Gastrointestinal and Hepatic Disease in Rheumatoid Arthritis

Prevalence of celiac disease in systemic lupus erythematosus, sjogren syndrome and systemic sclerosis: A systematic review and meta-analysis

BACKGROUND

Celiac disease (CeD) is an immune-mediated disorder affecting the small bowel, associated with genetic factors and increasing global prevalence.

AIM

This study explores the association between CeD, Systemic Lupus Erythematosus (SLE), primary Sjogren syndrome (pSS), and Systemic Sclerosis (SSc).

METHODS

A systematic review and meta-analysis were conducted following PRISMA guidelines. Searches across multiple databases yielded 2728 articles, with 15 studies selected. Data extraction included study characteristics, prevalence of CeD and CeD antibodies in SLE, pSS, and SSc. Quality assessment utilized the Newcastle-Ottawa Scale.

RESULTS

The meta-analysis revealed a pooled prevalence of biopsy-proven CeD in SLE, pSS, and SSc of approximately 3%. Seroprevalence of any CeD antibody in SLE, pSS, and SSc ranged from 3% to 10%. Notably, pSS exhibited the highest prevalence at 5.59%. High heterogeneity was observed in seroprevalence across autoimmune conditions. Quality assessment indicated robust methodological quality in the selected studies.

CONCLUSION

This study highlights a significantly higher prevalence of CeD, especially pSS, compared to the general population. The findings underscore the importance of recognizing elevated CeD antibodies in patients with SLE, pSS and SSc emphasizing the need for early detection and comprehensive care for gastrointestinal symptoms in these conditions.

Quercetin and ibuprofen combination displayed anti-inflammatory effects and also extenuates the enteric neurons damage of arthritic rats

This study aimed to investigate the antioxidant and anti-inflammatory properties of quercetin on the cellular components of the Enteric Nervous System in the ileum of rats with arthritis. Rats were distributed into five groups: control (C), arthritic (AIA), arthritic treated with ibuprofen (AI), arthritic treated with quercetin (AQ) and arthritic treated with both ibuprofen and quercetin (AIQ). The ileum was processed for immunohistochemical techniques for HuC/D, calcitonin gene-related peptide, and vasoactive intestinal polypeptide. Measurements in histological sections, chemiluminescence assays, and total antioxidant capacity were also performed. Rheumatoid arthritis resulted in a decrease in neuronal density, yet neuroplasticity mechanisms were evident through observed changes in varicosities size and neuronal area compared to the control group. Reduced paw edema and neuroprotective effects were predominantly noted in both plexuses, as evidenced by the increased density preservation of HuC/D-IR neurons in the AIQ group. The increase of lipoperoxidation levels and paw edema volume in the AQ group was observed compared to the arthritic, whereas the AIQ group mainly showed similar results to those observed in the control. The enteropathy associated with arthritis proved to be significant in the field of gastroenterology, and the combination of quercetin and ibuprofen demonstrated promising anti-inflammatory and neuroprotective effects.

Contextual AI models for single-cell protein biology

Understanding protein function and developing molecular therapies require deciphering the cell types in which proteins act as well as the interactions between proteins. However, modeling protein interactions across biological contexts remains challenging for existing algorithms. Here we introduce PINNACLE, a geometric deep learning approach that generates context-aware protein representations. Leveraging a multiorgan single-cell atlas, PINNACLE learns on contextualized protein interaction networks to produce 394,760 protein representations from 156 cell type contexts across 24 tissues. PINNACLE's embedding space reflects cellular and tissue organization, enabling zero-shot retrieval of the tissue hierarchy. Pretrained protein representations can be adapted for downstream tasks: enhancing 3D structure-based representations for resolving immuno-oncological protein interactions, and investigating drugs' effects across cell types. PINNACLE outperforms state-of-the-art models in nominating therapeutic targets for rheumatoid arthritis and inflammatory bowel diseases and pinpoints cell type contexts with higher predictive capability than context-free models. PINNACLE's ability to adjust its outputs on the basis of the context in which it operates paves the way for large-scale context-specific predictions in biology.

Contextual AI models for single-cell protein biology

Understanding protein function and developing molecular therapies require deciphering the cell types in which proteins act as well as the interactions between proteins. However, modeling protein interactions across biological contexts remains challenging for existing algorithms. Here, we introduce Pinnacle, a geometric deep learning approach that generates context-aware protein representations. Leveraging a multi-organ single-cell atlas, Pinnacle learns on contextualized protein interaction networks to produce 394,760 protein representations from 156 cell type contexts across 24 tissues. Pinnacle's embedding space reflects cellular and tissue organization, enabling zero-shot retrieval of the tissue hierarchy. Pretrained protein representations can be adapted for downstream tasks: enhancing 3D structure-based representations for resolving immuno-oncological protein interactions, and investigating drugs' effects across cell types. Pinnacle outperforms state-of-the-art models in nominating therapeutic targets for rheumatoid arthritis and inflammatory bowel diseases, and pinpoints cell type contexts with higher predictive capability than context-free models. Pinnacle's ability to adjust its outputs based on the context in which it operates paves way for large-scale context-specific predictions in biology.

Prevalence, Causes and Outcomes of Acute Gastrointestinal Bleeding in Rheumatoid Arthritis: A Systematic Review and Meta-Analysis

Aim

The present study aims to investigate the prevalence, causes and outcomes of acute gastrointestinal (GI) bleeding in Rheumatoid arthritis (RA).

