The effect of some anti-inflammatory (anti-rheumatic) drugs on the metabolism of connective tissues

Therapy and pharmacological properties of hydroxychloroquine and chloroquine in treatment of systemic lupus erythematosus, rheumatoid arthritis and related diseases

OBJECTIVES

This review examines the pharmacokinetics, modes of action and therapeutic properties of the anti-malarial drugs, hydroxychloroquine (HCQ) and chloroquine (CQ), in the treatment of systemic lupus erythematosus (SLE), rheumatoid arthritis (RA) and related conditions, as well as osteoarthritis (OA).

KEY FINDINGS

Both HCQ and CQ have historically been employed successfully for the treatment of SLE and RA for over 70 years. HCQ has been used extensively for SLE where it has a good reputation for controlling the dermatological complications in SLE. It has also been reported to effectively control the symptoms of Sjøgren's syndrome, as well as preventing thrombosis in phospholipid antibody (aPL) syndrome. In RA and SLE, HCQ is preferred because of the lower incidence of gastrointestinal adverse reactions compared with CQ and it might have a lower risk of ocular adverse reactions. There is increasing evidence that HCQ may reduce atherosclerosis and risks of cardiovascular disease in rheumatic patients. Both HCQ and CQ have been shown to improve glycaemia and reduce the risks of type II diabetes mellitus. Although both HCQ and CQ are effective in low-moderate RA, HCQ is now preferred as part of combination therapy for more severe disease. The advantages of combination therapy are that the doses of the individual drugs may be lowered so reducing adverse reactions. Both HCQ and CQ are diastereoisomers, have basic properties and are given as the sulphate and phosphate salts. While being relatively well absorbed orally and with good bioavailability, they have long and variable plasma terminal elimination half-lives (approximately 40-60 days). This reflects their high volume of distribution, V D (HCQ 44,000L; CQ 65,000L) which extends into aqueous compartments, long mean residence time (HCQ 1300 h; CQ 900 h) and with about half the drugs (metabolites) undergoing renal clearance. The strong binding to melanin reflects the ocular injury and dermatological properties of these drugs. The consensus is that the occurrence of ocular adverse reactions can be minimised by close attention to the dose (which should be set on a body weight basis) with regular (e.g. quarterly) retinal examination. Although HCQ and CQ can pass through the placenta, the use of these drugs during pregnancy does not appear to risk harm to the baby and might be beneficial to the mother with SLE and her child by controlling the SLE disease activity, which is known to be an important factor affecting pregnancy outcome. The modes of action of HCQ and CQ in these arthritides represent somewhat of an enigma. Undoubtedly, these drugs have multiple actions related, in part, their ability to accumulate in lysosomes and autophagosomes of phagocytic cells as well as affecting MHC Class II expression and antigen presentation; actions of the production of pro-inflammatory cytokines [e.g. interleukin-1 (IL-1) tumour necrosis factor-α (TNFα)]; control of toll-like receptor-9 activation; and leucocyte generation of reactive oxygen species (ROS); i.e. antioxidant activity. The actions of these drugs on T and B cells are less clear but may depend on these leucocyte-mediated actions. Anti-malarials also protect against cytokine-mediated cartilage resorption. This and other actions may underlie the potential benefits in treating OA. The exact relationships of these various actions, mostly determined in vitro, have not been specifically defined in vivo or ex vivo in relation to clinical efficacy.

OUTCOMES

HCQ and CQ have a good reputation for being effective and relatively safe treatments in SLE, mild-moderate RA and Sjøgren's syndrome. There is need for (a) more information on their mode of action in relation to the control of these diseases, (b) scope for developing formulations that have improved pharmacokinetic and therapeutic properties and safety, and (c) further exploring their use in drug combinations not only with other disease modifying agents but also with biologics.

