Treatment of early rheumatoid arthritis: Methotrexate and beyond

Surface saturation of drug-loaded hollow manganese dioxide nanoparticles with human serum albumin for treating rheumatoid arthritis

Rheumatoid arthritis (RA) is a chronic inflammatory joint disease accompanied by energy depletion and accumulation of reactive oxygen species (ROS). Inorganic nanoparticles (NPs) offer great promise for the treatment of RA because they mostly have functions beyond being drug carriers. However, conventional nanomaterials become coated with a protein corona (PC) or lose their cargo prematurely in vivo, reducing their therapeutic efficacy. To avoid these problems, we loaded methotrexate (MTX) into hollow structured manganese dioxide nanoparticles (H-MnO2 NPs), then coated them with a 'pseudo-corona' of human serum albumin (HSA) at physiological concentrations to obtain HSA-MnO2@MTX NPs. Efficacy of MTX, MnO2@MTX, and HSA-MnO2@MTX NPs was compared in vitro and in vivo. Compared to MnO2@MTX, HSA-coated NPs were taken up better by lipopolysaccharide-activated RAW264.7 and were more effective at lowering levels of pro-inflammatory cytokines and preventing ROS accumulation. HSA-MnO2@MTX NPs were also more efficient at blocking the proliferation and migration of fibroblast-like synoviocytes from rats with collagen-induced arthritis. In this rat model, HSA-MnO2@MTX NPs showed better biodistribution than other treatments, specifically targeting the ankle joint. Furthermore, HSA-MnO2@MTX NPs reduced swelling in the paw, regulated pro-inflammatory cytokine production, and limited cartilage degradation and signs of inflammation. These results establish the therapeutic potential of HSA-MnO2@MTX NPs against RA.

Kunduan Yimu Decoction affected Th17/Treg balance through microRNA-124 to improve rheumatoid arthritis pathology

BACKGROUND

Rheumatoid arthritis (RA) is an autoimmune condition characterized by inflammation and the deterioration of joints. Current treatments often have side effects, highlighting the need for safer options. This study investigates the therapeutic effects of Kunduan Yimu Decoction (KDYMD) on RA, focusing on the role of miR-124 in regulating Th17/Treg differentiation.

METHODS

PBMCs from RA patients were analyzed before and after KDYMD treatment. RT-qPCR was used to measure the miR-124 expressions. Flow cytometry was used to assess the ratios of Th17 to Treg cells. ELISA was used to quantify the cytokine concentrations. The effects of KDYMD on JAK2/STAT3 signaling were evaluated by western blot analysis. A CIA mouse model was used to validate the in vivo effects of KDYMD.

RESULTS

MiR-124 expression was significantly upregulated in PBMCs of RA patients after KDYMD treatment. This upregulation was associated with increased Tip60 and Foxp3 expression and decreased RORγt expression. In the cytokine analysis, IL-1, IL-6, and IL-17A were decreased, and IL-10 and TGF- were increased after treatment. Flow cytometry showed a restoration of the Th17/Treg balance, with a decrease in Th17 and an increase in Treg cells. In vivo, KDYMD treatment ameliorated ankle swelling and arthritis index in CIA mice, comparable to methotrexate (MTX). In addition, KDYMD modulated JAK2/STAT3 signaling and enhanced anti-inflammatory responses.

CONCLUSIONS

KDYMD exerts significant anti-inflammatory effects in RA by upregulating miR-124, which in turn regulates Th17/Treg differentiation and modulates JAK2/STAT3 signaling. A novel mechanism involving miR-124 and immune cell balance suggests KDYMD could be a promising therapeutic agent for RA.

Anti-rheumatic arthritis efficacy of Pueraria montana extract against type-II collagen-induced rheumatoid arthritis rat model an in vitro and in vivo assessment

ETHNOPHARMACOLOGICAL RELEVANCE

Pueraria montana (PM) is a Chinese medicinal herb used to treat alcoholism, inflammation, swelling, and anti-apoptosis. However, the mechanisms and active compounds of PM remain poorly understood.

AIM OF THE STUDY

Chronic inflammatory diseases such as rheumatoid arthritis (RA) can affect multiple joints. Inflammation begins in the synovium and spreads to the surrounding cartilage and bone if left untreated. This study assessed the probable anti-arthritic mechanisms of action of PM extracts. Type II collagen emulsion-induced rheumatoid used as an in vivo model.

MATERIALS AND METHODS

TNF-α-stimulated MC cells were used to investigate the mechanism of PM extract in RA, and the PM extract was confirmed using HPLC analysis. The antiproliferative efficacy of PM was assessed by MTT assay, and apoptotic activity was evaluated using Hoechst staining and flow cytometry assessment. Furthermore, the matrix metalloproteinase (MMP) ratio and mRNA expression of Bcl-2, Cas-3, Cas-9, and SOCS1 were determined using ELISA and qRT-PCR.

RESULTS

PM extract treatment possesses anti-arthritic properties in CIA rats and can suppress inflammation and inhibit the invasion and migration of MH7A cells. The upregulation of Bcl-2, a recognized inhibitor of apoptotic genes, prevents the release of cyto-C into the cytoplasm. The in vivo outcomes showed that PM reduced the arthritis score and toe swelling in CIA rats. In vitro, PM extract exhibited substantial antiproliferative and pro-apoptotic properties on TNF-α-induced MH7A cell lines. The invasive and adhesive properties of MH7A cells decreased, and MMP secretion was reduced.