Methods

A systemic search was conducted from electronic databases (PubMed/Medline, Cochrane Library, and Google Scholar) from inception to 14th November 2023. All statistical analyses were conducted in Review Manager 5.4.1. Studies meeting inclusion criteria were selected. A random-effect model was used when heterogeneity was seen to pool the studies, and the result was reported in prevalence and their corresponding 95% confidence interval (CI). Other outcomes were assessed using qualitative analysis.

Results

A total of eight studies (six observational studies and 2 trials were used to conduct this systematic review and meta-analysis. A total population of 138,041 patients was used. Pooled analysis showed a statistically significant risk of GI bleeding in RA patients receiving NSAIDs (prevalence = 2% (1%, 3%); P < 0.00001; I2 = 98%). Qualitatively, causes and outcomes were discussed.

Conclusion

Our study showed that 2% RA patients were subjected to GI bleeding, when they used NSAIDs. Other causes of GI bleeding were age-related factors, cardiovascular events, history of GI complications, and peptic ulcers. Outcome varied by the use of specific NSAIDs and the presence of comorbidities. Recent guidelines for the management of RA may mention GI bleeding as a potential complication, but the level of emphasis placed on this issue varies. Some guidelines provide comprehensive recommendations for its prevention and management, while others offer limited guidance.

Management of Rheumatoid Arthritis in Primary Care: A Scoping Review

Rheumatoid arthritis (RA) can lead to severe joint impairment and chronic disability. Primary care (PC), provided by general practitioners (GPs), is the first level of contact for the population with the healthcare system. The aim of this scoping review was to analyze the approach to RA in the PC setting. PubMed, Scopus, and Web of Science were searched using the MESH terms "rheumatoid arthritis" and "primary care" from 2013 to 2023. The search strategy followed the PRISMA-ScR guidelines. The 61 articles selected were analyzed qualitatively in a table and discussed in two sections, namely criticisms and strategies for the management of RA in PC. The main critical issues in the management of RA in PC are the following: difficulty and delay in diagnosis, in accessing rheumatological care, and in using DMARDs by GPs; ineffective communication between GPs and specialists; poor patient education; lack of cardiovascular prevention; and increase in healthcare costs. To overcome these criticisms, several management strategies have been identified, namely early diagnosis of RA, quick access to rheumatology care, effective communication between GPs and specialists, active patient involvement, screening for risk factors and comorbidities, clinical audit, interdisciplinary patient management, digital health, and cost analysis. PC appears to be the ideal healthcare setting to reduce the morbidity and mortality of chronic disease, including RA, if a widespread change in GPs' approach to the disease and patients is mandatory.

Xanthium strumarium seed extract boosts osteogenesis in human dental pulp stem cell model

BACKGROUND

In traditional medicine, Xanthium strumarium is used as an anti-inflammatory and anti-arthritic plant-based medicine. Human Dental Pulp Stem Cells (hDPSCs) are an ideal in vitro model for drug and bioactive compound screening. This study assessed the potential of X. strumarium aqueous extract on hDPSCs differentiation towards the osteogenic lineage.

MATERIALS AND METHODS

HDPSCs were isolated and cultured by explant method and characterized by surface marker expression, Colony Forming units fibroblasts (CFU-F), Population Doubling time (PDT), and tri-lineage differentiation. X. strumarium aqueous seed extract (XSE) was prepared and its cytotoxic effect on hDPSCs was examined by MTT assay. The effect of XSE on hDPSC differentiation into osteocytes was investigated by biochemical staining and gene expression.

RESULTS

The hDPSCs were positive for CD73, CD90, and CD105 and negative for CD34, CD45, and HLA-DR surface markers. The cells had a colony-forming ability with a PDT of 44.91 h. The hDPSCs differentiated into osteocytes, chondrocytes, and adipocytes. The XSE concentration of 15 μg/ml had a significant increase in hDPSC viability. Alizarin Red S staining revealed that XSE treatment enhanced calcium accumulation and matrix mineralization in hDPSCs. XSE treatment also increased osteonectin and IL-6 transcript expression in osteogenesis-induced hDPSCs.

CONCLUSION

X. strumarium aqueous extract is a suitable candidate for bone repair because it promotes osteogenic differentiation in hDPSCs. Therefore this could be explored further in the treatment of bone disorders.

Prevalence of Nonalcoholic Fatty Liver Disease in Patients With Rheumatoid Arthritis: A Systematic Review and Meta-analysis

BACKGROUND & AIMS

Previous studies have shown a potential association between nonalcoholic fatty liver disease (NAFLD) and some immune-mediated inflammatory diseases, such as rheumatoid arthritis (RA), but this association has not been analyzed systematically. Therefore, we aimed to perform a systematic review and meta-analysis to ascertain a pooled prevalence estimate of NAFLD among patients with RA to fill this gap in knowledge.

METHODS

We conducted a literature search in PubMed, Embase, Web of Science, Scopus, and ProQuest, for observational studies published from inception to August 31, 2022, which reported prevalence of NAFLD in 100 or more adult (age, ≥18 y) patients with RA. To be included, NAFLD diagnosis was based on either imaging or histologic assessment. The results were presented as pooled prevalence, odds ratio, and 95% CI. The I2 statistic was used to measure the heterogeneity between studies.

RESULTS

This systematic review included 9 eligible studies derived from 4 continents comprising 2178 patients (78.8% women) with RA. The pooled prevalence of NAFLD was 35.3% (95% CI, 19.9-50.6; I2 = 98.6%; P < .001) in patients with RA. All studies used ultrasound for the diagnosis of NAFLD, except for 1 study that used transient elastography. The pooled prevalence of NAFLD in men with RA was significantly higher than in women with RA (35.2%; 95% CI, 24.0-46.5 compared with 22.2%; 95% CI, 17.9-26.58; P for interaction = .048). Each 1-unit increase in body mass index was associated directly with a 24% increased risk of NAFLD in RA patients (adjusted odds ratio, 1.24; 95% CI, 1.17-1.31; I2 = 0.0%; P = .518).