Disposition and tolerance of suxibuzone in horses

Suxibuzone (SBZ), a nonsteroidal anti-inflammatory drug, was administered to 6 horses at a dose rate of 7.5 mg/kg bwt by intravenous (i.v.) route. Plasma and synovial fluid concentrations of suxibuzone and its main active metabolites, phenylbutazone (PBZ) and oxyphenbutazone (OPBZ), were measured simultaneously by a sensitive and specific high-performance liquid chromatographic method. The pharmacokinetic parameters were determined by noncompartmental analysis. Plasma SBZ concentrations rapidly decreased and were not detectable beyond 20 min after treatment. The parent drug was not detected in any synovial fluid samples. Average maximum plasma concentrations of PBZ (16.43 microg/ml) and OPBZ (2.37 microg/ml) were attained at 0.76 and 7.17 h, respectively. The mean residence time (MRT) of PBZ was 6.96 h in plasma. Oxyphenbutazone plasma concentrations were below those reached by phenylbutazone during the first 12 h after suxibuzone administration, even though its values were detectable for at least 24 h (MRT = 10.65 h). Plasma concentrations of PBZ and OPBZ exceeding EC50 and IC50 of TXB2 and PGE2 were reached by at least 12 h. Synovial fluid concentrations of PBZ and OPBZ were 2.87+/-0.37 microg/ml and 0.97+/-0.08 microg/ml at 9 h after suxibuzone administration and exceeded IC50 of PGE2 for at least this time. In the present study, suxibuzone was well tolerated following i.v. injection.

Pharmacokinetics and bioequivalence of two suxibuzone oral dosage forms in horses

A disposition and bioequivalence study with a suxibuzone granulated and a suxibuzone paste oral formulation was performed in horses. Suxibuzone (SBZ) is a nonsteroidal anti-inflammatory drug, which was administered to horses (n = 6) at a dosage of 19 mg/kg bwt by the oral route (p.o.) in a two period cross-over design. Suxibuzone is very rapidly transformed into its main active metabolites, phenylbutazone (PBZ) and oxyphenbutazone (OPBZ). Therefore plasma and synovial fluid concentrations of SBZ, PBZ and OPBZ were simultaneously measured by a sensitive and specific high-performance liquid chromatographic method. The pharmacokinetic parameters were determined by noncompartmental analysis. Suxibuzone could not be detected in any plasma and synovial fluid samples (< 0.04 microgram/mL). Plasma PBZ and OPBZ concentrations were detected between 30 min and 72 h after granulate and paste administration. Mean plasma concentration of PBZ peaked at 5 h (34.5 +/- 6.7 micrograms/mL) and at 7 h (38.8 +/- 8.4 micrograms/mL), and mean area under the concentration-time curve (AUC0-->LOQ) was 608.0 +/- 162.2 micrograms.h/mL and 656.6 +/- 149.7 micrograms.h/mL after granulate and paste administration, respectively. Mean plasma concentration of OPBZ increased to 5-6.7 micrograms/mL, with the maximum concentration (Cmax) appearing between 9 and 12 h after administration of both formulations. The AUCs0-->LOQ for OPBZ were also similar (141.8 +/- 48.3 micrograms.h/mL granulate vs. 171.4 +/- 45.0 micrograms.h/mL paste). It was concluded that the suxibuzone products were bioequivalent with respect to PBZ. For OPBZ, the 95% confidence intervals of the pharmacokinetic parameters were within the acceptable range of 80-125%. The paste formulation provided greater bioavailability of PBZ and OPBZ.

The dose-related effects of phenylbutazone and a methylprednisolone acetate formulation (Depo-Medrol) on cultured explants of equine carpal articular cartilage

The dose-related effects of phenylbutazone and Depo-Medrol on chondrocyte viability and chondrocyte-mediated synthesis and depletion of proteoglycans were investigated using cultured explants of equine middle carpal joint articular cartilage. Explants from 12 horses (941 x 3 mm diameter) were cultured for a total of 5 days, which included 3 days' exposure to either phenylbutazone (0, 2, 20, 200 or 2000 micrograms/mL) or Depo-Medrol (0, 20, 200 or 2000 micrograms/mL). For each explant, amino sugar content was used as a measure of proteoglycan content, 35S incorporation as a measure of the rate of proteoglycan synthesis and the number of pyknotic nuclei as a measure of cell death. During culture, control explants remained metabolically active and viable but suffered a net loss of proteoglycans. Proteoglycan loss was reduced by the presence of either phenylbutazone or Depo-Medrol. This effect was significant at clinically relevant concentrations of phenylbutazone (2-20 micrograms/mL), but not Depo-Medrol (20-200 micrograms/mL). Depo-Medrol caused a dose-dependent suppression of proteoglycan synthesis at all concentrations, but chondrocyte viability was affected only at the 2000 micrograms/mL dose. Phenylbutazone affected proteoglycan synthesis and cell viability only at the 2000 micrograms/mL concentration. At all concentrations, the anticatabolic effects of each drug influenced the proteoglycan content of the explants far more than did any antianabolic or cytotoxic drug effect. The results suggest that the therapeutic potential of both phenylbutazone and Depo-Medrol may not be restricted to their anti-inflammatory effects on the soft tissues of the joint.

