Hematologic abnormalities in rheumatoid arthritis

Chemometric profiling and anti-arthritic activity of aerial parts of Glinus oppositifolius (L.) Aug. DC

ETHNOPHARMACOLOGICAL RELEVANCE

Glinus oppositifolius (L.) Aug. DC. belongs to the family Molluginaceae, an annual prostrate herb traditionally used to treat inflammations, arthritis, malarial, wounds, fevers, diarrhoea, cancer, stomach discomfort, jaundice, and intestinal parasites. However, the anti-arthritic activity of the aerial part has still not been reported.

AIM OF THE STUDY

To investigate the antioxidant and anti-arthritic activity of G. oppositifolius in Complete Freund's Adjuvant (CFA) induced rats.

MATERIALS AND METHODS

The dried aerial parts of this plant material were defatted with n-hexane and extracted by methanol using a soxhlet apparatus. The in vitro anti-arthritic activity of methanolic extract of G. oppositifolius (MEGO) was evaluated in protein denaturation, membrane stabilization, and inhibition of proteinase assay at 25, 50, 100, 200, and 400 μg/ml concentrations. Female Wistar rats were immunized sub-dermally into the right hind paw with 0.1 ml of CFA. Rats were administered with MEGO at doses of 200 and 400 mg/kg once daily for fourteen days after arthritis induction. Assessment of arthritis was performed by measuring paw diameter, arthritic index, arthritic score, body weight, organ weight, and hematological and biochemical parameters, followed by the analysis of pro-inflammatory cytokines such as tumor necrosis factor-alpha (TNF-α), interleukin 6 (IL-6), interleukin-1-beta (IL-1β), cyclooxygenase-2 (COX-2), interleukin 13 (IL-13) and interleukin 10 (IL-10) and histopathological study. In vivo antioxidant effect was investigated in enzymatic assays. The presence of phytoconstituents was analyzed by Gas Chromatography-Mass Spectrometry (GC-MS) and Liquid Chromatography-Mass Spectrometry (LC-MS), respectively. In silico molecular docking study of the compounds was carried out against COX-2, IL-1β, IL-6, and TNF-α using AutoDock 4.2 and BIOVIA-Discovery Studio Visualizer software.

RESULTS

MEGO's in vitro anti-arthritic activity showed dose-dependent inhibition of protein denaturation, membrane stabilization, and proteinase inhibition, followed by significant in vivo anti-arthritic activity. The rats treated with MEGO showed tremendous potential in managing arthritis-like symptoms by restoring hematological, biochemical, and histological changes in CFA-induced rats. MEGO (200 and 400 mg/kg) showed a significant alleviation in the levels of hyper expressed inflammatory mediators (TNF-α, IL-1β, and IL-6) and oxidative stress (SOD, CAT, GSH, and LPO) in CFA-induced rats. Spergulagenin-A as identified by LC-MS analysis, exhibited the highest binding affinity against COX-2 (-8.6), IL-1β (7.2 kcal/mol), IL-6 (-7.4 kcal/mol), and TNF-α (-6.5 kcal/mol).

CONCLUSIONS

Provided with the comprehensive investigation, methanolic extract of G. oppositifolius against arthritic-like condition is a proof of concept that revalidates its ethnic claim. The presence of Spergulagenin-A might be responsible for the anti-arthritic activity.

Isolation and Characterization of Anti-Inflammatory Compounds from Ficus microcarpa L.f. Stem Bark

The anti-inflammatory effect of the ethyl acetate extract of F. microcarpa bark (EAFMB) was investigated in acute and chronic (21 days) inflammation induced in Wistar albino rats. EAFMB (200 mg/kg b.w.) exhibited comparable anti-inflammatory effects to the reference drug, with a reduction of 59.48% at 4 h in acute inflammation and 83.96% on day 21 in chronic inflammation. Bioassay-guided fractionation using DPPH radical scavenging activity led to isolating and identifying three compounds from EAFMB: oleanolic acid, catechin, and p-hydroxycinnamic acid. All these compounds demonstrated the concentration-dependent inhibition of COX enzymes and the protection of egg albumin from heat-induced denaturation. Catechin exhibited the highest COX inhibition (COX-1 and COX-2 IC50 = 9.02 and 50.38 μM, respectively) and anti-denaturation effect (IC50 = 27.13 μg/mL) compared to oleanolic acid and p-hydroxycinnamic acid. These isolated compounds are likely responsible for the anti-inflammatory activities of F. microcarpa bark.

Sarcococca saligna Hydroalcoholic Extract Ameliorates Arthritis in Complete Freund's Adjuvant-Induced Arthritic Rats via Modulation of Inflammatory Biomarkers and Suppression of Oxidative Stress Markers

Traditionally, Sarcococca saligna has been used for the treatment of arthritis and many other inflammatory disorders. The current study was planned to give scientific evidence to this traditional use of S. saligna. Phytochemical profiling of SSME was carried out by using electrospray ionization mass spectrometry (ESI-MS/MS). Complete Freund's adjuvant (CFA), 150 μL was injected in the subplantar region of the left hind paw to induce arthritis in rats. Aqueous methanolic extract of S. saligna (SSME) was administered orally at 250, 500, or 1000 mg/kg dose from the 7th day to the 28th day of the study to explore its anti-arthritic potential. Histopathological and radiographic assessment of joints and enzyme-linked immunosorbent assay (ELISA) and real-time polymerase chain reaction (RT-PCR) analyses were performed. Determination of oxidative stress biomarkers in the serum was also carried out. ESI-MS/MS identified ten such phytoconstituents which have reported strong anti-inflammatory and anti-arthritic activity. The SSME extract considerably reduced paw inflammation and arthritic index, subdued cachexia, and significantly improved biochemical and hematological changes. Oxidative stress decreased in SSME administered rats dose-dependently. Histopathological and radiographic evaluations also showed the anti-arthritic activity of SSME, which was associated with the downregulation of tumor necrosis factor (TNF)-α, nuclear factor (NF)-kB, COX-2, interleukin (IL)-6, and IL-1β and upregulation of I-kB, IL-4, and IL-10, in contrast to disease group rats. The outcomes of the study proposed that S. saligna have anti-arthritic potential, supporting its traditional use for rheumatoid arthritis treatment.

Green synthesis of gold nanoparticles from Manilkara zapota L. extract and the evaluation of its intrinsic in vivo antiarthritic potential

The aim of this study is to evaluate the in vivo acute and sub-acute antiarthritic activity of aqueous extract of M. zapota and its biosynthesized gold nanoparticles (AuNPs).

Evaluation of the anti-rheumatic properties of thymol using carbon dots as nanocarriers on FCA induced arthritic rats

Rheumatoid Arthritis (RA) is an autoimmune disease that commences as inflammation and progressively destroys the articular joint. In this study, we assess the anti-rheumatic potential of the monoterpenoid class of thymol conjugated with Carbon Dots (CDs). Waste biomass in the form of dried rose petals was chosen as a precursor for the synthesis of CDs via a one-step hydrothermal bottom-up methodology. The prepared CDs exhibited absorption in the near-visible region, and unique excitation-dependent emission behaviour was confirmed from UV-Visible and fluorescence measurements. The surface morphology of CDs was confirmed by SEM and HR-TEM analysis to be quasi-spherical particles with an average size of ∼5-6 nm. The presence of various functional moieties (hydroxyl, carbonyl, and amino) was confirmed via FT-IR measurement. The graphitization of CDs was confirmed by the D and G bands for sp2 and sp3 hybridization, respectively, through Raman analysis. Esterification methodology was adopted to prepare the CDs-thymol conjugate and confirmed via FT-IR analysis. CDs play the role of a nanocarrier for thymol, an anti-arthritic agent. The bioactive compound of thymol showed potent anti-arthritic activity against RA targets through in silico docking studies. Further, the in vivo studies revealed that CDs-thymol conjugates (10 mg per kg body weight) showed a significant reduction in rat paw volume along with reduced levels of RF and CRP (2.23 ± 0.42 IU ml-1 and 16.96 ± 0.22 mg ml-1) when compared to the disease control rats. X-ray radiography and ultrasonic imaging revealed less bone destruction, joint derangement, and swelling in arthritis-induced Wistar rats. They could also potentially improve the Hb (14.14 ± 0.19), RBC (6.01 ± 0.11), PCV (6.01 ± 0.11) levels and elevate the status of antioxidant enzymes (GPx, SOD, MDA), and the activity was comparable to the standard drug, ibuprofen (10 mg kg-1), suggesting that the CDs-thymol conjugate at 10 mg kg-1 could act as a strong anti-arthritic agent. This work is evidence for the utilization of waste biomass as a value-added product such as a nanocarrier for biomedical applications.

