Association of biomarkers of inflammation, cartilage and bone turnover with gender, disease activity, radiological damage and sacroiliitis by magnetic resonance imaging in patients with early spondyloarthritis

Matrix Metalloproteinases; A Biomarker of Disease Activity and Prognosis in Spondyloarthritis: A Narrative Review

BACKGROUND

Matrix metalloproteinases, as components of the proteolytic system, are deemed to be implicated in the pathogenesis and progression of several rheumatic diseases. Their role in spondyloarthritis has been investigated by several studies.

OBJECTIVE

This article aims to review and summarize the current knowledge related to metalloproteinases in patients with spondyloarthritis.

METHODS

To examine the association between matrix metalloproteinases and spondyloarthritis, we conducted a narrative review using a literature search in SCOPUS for English-language sources. The search included studies published from the database inception to December 2020.

RESULTS

A total number of 74 articles were included. It was found that levels of matrix metalloproteinases 3 were higher in radiographic axial spondyloarthritis patients and seemed to play a role in the progression of joint damage. The levels of matrix metalloproteinases 1, 2, and 9 were upregulated in psoriatic arthritis patients compared to psoriasis and could identify psoriasis patients who would develop rheumatic manifestations. The levels of matrix metalloproteinases correlated significantly with disease activity in ankylosing spondylitis and decreased upon treatment with Tumor Necrosis Factor inhibitors (TNFi).

CONCLUSION

Excessive matrix metalloproteinases activity is associated with articular destruction. Their levels can reflect disease activity, structural damage, and response to TNFi in patients with spondyloarthritis. Nevertheless, further studies are needed to confirm these results.

Physiotherapists' awareness, knowledge and confidence in screening and referral of suspected axial spondyloarthritis: A survey of UK clinical practice

BACKGROUND

Axial spondyloarthritis (axSpA) is an inflammatory disease associated with significant diagnostic delays and is commonly missed in assessments of persistent back pain.

OBJECTIVE

To explore musculoskeletal physiotherapists' awareness, knowledge and confidence in screening for signs, symptoms and risk factors of suspected axSpA and criteria for rheumatology referral.

DESIGN

An online UK survey was undertaken combining back pain vignettes (reflecting axSpA, non-specific back pain and radicular syndrome) and questioning on features of suspected axSpA. Recruitment utilised online professional forums and social media. Data analysis included descriptive statistics and conceptual content analysis for free text responses.

RESULTS

132 survey responses were analysed. Only 67% (88/132) of respondents identified inflammatory pathologies as a possible cause of persistent back pain. Only 60% (79/132) recognised the axSpA vignette compared to non-specific low back pain (94%) and radicular syndrome (80%). Most suspecting axSpA would refer for specialist assessment (77/79; 92%). Awareness of national referral guidance was evident in only 50% of 'clinical reasoning' and 20% of 'further subjective screening' responses. There was misplaced confidence in recognising clinical features of axSpA (≥7/10) compared to knowledge levels shown, including high importance given to inflammatory markers and human leucocyte antigen B27 (median = 8/10).

CONCLUSIONS

Musculoskeletal physiotherapists may not be giving adequate consideration to axSpA in back pain assessments. Awareness of national referral guidance was also limited. Professional education on screening and referral for suspected axSpA is needed to make axSpA screening and referral criteria core knowledge in musculoskeletal clinical practice, supporting earlier diagnosis and better outcomes.

Assessment of the relationship between estimated cardiovascular risk and structural damage in patients with axial spondyloarthritis

Aims

To evaluate the association of estimated cardiovascular (CV) risk and subclinical atherosclerosis with radiographic structural damage in patients with axial spondyloarthritis (axSpA).

Methods

Cross-sectional study including 114 patients axSpA from the SpA registry of Córdoba (CASTRO) and 132 age- and sex-matched healthy controls (HCs). Disease activity and the presence of traditional CV risk factors were recorded. The presence of atherosclerotic plaques and carotid intima media thickness (cIMT) were evaluated through carotid ultrasound and the SCORE index was calculated. Radiographic damage was measured though modified Stoke Ankylosing Spondylitis Spinal Score (mSASSS). The association between mSASSS and SCORE was tested using generalized linear models (GLM), and an age-adjusted cluster analysis was performed to identify different phenotypes dependent on the subclinical CV risk.