CONCLUSIONS

Based on this meta-analysis, 1 in 3 patients with RA had NAFLD, which appears comparable with its overall prevalence among the general population. Clinicians should actively screen for NAFLD in patients with RA.

Systemic Disease and the Liver-Part 1: Systemic Lupus Erythematosus, Celiac Disease, Rheumatoid Arthritis, and COVID-19

The development of liver dysfunction in patients having various systemic diseases is common and has a broad differential diagnosis, at times being the initial manifestation of the disorder. Liver injury associated with systemic lupus erythematosus is heterogeneous and may present with nonspecific histology. Differentiating autoimmune hepatitis from lupus hepatitis is challenging on histologic grounds alone. Other systemic diseases that may present mostly with nonspecific findings are rheumatoid arthritis and celiac disease. More recently COVID-19 cholangiopathy and secondary sclerosing cholangitis have become increasingly recognized as distinct liver conditions. Many patients may also have intrinsic liver disease or may develop drug-induced liver injury from the treatment of the systemic disease. Timely identification of the cause of the liver dysfunction is essential and liver biopsy may help the clinician in diagnosis and management.

Autoimmune Dysphagia Related to Rheumatologic Disorders: A Focused Review on Diagnosis and Treatment

Autoimmune dysphagia is defined as dysphagia caused by autoimmune processes affecting various components of the swallowing process such as muscle, neuromuscular junction, nerves, roots, brainstem, or cortex. These autoimmune causes can be classified into gastroenterological, dermatological, rheumatologic, and neurologic. Rheumatological disorders, such as scleroderma, Sjogren's syndrome, systemic lupus erythematosus, rheumatoid arthritis, sarcoidosis, Behcet's disease, anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis, or granulomatosis with polyangiitis, have been associated with dysphagia. Autoimmune dysphagia in the context of rheumatological disorders is particularly significant because it can occur as a sole manifestation or as part of a symptom complex associated with the underlying disorder and often responds to immunosuppressive therapies. However, diagnosing autoimmune dysphagia can be challenging as it requires the exclusion of structural and primary motility disorders through procedures such as endoscopy and manometry. Early diagnosis is important to improve the quality of life and prevent significant mortality and morbidity. Management focuses on treating the underlying disease activity, and a multidisciplinary approach involving various medical specialties may be necessary to achieve success. This article aims to review the autoimmune rheumatological conditions that can lead to dysphagia and discuss the associated pathophysiological mechanisms. We also outline the clinical clues and laboratory testing methods that facilitate early diagnosis, with the goal of improving patient outcomes through timely intervention and appropriate management.

Association between Gastroparesis and Rheumatoid Arthritis: A US Population-Based Study

OBJECTIVES

Patients with rheumatoid arthritis (RA) have a high prevalence of nausea, vomiting, postprandial fullness, and abdominal pain; these are symptoms that are similar to those in gastroparesis (GP). The aim of this study was to assess the association between GP and RA and the determinants of GP.

METHODS

We identified patients with RA and patients with GP from the 2012-2014 National Inpatient Sample database. The t test and the χ² test were used for continuous and categorical variables, respectively. We determined the association between RA and GP and independent predictors of GP by multivariate analysis.

RESULTS

Of 1,514,960 patients with RA, there were 1070 hospitalizations in which a primary diagnosis of GP was identified. The GP odds ratio in RA was found to be 1.36 and the 95% confidence interval was 1.24 to 1.49 (P < 0.0001). The variables increasing the odds of GP were age intervals of 18 to 35 years, 36 to 50 years, and 51 to 65 years; being female, White, or Black; a median household income in the 26th to 50th and the 51st to 75th percentiles; having diabetes mellitus; and having RA.

CONCLUSIONS

An increased likelihood of 36% of GP among patients with RA was determined. White and Black patients younger than age 65 showed a greater risk of developing GP.

IgA2 immune complexes selectively promote inflammation by human CD103+ dendritic cells

While immunoglobulin A (IgA) is well known for its neutralizing and anti-inflammatory function, it is becoming increasingly clear that IgA can also induce human inflammatory responses by various different immune cells. Yet, little is known about the relative role of induction of inflammation by the two IgA subclasses i.e. IgA1, most prominent subclass in circulation, and IgA2, most prominent subclass in the lower intestine. Here, we set out to study the inflammatory function of IgA subclasses on different human myeloid immune cell subsets, including monocytes, and in vitro differentiated macrophages and intestinal CD103+ dendritic cells (DCs). While individual stimulation with IgA immune complexes only induced limited inflammatory responses by human immune cells, both IgA subclasses strongly amplified pro-inflammatory cytokine production upon co-stimulation with Toll-like receptor (TLR) ligands such as Pam3CSK4, PGN, and LPS. Strikingly, while IgA1 induced slightly higher or similar levels of pro-inflammatory cytokines by monocytes and macrophages, respectively, IgA2 induced substantially more inflammation than IgA1 by CD103+ DCs. In addition to pro-inflammatory cytokine proteins, IgA2 also induced higher mRNA expression levels, indicating that amplification of pro-inflammatory cytokine production is at least partially regulated at the level of gene transcription. Interestingly, cytokine amplification by IgA1 was almost completely dependent on Fc alpha receptor I (FcαRI), whilst blocking this receptor only partially reduced cytokine induction by IgA2. In addition, IgA2-induced amplification of pro-inflammatory cytokines was less dependent on signaling through the kinases Syk, PI3K, and TBK1/IKKϵ. Combined, these findings indicate that IgA2 immune complexes, which are most abundantly expressed in the lower intestine, particularly promote inflammation by human CD103+ intestinal DCs. This may serve an important physiological function upon infection, by enabling inflammatory responses by this otherwise tolerogenic DC subset. Since various inflammatory disorders are characterized by disturbances in IgA subclass balance, this may also play a role in the induction or exacerbation of chronic intestinal inflammation.