Testing drugs on human osteoarthritic articular cartilage

New drugs are generally developed against animal models of the human disease. Before they are subjected to clinical trials it might be helpful to be able to test whether they are as effective against the disease in human tissue as they were in animals. It is proposed that this can be achieved by the use of organ maintenance culture of the human diseased tissue, the relevant biochemical parameters being measured by quantitative cytochemistry. In the present studies differences between the effect of indomethacin and of the 'chondroprotective' drug diclofenac sodium, on human osteoarthritic cartilage, have been measured.

In vitro influence of ketoprofen on the proteoglycan metabolism of human normal and osteoarthritis cartilage

We investigated the influences of ketoprofen on the proteoglycan (PG) turnover of human articular cartilage explants in three groups: normal young with a high basal PG synthesis, normal adult and osteoarthritis cartilage, both with a low basal PG synthesis. Ketoprofen had no influence on the mean PG synthesis rate of normal adult and OA cartilage after 4 days of culture nor on the cartilage PG content after 8 days of culture. There was no relation between the histological grade of OA and effects of ketoprofen. In normal young cartilage ketoprofen induced an increase of the PG synthesis rate when added to the culture in a concentration of 10(-4) M. No correlation existed between the effect of ketoprofen and the basal PG synthesis of normal cartilage.

Decrease of inorganic blood sulfate following treatment with selected antirheumatic drugs: potential consequence for articular cartilage

The elimination kinetics of inorganic blood sulfate in mice was followed for four hours after a single, oral administration of an antirheumatic drug. Sodium salicylate, aspirin, diflunisal and benorylate, all in a dose of 1.25 mmol/kg, reduced the sulfate level to the less than half that of control. This phenomenon was also demonstrated by phenylbutazone, oxyphenbutazone (both 1 mmol/kg), chloroquine diphosphate (0.6 mmol/kg) and tiaprofenic acid (0.02-0.35 mmol/kg). Niflumic acid (1.08 mmol/kg), piroxicam (0.03 mmol/kg), indomethacin (6.10(-3) mmol/kg), diclofenac (5.10(-3) mmol/kg), ketoprofen (0.2 mmol/kg), naproxen (0.08 mmol/kg) and ibuprofen (0.24 mmol/kg) possessed no sulfate lowering properties. The potential relevance of the use of sulfate lowering drugs for articular cartilage integrity is discussed in the light of what is already known about this subject.

NSAIDs and cartilage metabolism

Data from experimental studies on the influence of non-steroidal anti-inflammatory drugs (NSAIDs) on cartilage is reviewed. There is evidence from this data that some NSAIDs exert a harmful effect, but also that other NSAIDs do not influence cartilage metabolism or could even have a moderate beneficial effect. So far the experimental data must be interpreted with great caution to the clinical situation and no firm conclusions could be drawn from the few clinical reports available. However, the high frequency of other side effects of NSAIDs in the elderly calls a restrictive prescription of these drugs to osteoarthritic patients.

Chemically induced renal papillary necrosis and upper urothelial carcinoma. Part 1

In the past, renal papillary necrosis (RPN) has been commonly associated with long-term abusive analgesic intake, but over recent years a wide variety of industrially and therapeutically used chemicals have been shown to induce this lesion experimentally or in man. Destruction of the renal papilla may result in: (1) secondary degenerative cortical changes which precede chronic renal failure or (2) a rapidly metastasizing upper urothelial carcinoma, which has a very poor prognosis. This article will briefly review the published data on the morphology, function, and biochemistry of the normal renal medulla and the pathology associated with RPN, together with the secondary changes which give rise to cortical degeneration or epithelial carcinoma. It will then examine in detail those chemicals which have been reported to cause RPN in an attempt to delineate structure-activity relationships. Finally, the many different theories that have been proposed to explain the pathophysiology of RPN will be examined and an hypothesis will be put forward to explain the primary pathogenesis of the lesion and its secondary consequences.