Results

Increased traditional CV risk factors, SCORE, and the presence of carotid plaques were found in axSpA patients compared with HCs. The presence of atherosclerotic plaques and SCORE were associated with radiographic structural damage. The GLM showed that the total mSASSS was associated independently with the SCORE [β coefficient 0.24; 95% confidence interval (CI) 0.10-0.38] adjusted for disease duration, age, tobacco, C-reactive protein, and non-steroidal anti-inflammatory drugs (NSAID) intake. Hard cluster analysis identified two phenotypes of patients. Patients from cluster 1, characterized by the presence of plaques and increased cIMT, had a higher prevalence of CV risk factors and SCORE, and more structural damage than cluster two patients.

Conclusion

Radiographic structural damage is associated closely with increased estimated CV risk: higher SCORE levels in axSpA patients were found to be associated independently with mSASSS after adjusting for age, disease duration, CRP, tobacco and NSAID intake.

A new role for matrix metalloproteinase-3 in the NGF metabolic pathway: Proteolysis of mature NGF and sex-specific differences in the continuum of Alzheimer's pathology

Matrix metalloproteinase-3 (MMP-3) has been associated with risk of Alzheimer's disease (AD). In this study we introduce a novel role for MMP-3 in degrading nerve growth factor (NGF) in vivo and examine its mRNA and protein expression across the continuum of AD pathology. We provide evidence that MMP-3 participates in the degradation of mature NGF in vitro and in vivo and that it is secreted from the rat cerebral cortex in an activity-dependent manner. We show that cortical MMP-3 is upregulated in the McGill-R-Thy1-APP transgenic rat model of AD-like amyloidosis. A similar upregulation was found in AD and MCI brains as well as in cognitively normal individuals with elevated amyloid deposition. We also observed that frontal cortex MMP-3 protein levels are higher in males. MMP-3 protein correlated with more AD neuropathology, markers of NGF metabolism, and lower cognitive scores in males but not in females. These results suggest that MMP-3 upregulation in AD might contribute to NGF dysmetabolism, and therefore to cholinergic atrophy and cognitive deficits, in a sex-specific manner. MMP-3 should be further investigated as a biomarker candidate or as a therapeutic target in AD.

The relationship of ischemia-modified albumin levels to disease activity scores and HLA-B27 in patients with ankylosing spondylitis

OBJECTIVE:

Recent studies have implicated increased oxidative stress in the pathogenesis of Ankylosing spondylitis (AS). Ischemia-modified albumin (IMA), an altered form of albumin, increases oxidative stress. This study aimed to investigate the relationship between IMA levels and other indicators of disease severity in AS.

METHODS:

This study included 63 AS patients and 48 healthy controls. Patients were examined for serum lipid profile, C-reactive protein (CRP), complete blood count, Bath Ankylosing Spondylitis Disease Activity Index, human leukocyte antigen (HLA) B27, and treatment regimen. They were categorized based on disease activity, HLA-B27 status, and the drug treatment and compared for IMA levels.

RESULTS:

The patients had significantly higher IMA levels than controls (p=0.020); among patients, the levels were higher in those with active disease (p=0.001) and positively correlated with the CRP levels. No significant difference was found between the IMA levels of the patients with different HLA-B27 status or treatment method.

CONCLUSION:

The IMA levels were higher in patients than controls and further increased in patients with active AS. IMA was associated with disease activity and can be used as an inflammatory marker in AS. More comprehensive future studies with a larger sample size may help understand the relationship in greater detail.

Intensity of spinal inflammation is associated with radiological structural damage in patients with active axial spondyloarthritis

Objective

The aim was to investigate the relationship between the intensity of spinal inflammation using the apparent diffusion coefficient (ADC) and radiographic progression in axial SpA.

Methods

This is a cross-sectional study of participants with axial SpA and back pain. Clinical, biochemical and radiological parameters were collected. The ankylosing spondylitis disease activity score (ASDAS)-CRP was determined. Radiographic progression was represented by the modified Stoke ankylosing spondylitis spine score (mSASSS). MRI with short tau inversion recovery (STIR) and diffusion-weighted imaging sequences were performed simultaneously. Inflammatory lesions on STIR were used for the Spondyloarthritis Research Consortium of Canada (SPARCC) MRI indexes and as references in outlining regions of interest in ADC maps to produce mean (ADC_mean) and maximal (ADC_max) ADC values. Univariate and multivariate linear regression analyses were used to determine independent associations between ADC and radiographic progression.