Amelioration of Rheumatoid Arthritis by Anacardium occidentale via Inhibition of Collagenase and Lysosomal Enzymes

Anacardium occidentale (cashew) has been used in the traditional system of medicine for curing many inflammatory disorders. The present study investigates the antiarthritic effects of cashew leaves extract using the rat model of FCA-induced rheumatoid arthritis. Arthritic rats were treated with 100 and 200 mg/kg b.w. ethanolic extract of cashew leaves. Animals were sacrificed at day 23, and before sacrificing the animals, gross pathological changes were observed. Histopathology of ankle joint was evaluated with hematoxylin and eosin staining, whereas the serum levels of C-reactive protein (CRP) were evaluated by the agglutination method. Inflammatory cells and other hematological parameters were assessed by employing an automated hemocytometer and chemistry analyzer. Rheumatoid factor (Rf) and lysosomal enzymes levels were determined in blood. Results indicated that A. occidentale significantly decreased the CPR levels, macroscopic arthritic score, and rheumatoid factor as compared to the diseased group. Histopathological evaluation showed significant attenuation in bone erosion, joint inflammation, and pannus formation by plant extract. Treatment with A. occidentale significantly suppressed the levels of acid phosphatase, β-galactosidase, β-glucuronidase, N-acetylglucosaminidase, and collagenase. Moreover, A. occidentale significantly raised the HB levels and RBCs counts which were found depleted in the diseased group. The raised counts of total leukocytes, platelets, neutrophils, lymphocytes, and monocytes were also significantly decreased by treatment with plant extract. Comparative analysis showed that higher dose of A. occidentale demonstrated superior amelioration of rheumatoid arthritis as compared to low dose. In conclusion, A. occidentale possesses significant antiarthritic potential, which may be attributed to the suppression of lysosomal enzymes and collagenase levels.

Antiarthritic Potential of Comprehensively Standardized Extract of Alternanthera bettzickiana: In Vitro and In Vivo Studies

Alternanthera bettzickiana is being used as a folk remedy for treating arthritis by conventional healers in Thailand. The current research was undertaken to explore the antiarthritic potential of A. bettzickiana ethanolic extract (ABEE). Plant characterization, molecular docking, and in vitro and in vivo (ABEE at 250, 500, and 1000 mg/kg was administered orally to rats once daily for 28 days) studies to explore the antiarthritic effect and enzyme-linked immunosorbent assay (ELISA) and real-time polymerase chain reaction (RT-PCR) analyses were performed. Oxidative stress biomarkers (superoxide dismutase (SOD), catalase (CAT), malondialdehyde (MDA)) in the serum and histopathological and radiographic assessment of joints were also carried out. Gallic acid, catechin, chlorogenic acid, sinapic acid, quercetin, and γ- and α-tocopherol were identified in high-performance liquid chromatography (HPLC). Molecular docking revealed a strong interaction between these compounds and cyclooxygenase (COX) enzymes. The extract significantly subdued paw swelling and arthritic scoring, inhibited cachexia, and considerably improved biochemical and hematological modifications. SOD and CAT levels increased and the MDA level decreased in ABEE-treated rats dose-dependently. Radiographic and histopathological analyses also supported the antiarthritic effect of ABEE, which was linked with the downregulation of nuclear factor (NF)-kB, COX-2, interleukin (IL)-6, tumour necrosis factor (TNF)-α, and IL-1β and upregulation of IL-10, I-kB, and IL-4 as compared to disease control rats. Results suggested that A. bettzickiana possessed antiarthritic potential, supporting its folkloric use for treating rheumatoid arthritis.

Structural elucidation and in vivo anti-arthritic activity of β-amyrin and polpunonic acid isolated from the root bark of Ziziphus abyssinica HochstEx. A Rich (Rhamnaceae)

Two natural products, compounds 1 and 2 were isolated from the root bark of Ziziphus abyssinica for the first time and were structurally elucidated as β-amyrin and polpunonic acid, respectively. Both compounds were further subjected to an in vivo study in rats to evaluate their anti-arthritic potency. Compared to the arthritic control group, rats treated with different doses of 1 or 2 (3, 10, and 30 mg/kg) exhibited significantly higher total change in body weight as well as lower arthritic scores and total change in paw edema and erythema. Histopathological examinations of the hind paws of the rats further demonstrated the beneficial effects of both compounds as they significantly reversed cartilage erosion, subchondral cyst, and Weichselbaum's lacunae formation. Evidence of bone remodeling was also observed in all groups of rats treated with 1 or 2. Hematological and serum biochemical parameters were not significantly affected by treatment of 1 or 2. Taken together, the results from the present study suggest potential therapeutic benefit of β-amyrin and polpunonic acid in rheumatoid arthritis and related inflammatory disorders.

Anti-arthritic activity of ferulic acid in complete Freund's adjuvant (CFA)-induced arthritis in rats: JAK2 inhibition

Ferulic acid (FA), a hydroxycinnamic acid, is an organic compound found in several plant species. Previous studies have shown that FA contains anti-inflammatory and anti-arthritic properties. This study aimed to investigate the anti-arthritic activity and possible mechanism(s) of action of FA in complete Freund's adjuvant (CFA)-induced arthritis. The progression of rheumatoid arthritis (RA) involves the activation of the Janus kinase-signal transducer and activator of transcription (JAK/STAT) pathway by proinflammatory cytokines. Molecular docking of FA showed promising Janus kinase 2 (JAK2) inhibition with a docking score of - 6.7, which is comparable with that of ruxolitinib, a standard inhibitor. However, in vitro JAK2 inhibition assay showed a half maximal inhibitory concentration (IC50) of 6.67 ± 0.88 µg/ml. Both doses of FA (25 and 50 mg/kg) significantly attenuated primary (volume of paw edema) and secondary lesions. CFA-induced arthritic rats showed a significant decrease in body weight, A/G ratio, and Hb but showed a greater arthritic index, ESR levels, and percentage of lymphocytes. These alterations were significantly reduced in rats treated with FA and prednisolone. FA also reversed changes to biochemical parameters and inflammatory markers, such as C-reactive protein (CRP) and rhematoid factor (RF). Additionally, we found CFA-induced arthritis triggered the secretion of TNF- α, increased JAK2 levels, and reduced TGF-β levels in tissue homogenates. However, in rats treated with FA, such alterations significantly improved. Thus, our results reveal that FA contains anti-arthritic activity, which is possibly mediated by the inhibition of the JAK/STAT pathway.

Effect of ethanol and aqueous extracts of seed pod of Copaifera salikounda (Heckel) on complete Freund's adjuvant-induced rheumatoid arthritis in rats

The antirheumatoid arthritis potential of ethanol and aqueous extracts of seed pod of Copaifera salikounda (SPCS) was evaluated using the chicken collagen/complete Freund's adjuvant-induced arthritic rats model. Adjuvat-induced rats were treated with varied doses of the extracts (400, 600, and 800 mg/kg body weight) and with reference drug, indomethacin for 21 days. Antiarthritic evaluation was done through measurement of body weight, paw size, inflammatory makers, hematological parameters, cytokines, antioxidant enzymes, reduced glutathione, lipid peroxidation as well as histopathological examinations. Treatment with the ethanol and aqueous extracts of SPCS markedly inhibited the paw size and caused weight gain. The extracts considerably modulated the hematological as well as the antioxidant parameters. Likewise, the extract restored the altered lipid peroxidation, pro-inflammatory mediators, and inflammatory factors which further accentuate the implication in adjuvant-induced arthritis. Thus, the ethanol and aqueous extracts of SPCS showed a significant antiarthritic activity that was statistically analogous to that of indomethacin. Practical applications Copaifera salikounda (Heckel) has been used in treatment of different ailments including rheumatoid arthritis in folklore medicine. This is the first reported proof of the antiarthritic potential of the seed pod. Oxidative stress has been implicated in rheumatoid arthritis. Ethanol extract of SPCS has been shown to be predominantly rich in phenols, terpenoids, alkaloids, and flavonoids which are natural antioxidant. The present study has demonstrated that ethanol and aqueous extracts of SPCS can exert antioxidative and antiinflammatory effects, thus strengthening its antiarthritic potentials.