Chemically induced renal papillary necrosis and upper urothelial carcinoma. Part 2

In the past, renal papillary necrosis (RPN) has been commonly associated with long-term abusive analgesic intake, but over recent years a wide variety of industrially and therapeutically used chemicals have been shown to induce this lesion experimentally or in man. Destruction of the renal papilla may result in: (1) secondary degenerative cortical changes which precede chronic renal failure or (2) a rapidly metastasizing upper urothelial carcinoma, which has a very poor prognosis. This article will briefly review the published data on the morphology, function, and biochemistry of the normal renal medulla and the pathology associated with RPN, together with the secondary changes which give rise to cortical degeneration or epithelial carcinoma. It will then examine in detail those chemicals which have been reported to cause RPN in an attempt to delineate structure-activity relationships. Finally, the many different theories that have been proposed to explain the pathophysiology of RPN will be examined and an hypothesis will be put forward to explain the primary pathogenesis of the lesion and its secondary consequences.

Salicylic acid stimulation of palmitic acid oxidation by rat skeletal muscle mitochondria

The effects of salicylic acid on palmitic acid oxidation were studied using rat skeletal muscle mitochondria. Salicylic acid, in concentrations that exerted no effect on mitochondrial coupling (0.1 mM), significantly stimulated mitochondrial palmitic acid oxidation, with maximal stimulation occurring at subsaturating concentrations of substrate. In the same preparation, salicylate had no effect on the oxidation of palmitoylcarnitine or palmitoyl-CoA. Salicylate appears to augment the initial step of palmitic acid oxidation by lowering the apparent Michaelis constant (Km) of long chain fatty acid: CoASH ligase (AMP) (EC 6.2.1.3) for palmitic acid.

The effect of anti-inflammatory drugs on glycosaminoglycan sulphation in pig cartilage

Indomethacin, aspirin and hydrocortisone have been shown to inhibit glycosaminoglycan sulphation in pig costal cartilage discs. The doses at which inhibition was observed varied from pig to pig from 0.1 - 50 microgram/ml for indomethacin, 40 - 150 microgram/ml for aspirin and 0.5 - 1 mg/ml for hydrocortisone, doses which are achieved clinically in the treatment of joint diseases. In a minority of experiments a significant stimulation of glycosaminoglycan sulphation was observed at lower doses of indomethacin and hydrocortisone but not aspirin. THe results suggest that in rheumatoid arthritis but more especially osteoarthritis, treatment with these drugs should aim at finding the lowest doses which have a therapeutic effect. As importantly the clinician should always consider using lower doses just as much as higher doses when the first dose regimen is unsatisfactory.

Effects of some connective-tissue active drugs on protocollagen proline hydroxylase activity

The effect on protocollagen proline hydroxylase of drugs reported to be capable of inducing the lupus erythematosus syndrome and in some way acting on connective tissue and inflammation was studied in an in vitro system for the hydroxylation of 14C-Pro-labelled protocollagen. Some derivatives were also studied. It was found that benzoic acid and phenothiazine derivatives, hydroxyphenols, (+)catechin, beta-amino propionitrile, certain B vitamins, dihydrazinophthalazine, cysteine and dimethylcysteine were inhibitors of PPH. The chelation of Fe2+ions by the compounds mentioned is suggested to be essential.

Sulphated glycosaminoglycan synthesis in normal and osteoarthrotic hip cartilage

The in vitro sulphated glycosaminoglycan metabolism and uronate content of human aged and osteoarthrotic hip articular cartilages have been examined. Cartilages were sampled from nonfibrillated weight-bearing areas and cultured in Dulbecco Modified Eagle's medium with 35SO4. Uptake of 35SO4 was corrected for total sulphate concentration and related to uronate levels after papain digestion and dialysis. The levels of uronate in these tissues varied between 0 - 96% and 2 - 26% dry weight and did not correlate with either osteoarthrotic grading or sulphated glycosaminoglycan metabolism, irrespective of the source. Glycosaminoglycan metabolism of intact hip articular cartilage from clinically defined osteoarthrotics appears, from these results, to be comparable to that derived from nonsymptomatic hip joints from individuals of similar age. Sodium salicylate was found to depress sulphated glycosaminoglycan metabolism in osteoarthrotic cartilage.