Manifestations of the gastrointestinal tract in systemic rheumatic diseases: A narrative review

Gastrointestinal disorders are important place among the visceral manifestations of systemic autoimmune and immunoinflammatory rheumatic diseases (RD). Pathology of the esophagus, stomach, small and large intestine can vary from moderate functional disorders to the development of severe chronic inflammation with metaplasia and dysplasia of the mucous membrane, the formation of multiple erosions, hemorrhages and deep ulcers. Complications of gastrointestinal pathology in RD, such as bleeding, perforations and strictures, can cause death. This review examines the main clinical manifestations, possibilities of diagnosis and treatment of gastrointestinal lesions in systemic scleroderma, idiopathic inflammatory myopathies, systemic vasculitis, Sjogren’s syndrome and disease, as well as systemic lupus erythematosus.

Imaging of intestinal vasculitis focusing on MR and CT enterography: a two-way street between radiologic findings and clinical data

Diagnosis of intestinal vasculitis is often challenging due to the non-specific clinical and imaging findings. Vasculitides with gastrointestinal (GI) manifestations are rare, but their diagnosis holds immense significance as late or missed recognition can result in high mortality rates. Given the resemblance of radiologic findings with some other entities, GI vasculitis is often overlooked on small bowel studies done using computed tomography/magnetic resonance enterography (CTE/MRE). Hereon, we reviewed radiologic findings of vasculitis with gastrointestinal involvement on CTE and MRE. The variety of findings on MRE/CTE depend upon the size of the involved vessels. Signs of intestinal ischemia, e.g., mural thickening, submucosal edema, mural hyperenhancement, and restricted diffusion on diffusion-weighted imaging, are common in intestinal vasculitis. Involvement of the abdominal aorta and the major visceral arteries is presented as concentric mural thickening, transmural calcification, luminal stenosis, occlusion, aneurysmal changes, and collateral vessels. Such findings can be observed particularly in large- and medium-vessel vasculitis. The presence of extra-intestinal findings, including within the liver, kidneys, or spleen in the form of focal areas of infarction or heterogeneous enhancement due to microvascular involvement, can be another radiologic clue in diagnosis of vasculitis. The link between the clinical/laboratory findings and MRE/CTE abnormalities needs to be corresponded when it comes to the diagnosis of intestinal vasculitis.

Natural medicines of targeted rheumatoid arthritis and its action mechanism

Rheumatoid arthritis (RA) is an autoimmune disease involving joints, with clinical manifestations of joint inflammation, bone damage and cartilage destruction, joint dysfunction and deformity, and extra-articular organ damage. As an important source of new drug molecules, natural medicines have many advantages, such as a wide range of biological effects and small toxic and side effects. They have become a hot spot for the vast number of researchers to study various diseases and develop therapeutic drugs. In recent years, the research of natural medicines in the treatment of RA has made remarkable achievements. These natural medicines mainly include flavonoids, polyphenols, alkaloids, glycosides and terpenes. Among them, resveratrol, icariin, epigallocatechin-3-gallate, ginsenoside, sinomenine, paeoniflorin, triptolide and paeoniflorin are star natural medicines for the treatment of RA. Its mechanism of treating RA mainly involves these aspects: anti-inflammation, anti-oxidation, immune regulation, pro-apoptosis, inhibition of angiogenesis, inhibition of osteoclastogenesis, inhibition of fibroblast-like synovial cell proliferation, migration and invasion. This review summarizes natural medicines with potential therapeutic effects on RA and briefly discusses their mechanisms of action against RA.

Polymer nanotherapeutics: A versatile platform for effective rheumatoid arthritis therapy

Rheumatoid arthritis is an aggressive and severely debilitating disorder that is characterized by joint pain and cartilage damage. It restricts mobility in patients, leaving them unable to carry out simple tasks. RA presents itself with severe lasting pain, swelling and stiffness in the joints and may cause permanent disability in patients. Treatment regimens currently employed for rheumatoid arthritis revolve around keeping clinical symptoms like joint pain, inflammation, swelling and stiffness at bay. The current therapeutic interventions in rheumatoid arthritis involve the use of non-steroidal anti-inflammatory drugs, glucocorticoids, disease-modifying anti-rheumatic drugs and newer biological drugs that are engineered for inhibiting the expression of pro-inflammatory mediators. These conventional drugs are plagued with severe adverse effects because of their higher systemic distribution, lack of specificity and higher doses. Oral, intra-articular, and intravenous routes are routinely used for drug delivery which is associated with decreased patient compliance, high cost, poor bioavailability and rapid systemic clearance. All these drawbacks have enticed researchers to create novel strategies for drug delivery, the main approach being nanocarrier-based systems. In this article, we aim to consolidate the remarkable contributions of polymeric carrier systems including microneedle technology and smart trigger-responsive polymeric carriers in the management of rheumatoid arthritis along with its detailed pathophysiology. This review also briefly describes the safety and regulatory aspects of polymer therapeutics.