CONCLUSION

This study suggests that the PM extract possesses anti-arthritic properties in the CIA model and is an extension of the clinical treatment of rheumatic arthritis.

Tannic Acid-Based Biomimetic Nanomedicine with Pathological Reactive Oxygen Species-Responsive Cargo Release for Relieving Inflammation in Rheumatoid Arthritis

Rheumatoid arthritis (RA) is a chronic disease characterized by immune cell infiltration and cartilage damage. The local lesion of RA shows severe oxidative stress and proinflammatory cytokine secretion. For drug therapy, the efficacy of agents, such as methotrexate (MTX), may be greatly limited, resulting from the low bioavailability, immune clearance, and toxic side effects. A nanocarrier (TA-PBA NPs) was developed with anti-inflammatory and antioxidant activities, combined with MTX to prepare nanomedicine (MTX NPs) for synergistic treatment of RA. Moreover, inspired by the biological functions homing to inflammation lesion of macrophages, the biomimetic nanomedicine camouflaged with macrophage membrane (MM@MTX NPs) was constructed. TA-PBA NPs could timely promote MTX release in response to the overaccumulated ROS to exhibit high anti-inflammatory and antioxidant activities for alleviating RA progression. The experimental results confirmed that MM@MTX NPs could significantly reduce the secretion of proinflammatory cytokines (TNF-α) while significantly increasing the typical anti-inflammatory cytokines (IL-10), promote the phenotype transformation of macrophages from M1 to M2, and up-regulate the Nrf2-keap1 pathway-related proteins (HO-1 and NRF2) to positively regulate the local inflammation for effectively inhibiting RA development. Thus, MM@MTX NPs represent a possible candidate as a safe and efficient nanotherapy platform for RA management.

Astaxanthin, Compared to Other Carotenoids, Increases the Efficacy of Methotrexate in Rat Adjuvant Arthritis

This in vivo study performed in rat adjuvant arthritis aims to advance the understanding of astaxanthin's therapeutic properties for the possible treatment of rheumatoid arthritis (RA) in monotherapy and along with the standard RA treatment, methotrexate (MTX), in combination therapy. The main goal was to elucidate astaxanthin's full therapeutic potential, evaluate its dose dependency, and compare its effects in monotherapy with other carotenoids such as β-carotene and β-cryptoxanthin (KXAN). Moreover, potential differences in therapeutic activity caused by using different sources of astaxanthin, synthetic (ASYN) versus isolated from Blakeslea trispora (ASTAP), were evaluated using one-way ANOVA (Tukey-Kramer post hoc test). KXAN was the most effective in reducing plasma MMP-9 levels in monotherapy, significantly better than MTX, and in reducing hind paw swelling. The differences in the action of ASTAP and ASYN have been observed across various biometric, anti-inflammatory, and antioxidative parameters. In combined therapy with MTX, the ASYN + MTX combination proved to be better. These findings, especially the significant anti-arthritic effect of KXAN and ASYN + MTX, could be the basis for further preclinical studies.

Assessing the accuracy and completeness of artificial intelligence language models in providing information on methotrexate use

We aimed to assess Large Language Models (LLMs)-ChatGPT 3.5-4, BARD, and Bing-in their accuracy and completeness when answering Methotrexate (MTX) related questions for treating rheumatoid arthritis. We employed 23 questions from an earlier study related to MTX concerns. These questions were entered into the LLMs, and the responses generated by each model were evaluated by two reviewers using Likert scales to assess accuracy and completeness. The GPT models achieved a 100% correct answer rate, while BARD and Bing scored 73.91%. In terms of accuracy of the outputs (completely correct responses), GPT-4 achieved a score of 100%, GPT 3.5 secured 86.96%, and BARD and Bing each scored 60.87%. BARD produced 17.39% incorrect responses and 8.7% non-responses, while Bing recorded 13.04% incorrect and 13.04% non-responses. The ChatGPT models produced significantly more accurate responses than Bing for the "mechanism of action" category, and GPT-4 model showed significantly higher accuracy than BARD in the "side effects" category. There were no statistically significant differences among the models for the "lifestyle" category. GPT-4 achieved a comprehensive output of 100%, followed by GPT-3.5 at 86.96%, BARD at 60.86%, and Bing at 0%. In the "mechanism of action" category, both ChatGPT models and BARD produced significantly more comprehensive outputs than Bing. For the "side effects" and "lifestyle" categories, the ChatGPT models showed significantly higher completeness than Bing. The GPT models, particularly GPT 4, demonstrated superior performance in providing accurate and comprehensive patient information about MTX use. However, the study also identified inaccuracies and shortcomings in the generated responses.

Application of Cartilage Extracellular Matrix to Enhance Therapeutic Efficacy of Methotrexate

BACKGROUND

Rheumatoid arthritis (RA) is characterized by chronic inflammation and joint damage. Methotrexate (MTX), a commonly used disease-modifying anti-rheumatic drug (DMARD) used in RA treatment. However, the continued use of DMARDs can cause adverse effects and result in limited therapeutic efficacy. Cartilage extracellular matrix (CECM) has anti-inflammatory and anti-vascular effects and promotes stem cell migration, adhesion, and differentiation into cartilage cells.