Results

The 84 participants with identifiable lesions on spinal ADC maps recruited were characterized by a mean (s.d.) age of 45.01 (13.68) years, long disease duration [13.40 (11.01) years] and moderate clinical disease activity [ASDAS-CRP 2.07 (0.83)]. Multivariate regression analysis using ADC_mean as the independent variable showed that age (regression coefficient [B] = 0.34; P = 0.01), male sex (B = 0.25; P = 0.04) and ADC_mean (B = 0.30; P = 0.01) were positively associated with mSASSS. Multivariate regression analysis using ADC_max as the independent variable showed a tendency for ADC_max to be associated with mSASSS (B = 0.21; P = 0.07).

Conclusion

The intensity of spinal inflammation as determined by ADC is associated with radiographic progression in participants with active axial SpA.

Theaflavin-3, 3'-Digallate Attenuates Rheumatoid Inflammation in Mice Through the Nuclear Factor-κB and MAPK Pathways

Rheumatoid arthritis (RA) is a common autoimmune disease which impacts a large number of patients worldwide, and new drugs are required for lower the disease burden. Theaflavin-3, 3'-digallate (TFDG) is polyphenol exhibiting inhibition on inflammatory factors. This study aimed to explore the attenuation of TFDG on RA. The collagen-induced arthritis (CIA) mouse model was established and administered with TFDG. The arthritis score and incidence was recorded to assess the amelioration of TFDG on arthritis. Histopathological change of the mouse joint tissues was evaluated by haemotoxylin and eosin staining. The expression of pro-inflammatory mediators including interleukin (IL)-1β, tumor necrosis factor (TNF)-α, and IL-6 was quantified by ELISA. The activation of nuclear factor (NF)-κB and mitogen-activated protein kinase (MAPK) signaling pathways in the synovium were determined by Western blotting. In comparison with the control, administration of TFDG significantly reduced arthritis score and incidence in the CIA mouse model. TFDG significantly suppressed the expression of IL-1β, TNF-α, and IL-6, as well as the levels of MMP-1, MMP-2, and MMP-3 in the synovium. TFDG also showed remarkable inhibition on the activation of NF-κB and the phosphorylation of P38, JNK2, and ERK. This study puts up evidence that TFDG exerts protection on RA via inhibiting the activation of NF-κB- and MAPK-signaling pathways.

MicroRNA-146a suppresses rheumatoid arthritis fibroblast-like synoviocytes proliferation and inflammatory responses by inhibiting the TLR4/NF-kB signaling

This study investigated whether microRNA-146a (miR-146a) mediating TLR4/NF-κB pathway affected proliferation and inflammatory responses of rheumatoid arthritis fibroblast-like synoviocytes from 12 RA patients (RA-FLSs). FLSs in the logarithmic growth phase were assigned into the control, miR-146a mimic miR-146a inhibitor, Tak-242 (treated with TLR4/NF-κB pathway inhibitor) and mimic + lipopolysaccharide (LPS) groups. Cell proliferation and apoptosis were detected using CCK-8 assay and flow cytometry. The expression of miR-146a, TLR4/NF-κB pathway-related proteins and cytokines were determined by RT-qPCR, western blotting and ELISA, and the release of NO by Greiss reaction. RA rat models were constructed and the primary cells were classified into the control, negative control (NC), miR-146a mimic, miR-146a inhibitor, Tak-242, mimic + LPS, and TLR4 groups. Immunohistochemistry was used to detect the expression of proliferating cell nuclear antigen (PCNA) and intercellular adhesion molecular-1 (ICAM-1). The results showed that miR-146a levels were lower in RA-FLSs than control fibroblasts. miR-146a mimic and Tak-242 decreased RA-FLS proliferation and increased RA-FLS apoptosis, while miR-146a inhibitor had an opposite trend. miR-146a mimic and Tak-242 also decreased expression of TLR4, NF-κB, IL-1β, IL-6, IL-8, IL-17, COX-2, MMP-3, Seprase, and iNOS, as well as reduced NO level in RA-FLSs while miR-146a inhibitor and TLR4 increased them. TLR4 and NF-κB levels and the positive rates of PCNA and ICAM-1 expressions were lower in RA-FLSs from RA rats given miR-146a mimic from control or miR-146a inhibitor-treated rats. These results suggest that miR-146a inhibits the proliferation and inflammatory response of RA-FLSs by down-regulating TLR4/NF-κB pathway.