Effect of anti-inflammatory drugs on sulphated glycosaminoglycan synthesis in aged human articular cartilage

The anti-inflammatory drugs, sodium salicylate, indomethacin, hydrocortisone, ibuprofen, and flurbiprofen, were examined for their effects on sulphated glycosaminoglycan synthesis in aged human cartilage in vitro. Cartilage was obtained from femoral heads removed during surgery and drug effects were found to vary significantly from one head to another. Statistical analysis of the results showed that sodium salicylate exhibits concentration-dependent inhibition of glycosaminoglycan synthesis over the concentration range used. Indomethacin, hydrocortisone, and ibuprofen, at concentrations comparable to those attained in man, caused a statistically significant depression of sulphated glycosaminoglycan synthesis in cartilage from some femoral heads but not others, reflecting the variable response of human articular cartilage to anti-inflammatory drugs. Sodium salicylate and indomethacin at higher doses produced significant (Pless than 0-005) inhibition of sulphated glycosaminoglycan synthesis in all femoral heads studied. The results for flurbiprofen were less conclusive; this compound appears not to inhibit glycosaminoglycan synthesis over the concentration range used.

The metabolic heterogeneity of glycosaminoglycans of the different zones of the epiphyseal growth plate and the effect of ethane-1-hydroxy-1, 1-diphosphonate (EHDP) upon glycosaminoglycan synthesis in vivo

The synthesis of total and unextractable glycosaminoglycans of rabbit epiphyseal growth plate was studied by determination of the incorporation in vivo of 35S-sulphate into various glycosaminoglycans separated by microfractionation procedures using CPC and ECTEOLA columns. In the narrow hypertrophic zone, hyaluronic acid and chondroitin sulphate of low molecular weight were found to be unextractable with 3M guanidinium chloride for 24 h, thus being firmly bound within the tissue. While the unextractable chondroitin sulphate showed a sharply reduced synthesis rate in the hypertrophic zone compared with that in the columnar and resting zones, a rapid increase in the synthesis of extractable chondroitin sulphate toward the calcification front is indicated. At microfractionation, solubility profiles indicated that the unextractable chondroitin sulphate was of predominantly lower molecular weight and/or charge density compared to that of the whole tissue, most evident in the hypertrophic zone. The distribution pattern of incorporated 35S showed a close correspondence to the distribution of the various chondroitin sulphate fractions both for extracted and unextracted tissue. In the hypertrophic zone, higher radioactivity was found for chondroitin sulphate of predominantly low molecular weight and/or charge density in extracted compared to unextracted tissue. Low doses of EHDP caused no change of distribution of the various glycosaminoglycans but generally inhibited their synthesis.

Glucocorticoid and starvation effect on glycosaminoglycans in vascular connective tissue. Biochemical studies on repair processes in rabbit aorta

Male rabbits were injured by a single mechanical dilatation injury of aorta and then injected with prednisone 2 mg/kg or saline for 14 days or subjected to starvation. The biosynthesis of the sulfated glycosaminoglycans as evaluated by the uptake of 35S-sulfate and the content of the glycosaminoglycans were measured on the intima-media layer of the descending thoracic aorta. The results indicate that prednisone may inhibit the biosynthesis of heparan and/or dermatan sulfate while starvation increases the biosynthesis of all the sulfated glycosaminoglycans. No alterations were observed in the total amount of glycosaminoglycans in aorta following glucocorticoid injection or starvation. The metabolism of aortic glycosaminoglycans during repair is less sensitive to the action of prednisone than in undamaged aorta. This contrasts with the effect of prednisone on the metabolism of aortic collagen.

