Up to now, the exact pathogenesis of MDD remains poorly understood. Recent research has begun to reveal that the pro-inflammatory cytokines, particularly, tumor necrosis factor-α (TNF-α), play an integral role in the pathophysiology of depressive disorders and the mechanism of antidepressant treatment. On the base of several observations: it is found that subsets of MDD patients have enhanced plasma levels TNF-α; antidepressant treatments had linked with the decline of TNF-α; central administration of TNF-α gives rise to sickness behavior which shares features with depression; and a blockade of it can ameliorate depressive symptomatology in animal models and clinical trials. In this review article, we focus on recent evidence linking TNF-α and MDD looking at data from animal and clinical studies, illustrating the pathophysiological role, susceptibility and its therapeutic application in depression. We conclude by discussing future directions for research, in particular the opportunities for the development of novel therapeutics that target TNF-α. This will be very important for designing preventative strategies and for the identification of new drug targets and preventative strategies.
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Affiliation(s)
- Ke Ma
- Department of Physiology, Medical College of Qingdao University, Qingdao 266071, China.
| | - Hongxiu Zhang
- Faculty of Life Science and Technology, Kunming University of Science and Technology, Kunming 650500, China.
| | - Zulqarnain Baloch
- Faculty of Life Science and Technology, Kunming University of Science and Technology, Kunming 650500, China.
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16
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Miwa Y, Isojima S, Saito M, Ikari Y, Kobuna M, Hayashi T, Takahashi R, Kasama T, Hosaka M, Sanada K. Comparative Study of Infliximab Therapy and Methotrexate Monotherapy to Improve the Clinical Effect in Rheumatoid Arthritis Patients. Intern Med 2016; 55:2581-5. [PMID: 27629950 DOI: 10.2169/internalmedicine.55.6872] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Objective We examined whether infliximab (IFX) therapy was more effective than methotrexate (MTX) monotherapy to achieve an improvement in depressive states in Rheumatoid Arthritis (RA) patients. Methods We examined 152 RA patients (72 IFX patients and 80 MTX patients). We conducted an open-label cohort study to evaluate the disease activity of RA (Simplified Disease Activity Index; SDAI), depressive states (Hamilton Rating Scale for Depression; HAM-D), Activity of Daily Living (ADL) (modified Health Assessment Questionnaire; mHAQ) and Quality of Life (QOL) [Short Form (SF)-36] in patients before and 6 months after receiving therapy. The HAM-D, SDAI, mHAQ and SF-36 scores after 6 months of therapy were measured as the outcomes. Results We analyzed 60 IFX patients and 53 MTX patients. The HAM-D scores significantly improved in both groups (p<0.001), but there was no significant difference in the effectiveness between the IFX and MTX therapies (p=0.792). The SDAI scores significantly improved in both groups after therapy (p<0.001), and IFX therapy was more effective than MTX therapy (p=0.004). The mHAQ and HAM-D scores also improved significantly in both groups after therapy (p<0.001), but no significant difference in the effectiveness between the IFX and MTX therapies was observed (p=0.272, 0.792). The scores of all 8 items of the SF-36 improved in both groups after therapy, but IFX therapy was more effective than MTX therapy in only 4 of the 8 items (p<0.05). Conclusion Both IFX and MTX therapy improved the clinical efficacy, ADL, QOL and depressive states. However, no significant differences regarding an improvement in the depressive states and ADL were observed between IFX therapy and MTX monotherapy.
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Affiliation(s)
- Yusuke Miwa
- Division of Rheumatology, Department of Medicine, Showa University School of Medicine, Japan
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17
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Abbott R, Whear R, Nikolaou V, Bethel A, Coon JT, Stein K, Dickens C. Tumour necrosis factor-α inhibitor therapy in chronic physical illness: A systematic review and meta-analysis of the effect on depression and anxiety. J Psychosom Res 2015; 79:175-84. [PMID: 25935351 DOI: 10.1016/j.jpsychores.2015.04.008] [Citation(s) in RCA: 77] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2015] [Revised: 04/14/2015] [Accepted: 04/20/2015] [Indexed: 01/26/2023]
Abstract
OBJECTIVE Depression is more common among individuals with chronic physical illness than in the general population. New treatments for severe and chronic inflammatory conditions which inhibit tumour necrosis factor alpha (TNF-α), a pro-inflammatory cytokine, may be able to shed some light on the role of inflammatory mediators in depression. This systematic review and meta-analysis of randomised controlled trials determined the effects of TNF-α inhibitor therapy on depression and anxiety in people with chronic physical illness. METHODS Seven databases were searched from inception to January 2014: AMED, Central, Cochrane Database of Systematic Reviews, CINAHL, Embase, MEDLINE, and PsycINFO. Articles were screened for inclusion independently by two reviewers. Data extraction and appraisal were conducted by one reviewer and checked by a second. Random-effects meta-analyses were performed. RESULTS Six randomised controlled trials (reported in seven articles) met eligibility criteria and were included in the final review. In total 2540 participants were enrolled across the trials, with participants presenting with rheumatoid arthritis (n=3 trials), psoriasis (n=2) or ankylosing spondylitis (n=1). Meta-analyses, using standardised mean differences, showed evidence of small reductions in depression (-0.24; 95% CI -0.33 to -0.14; p<0.001), and anxiety (-0.17; 95% CI -0.31 to -0.02; p=0.02). CONCLUSION TNF-α inhibitor therapy reduces depression in people with chronic disease though the effects are small. Whilst this is consistent with inflammation contributing to the development of depression, further studies investigating a more detailed timeline of changes in depression, inflammatory biomarkers and disease activity status are required.