IL-23R and IL-17A polymorphisms correlate with susceptibility of ankylosing spondylitis in a Southwest Chinese population

The association between the IL-23R and IL-17A polymorphisms and ankylosing spondylitis (AS) in the Southwest Chinese Population is still unclear. The purpose of this study is to detect the association between IL-23R and IL-17A polymorphisms and AS. A case-control study consisting of 486 AS patients and 480 healthy controls was performed. We used the high-resolution melting methods (HRM) to genotype five selected single nucleotide polymorphisms (SNPs), rs6693831, rs7517847, rs1884444, rs10889677 in the IL-23R gene and rs2275913 in the IL-17A gene. Meanwhile, the laboratory indexes were recorded. In this study, patients with genotype CC (p = 8.574E-8) and allele C (p = 3.206E-31) on SNP rs6693831 (IL-23R) showed decreased risk of AS. The genotype TT (p = 4.551E-6) and allele T (p = 0.02) on SNP rs1884444 (IL-23R) showed significant lower risk of AS. Individuals carrying the allele A of rs2275913 showed higher morbidity of AS (p = 0.04). We first detected that rs6693831 and rs1884444 in IL-23R gene and rs2275913 in IL-17A gene have genetic association with AS.

Correlation of serum MMP3 and other biomarkers with clinical outcomes in patients with ankylosing spondylitis: a pilot study

The studies aimed to assess a set of biomarkers for their correlations with disease activity/severity of patients with ankylosing spondylitis (AS). A total of 24 AS patients were treated with etanercept and prospectively followed for 12 weeks. Serum levels of TNF-α, IFN-γ, TGF-β, IL6, IL15, IL17, MMP3, and MICA were measured at baseline and after treatment. The change of these biomarkers was analyzed for correlations with MRI indices for joint inflammation, Bath Ankylosing Spondylitis Disease Activity Index, Bath Ankylosing Spondylitis Functional Index, AS Disease Activity Score, serum CRP, and ESR. The Wilcoxon rank sum test was used to compare the biomarker levels between pre- and post-treatment and between pre-treatment and controls. Both step-wise procedures based on the Akaike information criterion (AIC) and least absolute shrinkage and selection operator with fivefold cross-validation were used to select the best model for pairwise correlations between the above clinical measures and the serum biomarkers. Serum levels of both MMP3 and IL6 were significantly higher in AS patients at baseline. After treatment, the levels of MMP3 decreased, but TGF-β and TNF-α increased significantly. The changes of serum MMP3 and MICA were significantly associated with MRI sacroiliac joint (SIJ) scores. CRP was positively correlated with serum MMP3 and IL6. The pattern of combined changes of serum MICA, MMP3, TGF-β, IL17, TNF-α, and IFN-γ predicted the MRI score of SIJ by logistic regression analysis. Specific serum biomarkers were significantly associated with clinical measures of AS. Most prominently, serum MMP3 level was found to have a positive correlation with the MRI score of SIJ and CRP. Serum MICA level negatively correlated with disease remission.

Spondyloarthritis: Matrix Metalloproteinasesas Biomarkers of Pathogenesis and Response to Tumor Necrosis Factor (TNF) Inhibitors

The term spondyloarthritis (SpA) is used to describe a group of multifactorial chronic inflammatory diseases characterized by a predisposing genetic background and clinical manifestations typically involving the sacroiliac joint. The absence of pathognomonic clinical and/or laboratory findings generally results in a delay in diagnosis and, consequently, in treatment. In addition, 20–40% of SpA patients are non-responders to tumor necrosis factor (TNF) inhibitor therapies. Given these considerations, it is important to identify biomarkers that can facilitate the diagnosis and assessment of disease activity. As inflammation plays a key role in the pathogenesis of SpA, inflammatory mediators have been investigated as potential biomarkers for diagnosing the disease and predicting response to therapy. Some investigators have focused their attention on the role of matrix metalloproteinases (MMPs), which are known to be markers of synovial inflammation that is generated in the joint in reaction to inflammatory stimuli. Several studies have been carried out to verify if serum MMPs levels could be useful to diagnose SpA, to assess disease severity, and to predict response to TNF inhibitor therapy. The current review focuses on MMPs’ role in SpA pathogenesis, diagnosis and therapeutic implications.