METHODS

CECM was assessed the dsDNA, glycosaminoglycan, collagen contents and FT-IR spectrum of CECM. Furthermore, we determined the effects of CECM and MTX on cytocompatibility in the SW 982 cells and RAW 264.7 cells. The anti-inflammatory effects of CECM and MTX were assessed using macrophage cells. Finally, we examined the in vivo effects of CECM in combination with MTX on anti-inflammation control and cartilage degradation in collagen-induced arthritis model. Anti-inflammation control and cartilage degradation were assessed by measuring the serum levels of RA-related cytokines and histology.

RESULTS

CECM in combination with MTX had no effect on SW 982, effectively suppressing only RAW 264.7 activity. Moreover, anti-inflammatory effects were enhanced when low-dose MTX was combined with CECM. In a collagen-induced arthritis model, low-dose MTX combined with CECM remarkably reduced RA-related and pro-inflammatory cytokine levels in the blood. Additionally, low-dose MTX combined with CECM exerted the best cartilage-preservation effects compared to those observed in the other therapy groups.

CONCLUSION

Using CECM as an adjuvant in RA treatment can augment the therapeutic effects of MTX, reduce existing drug adverse effects, and promote joint tissue regeneration.

Safety of the JAK and TNF inhibitors in rheumatoid arthritis: real world data from the Hong Kong Biologics Registry

OBJECTIVES

To compare the incidence of major adverse cardiovascular events (MACEs), cancer and infective complications in RA patients using Janus kinase (JAKis) and TNF (TNFis) inhibitors.

METHOD

A retrospective analysis of data from the Hong Kong Biologics Registry 2008-2021 was performed. RA patients who had ever used JAKis or TNFis were included. The incidence of MACEs, cancer and infections were compared between the two groups, with adjustment for confounding factors.

RESULTS

A total of 2471 courses of JAKis (n = 551) and TNFis (n = 1920) were used in 1732 RA patients (83.7% women, age 53.8 [12.5] years; follow-up 6431 patient-years). JAKi users had significantly older age, more atherosclerotic risk factors and higher frequency of past malignancies. A total of 15 and 40 MACEs developed in the JAKi and TNFi users, respectively (incidence 1.34 vs 0.75 per 100 patient-years; P = 0.22). There was no significant difference in the incidence of cancers between the two groups (0.81 [JAKi] vs 0.85 [TNFi] per 100 patient-years; P = 0.25). The adjusted hazard ratios of MACE and cancer in the JAKi users were 1.36 (95% CI: 0.62, 2.96) (P = 0.44) and 0.87 (95% CI: 0.39, 1.95) (P = 0.74), respectively. Rates of infections were significantly higher in the JAKi than TNFi users (16.3 vs 9.9 per 100 patient-years; P = 0.02), particularly herpes zoster (3.49 vs 0.94 per 100 patient-years; P < 0.001).

CONCLUSIONS

In a real-life setting, there is no increase in MACEs or cancers in users of JAKis compared with TNFis. However, the incidence of non-serious infections, including herpes zoster, was increased in users of JAKis.

Anti-CD64 Antibody-Conjugated PLGA Nanoparticles Containing Methotrexate and Gold for Theranostics Application in Rheumatoid Arthritis

Rheumatoid arthritis, an autoimmune disorder, exerts a considerable effect on quality of life. The inflammatory mechanism involved in rheumatoid arthritis is not clearly known, and therefore the need to develop effective medicines as well as new methods for early detection is a challenge. In this study, we developed PLGA nanoparticles containing gold and methotrexate in core and anti-CD64 antibody conjugated to nanoparticle surface via coupling process. The nanoparticles were examined for their surface morphology using SEM and TEM. The mean particle size, zeta potential, and PDI values of nanoparticles were 413.6 ± 2.89 nm, -10.12 ± 2.12 mV, and 0.23 ± 0.04, respectively, indicating good stability and particle homogeneity. In vitro drug release revealed a controlled release pattern with 93.44 ± 1.60% up to 72 h of release in the presence of pH 5.8, indicating the influence of pH and NIR on drug release. In vivo results on adjuvant-induced arthritis on Wistar rats indicated that animals receiving antibody-conjugated nanoparticles showed improvement in clinical indices and arthritic score as compared to non-conjugated nanoparticles and free drugs. This innovative drug delivery system will be an excellent strategy to maximize therapeutic effectiveness by limiting dosage-related side effects.

Efficient delivery of the lncRNA LEF1-AS1 through the antibody LAIR-1 (CD305)-modified Zn-Adenine targets articular inflammation to enhance the treatment of rheumatoid arthritis

BACKGROUNDS

Rheumatoid arthritis (RA) is a chronic inflammatory autoimmune disease characterized by synovial hyperplasia. Maintaining a balance between the proliferation and apoptosis of rheumatoid arthritis synovial fibroblasts (RASFs) is crucial for preventing the erosion of bone and cartilage and, ultimately, mitigating the progression of RA. We found that the lncRNA LEF1-AS1 was expressed at low levels in the RASFs and inhibited their abnormal proliferation by targeting PIK3R2 protein and regulating the PI3K/AKT signal pathway through its interaction with miR-30-5p. In this study, we fabricated a nano-drug delivery system for LEF1-AS1 using Zn-Adenine nanoparticles (NPs) as a novel therapeutic strategy against RA.