The colon and terminal ileum in patients with ankylosing spondylitis and controls in Bangladesh: a macroscopic and microscopic study

OBJECTIVE

Little is known about gut lesions in AS patients in a developing country, such as Bangladesh.

METHODS

Full colonoscopy, including the terminal ileum, was performed in 60 AS patients and 20 controls, without diarrhoea, to study macroscopic and microscopic lesions.

RESULTS

In the colon, in 60 AS patients 17 macroscopic lesions were found, of which 11 were in the rectum; only one lesion was found in 20 controls. The prevalence of microscopic lesions in the ascending colon, sigmoid colon and rectum was 51, 44 and 50 in patients, respectively, and 13, 9 and 8 in controls. In the terminal ileum, macroscopic and microscopic lesions were seen in 21/56 and 43/56 AS patients, respectively, and in 1/20 and 9/20 controls. In the AS group, macroscopic (38.5 vs 5%, P < 0.01) and microscopic (76.8 vs 45%, P = 0.009) lesions were more frequent than in controls; no IBD was diagnosed. Findings were comparable in the axial AS group (n = 25) and the mainly peripheral group (n = 35). In AS patients, marked eosinophilic infiltration was observed in the ascending colon and sigmoid colon but not in the rectum, and this infiltration was more than in controls. The colonic mucosa in controls was otherwise comparable with western studies. Anaemia was seen in 18/60 cases. No association was found between anaemia or HLA-B27 status and gut lesions.

CONCLUSION

There was an equal percentage of microscopic lesions in the whole gut in AS cases and healthy controls. Previous helminth invasions might have played a role. Lesions differ significantly between AS and controls only in the ileum; therefore, the ileal lesions might be more disease related than the colonic ones.

In vivo antiarthritic activity of the ethanol extracts of stem bark and seeds of Calophyllum inophyllum in Freund's complete adjuvant induced arthritis

CONTEXT

Calophyllum inophyllum Linn. (Clusiaceae) (CI) is traditionally used to treat pain, inflammation, eye disorders and rheumatism.

OBJECTIVE

The present study evaluates the antiarthritic activity of the ethanol extract of the stem bark (ESBCI) and seeds (ESCI) of Calophyllum inophyllum in Freund's adjuvant induced arthritic Wistar albino rat model.

MATERIALS AND METHODS

ESBCI and ESCI were screened for in vitro anti-inflammatory activity by proteinase inhibition and membrane stabilization assays. Acute oral toxicity studies were conducted according to OECD-425 guidelines. Antiarthritic activity of ESBCI and ESCI at the dose of 250 mg/kg/p.o. was evaluated by Freund's adjuvant induced arthritic rat model.

RESULTS

ESBCI and ESCI have shown maximum inhibition at 250 μg/mL in proteinase inhibition and haemolysis assays. The LD₅₀ of ESBCI and ESCI was found to be greater than 5000 and 2000 mg/kg/p.o., respectively. In Freund's adjuvant induced arthritic rat model ESBCI, ESCI and Diclofenac treatment have shown 28.57, 36.36, and 43.51% as maximum reduction in rat paw oedema volume respectively when compared with the arthritic control rats. ESBCI and ESCI treatment at the dose level of 250 mg/kg/p.o. normalized the altered haematological and biochemical parameters of arthritic control rats. Histological and radiological evaluation confirmed the antiarthritic effect of ESBCI and ESCI.

DISCUSSION

ESBCI and ESCI were found to show significant antiarthritic activity evidenced with clinical, biochemical, histological and radiological evaluations.

CONCLUSION

The present study indicates the antiarthritic activity of ESBCI and ESCI, however its mechanism of action has to be studied in the future.

Modulatory effect of standardised amentoflavone isolated from Juniperus communis L. agianst Freund's adjuvant induced arthritis in rats (histopathological and X Ray anaysis)

ETHOPHARMACOLOGIC RELEVANCE

Juniperus communis. L. is a shrub or small evergreen tree, native to Europe, South Asia, and North America, and belongs to family Cupressaceae. It has been used traditionally in unani system and in Swedish medicine as a decoction in inflammatory diseases. The main chemical constituents, which were reported in J. communis L. was α-pinene,, apigenin, sabinene, β-sitosterol, campesterol, limonene, Amentoflavone (AF), cupressuflavone, and many others.

AIM

The aim of present study was to isolate the amentoflavone from the plant juniperus communis L. extracts and its protective effects against Freund's adjuvant induced arthritis in rats.

MATERIAL METHODS

Adjuvant arthritis was induced by an injection of 1mg heat killed Mycobacterium tuberculosis (CFA) into the left hind paw of rat by sub planter route (at day 0). The experiment was designed and modified as per method available in literature.

RESULTS

The study showed that at a dose of 40mg/kg of amentoflavone (AF) from methanolic extract of Juniperus Communis L. possessed potentially useful anti-arthritic activity as it gave a positive result in controlling inflammation in the adjuvant induced experimental model.

CONCLUSION

From the present experimental findings of both pharmacological and biochemical parameters observed, it had been concluded that at the doses of 20mg/kg and 40mg/kg of AF fraction from methanolic extract of Juniperus communis L. It possesses useful anti-arthritic activity since it gives a positive result in controlling inflammation in the adjuvant induced arthritic model in rats. The drug is a promising anti-arthritic agent of plant origin in the treatment of inflammatory disorders.

Melastoma malabathricum Linn attenuates complete freund's adjuvant-induced chronic inflammation in Wistar rats via inflammation response

BACKGROUND

Natural products use for arthritis treatment is gaining importance in the medical worldt. Various studies reports medical importance of Melastoma malabathricum Linn. (MM) (Melastomataceae), also known as "putki," has a broad range of health benefits, for its free radical scavenging constituents. The current investigation scrutinizes the antioxidant and anti-inflammatory effect of MM against adjuvant-induced arthritis in experimental rats.

METHODS

High-performance thin layer chromatography (HPTLC) was used for estimation of phytochemical-constituents present in the MM extract. Protective effect of MM extract in Wistar rats was estimated using CFA-induced model. The rats were divided into different groups with six rats in each group. All animals received oral administration of MM and indomethacin for 28 days. The body weight and arthritic score were scrutinized at regular intervals. At the end of experimental protocol, the rats were sacrificed, and blood samples were used for antioxidant, hematological parameters, pro-inflammatory and inflammatory mediator, respectively. Histopathological observation was used to evaluate the protective effect of MM extract.

RESULT & DISCUSSION

Current study confirmed the preventive effect of MM against adjuvant-induced paw edema, paw redness and arthritic progression. MM significantly (P < 0.001) modulated the oxidative stress parameters as well as hematological parameter induced by CFA. The result also altered the distorted level of proinflammatory mediators and inflammatory mediator, which further reinforce the implication of MM in CFA induced arthritis. Histological analyses of joints of rats showed a reduction in the synovial hyperplasia and mononuclear infiltration in the MM treated group which provides evidence for the antiarthritic effect of MM.

CONCLUSION

From above parameters our study states that the MM is capable of restraining the alteration produced via adjuvant-induced arthritis in aminals. The repressing effect of MM could be attributed, at least in part, to antioxidant, hematological and anti-inflammatory effect. Figure Caption: Melastoma Malabathricum Linn Attenuates Complete Freund's Adjuvant-Induced Chronic Inflammation in Wistar rats by Inflammation Response.

A new ursane triterpenoic acid and other potential anti-inflammatory and anti-arthritic constituents from EtOAc extracts of Vitellaria paradoxa stem bark

OBJECTIVE

Vitellaria paradoxa (shea tree) is used in traditional medicine for the treatment of various ailments, including, inflammation and fever. Therefore the present research investigates the anti-inflammatory and anti-rheumatic effects of V. paradoxa stem bark extracts in rats and the isolation and characterization of its active constituents.