The biosynthesis of intestinal mucins. The effect of salicylate on glycoprotein biosynthesis by sheep colonic and human gastric mucosal tissues in vitro

1. Incubation of sheep colonic mucosal scrapings in Krebs-Ringer buffer for 2(1/2)hr. in the presence of salicylate (15mm) resulted in decreased incorporation of radioactivity into the epithelial glycoprotein from the following labelled precursors: 16.6mum-d-[2-(14)C]glucose (83.9% inhibition), 20mum-l-[U-(14)C]threonine (82%) and (35)SO(4) (2-)(79%). Oxygen uptake measured simultaneously was diminished to 41% of the control value. 2. At lower concentrations of salicylate (e.g. 3.75mm), incorporation of 20mum-l-[U-(14)C]threonine was little affected (3-6% inhibition), whereas utilization of 4mum-d-[U-(14)C]glucose and (35)SO(4) (2-) was inhibited (41-48% and 40-59% of the control values respectively). 3. Analysis of the papain-digested glycoprotein from tissue incubations with 16.6mum-d-[2-(14)C]glucose in the presence of salicylate (3.75mm) showed large decreases in labelling of N-acetylneuraminic acid and N-glycollylneuraminic acid residues (57% and 34% of the control values respectively) and of hexosamine constituents (glucosamine, 55% inhibition; galactosamine, 33% inhibition). Labelling of neutral sugars (galactose and fucose) was relatively little affected (9 and 11% inhibition respectively). 4. Glucose 6-phosphate transaminase and glucosamine 6-phosphate acetylase in particle-free enzyme preparations of the sheep tissue were unaffected by salicylate at the above concentrations. Acetyl-CoA synthetase was markedly inhibited. 5. Human gastric mucosa (from operation), on incubation as above, had in one experiment an oxygen consumption of 9.9mul./hr./mg. dry wt. of tissue and incorporated 5mum-d-[U-(14)C]glucose (15.8% of the total radioactivity added) into bound hexosamine (20.6% of the total radioactivity incorporated), hexoses (glucose and galactose, 5.7%) and fucose (14.2%). The presence of salicylate (15mm) decreased the incorporation of 5mum-d-[U-(14)C]glucose into the glycoprotein by 74%, all sugar constituents being affected, without influence on the rate of oxygen consumption. 6. The results suggest an inhibitory effect of salicylate on glycoprotein biosynthesis at the level of the amino sugar intermediates.

Evaluation of potential antirheumatic drugs in vitro using lymphocytes and epithelial cells. The selective action of indoxole, methyl glyoxal and chloroquine

Anti-inflammatory steroids and non-steroid drugs rapidly inhibit the incorporation of radioactivity from tritiated uridine and thymidine into the nucleic acid fraction of cultured epithelial cells and lymphocytes obtained from sheep, rats, rabbits and chickens. Acidic (uncoupling) drugs were also found to inhibit protein synthesis in these particular cells, and protein and nucleic acid synthesis in other cells which were steroid-insensitive, DNA synthesis in epithelial cells and lymphocytes was inhibited by methyl glyoxal (pyruvaldehyde). Chloroquine selectively inhibited thymidine incorporation by the epithelial cells. Indoxole was a potent inhibitor of the metabolism of circulating lymphocytes incubated in protein-free media. These findings may indicate why some of these drugs suppress adjuvant arthritis in rats.

The metabolism of mucopolysaccharides. 3. The effect of adrenocortical hormones on enzymes involved in glucuronide synthesis and metabolism in connective tissue

The levels of activity of hexokinase, phosphoglucomutase, uridine diphosphoglucose pyrophosphorylase, and uridine diphosphoglucose dehydrogenase, which are involved in the synthesis of glucuronic acid, and the levels of glucuronosyltransferase and β-glucuronidase, which are involved in its metabolism, were studied in connective tissue from polyvinyl sponge implants from sham-operated and adrenalectomized rats which had received "replacement therapy" of individual steroids.The levels of activity of these enzymes were significantly increased in sham-operated rats which had been treated with corticosterone, cortisone, or hydrocortisone. In adrenalectomized animals, the increased or decreased enzyme activities were restored to normal levels by "therapy" with corticosterone, cortisone, or hydrocortisone. In some cases there was an over-correction at the particular level of hormone treatment. In both sham-operated and adrenalectomized animals, treatment with deoxycorticosterone, progesterone, or Reichstein's substance S frequently, but not always, resulted in little or no change in activity of the enzymes.