METHODS

The expression levels of LEF1-AS1, miR-30-5p, PIK3R2, p-PI3K, and p-AKT were detected in the primary RASFs and a human fibroblast-like synovial cell line (HFLS). Zn-Adenine nanoparticles (NPs) were functionalized with anti-CD305 antibody to construct (Zn-Adenine)@Ab. These NPs were then loaded with LEF1-AS1 to form (Zn-Adenine)@Ab@lncRNA LEF1-AS1. Finally, the (Zn-Adenine)@Ab@lncRNA LEF1-AS1 NPs were locally injected into a rat model with collagen-induced arthritis (CIA). The arthritic injuries in each group were evaluated by HE staining and other methods.

RESULTS

LEF1-AS1 was expressed at low levels in the primary RASFs. High expression levels of LEF1-AS1 were detected in the HFLS cells, which corresponded to a significant downregulation of miR-30-5p. In addition, the expression level of PIK3R2 was significantly increased, and that of p-PI3K and p-AKT were significantly downregulated in these cells. The (Zn-Adenine)@Ab@lncRNA LEF1-AS1 NPs significantly inhibited the proliferation of RASFs and decreased the production of inflammatory cytokines (IL-1β, IL-6, TNF-α). Intra-articular injection (IAI) of (Zn-Adenine)@Ab@lncRNA LEF1-AS1 NPs significantly alleviated cartilage destruction and joint injury in the CIA-modeled rats.

CONCLUSIONS

LEF1-AS1 interacts with miR-30-5p to inhibit the abnormal proliferation of RASFs by regulating the PI3K/AKT signal pathway. The (Zn-Adenine)@Ab NPs achieved targeted delivery of the loaded LEF1-AS1 into the RASFs, which improved the cellular internalization rate and therapeutic effects. Thus, LEF1-AS1 is a potential target for the treatment of RA.

The overturn of Roe v. Wade beyond abortion: a snapshot of methotrexate accessibility for people with rheumatic and musculoskeletal diseases-a mixed methods study using Twitter data

In June 2022, the Supreme Court of the United States (US) overturned the right established in Roe v. Wade to terminate a pregnancy. Subsequently, some states passed abortion ban laws prohibiting the use of abortive methods, including methotrexate (MTX), which has been a cornerstone drug in rheumatology. We aimed to explore and analyze Twitter data to comprehend the short-term implications of the overturn on rheumatology care. We conducted a mixed methods study using social media (SoMe) data. Tweets publicly posted using "#Methotrexate or Methotrexate" were tracked. A combination of SoMe performance data with qualitative hashtag co-occurrence analysis and content analysis was conducted. A total of 5180 posts were generated and reached approximately 40 million users. Seventy-three percent of all publications came from the US. Females posted more than males. Additionally, the three pairs of hashtags with higher co-occurrence were: #roevswade, #abortionishealthcare, and #rheumatoidarthritis. From the content analysis, three main themes were generated: (i) violence against women, (ii) health policy without public health intelligence, and (iii) call for strategic alliances in favor of public health. The combination of biological sex and state of residence could condition the use of MTX. Men will be able to continue their treatment; however, women could lose continuity of it. Inequity in access to treatment is a political decision, just as it is to reproduce inequities and vulnerabilities through the actions taken. Not having access to MTX for rheumatic and musculoskeletal diseases (RMDs) is a critical issue that endangers the physical and mental health of people with RMDs.

An AI Approach to Identifying Novel Therapeutics for Rheumatoid Arthritis

Rheumatoid arthritis (RA) is a chronic autoimmune disorder that has a significant impact on quality of life and work capacity. Treatment of RA aims to control inflammation and alleviate pain; however, achieving remission with minimal toxicity is frequently not possible with the current suite of drugs. This review aims to summarise current treatment practices and highlight the urgent need for alternative pharmacogenomic approaches for novel drug discovery. These approaches can elucidate new relationships between drugs, genes, and diseases to identify additional effective and safe therapeutic options. This review discusses how computational approaches such as connectivity mapping offer the ability to repurpose FDA-approved drugs beyond their original treatment indication. This review also explores the concept of drug sensitisation to predict co-prescribed drugs with synergistic effects that produce enhanced anti-disease efficacy by involving multiple disease pathways. Challenges of this computational approach are discussed, including the availability of suitable high-quality datasets for comprehensive analysis and other data curation issues. The potential benefits include accelerated identification of novel drug combinations and the ability to trial and implement established treatments in a new index disease. This review underlines the huge opportunity to incorporate disease-related data and drug-related data to develop methods and algorithms that have strong potential to determine novel and effective treatment regimens.

Low serum level and chronic toxicity for methotrexate. Case Report

INTRODUCTION

Methotrexate (MTX) is a folic acid antagonist used to treat different immunological or proliferative illnesses because of its anti-proliferative and anti-inflammatory effects. MTX Toxicity is considered a severe problem. Although acute toxicity related to high-dose administration (doses ≥500 mg/m2) can be predicted based on the given dose, chronic toxicity still has no specific factors to predict it, so treatment depends on the history and symptoms of toxicity. MTX was initially used for oncology indications with high cyclic doses, then expanded to non-oncology indications with different low doses and frequencies. This significant change in doses resulted in dosing errors that contributed to MTX toxicity reports. Measures to prevent the toxicity of MTX should be implemented.