METHODS

The anti-inflammatory activity of ethyl acetate extract of V. Paradoxa (VPEE) was evaluated by use of the carrageenan-induced paw oedema model in rats. Moreover, rheumatoid arthritis (RA) was induced by injection of Freund's Completed Adjuvant (FCA) into the subplantar surface of the hind paw of the male Wistar rats. Paw volume was measured plethysmometrically. Joint swelling was measured using electronic vernier caliper. Hot plate test was used to assess the effect of VPEE on hyperalgesia while open field was used to assess the locomotors activity. The relative weight of spleen, liver and thymus was obtained as well as some haematological parameters. Tibiotarsal joint was extracted for histopathology under light microscope. Chemical analysis was carried out by high resolution mass spectrometry and one and two-dimensional NMR techniques.

RESULTS

LC-MS analysis of the EtOAc extract revealed the presence of a new triterpenoid and several known compounds. The structure of the novel compound was elucidated by means of LC-MS and selected 1D and 2D-NMR experiments. The biological effects of ethyl acetate (VPEE), methanol (VPME) and water extracts (VPAE) of V. paradoxa were tested on carrageenan model of acute inflammation and FCA-induced rheumatoid arthritis animal model. In the carrageenan-induced inflammation, VPEE (150 mg/kg) significant (66.67%) inhibited the first (after 1h) and the second phase (4-6h) of edema formation. On the Complete Freund's adjuvant-induced rheumatoid arthritis, VPEE at the same dose showed a significantly protective effect. On days 19-28th of treatment, the maximum inflammatory percentage was between 9.60 and 8.91% for the VPEE compared to 30.91-24.29% for the controls. All the extracts significantly reduced the score of arthritis but the maximal reduction was obtained with the VPEE on day 24th of the experimentation. The altered haematological parameters in the arthritic rats were significantly recovered to near normal by the treatment with VPEE at the dose of 150 mg/kg. Further histological studies revealed the anti-arthritic activity by preventing cartilage destruction of the arthritic joints of adjuvant arthritic rats. The spleen hypertrophy induced by the FCA was also significantly inhibited.

CONCLUSION

These findings provide pharmacological basis for the application of the VPEE in inflammatory disorders.

Anti-inflammatory and antiarthritic activity of anthraquinone derivatives in rodents

Aloe emodin is isolated compound of aloe vera which is used traditionally as an anti-inflammatory agent. In vitro pharmacokinetic data suggest that glucuronosyl or sulfated forms of aloe emodin may provide some limitations in its absorption capacity. Aloe emodin was reported to have in vitro anti-inflammatory activity due to inhibition of inducible nitric oxide (iNO) and prostaglandin E2, via its action on murine macrophages. However, present work evidenced that molecular docking of aloe emodin modulates the anti-inflammatory activity, as well as expression of COX-2 (cyclooxygenase-2) in rodent. The AEC (4,5-dihydroxy-9,10-dioxo-9,10-dihydroanthracene-2 carboxylic acid) was synthesized using aloe emodin as starting material. The study was planned for evaluation of possible anti-inflammatory and antiarthritic activity in carrageenan rat induced paw oedema and complete Freund's adjuvant induced arthritis in rats. The AE (aloe emodin) and AEC significantly (P < 0.001) reduced carrageenan induced paw edema at 50 and 75 mg/kg. Complete Freund's adjuvant induced arthritis model showed significant (P < 0.001) decrease in injected and noninjected paw volume, arthritic score. AE and AEC showed significant effect on various biochemical, antioxidant, and hematological parameters. Diclofenac sodium 10 mg/kg showed significant (P < 0.001) inhibition in inflammation and arthritis.

Alginic acid isolated from Sargassum wightii exhibits anti-inflammatory potential on type II collagen induced arthritis in experimental animals

The present study evaluated the anti-inflammatory potential of alginic acid isolated from the brown algae Sargassum wightii in type II collagen induced arthritic rats, a well established arthritic model that resembles more closely to human rheumatoid arthritis in its clinical, pathological, immunological and histological aspects. Type II collagen induced arthritic rats showed increased activities of inflammatory marker enzymes like cycloxygenase-2 (COX-2), lipoxygenase (5-LOX), xanthine oxidase (XO) and myeloperoxidase (MPO) along with increased concentration of rheumatoid factor (RF), ceruloplasmin and C-reactive protein (CRP). Treatment with alginic acid significantly reduced the activities of COX-2 and 5-LOX along with reduction in MPO, XO, RF and CRP. Alginic acid treatment reverted to the altered levels of hematological parameters like RBC count, WBC count and ESR in arthritic rats. Concentrations of proinflammatory cytokines like IL-1 β, TNF α and IL-6 were significantly higher in arthritic rats which were reduced on treatment with alginic acid. Increased activities of lysosomal enzymes that manifest the systemic damage during arthritis were significantly reduced by the treatment with alginic acid which indicates the reduction in the rupture and degradation of connective tissue. Histopathology of knee joint tissues showed that extensive bone degradation and synovial hyperplasia along with infiltrating cells and treatment with alginic acid reversed the histopathological changes which indicate the protective potential of alginic acid in rheumatoid arthritis.

Anti-inflammatory activity of lycopene isolated from Chlorella marina on type II collagen induced arthritis in Sprague Dawley rats

The role of commercially available lycopene (all-trans) from tomato in controlling arthritis has been reported. Even though many reports are available that the cis form of lycopene is more biologically active, no report seems to be available on lycopene (cis and trans) isolated from an easily available and culturable sources. In the present study, the anti-arthritic effect of lycopene (cis and trans) from the algae Chlorella marina (AL) has been compared with lycopene (all-trans) from tomato (TL) and indomethacin (Indo). Arthritis (CIA) was developed in male Sprague dawley rats by collagen and the following parameters were studied. The activities of inflammatory marker enzymes like cyclooxygenase (COX), lipoxygenase (LOX) and myeloperoxidase (MPO) were found to be decreased on treatment with AL when compared to TL and Indo. Changes in Erythrocyte sedimentation rate (ESR), white blood cell (WBC) count, red blood cells (RBC) count, hemoglobin (Hb), C-reactive protein (CRP), rheumatoid factor (RF), and ceruloplasmin levels observed in the blood of arthritic animals were brought back to normal by AL when compared to TL and Indo. Histopathology of paw and joint tissues showed marked reduction in edema on supplementation of AL. Thus these results indicate the potential beneficiary effect of algal lycopene on collagen induced arthritis in rats when compared to TL and even to the commonly used anti-inflammatory drug indomethacin. Therefore lycopene from C. marina would be recommended as a better natural source with increased activity and without side effects in the treatment of anti-inflammatory diseases.

Anti-inflammatory and antioxidative effects of mucilage of Trigonella foenum graecum (Fenugreek) on adjuvant induced arthritic rats

The aim of this study was to investigate anti-inflammatory and antioxidant effects of mucilage from fenugreek in adjuvant induced arthritis in rats. Arthritis was induced by intradermal injection of complete Freund's adjuvant into the right hind paw produce inflammation of the joint. The activities of inflammatory enzymes like cyclooxygenase, lipoxygenase and myeloperoxidase, and levels of nitrite and C-reactive protein were observed. Also oxidative stress was measured by analyzing the activity of catalase, superoxide dismutase, glutathione peroxidase and the levels of glutathione and vitamin C and lipid peroxidation. The blood parameters like ESR, total WBC, RBC and hemoglobin content was checked. Fenugreek mucilage exhibited maximum percentage of edema inhibition at a dose of 75 mg/kg on 21st day of adjuvant arthritis. The effect was higher than that of standard drug indomethacin. The activities of cyclooxygenase-2 and myeloperoxidase and concentration of thiobarbituric acid reactive substance (TBARS) were decreased and the activities of antioxidant enzymes, vitamins C and reduced glutathione level were increased on treatment with fenugreek mucilage. The increment in ESR and total WBC, reduction in RBC count and hemoglobin and aberrant changes to the C-reactive protein (CRP) levels observed in the arthritic animals were also found to be significantly restored in fenugreek mucilage treated rats. Histopathology of paw tissue showed decreased edema formation and cellular infiltration on supplementation with fenugreek mucilage. Thus the results demonstrated the potential beneficiary effect of fenugreek mucilage on adjuvant induced arthritis in rats.