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Affiliation(s)
- Rebecca Abbott
- PenCLAHRC, University of Exeter Medical School, St. Luke's Campus, Exeter EX1 2LU, United Kingdom.
| | - Rebecca Whear
- PenCLAHRC, University of Exeter Medical School, St. Luke's Campus, Exeter EX1 2LU, United Kingdom
| | - Vasilis Nikolaou
- PenCLAHRC, University of Exeter Medical School, St. Luke's Campus, Exeter EX1 2LU, United Kingdom
| | - Alison Bethel
- PenCLAHRC, University of Exeter Medical School, St. Luke's Campus, Exeter EX1 2LU, United Kingdom
| | - Jo Thompson Coon
- PenCLAHRC, University of Exeter Medical School, St. Luke's Campus, Exeter EX1 2LU, United Kingdom
| | - Ken Stein
- PenCLAHRC, University of Exeter Medical School, St. Luke's Campus, Exeter EX1 2LU, United Kingdom
| | - Chris Dickens
- Mental Health Research Group, University of Exeter Medical School, St. Luke's Campus, Exeter EX1 2LU, United Kingdom
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18
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Tornero-Molina J. Clinical repercussions of introducing biological therapies: the well-controlled patient. ACTA ACUST UNITED AC 2015; 11:131-2. [PMID: 25769793 DOI: 10.1016/j.reuma.2015.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2014] [Revised: 01/25/2015] [Accepted: 01/31/2015] [Indexed: 11/17/2022]
Affiliation(s)
- Jesús Tornero-Molina
- Sección de Reumatología, Hospital Universitario de Guadalajara, Guadalajara, España; Departamento de Medicina, Universidad de Alcalá, Alcalá de Henares, Madrid, España.
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19
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Weiterer S, Schulte D, Müller S, Kohlen T, Uhle F, Weigand MA, Henrich M. Tumor necrosis factor alpha induces a serotonin dependent early increase in ciliary beat frequency and epithelial transport velocity in murine tracheae. PLoS One 2014; 9:e91705. [PMID: 24626175 PMCID: PMC3953516 DOI: 10.1371/journal.pone.0091705] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2013] [Accepted: 02/14/2014] [Indexed: 12/21/2022] Open
Abstract
The tracheal epithelium prevents via its highly effective clearance mechanism the contamination of the lower airways by pathogens. This mechanism is driven by ciliary bearing cells which are not only in contact with the gas phase; in addition they are also influenced by inflammatory mediators. These mediators can alter the protective function of the epithelium. Since the pro-inflammatoric cytokine tumor necrosis factor-α (TNF-α) plays a pivotal role within the inflammatory cascade, we investigated its effect onto the tracheal epithelium measured by its ciliary beat frequency and the particle transport velocity. In organ explant experiments the ciliary beat frequency and the particle transport velocity were measured under the application of TNF-α using tracheae from male C57BL6J mice. We observed a dose dependent TNF-α induced increase of both particle transport velocity and ciliary beat frequency. Knock out mice experiments made evident that the increase was depended on the expression of tumor necrosis factor receptor 1 (TNF-R1). The increases in ciliary beat frequency as well as the accelerated particle transport velocity were either inhibited by the unspecific serotonin antagonist methysergide or by cyproheptadine a specific 5-HT2 receptor antagonist. Thus, acetylcholine antagonists or nitric oxide synthase (NOS) inhibitors failed to inhibit the TNF-α induced activation. In conclusion, TNF-α may play a pivotal role in the protection of lower airways by inducing ciliary activity and increase in particle transport velocity via TNF-R1 and 5-HT2 receptor.
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Affiliation(s)
- Sebastian Weiterer
- Department of Anaesthesiology, Intensive Care Medicine, Pain Therapy, Justus-Liebig-University Giessen, Giessen, Germany
| | - Dagmar Schulte
- Department of Anaesthesiology, Intensive Care Medicine, Pain Therapy, Justus-Liebig-University Giessen, Giessen, Germany
| | - Sabrina Müller
- Department of Anaesthesiology, Intensive Care Medicine, Pain Therapy, Justus-Liebig-University Giessen, Giessen, Germany
| | - Thomas Kohlen
- Department of Anaesthesiology, Intensive Care Medicine, Pain Therapy, Justus-Liebig-University Giessen, Giessen, Germany
| | - Florian Uhle
- Department of Anaesthesiology, Intensive Care Medicine, Pain Therapy, Justus-Liebig-University Giessen, Giessen, Germany
| | - Markus A. Weigand
- Department of Anaesthesiology, Intensive Care Medicine, Pain Therapy, Justus-Liebig-University Giessen, Giessen, Germany
| | - Michael Henrich
- Department of Anaesthesiology, Intensive Care Medicine, Pain Therapy, Justus-Liebig-University Giessen, Giessen, Germany
- * E-mail:
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Bagnato G, De Andres I, Sorbara S, Verduci E, Corallo G, Ferrera A, Morgante S, Roberts WN, Bagnato G. Pain threshold and intensity in rheumatic patients: correlations with the Hamilton Depression Rating scale. Clin Rheumatol 2014; 34:555-61. [DOI: 10.1007/s10067-013-2477-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2013] [Revised: 11/03/2013] [Accepted: 12/23/2013] [Indexed: 11/28/2022]
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