CASE

A 66-year-old female patient ingested 10 mg of MTX daily for one month instead of the once-toxicity symptoms. The serum level of MTX was requested, and treatment with folinic acid was initiated until the patient improved with the discontinuation of MTX.

DISCUSSION

There is limited literature about the lack the total cumulative dose, duration of intake, or serum level of MTX. All this information was provided in this case report, but drug-drug interactions were not reviewed, although aspirin and pantoprazole were identified as having interactions with methotrexate in this patient. Minimum total cumulative dose identification may help assess the toxicity risk in such patients.

CONCLUSION

Low-dose MTX chronic toxicity still needs further information to guide the patient's risk of toxicity and when to initiate treatment. Safety-practical measures should be implemented to prevent such administration errors.

Filgotinib Modulates Inflammation-Associated Peripheral Blood Protein Biomarkers in Adults with Active Rheumatoid Arthritis and Prior Inadequate Response to Methotrexate

INTRODUCTION

Our aim was to evaluate protein biomarker changes related to the administration of filgotinib, a Janus kinase (JAK) 1 preferential inhibitor, in patients with moderately to severely active rheumatoid arthritis (RA) with inadequate response to methotrexate.

METHODS

Plasma and serum samples were collected from patients enrolled in FINCH 1 (NCT02889796), a Phase 3 trial. Patients with stable backgrounds of methotrexate were randomly assigned once-daily oral filgotinib 200 or 100 mg, subcutaneous adalimumab 40 mg every 2 weeks (W), or placebo. Up to 35 biomarkers were analyzed at baseline, W4, and W12 with enzyme-linked immunosorbent assays and chemiluminescence and electrochemiluminescence assays.

RESULTS

At baseline, four distinct biomarker clusters were identified. The strongest intragroup correlations were in bone-cartilage resorption/inflammation and JAK/signal transducer and activator of transcription (STAT) signaling activity. At baseline, significant positive correlations were identified for cytokines with patient-reported pain and with patient measures of fatigue. Filgotinib reduced levels of cytokines associated with inflammation and cell migration as early as W4 and through W12. Compared to adalimumab, filgotinib induced significant reductions in bone-related turnover biomarkers, N-telopeptide of type 1 collagen and C-telopeptide 1, as well as biomarkers associated with baseline disease activity. No baseline predictors of therapeutic response to filgotinib were identified.

CONCLUSIONS

Filgotinib reduced peripheral protein biomarkers associated with JAK/STAT signaling, inflammatory signaling, immune cell migration, and bone resorption as soon as W4 in FINCH 1. Effects were dose-dependent and consistent with the clinical efficacy of filgotinib observed in FINCH 1. The changes in peripheral biomarkers associated with filgotinib treatment in methotrexate-experienced patients are consistent with changes observed in both methotrexate-naïve and biologic disease-modifying antirheumatic drug-experienced RA populations. These data demonstrate dose-dependent effects of preferential JAK1 inhibition by filgotinib on peripheral blood protein biomarkers in methotrexate-experienced patients with RA.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02889796.

The administration of methotrexate in patients with Still's disease, "real-life" findings from AIDA Network Still Disease Registry

OBJECTIVES

To describe clinical characteristics of patients with Still's disease treated with methotrexate (MTX) and to assess drug effectiveness evaluating change in disease activity, reduction of inflammatory markers, and glucocorticoid (GC)-sparing effect.

METHODS

Patients with Still's disease treated with MTX were assessed among those included in AIDA Network Still Disease Registry.

RESULTS

In this registry, 171 patients with Still's disease were treated with MTX (males 43.3%, age 37.1 ± 16.0 years). They were mainly characterised by joint features and fever without a prominent multiorgan involvement. MTX was administered with GCs in 68.4% of patients, with other conventional synthetic DMARDs in 6.4%, and with biologic DMARDs in 25.1%. A significant reduction of the modified systemic score was observed, and 38.6% patients were codified as being in clinical remission at the end of follow-up. The concomitant administration of a biologic DMARD resulted a predictor of the clinical remission. Furthermore, a reduction of inflammatory markers and ferritin levels was observed following the administration of MTX. Additionally, a marked reduction of the dosage of concomitant GCs was identified, while 36.7% discontinued such drugs. Male gender appeared as a predictor of GC discontinuation. MTX was discontinued in 12.3% of patients because of adverse effects, and in 12.3% for lack of efficacy.

CONCLUSIONS

Clinical characteristics of patients with Still's disease treated with MTX were described, mainly joint features and fever without a prominent multiorgan involvement. The clinical usefulness of MTX was reported in reducing the disease activity, decreasing the inflammatory markers, and as GC-sparing agent.

Rhodiola rosea L. Extract, a Known Adaptogen, Evaluated in Experimental Arthritis

Rhodiola rosea L. extract (RSE) is mostly known for its adaptogen properties, but not for its antiarthritic activities, therefore monotherapy and combination with low-dose methotrexate (MTX) was studied. The collagen-induced arthritis (CIA) model was used to measure the functional score, and the change in hind paw volume (HPV). Both parameters had significant antiarthritic effects. Based on these preliminary results, an adjuvant arthritis (AA) model was further applied to assess another parameters. The experiment included these animal groups: healthy controls, untreated AA, AA administered with RSE (150 mg/kg b.w. daily, p.o.), AA administered by MTX (0.3 mg/kg b.w. twice a week, p.o.), and AA treated with the combination of RSE+MTX. The combination of RSE+MTX significantly reduced the HPV and increased the body weight. The combination significantly decreased HPV when compared to MTX monotherapy. The plasmatic levels of inflammatory markers (IL-6, IL-17A, MMP-9 and CRP) were significantly decreased by MTX+RSE treatment. The RSE monotherapy didn't influence any of the inflammatory parameters studied. In CIA, the RSE monotherapy significantly decreased the arthritic parameters studied. In summary, the combination of RSE and sub-therapeutic MTX was significantly effective in AA by improving inflammatory and arthritic parameters.