Evaluation of antiarthritic activity of Strychnos potatorum Linn seeds in Freund's adjuvant induced arthritic rat model

BACKGROUND

Strychnos potatorum Linn (Loganiaceae) is a moderate sized tree found in southern and central parts of India, Sri Lanka and Burma. In traditional system of medicine, Strychnos potatorum Linn seeds were used for various ailments including inflammation, diabetes etc. To investigate the folkloric use of the seeds the present study was carried out on Freund's adjuvant induced arthritic rats.

METHODS

The present study states the effect of the aqueous extract (SPE) and the whole seed powder (SPP) of Strychnos potatorum Linn seeds on the Freund's complete adjuvant (FCA) induced arthritic rat paw edema, body weight changes and alterations in haematological and biochemical parameters in both developing and developed phases of arthritis. Histopathology of proximal interphalangeal joints and radiology of hind legs were studied.

RESULTS

In FCA induced arthritic rats, there was significant increase in rat paw volume and decrease in body weight increment, whereas SPP and SPE treated groups, showed significant reduction in paw volume and normal gain in body weight. The altered haematological parameters (Hb, RBC, WBC and ESR) and biochemical parameters (blood urea, serum creatinine, total proteins and acute phase proteins) in the arthritic rats were significantly brought back to near normal by the SPP and SPE treatment at the dose of 200 mg/kg/p.o in both developing and developed phases of arthritis. Further the histopathological and radiological studies revealed the antiarthritic activity of SPP and SPE by indicating fewer abnormalities in these groups when compared to the arthritic control group.

CONCLUSION

In conclusion, both SPP and SPE at the specified dose level of 200 mg/kg, p.o. showed reduction in rat paw edema volume and it could significantly normalize the haematological and biochemical abnormalities in adjuvant induced arthritic rats in both developing and developed phases of FCA induced arthritis. Further the histopathological and radiological studies confirmed the antiarthritic activity of SPP and SPE.

Anti-arthritic potential of the plant Justicia gendarussa Burm F

OBJECTIVE

To evaluate the anti-arthritic potential of the plant Justicia gendarussa using two different rat models.

MATERIALS AND METHOD

The anti-arthritic potential of the alcoholic extract of the plant Justicia gendarussa was evaluated using the Freund's adjuvant-induced and collagen-induced arthritic rat models. The rats were treated with the ethanolic extract of Justicia gendarussa and with standard aspirin.

RESULTS

The ethanolic extract of Justicia gendarussa showed significant anti-arthritic activity that was statistically similar to that of aspirin. Our results suggest that the alcoholic extract of Justicia gendarussa exhibits significant anti-arthritic potential.

Anti-Inflammatory Activity ofCleome gynandraL. on Hematological and Cellular Constituents in Adjuvant-Induced Arthritic Rats

Cleome gynandra L. (cat whiskers) has traditionally been used for the treatment of rheumatic and other inflammatory conditions. In this work, the methanolic extract of the leaves of C. gynandra exhibited significant anti-inflammatory activity in adjuvant-induced arthritic rats. Phytochemical screening was carried out to ascertain the qualitative composition of the leaves. Arthritis was induced by Freund's complete adjuvant. A significant decrease in paw edema with a remarkable increase in body weight was observed following oral administration of the leaf extract (150 mg/kg of body weight). The alterations in hematological and other biochemical parameters were restored to near normal after a treatment period of 30 days. These results demonstrate that the plant extract has no harmful effect and exerts in vivo anti-inflammatory properties against adjuvant-induced arthritis.

Anakinra

Anakinra, a recombinant human interleukin-1 (IL-1) receptor antagonist, is the first biological agent approved to block the pro-inflammatory effects of IL-1 in patients with rheumatoid arthritis. In a double-blind, randomised trial in 472 patients with active, severe or very severe rheumatoid arthritis, recipients of subcutaneous anakinra 150 mg/day achieved higher response rates [assessed using the American College of Rheumatology (ACR) composite score] and accumulated more mean productivity days after 6 months than placebo recipients. However, the response rates and accumulated productivity days of patients receiving subcutaneous anakinra 30 or 75 mg/day for 6 months were similar to those of placebo. With respect to the total Genant radiographic scores, the same study showed that all anakinra treatment regimens slowed disease progression after 6 months to a greater extent than placebo. In double-blind, randomised trials in patients with rheumatoid arthritis, combined treatment with anakinra and methotrexate was associated with higher ACR 20, 50 and 70 response rates than with methotrexate alone. Anakinra, used alone or in combination with methotrexate, was generally well tolerated, with the most frequent adverse event being a mild injection-site reaction of transient duration. Infections requiring antibacterial therapy or hospitalisation occurred more commonly in anakinra recipients than in placebo recipients, but were a rare cause for discontinuation of anakinra therapy (approximately 1%) in clinical trials.

Erythroblast iron metabolism and serum soluble transferrin receptor values in the anemia of rheumatoid arthritis

OBJECTIVES

We have investigated in vitro erythroblast iron metabolism in the anemia of rheumatoid arthritis (RA). We also have examined the results in relation to bone marrow iron status in an attempt to explain the reported difference between serum soluble transferrin receptor (sTfR) values in anemia of chronic disease (ACD) and iron deficiency anemia (IDA) in patients with RA.

METHODS

Bone marrow was examined in 29 anemic patients with RA, 9 healthy volunteers, and 6 patients with simple IDA. High purity erythroblast fractions were prepared from these bone marrow samples. Erythroblast surface TfR expression and iron uptake was assessed in vitro using (125)I-transferrin (Tf) and (59)Fe-Tf, respectively. The efficiency of erythroblast surface TfR function for Tf-iron uptake was determined by relating total iron uptake at 4 hours to surface TfR number. Serum sTfR values were measured for the RA anemia group, which was subdivided as RA-ACD (marrow iron present) or RA-IDA (marrow iron absent) on the basis of visible reticuloendothelial (RE) marrow iron stores.

RESULTS

High purity (87 +/- 5%) erythroblast fractions were obtained from 35 of the 44 marrow samples. Erythroblasts obtained from patients with simple IDA showed a significant increase in surface TfR expression (P = 0.0003) and Tf-iron uptake (P = 0.001). RA anemia also led to a significant increase in erythroblast Tf-iron uptake (P = 0.016). This increase was not associated with an increase in surface TfR expression (P = 0.5), but was seen to occur as a result of a significant increase in the efficiency of surface TfR for Tf-iron uptake (P = 0.027). Within the RA anemia group, the increase in erythroblast Tf- iron uptake at 4 hours was more evident for RA-IDA (3.96 +/- 1.73 versus 1.66 +/- 0.66; P = 0.03) than for RA-ACD (2.69 +/- 1.18 versus 1.66 +/- 0.66; P = 0.057). This additional erythroblast response to absent RE iron stores led to a highly significant difference in serum sTfR values between RA-IDA and RA-ACD (40.2 +/- 14.0 versus 23.9 +/- 5.3 nmoles/liter; P = 0.001)

CONCLUSIONS

An increase in erythroblast surface TfR efficiency for Tf-iron uptake compensates for the low plasma iron levels associated with anemia in RA and helps to maintain RA erythroblast iron uptake. With adequate RE iron stores, this increased efficiency limits intracellular iron deprivation and consequently reduces the need to increase surface TfR expression. As a result, serum sTfR levels in RA-ACD remain within the normal range. RA erythroblasts, however, are still able to respond to any additional worsening of the iron supply caused by absent RE iron stores. This additional response causes the highly significant increase in serum sTfR values seen between RA-IDA and RA-ACD.