Ultrasonographic evaluation of femoral cartilage thickness in patients with psoriatic arthritis

BACKGROUND

Psoriatic arthritis (PsA) is a common form of arthritis that may vary from asymmetric oligoarthritis to symmetric polyarthritis and spondyloarthritis.

OBJECTIVES

To evaluate femoral cartilage thickness using ultrasonography in patients with PsA.

METHODS

Thirty-three patients (24 female, 9 male) with a diagnosis of PsA and 31 age-, sex- and body mass index-similar healthy subjects were enrolled in this study. Demographic and clinical characteristics of the patients were recorded, including disease duration, morning stiffness and medications. The femoral cartilage thicknesses of both knees (while held in maximum flexion) were measured with a 7-12 MHz linear probe. Three mid-point measurements were taken from both knees (at the lateral condyle, intercondylar area and medial condyle).

RESULTS

Cartilage thicknesses were similar between PsA patients and healthy control subjects. However, there were significant correlations between cartilage thickness and the Maastricht Ankylosing Spondylitis Enthesitis Score, Bath AS functional index and Bath AS disease activity index scores.

CONCLUSION

Femoral cartilage thickness is similar between PsA patients and healthy controls. The femoral cartilage thickness in PsA patients is associated with disease activity, functional inadequacy, and enthesopathy scores.

Severe bone marrow edema on sacroiliac joint MRI increases the risk of low BMD in patients with axial spondyloarthritis

To determine the association between inflammatory and structural lesions on sacroiliac joint (SIJ) MRI and BMD and to identify risk factors for low BMD in patients with axial spondyloarthritis (axSpA). Seventy-six patients who fulfilled the ASAS axSpA criteria were enrolled. All underwent SIJ MRI and BMD measurement at the lumbar spine, femoral neck, and total hip. Inflammatory and structural lesions on SIJ MRI were scored. Laboratory tests and assessment of radiographic and disease activity were performed at the time of MRI. The association between SIJ MRI findings and BMD was evaluated. Among the 76 patients, 14 (18%) had low BMD. Patients with low BMD showed significantly higher bone marrow edema (BME) and deep BME scores on MRI than those with normal BMD (p < 0.047 and 0.007, respectively). Inflammatory lesions on SIJ MRI correlated with BMD at the femoral neck and total hip. Multivariate analysis identified the presence of deep BME on SIJ MRI, increased CRP, and sacroiliitis on X-ray as risk factors for low BMD (OR = 5.6, 14.6, and 2.5, respectively). The presence of deep BME on SIJ MRI, increased CRP levels, and severity of sacroiliitis on X-ray were independent risk factors for low BMD.

Vasoactive Intestinal Peptide in Early Spondyloarthritis: Low Serum Levels as a Potential Biomarker for Disease Severity

Spondyloarthritis (SpA) is a family of inflammatory diseases sharing clinical, genetic, and radiological features. While crucial for tailoring early interventions, validated prognostic biomarkers are scarce in SpA. We analyze the correlation between serum levels of vasoactive intestinal peptide (VIP) and disease activity/severity in patients with early chronic inflammatory back pain. The study population comprised 54 patients enrolled in our early chronic inflammatory back pain register. We collected demographic information, clinical data, laboratory data, and imaging findings. VIP levels were measured by enzyme immunoassay in serum samples from 162 visits. The association between independent variables and VIP levels was analyzed using longitudinal multivariate analysis nested by patient and visit. No significant differences were observed in VIP levels between these two groups. Lower levels of VIP were significantly associated with a higher Bath Ankylosing Spondylitis Disease Activity Index (BASFI) score, presence of bone edema in magnetic resonance imaging (MRI) scan, and lower hemoglobin levels. Coexistence of cutaneous psoriasis was independently associated with lower VIP levels, and similar trend was observed for enthesitis. We conclude that SpA patients with low serum VIP levels had worse 2-year disease outcome, suggesting that serum VIP levels could be a valid prognostic biomarker.