Intra-articular delivery system of methotrexate for rheumatoid arthritis therapy: An in-suit thermosensitive comprehensive gel of polysaccharide from Aconitum carmichaelii Debx

The polysaccharides (FP) extracted from the lateral roots of Aconitum carmichaelii Debx. (Fuzi) are natural compounds, which have effective therapy for rheumatoid arthritis (RA). Methotrexate (MTX) is the first-line drug for RA, but its application is greatly limited to the toxicity in liver and kidney and drug resistance. In this study, an attempt is made to apply oxidized FP (OFP) as a polymer carrier based on intra-articular delivery system loaded MTX. The FP could be developed and used as comprehensive gel carriers with biocompatibility and degradability for therapy of RA. Firstly, OFP-chitosan-poloxamer 407 (OFP-CS-F407-MTX) gel was prepared by natural non-toxic cross-linking agents. Physicochemical characterization was performed by using ¹H NMR and FTIR spectroscopic techniques to assess the successful functionalization of OFP. TGA, SEM and rheological experiment of OFP-CS-F407-MTX gel were investigated. Notably, we loaded MTX into OFP-CS-F407-MTX gel which had remarkable therapeutic efficacy and biosafety for RA. Based on advantages of intra-articular injection of OFP-CS-F407-MTX gel releasing MTX, it modulated proinflammatory cytokines by down-regulating TNF-α, IL-6 and IL-1β expression. Therefore, OFP-CS-F407-MTX in situ gel delivery system can potentially reduce systemic toxicity and irritation of oral administration of MTX but give a controlled release of drug for a long period of time.

Andrographis paniculata (Burm.f.) Nees Alleviates Methotrexate-Induced Hepatotoxicity in Wistar Albino Rats

Andrographis paniculata is a herbal plant used in traditional medicinal approaches to treat various ailments and diseases. Methotrexate (MTX) is a clinically used immunosuppressant and anticancer drug. One of the increasing concerns with MTX use is liver toxicity. The aim of this study is to investigate the potential effect of aqueous leaf extract of Andrographis paniculata against methotrexate-induced hepatotoxicity. Wistar albino rats were grouped into five groups, and the drugs were administered. MTX (20 mg/kg b.w.) was intraperitoneally injected into rats on the ninth day alone. Aqueous leaf extract of Andrographis paniculata (500 mg/kg b.w./day) was orally administered for 10 days. We confirmed the beneficial effect of aqueous extracts of Andrographis paniculata on restoring the hepatic enzyme markers, lipid profile, antioxidant level, anti-inflammatory marker (IL-10), anti-apoptosis (bcl-2), significant suppression of inflammatory cytokines (TNF-α, and IL-6), apoptosis marker (caspase 3) and cellular tissue damage caused by MTX. Overall, we revealed that Andrographis paniculata reduces critical aspects of oxidative stress, inflammatory processes, and apoptosis, thus protecting against methotrexate-induced hepatotoxicity.

KW2449 ameliorates collagen-induced arthritis by inhibiting RIPK1-dependent necroptosis

Objective

Necroptosis has recently been found to be associated with the pathogenesis of many autoimmune diseases, including rheumatoid arthritis (RA). This study was undertaken to explore the role of RIPK1-dependent necroptosis in the pathogenesis of RA and the potential new treatment options.

Methods

The plasma levels of receptor-interacting protein kinase 1 (RIPK1) and mixed lineage kinase domain-like pseudokinase (MLKL) in 23 controls and 42 RA patients were detected by ELISA. Collagen-induced arthritis (CIA) rats were treated with KW2449 by gavage for 28 days. Arthritis index score, H&amp;E staining, and Micro-CT analysis were used to evaluate joint inflammation. The levels of RIPK1-dependent necroptosis related proteins and inflammatory cytokines were detected by qRT-PCR, ELISA and Western blot, and the cell death morphology was detected by flow cytometry analysis and high-content imaging analysis.

Results

The plasma levels of RIPK1 and MLKL in RA patients were higher than those in healthy people, and were positively correlated with the severity of RA. KW2449 could reduce joint swelling, joint bone destruction, tissue damage, and the plasma levels of inflammatory cytokines in CIA rats. Lipopolysaccharide combined with zVAD (LZ) could induce necroptosis in RAW 264.7 cells, which could be reduced by KW2449. RIPK1-dependent necroptosis related proteins and inflammatory factors increased after LZ induction and decreased after KW2449 treatment or knockdown of RIPK1.

Conclusion

These findings suggest that the overexpression of RIPK1 is positively correlated with the severity of RA. KW2449, as a small molecule inhibitor targeting RIPK1, has the potential to be a therapeutic strategy for RA treatment by inhibiting RIPK1-dependent necroptosis.