The use of folates concomitantly with low-dose pulse methotrexate

Toxicities related to low-dose weekly methotrexate are largely due to its antifolate properties. Preexisting folate deficiency is associated with methotrexate toxicity in some patients. At the onset of methotrexate therapy and throughout therapy, the physician should be vigilant regarding one or more nutrient deficiencies. A multivitamin and, where appropriate, specific daily folic acid supplements should be employed. The only regimen known presently (through controlled trials) to treat side effects is the low-dose folinic acid (leucovorin) protocol outlined herein. Folic acid may be helpful to treat mild gastrointestinal symptoms. Folinic acid supplementation should be considered prophylactically in those requiring methotrexate who are at increased risk of hepatic disease. Other possible factors besides methotrexate should always be considered with the onset of new patient complaints or laboratory abnormalities. Claims that folic acid therapy is safer and more convenient than folinic acid seem unwarranted when one reviews the literature carefully. Cost differences between folic acid supplementation and folinic acid supplementation have been exaggerated.

Comparison between intravenous and subcutaneous recombinant human erythropoietin (Epoetin alfa) administration in presurgical autologous blood donation in anemic rheumatoid arthritis patients undergoing major orthopedic surgery

BACKGROUND AND OBJECTIVES

Intravenous (i.v.) Recombinant erythropoietin (Epoetin alfa) is effective in allowing autologous blood donation in patients unable to donate because of anemia. We undertook this open pilot study in order to asses whether a low subcutaneous (s.c.) dose of Epoetin alfa would prove as effective and well tolerated as the higher i.v. dose. Such a move would also decrease costs.

MATERIALS AND METHODS

A total Epoetin alfa s.c. dose of 800 IU/kg was compared with a total i.v. dose of 1,800 IU/kg. Twenty-two rheumatoid arthritis patients, unable to donate because of hemoglobin (Hb) < 11 g/dl, received 300 IU/kg of IV Epoetin alfa twice weekly for 3 weeks (11 patients), or 100 IU/kg of s.c. Epoetin alfa twice weekly for 3 weeks plus an i.v. bolus of 200 IU/kg of Epoetin alfa at the first visit (11 patients). At each visit, all patients received 100 mg of i.v. iron saccharate and when the hematocrit (hct) > or = 34%, 350 ml of autologous blood (AB) were collected.

RESULTS

No significant differences were observed between the 2 groups of treated patients in terms of units of AB collected (2.6 +/- 0.6 vs. 2.5 +/- 0.5 units for i.v. and s.c. groups, respectively), ml of RBC produced during the study period (291 +/- 99 vs. 337 +/- 65 ml for the i.v. and s.c. groups, respectively), or in the degree of reduced exposure to allogeneic blood in comparison with the control group.

CONCLUSIONS

Lower dose of Epoetin alfa (reduced by 56%), supplemented by i.v. iron, is as effective and well tolerated as higher doses administered i.v., supplemented by i.v. iron.

Prediction of iron deficiency in chronic inflammatory rheumatic disease anaemia

We prospectively studied 45 anaemic patients (37 women, 8 men) with chronic inflammatory rheumatic diseases. The combination of serum ferritin and CRP (as well as ESR) in its predictive capacity for bone marrow iron stores was examined. The relationship between other iron-related measurements (transferrin, transferrin saturation, soluble transferrin receptor, erythrocyte porphyrins and percentage of hypochromic/microcytic erythrocytes) and bone marrow iron stores was also investigated. Stainable bone marrow iron was taken as the most suitable standard to separate iron-deficient from iron-replete patients. 14 patients (31%) were lacking bone marrow iron. Regression analysis showed a good correlation between ferritin and bone marrow iron (adjusted R2 = 0.721, P < 0.0001). The combination of ferritin and CRP (ESR) did not improve the predictive power for bone marrow iron (adjusted R2 = 0.715) in this cohort of patients with low systemic inflammatory activity. With respect to the bone marrow iron content the best predictive cut-off value of ferritin was 30 micrograms/l (86% sensitivity, 90% specificity). The other iron-related parameters both individually and when combined were less powerful in predicting bone marrow iron than ferritin alone. Only zinc bound erythrocyte protoporphyrin in combination with ferritin slightly improved prediction (adjusted R2 = 0.731). A cut-off point of 11% hypochromic erythrocytes reached a high specificity (90%), but was less sensitive (77%).

Peripheral blood mononuclear cells from patients with rheumatoid arthritis suppress erythropoiesis in vitro via the production of tumor necrosis factor alpha

Anemia is a frequent manifestation of rheumatoid arthritis, with a probably multifactorial etiology. We investigated the effect of peripheral blood mononuclear cell supernatants (PBMCS) from rheumatoid arthritis (RA) patients on hematopoietic colony formation in vitro, by using a methylcellulose assay. PBMCS from patients suppress in vitro erythroid (BFU-E), mixed-lineage (CFU-GEMM) and to a lesser degree granulocyte-macrophage (CFU-GM) progenitors. PBMCS from anemic RA patients were more suppressive for BFU-E than those from non-anemic patients. Addition of antibodies to tumor-necrosis factor alpha (TNF alpha) almost completely reversed the inhibition of BFU-E and CFU-GEMM, but had little effect on the CFU-GM colony formation. Antibodies to interferon-gamma (IFN gamma) and interleukin-1 (IL-1) were not effective. The above data suggest that PBMCS from RA patients suppress in vitro erythropoiesis via the production of TNF alpha; a pathogenetic role for TNF alpha in the anemia of RA can be implied.

Abnormal haem biosynthesis in the chronic anaemia of rheumatoid arthritis

OBJECTIVES

The chronic microcytic anaemia of rheumatoid arthritis (RA) occurs despite the presence of adequate reticulo-endothelial iron stores. The red cell microcytosis is evidence of impaired haemoglobin production. This study has examined possible abnormalities of erythroid haem biosynthesis that may contribute to the anaemia.

METHODS

5-Aminolaevulinate (ALA) synthase and ferrochelatase activities were assayed in whole bone marrow and in purified erythroblasts from patients with RA and in control subjects. All patients were iron replete with demonstrable iron in the bone marrow.

RESULTS

ALA synthase activity was significantly reduced in both whole bone marrow and purified erythroblasts from patients with the anaemia of RA. Erythrocyte protoporphyrin levels were raised in nine of 12 patients tested while ferrochelatase activity was normal.

CONCLUSION

These abnormalities provide absolute evidence of abnormal erythroblast haem biosynthesis and iron metabolism in the anaemia of RA and most likely reflect decreased ALA synthase mRNA translation and some abnormality of erythroblast iron transport. Further studies using highly purified erythroblast populations will attempt to identify the causal factors leading to this abnormal erythroblast metabolism.

Rheumatoid arthritis in a population sample in the Gulf: clinical observations

In our practice we had constantly been under the impression that most Arab patients with RA tend to have a non-aggressive and rather nondisabling disease. Therefore, the spectrum of RA was studied in 42 hospital patients with classic or definite forms. Their mean age was 41.2 years and the mean duration of illness was 5.25 years. F:M ratio was 3.6:1. Seropositivity and radiological findings were observed in 59.5% and 45.2% of the patients respectively. They showed a marked lack of nonarticular manifestations with insignificant functional incapacity. The over-all assessment appeared to be in agreement with the initial clinical impression.

Response of anaemia in rheumatoid arthritis to treatment with subcutaneous recombinant human erythropoietin

Eleven patients with chronic inflammatory arthritides and haemoglobin concentrations less than 105 g/l with symptoms from their anaemia were treated with a dose of 250 IU/kg/week of recombinant human erythropoietin for six weeks. The treatment was given as subcutaneous injections five days a week. All patients had active inflammatory disease. Nine patients responded to treatment with an increase in haemoglobin of more than 15 g/l. The mean (SD) haemoglobin concentration increased from 93.0 (8.0) g/l before treatment to 115.0 (12.0) g/l after six weeks. There was no correlation between the initial serum concentration of erythropoietin and the response. It was concluded that anaemia in chronic inflammatory arthritides responds to treatment with subcutaneous injections of recombinant human erythropoietin.

Multicenter study of recombinant human erythropoietin in correction of anemia in rheumatoid arthritis

PURPOSE

To administer recombinant erythropoietin to patients with rheumatoid arthritis who had significant anemia, while monitoring hematologic and rheumatologic clinical responses as well as potential toxicity.

PATIENTS AND METHODS

Seventeen patients with rheumatoid arthritis from five rheumatology care settings were studied. The patients had initial hematocrits of 34% or less and stable clinical status, and were not being treated with second-line drugs or corticosteroids. An 8-week randomized double-blind study involving various dosages of recombinant erythropoietin, as well as placebo, was followed by a 24-week open-label study in which dosage could be titrated to achieve a normal hematocrit.