Anti-inflammatory and anti-arthritic effects of compounds from Buddleja coriacea

Buddleja coriacea (B. coriacea) commonly known as 'Kiswara' is used as infusions for stomach and joint pain. This study aims to evaluate the in vitro and in vivo anti-inflammatory and anti-arthritic activity was evaluated by measuring inflammatory parameters (TNF-α, C-reactive protein and Fibrinogen) in murine models of the aqueous extract and isolated compounds of B. coriacea. A bio-guided phytochemical analysis based on NMR/MS was performed identifying three (1-3) compounds of the aqueous extract. All compounds inhibited the production of TNF-α in RAW 264.7 cell line, with IC₅₀ of 13.44 (1), 1.13 (2) and 0.57 μM (3), respectively. In addition, compounds 2 and 3 decreased the levels of TNF-α, C-reactive protein and fibrinogen at a concentration of 5 mg/kg in murine models. Our research shows that the compounds isolated from B. coriacea have anti-inflammatory and anti-arthritic properties, providing scientific evidence for the traditional use of this plant species.

Rheumatologie und Hepatologie interdisziplinär

Rheumatologische und hepatologische Erkrankungen haben einige Überschneidungen, die für Behandler aus beiden Disziplinen relevant sind. In dieser Übersicht wird ein Schlaglicht auf 2 Erkrankungen geworfen, die sich an der Schnittstelle befinden: Arthropathie bei Hämochromatose und Systemische Sklerose bei Primär Biliärer Cholangitis. Daneben werden hepatologische Fragestellungen bei rheumatologischer Therapie beleuchtet.

Rheumatologische Erkrankungen und der Gastrointestinaltrakt

Die meisten rheumatologischen Krankheitsbilder können Einfluss auf den Gastrointestinaltrakt haben. Dabei können intestinale Manifestationen (z. B. rheumatoide Vaskulitis, IgG4-assoziierte Pankreatitis, IgG4-assoziierte Cholangitis, Lupus-Enteritis, Polyarteriitis nodosa, Purpura Schoenlein-Henoch, nekrotisierende Vaskulitis), assoziierte intestinale Erkrankungen (chronisch-entzündliche Darmerkrankungen (CED), Zöliakie) und intestinale Komplikationen der rheumatologischen Erkrankung (z. B. Amyloidose, erosive Refluxerkrankung bei Sklerodermie) bzw. ihrer Behandlung (z. B. NSAR-Magenulcus, MTX-Mukositis, Soor-Ösophagitis, intestinale Tuberkulose, ulzerierende HSV-Ösophagitis, CMV-Kolitis) voneinander abgegrenzt werden. Dadurch kommen gastrointestinale Symptome bei Patienten mit rheumatologischen Erkrankungen sehr häufig vor. Die Diagnosestellung (er)fordert Gastroenterologen im interdisziplinären Behandlungsnetzwerk mit Rheumatologen. Insbesondere bei Behandlung von CED ergeben sich für die überschneidenden Zulassungsindikationen der zur Verfügung stehenden Medikamente in der interdisziplinären Absprache zwischen Rheumatologen und Gastroenterologen synergistische Behandlungsoptionen.

[Severe Hepatitis E virus infection in a patient with rheumatoid arthritis treated with baricitinib]

Es wurde ein Patient mit rheumatoider Arthritis (RA) vorgestellt, der unter der Therapie mit dem Januskinase-1/2-Inhibitor Baricitinib eine Infektion mit dem Hepatitis-E-Virus (HEV) entwickelte. Unser Patient hatte bei seiner vierteljährlichen Routineuntersuchung deutlich erhöhte Transaminasen bei einer unauffälligen körperlichen Untersuchung. Es fanden sich Antikörper der IgM- und IgG-Klasse gegen HEV und ein erhöhtes C‑reaktives Protein (CRP) sowie HEV-RNA mittels Real-Time-PCR, was auf eine frische HEV-Infektion hinwies. Baricitinib wurde sofort abgesetzt. Die ausführliche Anamnese ergab, dass der Patient Tage vor der Konsultation Rindertartar verzehrt hatte, ohne dass gastrointestinale Symptome oder Fieber aufgetreten waren. Im weiteren Verlauf erholte sich der Patient vollständig, und die Leberfunktionstests und das CRP normalisierten sich innerhalb von 3 Monaten. Baricitinib wurde daraufhin wieder eingenommen. Bisher wurden nur wenige Daten zu HEV-Infektionen bei RA-Patienten, die mit JAK-Inhibitoren behandelt wurden, publiziert.

Gastrointestinal Adverse Drug Reaction Profile of Etanercept: Real-world Data From Patients and Healthcare Professionals

OBJECTIVE

We aimed to describe the nature and frequency of gastrointestinal adverse drug reactions (GI-ADRs) of etanercept (ETN) using patient-reported and healthcare professional (HCP)-registered data and compared this frequency with the GI-ADR frequency of the widely used tumor necrosis factor-α inhibitor adalimumab (ADA).

METHODS

Reported GI-ADRs of ETN for rheumatic diseases were collected from the Dutch Biologic Monitor and DREAM registries. We described the clinical course of GI-ADRs and compared the frequency with ADA in both data sources using Fisher exact test.