Potential Anti-Rheumatoid Arthritis Activities and Mechanisms of Ganoderma lucidum Polysaccharides

Rheumatoid arthritis (RA) is a chronic and autoimmune disease characterized by inflammation, autoimmune dysfunction, and cartilage and bone destruction. In this review, we summarized the available reports on the protective effects of Ganoderma lucidum polysaccharides (GLP) on RA in terms of anti-inflammatory, immunomodulatory, anti-angiogenic and osteoprotective effects. Firstly, GLP inhibits RA synovial fibroblast (RASF) proliferation and migration, modulates pro- and anti-inflammatory cytokines and reduces synovial inflammation. Secondly, GLP regulates the proliferation and differentiation of antigen-presenting cells such as dendritic cells, inhibits phagocytosis by mononuclear macrophages and nature killer (NK) cells and regulates the ratio of M1, M2 and related inflammatory cytokines. In addition, GLP produced activities in balancing humoral and cellular immunity, such as regulating immunoglobulin production, modulating T and B lymphocyte proliferative responses and cytokine release, exhibiting immunomodulatory effects. Thirdly, GLP inhibits angiogenesis through the direct inhibition of vascular endothelial cell proliferation and induction of cell death and the indirect inhibition of vascular endothelial growth factor (VEGF) production in the cells. Finally, GLP can inhibit the production of matrix metalloproteinases and promote osteoblast formation, exerting protective effects on bone and articular cartilage. It is suggested that GLP may be a promising agent for the treatment of RA.

Research on Liver Damage Caused by the Treatment of Rheumatoid Arthritis with Novel Biological Agents or Targeted Agents

Rheumatoid arthritis (RA) is a chronic autoimmune disease characterized by polyarticular, symmetric, and aggressive inflammation of the small joints in the hands and feet, resulting in dysfunction. With progress and development in medicine, treatment of RA is constantly evolving, making several drugs available for the treatment of RA. From the nonsteroidal anti-inflammatory drugs (NSAIDs) at the start of illness to glucocorticoids and then to conventional synthetic DMARDs (csDMARDs), biologic DMARDs (bDMARDs), and targeted synthetic DMARDs (tsDMARDs), therapeutic-use drugs for RA have been keeping pace with scientific research. However, various types of drugs have additional side effects when used over the long-term. New and emerging biological and targeted agents have been widely applied in recent years; however, the side effects have not been thoroughly investigated. In this paper, we review the research progress on liver damage caused by novel biological and targeted agents available for RA treatment. The aim is to provide a reference for rational clinical administration of such drugs.

Hexokinase inhibitor 2-deoxyglucose coordinates citrullination of vimentin and apoptosis of fibroblast-like synoviocytes by inhibiting HK2 /mTORC1-induced autophagy

High hexokinase 2 (HK2) expression is associated with aberrant activation of fibroblast-like synoviocytes (FLSs) in rheumatoid arthritis (RA). However, the mechanism by which this occurs has not been fully elucidated. To investigate the role of HK2 and its underlying mechanism, adjuvant arthritis (AA) rats were treated with the HK2 inhibitor, 2-deoxyglucose (2-DG). In conjunction with HK2 knockdown experiments in FLSs, we evaluated the effect of HK2 on the citrullination of vimentin (cVIM), autophagy and apoptosis-associated protein expression, including that of cVIM, LC3, p62, Beclin1, Bax, Bcl2, and caspase 3. We further investigated the interaction of HK2 with downstream mTORC1 signaling effectors. Correlation analysis revealed that 2-DG treatment and HK2 knockdown upregulated the expression levels of caspase3, Bax, and p62 and downregulated the expression levels of LC3, Bcl2, and Beclin1, as well as decreasing vimentin citrullination. Furthermore, interactions between HK2 and mTOR decreased, coinciding with mTORC1 pathway activation. These findings suggest that the regulation of apoptosis and cVIM by HK2/mTORC1-dependent autophagy involves the inhibition of aberrant FLSs activation in the rat model of arthritis.

Pharmacokinetics and bioequivalence evaluation of 2 oral formulations of methotrexate tablets in healthy Chinese volunteers under fasting and fed conditions

Methotrexate is an anti-metabolite drug that is frequently used for rheumatoid arthritis treatment. This study is aimed at evaluating the bioequivalence of 2 methotrexate tablets (2.5 mg) under fasting and fed conditions in healthy Chinese volunteers. A single-center, randomized, open-label, two-drug, two-period, crossover, single-dose trial protocol was designed. Fifty-two healthy Chinese participants were enrolled and randomly classified into fasting (n = 26) and fed (n = 26) group. Fifty of them participated in the whole trial course. Blood samples for pharmacokinetic (PK) analysis were collected 1 h before and up to 24 h after drug administration. To evaluate the bioequivalence of test and reference tablets, PK parameters including maximum plasma drug concentration (C_max), time to reach maximum concentration (T_max), area under the plasma concentration-time curve from time 0 to the last measurable concentration (AUC_0-t), and area under the plasma concentration-time curve from time 0 to infinity (AUC_0-∞) were calculated. Our data revealed that 90% CIs of geometric mean ratio of the test or reference drugs for C_max, AUC_0-t, and AUC_0-∞ fell within the acceptance range for bioequivalence (80-125%). Besides, it is worthwhile to mention that C_max and T_max in the fed group were lower than those in the fasting group. Interestingly, the absorption, measured by AUC, did not have significant difference in both groups. There were no suspected serious adverse reactions or serious adverse events over the entire trial. Our results demonstrated that the test and reference tablets were bioequivalent under fasting and fed conditions.