RESULTS

In the 8-week randomized study, four of 13 patients who received injections of recombinant erythropoietin showed a hematologic response, arbitrarily defined as at least a 6-unit increase in hematocrit. None of four placebo-treated patients showed a meaningful hematologic response. All 11 patients who completed the subsequent 24-week open-label study reached a normal hematocrit level at some time during the study, and 10 of 11 showed an increase of hematocrit 6 units or greater. At least one adjustment, i.e., an increase, decrease, or omission of the erythropoietin dosage, was required in all patients to maintain the hematocrit at a target range of 35% for women or 40% for men. Meaningful changes were not seen in patients' capacity to perform activities of daily living or pain levels during either the 8-week randomized study or the 24-week open-label study. No adverse effects were associated with recombinant erythropoietin therapy.

CONCLUSION

Patients with rheumatoid arthritis showed excellent hematologic responses to recombinant erythropoietin, without toxicity, during careful monitoring for appropriate dosage adjustment, although a meaningful change in rheumatologic clinical status was not seen.

Iron deficiency anaemia in patients with rheumatic disease receiving non-steroidal anti-inflammatory drugs: the role of upper gastrointestinal lesions

Upper gastrointestinal lesions associated with non-steroidal anti-inflammatory drug (NSAID) treatment are commonly implicated as the cause for iron deficiency anaemia in patients with rheumatic diseases. Such patients, however, may also have other causes for iron deficiency, including blood loss from the intestine. One hundred and four patients (mean age 58 years; male 21, female 83; smokers 14) with rheumatic disease (rheumatoid 91, others 13) and absent bone marrow iron stores (mean haemoglobin 83 g/l) were examined. At endoscopy 47 of 104 (45%) had upper gastrointestinal lesions (oesophageal ulcer 4, gastric ulcer 25, gastric erosion 13, duodenal ulcer 4, gastric ulcer and duodenal ulcer 1). Endoscopic healing was assessed in 23 patients with upper gastrointestinal lesions. Eighteen of 23 (78%) lesions healed with treatment. An improvement of anaemia occurred in 10 of 18 (56%) patients with healed lesions. Twenty three of 104 (22%) patients had dyspeptic symptoms. Ten of 23 (43%) patients with dyspepsia had an upper gastrointestinal lesion as compared with 30 of 81 (37%) patients without dyspepsia. A faecal occult blood test result was available in 53 patients. Of these, 13 were positive while 40 were negative. An upper gastrointestinal lesion was present in seven of 13 (54%) patients positive for the faecal occult blood test as compared with 14 of 40 (35%) negative for the test. Thus upper gastrointestinal lesions have previously been overestimated as the cause of iron deficiency anaemia in patients receiving NSAIDs. A positive faecal occult blood test or the presence of dyspepsia is not associated with upper gastrointestinal lesions in such patients.

Anaemia in rheumatoid arthritis: pathogenesis, diagnosis and treatment

The pathogenesis, diagnosis and treatment of the anaemia of chronic disorders (ACD) in rheumatoid arthritis (RA) were reviewed. Causes of anaemia other than ACD frequently present in RA. Decreased iron absorption was shown to be the result of active RA rather than a cause of ACD or iron deficiency. It has been hypothesized that bone marrow iron availability decreases due to decreased iron release by the mononuclear phagocyte system or that the anaemia in ACD is due to ineffective erythropoiesis; these remain controversial theories. Studies considering a decreased erythropoietin responsiveness have not produced consistent results. Erythroid colony growth is suppressed in vitro by interleukins and tumour necrosis factor but their role in vivo in ACD is unknown. The diagnosis of ACD is made by exclusion. Iron deficiency is detected by transferrin, ferritin, and cellular indices after adaptation of their normal values. Treatment of the anaemia consists merely of antirheumatic treatment. Iron administration is counterproductive since iron chelators or exogenous erythropoietin administration might increase erythropoiesis.

Prediction and evaluation of the effect of iron treatment in anaemic RA patients

In order to predict a haemoglobin (Hb) rise, in response to treatment with iron from simple erythrocyte and serological parameters, we treated 28 anaemic RA patients with oral iron during 6 weeks. Iron deficiency, present in 57% of patients, was assessed by staining a bone marrow aspirate for iron. Response rate in this group was 81% and median Hb increase was 0.8 mmol/l. After 6 weeks 69% of iron deficient patients were still anaemic. Patients without iron deficiency, considered as having anaemia of chronic disease (ACD), showed no significant Hb rise. The finding of a hypochromic microcytic anaemia was associated with a significant Hb rise. MCV showed highest specificity and predictive value (90 and 88%) and ferritin was the most valid predictor of a Hb rise within 6 weeks. Combination of low MCV and low ferritin resulted in a 100% specificity and predictive value indicating that patients with values below cut off point of these variables will definitely respond to treatment. Disease activity tended to decrease after 6 weeks, but this was not correlated with a Hb rise. It was concluded that a Hb rise can be predicted accurately by blood parameters. Using certain combinations, bone marrow aspiration is rarely necessary. Iron treatment is only useful in iron deficient RA patients, although active RA limits maximal Hb rise. In contrast to earlier findings, iron treatment had no deleterious effects on disease activity.

Corticosteroid-responsive pure red cell aplasia in rheumatoid arthritis and its association with pregnancy: a case report

Pure red cell aplasia (PRCA) often occurs secondary to drug therapy for rheumatoid arthritis (RA). However, idiopathic PRCA in RA is very rare. Though different immunosuppressive therapies have been tried in the past with variable responses, there has been no case report in adults of favourable response to corticosteroids alone. We report a rare case of PRCA in RA, which responded to steroid therapy. Subsequently, the patient relapsed twice, during the first trimester of consecutive pregnancies. The association of PRCA with RA and pregnancy is discussed.

Rheumatoid arthritis in blacks in South Africa

The spectrum of rheumatoid arthritis (RA) was studied in a group of 52 blacks who attended a rheumatology unit in Cape Town, South Africa. The mean age of the patients was 44.6 years, and the female to male ratio was 3.7:1. Significant radiographic changes were frequently noted, and the mean Larsen scores were 34.9 for the hands, 19.6 for the feet, and 6.6 for the wrists. About two thirds of the patients had received an immunomodulatory drug and 20 (38%) had had one or more surgical procedures for their RA. Anaemia was the commonest extra-articular manifestation, and although the other extra-articular features were uncommon, a variety of features had been detected during the course of the disease. Earlier studies on blacks in Africa suggested that RA was a mild disease; our findings, however, are in agreement with the more recent surveys, which suggest that severe disease is not uncommon.

Alteration of interleukin-1 activity and the acute phase response in adjuvant arthritic rats treated with disease modifying antirheumatic drugs

Interleukin-1 (IL-1) activity and the acute phase response, as measured by plasma CRP and iron, were used to determine if the standard disease modifying antirheumatic drugs (DMARDs), gold, chloroquine and D-penicillamine had a common profile of activity in the adjuvant arthritic (AA) rat. All drugs were tested at a dose which significantly reduced noninjected paw swelling in AA rats. Inhibition of paw edema ranged from 37% for D-penicillamine (100 mg/kg) to 69% for auranofin (10 mg/kg). Two week medication of AA rats with gold sodium thiomalate (GST, 10 mg/kg, i.m.) or auranofin (10 mg/kg, p.o.) resulted in a significant decrease in splenic IL-1 activity, as measured in the standard lymphocyte activating factor (LAF) assay. The acute phase response, often associated with elevated IL-1 activity, was also significantly reduced following treatment of AA rats with 10 mg/kg of GST or auranofin (oral gold). Inhibition of the acute phase response by gold was determined by a significant reduction of plasma CRP levels (56-71% reduction) and enhancement of plasma iron levels (27-52% enhancement). In contrast to the effect of GST and auranofin on IL-1, CRP and iron, treatment with chloroquine (20, 30 and 35 mg/kg) and D-penicillamine (55 and 100 mg/kg) failed to reduce the acute phase response (as measured by plasma CRP and iron) or alter LAF activity from AA rat spleen cell supernatants. Based on its ability to reduce LAF activity in spleen cell supernatants and reduce the acute phase response, it is possible that the activity of gold in the AA rat may in part be due to its ability to inhibit IL-1 production in vivo. The inability of chloroquine and D-penicillamine to alter LAF activity and the acute phase response in AA rats does not preclude their possession of an immunoregulatory mechanism of action, but it does indicate that their mechanism of action in the AA rat probably differs from that of GST and auranofin.