RESULTS

Out of 416 patients using ETN for inflammatory rheumatic diseases in the Dutch Biologic Monitor, 25 (6%) patients reported 36 GI-ADRs. In the DREAM registries 11 GI-ADRs were registered for 9 patients (2.3%), out of 399 patients using ETN, with an incidence of 7.1 per 1000 patient-years. Most GI-ADRs consisted of diarrhea, nausea, and abdominal pain. GI-ADRs led to ETN discontinuation in 1 patient (4%) and dose adjustment in 4 (16%) in the Dutch Biologic Monitor. Eight GI-ADRs (73%) led to ETN discontinuation in the DREAM registries. The frequency of GI-ADRs of ETN did not significantly differ from GI-ADRs of ADA in both data sources (Dutch Biologic Monitor: ETN 8.7% vs ADA 5.3%, P = 0.07; DREAM: ETN 2.8% vs ADA 4.7%, P = 0.16).

CONCLUSION

Most GI-ADRs associated with ETN concerned gastrointestinal symptoms. These ADRs may lead to dose adjustment or ETN discontinuation. The frequency of ETN-associated GI-ADRs was comparable to the frequency of ADA-associated GI-ADRs. Knowledge about these previously unknown ADRs can facilitate early recognition and improve patient communication.

Anti-Inflammatory and Anti-Arthritic Potential of Standardized Extract of Clerodendrum serratum (L.) Moon

Aims: Scientific biological evaluation of standardized extracts is becoming one of the central needs for the globalization of customary medication in current times. And to validate the presence of active constituents in crude medicinal extracts, analytical techniques like HPLC and HPTLC are the most suitable authentication systems. In the current study we aimed to standardize and evaluate Clerodendrum serratum (L.) Moon (Verbenaceae). For its unique anti-inflammatory and anti-arthritic properties. Evaluation and analysis of the plant, therefore, offers a new platform for the development of the herbal drug and could prove to be a safe and cost effective treatment for arthritis management.

Methods: The aqueous extract of C. serratum, a common plant in the Southeastern Asian region, was used for phytochemical investigation and standardization by HPTLC and HPLC. The standardized HPLC method was further validated by using ICH guidelines. The standardized extract was investigated for anti-inflammatory and anti-arthritic activity. Complete Freund’s adjuvant (CFA) model was performed to evaluate the activity. Paw diameter, joint diameter, arthritic score, and body weight was accepted as a parameter for the evaluation of biological activity.

Results: HPTLC method revealed the presence of ursolic acid with an R_f value of 0.38 and the amount quantified was 0.03% w/w. The presence of the bioactive phytochemical was further analyzed and confirmed by HPLC for which the validation was done successfully in accordance with ICH guidelines. The assay content for ursolic acid was found to be 0.059% with relative standard deviation (RSD) <2.5% for specificity and precision with spike recovery between 95–110%. The anti-arthritic activity of aqueous extract exhibited COX-2 and TNF-α inhibition as observed in various parameters like paw edema, arthritic index, and joint diameter. Plant extract showed reclamation of arthritis in regard to body weight, arthritic score, paw edema, and joint diameter. The extract showed significant results for TNF-α and COX-2(p < 0.0001). The plant extract also exhibited in-vitro anti-inflammatory activity.

Conclusion: The current study established the scientific basis of ethnomedicinal use of the plant for anti-inflammatory purposes and the management of arthritis and can also be used for quality control purposes.

New Studies of Pathogenesis of Rheumatoid Arthritis with Collagen-Induced and Collagen Antibody-Induced Arthritis Models: New Insight Involving Bacteria Flora

Much public research suggests that autoimmune diseases such as rheumatoid arthritis (RA) are induced by aberrant “self” immune responses attacking autologous tissues and organ components. However, recent studies have reported that autoimmune diseases may be triggered by dysbiotic composition changes of the intestinal bacteria and an imbalance between these bacteria and intestinal immune systems. However, there are a few solid concepts or methods to study the putative involvement and relationship of these inner environmental factors in RA pathogenesis. Fortunately, Collagen-Induced Arthritis (CIA) and Collagen Antibody-Induced Arthritis (CAIA) models have been widely used as animal models for studying the pathogenesis of RA. In addition to RA, these models can be extensively used as animal models for studying complicated hypotheses in many diseases. In this review, we introduce some basic information about the CIA and CAIA models as well as how to apply these models effectively to investigate relationships between the pathogenesis of autoimmune diseases, especially RA, and the dysbiosis of intestinal bacterial flora.

Clinical outcomes and resource utilization analysis in patients with rheumatoid arthritis undergoing endoscopic retrograde cholangiopancreatography

BACKGROUND AND AIM

The literature is lacking on associations of endoscopic retrograde cholangiopancreatography (ERCP) related outcomes in rheumatoid arthritis (RA) patients. The aim of this study is to evaluate the effects of RA on clinical outcomes and hospital resource utilization in patients undergoing ERCP.

METHODS

The National Inpatient Sample database was used to identify hospitalized patients who had underwent an ERCP study from 2012 to 2014 using International Classification of Diseases-Ninth Edition (ICD-9) codes. Primary outcomes were mortality, hospital charges, and length of stay. Secondary outcomes were ERCP-related complications. Chi-squared tests for categorical data and independent t-test for continuous data were utilized. Multivariate analysis was performed to assess the primary outcomes.

RESULTS

There was 83 890 ERCP procedures performed, of which 970 patients had RA. In patients with RA, 74.2% were female, and the average age was 65.7 years. RA primary outcomes of mortality rate and hospital cost were lower and statistically significant. There was no statistically significant difference in secondary outcomes except for lower cholecystectomy rates in RA patients.