Composing On-Program Triggers and On-Demand Stimuli into Biosensor Drug Carriers in Drug Delivery Systems for Programmable Arthritis Therapy

Medication in arthritis therapies is complex because the inflammatory progression of rheumatoid arthritis (RA) and osteoarthritis (OA) is intertwined and influenced by one another. To address this problem, drug delivery systems (DDS) are composed of four independent exogenous triggers and four dependent endogenous stimuli that are controlled on program and induced on demand, respectively. However, the relationships between the mechanisms of endogenous stimuli and exogenous triggers with pathological alterations remain unclear, which results in a major obstacle in terms of clinical translation. Thus, the rationale for designing a guidance system for these mechanisms via their key irritant biosensors is in high demand. Many approaches have been applied, although successful clinical translations are still rare. Through this review, the status quo in historical development is highlighted in order to discuss the unsolved clinical difficulties such as infiltration, efficacy, drug clearance, and target localisation. Herein, we summarise and discuss the rational compositions of exogenous triggers and endogenous stimuli for programmable therapy. This advanced active pharmaceutical ingredient (API) implanted dose allows for several releases by remote controls for endogenous stimuli during lesion infections. This solves the multiple implantation and local toxic accumulation problems by using these flexible desired releases at the specified sites for arthritis therapies.

Influence of Iguratimod on Bone Metabolism in Patients with Rheumatoid Arthritis: A Meta-analysis

Background

Influence of iguratimod on bone mineral density (BMD) and biomarkers of bone metabolism in patients with rheumatoid arthritis (RA) remains not determined. Accordingly, a meta-analysis was performed for systematical evaluation.

Methods

Relevant randomized controlled trials (RCTs) were retrieved by searching of PubMed, Embase, Cochrane's Library, China National Knowledge Infrastructure (CNKI), and Wanfang databases. A random-effect model was used to pool the results.

Results

In total, 24 RCTs including 2439 patients with RA contributed to the meta-analysis. Pooled results showed that compared to methotrexate alone, additional use of iguratimod 25 mg Bid for 12∼24 weeks significantly improved lumbar-spine BMD (mean difference [MD]: 0.12, 95% confidence interval [CI]: 0.04 to 0.20, p=0.002, I 2 = 39%) in patients with RA. Moreover, treatment with iguratimod was associated with increased serum osteoprotegerin (MD: 180.36 pg/ml, 95% CI: 122.52 to 238.20, p < 0.001, I 2 = 48%), and decreased serum receptor activator for nuclear factor kappa-B ligand (MD: -10.65 pmol/l, 95% CI: -15.59 to -5.72, p < 0.001, I 2 = 53%). In addition, iguratimod was associated with increased bone formation markers such as the serum N-terminal middle molecular fragment of osteocalcin (MD: 4.23 ng/ml, 95% CI: 3.74 to 4.71, p < 0.001, I 2 = 35%) and total procollagen type I amino-terminal propeptide (MD: 9.10 ng/ml, 95% CI: 7.39 to 10.80, p < 0.001, I 2 = 86%), but decreased the bone resorption marker such as serum β-C terminal cross-linking telopeptide of type 1 collagen (MD: -0.18 pg/ml, 95% CI: -0.21 to -0.14, p < 0.001, I 2 = 70%).

Conclusions

Iguratimod could prevent the bone loss and improve the bone metabolism in patients with RA.

Needle-Warming Moxibustion plus Multirehabilitation Training to Improve Quality of Life and Functional Mobility of Patients with Rheumatoid Arthritis after Medication

Objective

Patients treated with medication for rheumatoid arthritis (RA) often improve but continue to have active diseases. The study aims to investigate whether needle-warming moxibustion (NWM) plus multirehabilitation training can improve quality of life (QoL) and functional mobility of RA patients after medication.

Methods

Eighty-four RA patients were selected as study participants, including 42 patients receiving medication (medication group) and 42 patients receiving NWM plus multirehabilitation training (NWM + MRT group). The scores of disease symptoms, pain (visual analogue scale (VAS)), sleep quality (Pittsburgh Sleep Quality Index (PSQI)), functional mobility (Fugl-Meyer assessment scale (FMAS)), self-rating anxiety scale (SAS), self-rating depression scale (SDS), and QoL (SF-36) were compared before and after treatment. When patients were discharged from the hospital, they were given a questionnaire for treatment satisfaction.

Results

After treatment, decreases in the scores of the VAS, PSQI, SAS, and SDS were observed in both cohorts, especially in the NWM + MRT group (P < 0.05). The FMAS scores of upper limbs and lower limbs were increased after treatment, which were higher in the NWM + MRT group in comparison with the medication group (P < 0.05). Of note, patients in the NWM + MRT group scored higher in various dimensions of the SF-36 scale (P < 0.05), showing better QoL. The satisfaction survey showed that the NWM + MRT group had a higher proportion of patients being satisfied and a lower proportion of patients being dissatisfied (P < 0.05).

Conclusion

NWM plus multirehabilitation training could significantly attenuate disease symptoms, improve QoL, recover functional mobility, and reduce the risk of anxiety and depression in RA patients.