Modulation of the acute phase response and in vitro measurement of interleukin-1 activity following administration of dexamethasone to adjuvant-arthritic rats

Adjuvant-arthritic (AA) rats were medicated with dexamethasone to determine if this glucocorticoid suppressed the activity of interleukin-1 (IL-1) or the acute phase response. Dexamethasone (0.1 mg/kg, p.o.) administered daily for two weeks to AA rats, significantly (p less than or equal to 0.01) decreased high splenic IL-1 production (60% inhibition). Dexamethasone at a 0.5 mg/kg dose reduced AA rat splenic IL-1 production below normal (100% inhibition). In addition, dexamethasone significantly inhibited the AA rat acute phase response as measured by reduction of plasma C-reactive protein levels and enhancement of plasma albumin and iron levels. Following medication with 0.02, 0.1 or 0.5 mg/kg dexamethasone, high plasma C-reactive protein levels decreased by 33, 77 and 95% respectively, compared to untreated AA controls. Under the same dosing regimen of 0.02, 0.1 or 0.5 mg/kg dexamethasone, plasma albumin levels increased by 44, 128 and 239% respectively, while plasma iron levels rose by 19, 64 and 98% respectively, compared to AA controls. At the 0.02, 0.1 and 0.5 mg/kg doses dexamethasone also significantly reduced injected and noninjected paw swelling in AA rats. In view of the ability of dexamethasone to decrease IL-1 production and the acute phase response often associated with it, it is possible that part of the anti-inflammatory activity of dexamethasone may stem from inhibition of IL-1 formation in vivo.

Malnutrition in rheumatoid arthritis

A nutrition study was conducted in thirty-eight hospitalized rheumatoid arthritis (RA) patients. Twenty-seven (71.1%) had a high likelihood of malnutrition (LOM). Laboratory and anthropometric data suggest that multiple vitamin, calory, and protein deficiencies are present. Age, female sex and a poor grip strength correlated with some indices of malnutrition. Fifteen of 18 patients with a high LOM had a bad outcome whereas 3 of 7 patients with a low LOM had a bad outcome. Malnutrition per se may be a contributing factor to increased morbidity and mortality in RA.

Blunted erythropoietin response to anaemia in rheumatoid arthritis

The relationship of serum immunoreactive erythropoietin to haemoglobin concentration was defined for 54 patients with rheumatoid arthritis (RA) and 41 patients with anaemia of varying aetiology (excluding pregnancy and renal insufficiency), not associated with RA. Significant inverse correlations between the logarithm of serum immunoreactive erythropoietin and the haemoglobin concentration were noted for the anaemic patients in both groups. The regression line for the RA patients had a similar slope, but a significantly lower y-intercept as compared to that for the non-RA patients. Erythropoietin levels were also significantly lower for the group of RA patients than for the group of non-RA patients when matched for comparable haemoglobin concentrations. These studies suggest that the erythropoietin response to anaemia in RA is intact but blunted relative to that for anaemia of other aetiologies. Lower levels of serum erythropoietin in anaemic RA patients may contribute to the pathogenesis of their anaemia.

Relationship between serum ferritin, iron stores and disease activity in rheumatoid arthritis

Bone marrow aspirate from the sternum of 40 patients with active or inactive rheumatoid arthritis (RA) was stained with Perls' Prussian blue for iron determination. In these patients serum ferritin concentrations were correlated with other indices of iron stores and disease activity. In patients with active RA and without bone marrow iron stores, serum ferritin was significantly lower than in patients with either active or inactive RA and iron stores. In patients with bone marrow iron stores, serum ferritin was directly correlated with erythrocyte sedimentation rate (ESR), Ritchie index, alpha 1-antitrypsin, alpha 1-acid glycoprotein and desferrioxamine (DFO)-induced sideruria, while an inverse correlation of serum ferritin with hemoglobin and serum iron was observed. In all patients serum ferritin was significantly correlated only with DFO-induced sideruria and unsaturated iron-binding capacity (UIBC). Thus, serum ferritin is an index of iron stores also in rheumatoid arthritis. In active disease, higher than expected values of serum ferritin are probably due to a shifting of iron from the circulating pool to the reticuloendothelial cells of the synovial membrane.

Serum ferritin and free erythrocyte protoporphyrin in rheumatoid arthritis

In this prospective study 20 newly diagnosed patients with definite or classical rheumatoid arthritis were followed with serial measurements of serum ferritin and erythrocyte-free protoporphyrin at the beginning of the trial and at 3 and 6 months. The values were correlated with clinical disease activity ad with various laboratory parameters. It was shown that free erythrocyte protoporphyrin has a constant negative correlation with erythrocyte haemoglobin concentration independent of disease activity, while serum ferritin behaves like an acute phase protein. Initial serum ferritin or free erythrocyte protoporphyrin values or their early changes appeared to have no prognostic value as evaluated by the development of new erosions or by the response of the patient to the therapy.

The mechanism of the anaemia in rheumatoid arthritis: effects of bone marrow adherent cells and of serum on in-vitro erythropoiesis

Clonal assays for erythroid progenitors (BFU-e and CFU-e) were used to study 20 patients with rheumatoid arthritis, 15 of whom had anaemia of chronic disease and five of whom were haematologically normal. The numbers of bone marrow BFU-e and CFU-e in the anaemic patients did not differ significantly from those in normal controls. Macrophages were removed from the bone marrow by a combination of adherence and buoyant density centrifugation over a sucrose gradient and the resulting fractions were cultured alone or together with autologous adherent cells in BFU-e assays. Co-culture with adherent cells significantly increased colony growth in both the controls and in seven of eight anaemic patients studied. Serum from 14 anaemic patients and from five non-anaemic patients was added to cultures of bone marrow or to control peripheral blood 'null' cells. Anaemic serum uniformly either inhibited or failed to stimulate BFU-e growth under these conditions. Serum from non-anaemic patients and from 10 healthy controls stimulated BFU-e growth from 'null' cells to an equal degree.

Red cell ferritin content: a re-evaluation of indices for iron deficiency in the anaemia of rheumatoid arthritis

In iron deficiency anaemia basic red cell content of ferritin is appreciably reduced. This variable was determined in 62 patients with rheumatoid arthritis to evaluate conventional laboratory indices for iron deficiency in the anaemia of rheumatoid arthritis. For 23 patients with rheumatoid arthritis and normocytic anaemia irrespective of plasma ferritin concentration, red cell ferritin content did not differ significantly from that for non-anaemic patients with rheumatoid arthritis. For 27 patients with rheumatoid arthritis and microcytic anaemia, the mean red cell ferritin content for patients with a plasma ferritin concentration in the 13-110 micrograms/l range was appreciably reduced. It was indistinguishable from that for patients with rheumatoid arthritis and classical iron deficiency anaemia, indicated by plasma ferritin concentrations of less than 12 micrograms/l. In contrast, the mean red cell ferritin content for patients with rheumatoid arthritis, microcytic anaemia, and plasma ferritin concentrations above 110 micrograms/l did not differ from that for patients with rheumatoid arthritis and normocytic anaemia. Oral treatment with iron in patients with rheumatoid arthritis, microcytic anaemia, and appreciably reduced red cell ferritin concentrations was accompanied by significant increases in haemoglobin concentration (p less than 0.01), mean corpuscular volume (p less than 0.01), and red cell ferritin contents (p less than 0.05). This treatment, however, did not produce any appreciable change in haemoglobin concentration in patients with rheumatoid arthritis, normocytic anaemia, and normal red cell ferritin contents. These findings suggest that the indices for iron deficiency in patients with rheumatoid arthritis and anaemia should include peripheral blood microcytosis together with a plasma ferritin concentration of less than 110 micrograms/l.