CONCLUSION

With a high inflammatory state, it was hypothesized that RA would be associated with worse outcomes after ERCP. Yet, the primary outcomes of mortality and hospital cost were found to be lower than controls, with no difference in secondary outcomes. We posit that immunosuppressants used to treat RA provides a protective effect to overall complications with ERCP.

miR-34a in extracellular vesicles from bone marrow mesenchymal stem cells reduces rheumatoid arthritis inflammation via the cyclin I/ATM/ATR/p53 axis

Extracellular vesicles (Evs) participate in the development of rheumatoid arthritis (RA), but the mechanisms remain unclear. This study aimed to determine the mechanism by which microRNA‐34a (miR‐34a) contained in bone marrow mesenchymal stem cell (BM‐MSC)‐derived Evs functions in RA fibroblast‐like synoviocytes (RA‐FLSs). BM‐MSC‐derived Evs and an Evs inhibitor were extracted. A rat model of RA was established. miR‐34a gain‐ and loss‐of‐function experiments were performed, and the inflammation in rat synovial fluid and tissues was detected. The role of miR‐34a in RA‐FLSs was also measured in vitro. The target gene of miR‐34a was predicted using the online software TargetScan and identified using a dual‐luciferase reporter gene assay, and the activation of the ATM/ATR/p53 signalling pathway was assessed. BM‐MSC‐derived Evs mainly elevated miR‐34a expression, which reduced RA inflammation in vivo and inhibited RA‐FLS proliferation and resistance to apoptosis in vitro, while inhibited miR‐34a expression enhanced RA development. In addition, miR‐34a could target cyclin I to activate the ATM/ATR/p53 signalling pathway, thus inhibiting abnormal RA‐FLS growth and RA inflammation. Our study showed that miR‐34a contained in BM‐MSC‐derived Evs could reduce RA inflammation by inhibiting the cyclin I/ATM/ATR/p53 signalling pathway.

Endothelial Dysfunction and Extra-Articular Neurological Manifestations in Rheumatoid Arthritis

Rheumatoid arthritis (RA) is a chronic, systemic, inflammatory autoimmune disease that affects about 1% of the global population, with a female–male ratio of 3:1. RA preferably affects the joints, with consequent joint swelling and deformities followed by ankylosis. However, evidence has accumulated showing that patients suffering from RA can also develop extra-articular manifestations, including cardiovascular disease states, neuropathies, and multiorgan dysfunction. In particular, peripheral nerve disorders showed a consistent impact in the course of the disease (prevalence about 20%) mostly associated to vasculitis of the nerve vessels leading to vascular ischemia, axonal degeneration, and neuronal demyelination. The pathophysiological basis of this RA-associated microvascular disease, which leads to impairment of assonal functionality, is still to be better clarified. However, endothelial dysfunction and alterations of the so-called brain-nerve barrier (BNB) seem to play a fundamental role. This review aims to assess the potential mechanisms underlying the impairment of endothelial cell functionality in the development of RA and to identify the role of dysfunctional endothelium as a causative mechanism of extra-articular manifestation of RA. On the other hand, the potential impact of lifestyle and nutritional interventions targeting the maintenance of endothelial cell integrity in patients with RA will be discussed as a potential option when approaching therapeutic solutions in the course of the disease.

The effects of drug transporters on the efficacy of methotrexate in the treatment of rheumatoid arthritis

The ATP-binding cassette (ABC) and solute carrier (SLC) transporter families consist of common drug transporters that mediate the efflux and uptake of drugs, respectively, and play an important role in the absorption, distribution, metabolism and excretion of drugs in vivo. Rheumatoid arthritis (RA) is an autoimmune disease characterized by erosive arthritis, and there are many RA patients worldwide. Methotrexate (MTX), the first-choice treatment for RA, can reduce the level of inflammation, prevent joint erosion and functional damage, and greatly reduce pain in RA patients. However, many patients show resistance to MTX, greatly affecting the efficacy of MTX. Many factors, such as irrational drug use and heredity, are associated with drug resistance. Considering the effect of drug transporters on drugs, many studies have compared the expression of drug transporters in drug-resistant and drug-sensitive patients, and abnormal transporter expression and transport activity have been found in patients with MTX resistance. Thus, drug transporters are involved in drug resistance. This article reviews the effects of transporters on the efficacy of MTX in the treatment of RA.

Beyond Helicobacter: dealing with other variants of gastritis-an algorithmic approach

In daily practice, the presence of inflammation in gastric biopsies prompts a mental algorithm, an early question being whether the lesion present is Helicobacter-associated. If Helicobacter organisms are not found, then there is a further algorithm, governed by the predominant type of inflammatory cells present, and the presence of other features such as intraepithelial lymphocytosis, a subepithelial collagen band, granulomas, coexisting chronic inflammation, focality, and superimposed reactive changes including erosions and ulcers. Each of these generates its own differential diagnosis. If no inflammation is present, then the two major changes specifically looked for are the changes associated with hypergastrinaemia, by far the most common cause of which is treatment with proton pump inhibitors, and reactive changes. These may be present with and without accompanying inflammation, and, when the epithelial changes dominate, the term gastropathy is preferred. In this article, we present an approach to non-Helicobacter inflammation and gastropathies.

Hepatitis E Virus and rheumatic diseases: what do rheumatologists need to know?

BACKGROUND

Hepatitis E virus (HEV) represents the most common cause of acute hepatitis and jaundice in the world. About 2 million of infection cases occur each year in Europe, mainly as autochthonous anthropozoonosis, and HEV can be transmitted through undercooked pork meat. This infection has been linked to various extra-hepatic manifestations, while chronic infections with a rapid development of liver failure have been described in heavily immunosuppressed patients undergoing solid organ transplantations (SOTs), in patients with hematological diseases or with immunodeficiency virus infection.

MAIN BODY OF ABSTRACT

The purpose of this review article is to describe rheumatic manifestations related to HEV infection and their implications for rheumatologists in the daily clinical practice. Despite recent accumulating literature in this field, little is known about the course of the infection in patients with rheumatic diseases (RDs) and about the impact of immunosuppressive drugs. Moreover, HEV infection can mimic RDs' manifestations or drugs toxicity. Specific guidelines on management are lacking and the majority of data are referred to SOTs receivers.

CONCLUSIONS

More studies are needed to better understand the real impact of HEV infection in patients with RDs, regarding both clinical outcomes and their management.

Bidirectional association between GERD and rheumatoid arthritis: two longitudinal follow-up studies using a national sample cohort

Several previous studies have suggested a relationship between GERD and RA. However, no study has investigated the bidirectional relationship between GERD and RA. This study aimed to evaluate the causal relationships between rheumatoid arthritis (RA) and gastroesophageal reflux disease (GERD). Participants aged ≥ 20 years old in the Korean Health Insurance Review and Assessment Service-National Sample Cohort from 2002 to 2013 were enrolled. In study I, 132,140 GERD participants were 1:2 matched with 264,280 control I participants. In study II, 6615 RA participants were 1:4 matched with 26,460 control II participants. Both control I and control II groups were matched with their study groups for age, sex, income, and region of residence. The occurrence of RA (study I) and GERD (study II) were followed up in both the study and control groups. The hazard ratios (HRs) of GERD for RA (study I) and of RA for GERD (study II) were analysed using stratified Cox-proportional hazards models. In study I, 0.8% (1,034/132,140) of the GERD group and 0.5% (1,290/264,280) of the control I group had RA (P < 0.001). The GERD group demonstrated a 1.49-fold higher adjusted HR than did the control I group (95% confidence interval (95% CI) = 1.37-1.62, P < 0.001). In study II, 22.5% (1,490/6,615) of the RA group and 15.2% (4,034/26,460) of the control II group had GERD (P < 0.001). The RA group showed a 1.46-fold higher adjusted HR than did the control II group (95% CI = 1.38-1.55, P < 0.001). GERD and RA have bidirectional associations in Korean adult population. Key Points • Several previous studies have suggested a relationship between gastroesophageal reflux disease (GERD) and rheumatoid arthritis (RA). • However, no study has investigated the bidirectional relationship between GERD and RA. • This is the first study to present a bidirectional relationship between GERD and RA. • GERD and RA have bidirectional relations with each other.

Gastrointestinal Manifestations of Rheumatological Diseases

Rheumatological diseases (RDs) represent a diverse group of diseases that are inherited or related to environmental factors. RDs frequently affect the gastrointestinal (GI) tract, and gastroenterologists are often asked to evaluate patients with symptoms thought to represent an underlying or coexisting RD. GI manifestations of RDs vary based on the organ involved as well as the extent and duration of involvement. Although most manifestations of RD are nonspecific and not life-threatening, the chronicity and severity of symptoms can be debilitating and may lead to serious injury. This narrative review discusses the most common RD encountered by gastroenterologists: systemic lupus erythematosus, systemic sclerosis (scleroderma), dermatomyositis/polymyositis, rheumatoid arthritis, Sjögren syndrome, overlap syndromes, mixed connective tissue disease, Ehlers-Danlos syndromes, and other vasculitides. Each section begins with a brief overview of the condition, followed by a discussion of the etiopathophysiology, physical examination findings, GI manifestations, diagnostic tools (i.e., serologic, imaging, endoscopic, and functional), and treatment options.

Hepatitis E infection in a patient with rheumatoid arthritis treated with leflunomide: A case report with emphasis on geoepidemiology

RATIONALE

Hepatitis E is an infectious disease due to inflammation of the liver caused by hepatitis E virus (HEV) and represents one of the most common causes of acute hepatitis and jaundice in the world. Although data of hepatitis E infection in patients with rheumatoid arthritis (RA) are accumulating, little is known on the course of HEV infection. We reported, for the 1st time, a case of patient with RA with hepatitis E that developed during leflunomide therapy in combination with low-dose steroids.

PATIENT CONCERNS

We present a 39-year-old woman, affected by RA and treated with leflunomide, reported diffuse itching and persistent fatigue laboratory data revealed elevated liver enzyme levels.

DIAGNOSIS

Positivity for anti-HEV IgM and IgG was observed. HEV-RNA of the genotype 3 was detected, indicating acute E hepatitis.

INTERVENTIONS AND OUTCOMES

Leflunomide was stopped and restarted 5 months after the initial diagnosis at the same dosage, with a close clinical and laboratory follow-up. The virus was eradicated from the serum without chronic transformation. The patient is alive and well 7 months after the initial diagnosis.

LESSONS

To our knowledge, this report is the 1st case of acute E hepatitis in a patient with RA developed during leflunomide therapy in combination with low-dose steroids. Moreover, geoepidemiology of infection is important, due to the fact that Abruzzo, a central region of Italy, has the highest HEV seroprevalence in general population, related to the zoonotic transmission of the infection from domestic and wild animals. Our case highlighted that immunosuppressive therapy, and in particular leflunomide, could be safely reintroduced after the resolution of the infection and the clearance of the virus. Further studies are needed to evaluate potential advantages in serologic testing for HEV infection as a part of the routine workup done to patients with rheumatic diseases and selected for immunosuppressive therapy.