Sex hormone adjuvant therapy in rheumatoid arthritis

Impact of the malnutrition on mortality in Rheumatoid arthritis patients: A cohort study from NHANES 1999-2014

Background

Patients with Rheumatoid arthritis (RA) are prone to malnutrition. However, it is rare studies assessing the relationship between malnutrition and all-cause mortality in patients with RA.

Objective

To investigate the relationship between malnutrition and all-cause mortality in patients with RA in a large national sample cohort.

Methods

We analyzed data on 1,976 adults ≥ 18 years of age during National Health and Nutrition Examination Survey (NHANES) 1999-2014. We chose the Controlled Nutritional Status Score (CONUT) and the Nutritional Risk Index (NRI) to assess the nutritional status of patients with RA. The Kaplan-Meier (KM) survival curves Cox proportional hazards regression models were used to analyze the associations between malnutrition and all-cause mortality.

Results

Of the 1,976 patients with RA (57.38 ± 0.40 years, female 59.9%, non-Hispanic white 69.9%), the prevalence of malnutrition was 18.8% by used the CONUT and 26.6% by used the NRI. The KM survival curves showed that malnutrition was associated with a higher incidence of all-cause mortality during the 10-year follow-up period (log-rank test, P < 0.001). In the fully corrected model, the adjusting hazard ratio (aHR) for all-cause mortality in patients with moderate to severe malnutrition with CONUT and NRI were 5.63 (95% CI, 2.55-12.45; P < 0.001) and 2.56 (95% CI, 1.81-3.62; P < 0.001), respectively, compared with patients without malnutrition.

Conclusion

Malnutrition is very prevalent in patients with RA, approximately 18.8% (CONUT) to 26.6% (NRI). Malnutrition is strongly associated with an increased risk of all-cause mortality. These findings underscore the importance of attention and intervention in the nutritional status of patients with RA. Further clinical trials are needed to prospectively assess the effect of nutritional interventions on the prognosis of patients with RA.

Risk factors for osteoporosis and fractures in rheumatoid arthritis

People with rheumatoid arthritis (RA) have both disease-specific risk factors for osteoporosis and fractures in addition to those that affect the general population. Disease specific risks include directly pathogenic auto-antibodies, chronic exposure to systemic inflammation, and joint damage causing early disability. Risk factors that affect the general population which may have a higher prevalence in RA include smoking, calcium and vitamin D deficiency as well as hypogonadism. Additionally, chronic exposure to glucocorticoids results in reduced bone mineral density and body composition changes which can further increase fracture risk. In this review we discuss these risk-factors for osteoporosis as well as factors that may impact fall and fracture risk in people with RA.

Risk factors associated with the progression from mild keloids to severe mild keloids

Background:

Keloids are benign fibrous growths that are caused by excessive tissue build-up. Severe keloids exert more significant effects on patients’ quality of life than do mild keloids. We aimed to identify factors associated with the progression from mild keloids to severe keloids, as distinct from those associated with the formation of keloids.

Methods:

In this retrospective case-control study, 251 patients diagnosed with keloids at West China Hospital between November 2018 and April 2021 were grouped according to the severity of lesions (mild [n = 162] or severe [n = 89]). We collected their basic characteristics, living habits, incomes, comorbidities, and keloid characteristics from Electronic Medical Records in the hospital and the patients’ interviews. Conditional multivariable regression was performed to identify the independent risk factors for the progression of keloids.

Results:

Eighty-nine patients (35.5%) were classified as having severe keloids. We found the distribution of severe keloids varied with sex, age, excessive scrubbing of keloids, family income, the comorbidity of rheumatism, disease duration, characteristics of the location, location in sites of high-stretch tension, the severity and frequency of pain, the severity of pruritus, and infection. Multivariable analysis revealed significant associations between severe keloids and infection (odds ratio [OR], 3.55; P = 0.005), excessive scrubbing of keloids (OR, 8.65; P = 0.001), low or middle family income (OR, 13.44; P = 0.021), comorbidity of rheumatism (OR, 18.97; P = 0.021), multiple keloids located at multiple sites (OR, 3.18; P = 0.033), and disease duration > 15 years (OR, 2.98; P = 0.046).

Conclusion:

Doctors should implement more active and thorough measures to minimize the progression of mild keloids in patients who have any of the following risk factors: infection, excessive scrubbing of keloids, low or middle family income, comorbidity of rheumatism, multiple keloids located at multiple sites, and disease duration > 15 years.

The maximum dose and duration in the therapy single use methotrexate to achieve remission by rheumatoid arthritis patients through disease activity score 28 (DAS28)

OBJECTIVES

One of the treatments for rheumatoid arthritis (RA) was methotrexate which a disease modifying antirheumatic drug therapy. The use of methotrexate required the right dose and length of therapy to achieve remission. The effectivity of methotrexate could be accounted by disease activity score 28 (DAS28) as a tool has been used clinically with a combination number of tender joints, swollen joints, erythrocyte sedimentation rate, and global clinical assessment by the patient. The aim of this study was to determine the effective dose and length of therapy methotrexate was measured by DAS28 score.

METHODS

This research was a cross-sectional study and data was collected from patient medical records in Saiful Anwar Hospital, Malang, from February to July 2018. The research has been given ethical clearance. The inclusion criteria for the 88 subjects were men and women, over 20 years of age, usage of only methotrexate for at least three months, an erythrocyte sedimentation rate score, uncomplicated inflammatory bowel disease, cancer, and systemic lupus erythematosus. All data obtained was entered in formula DAS28. The Statistic analysis used both Pearson and Spearman's rank correlation.

RESULTS

Only 16 patients achieved remission. There were not significant correlation in statistical analysis between DAS score and cumulative dose (r=-0.091; p=0.400), average dose (r=0.043; p = 0.692), maximum dose (r=0.074; p=0.492), and length of therapy (r=-0.075; p = 0.489). The initial dose of therapy methotrexate was different and the length of therapy was adjusted to the patient's health condition.

CONCLUSIONS

The maximum dose and length of therapy methotrexate was required to achieve remission in RA.

Testosterone target therapy: focus on immune response, controversies and clinical implications in patients with COVID-19 infection

The pandemic acute respiratory syndrome coronavirus 2 (SARS-CoV-2) named COVID-19 is causing a severe health emergency, and an individual's hormonal milieu may play an important role in both susceptibility to infection and severity of clinical course. We analyzed the role of testosterone in the immune response, and we hypothesized possible mechanisms to explain the high incidence of COVID-19 infection and a worse clinical course in elderly male patients. Testosterone may impair the immune response, and this effect could explain the greater susceptibility of men to infection. Transmembrane serine protease 2 (TMPRSS2) plays a crucial role in the entry of the virus into the respiratory epithelial cells, leading to COVID-19 disease. It is crucial to emphasize that testosterone levels and chemical castration (e.g. by androgen deprivation therapy for prostate cancer) may have contrasting roles in the phases of COVID-19 infection. Whereas low testosterone levels may be protective against the initial susceptibility (due to a restoration of immunological functions and a block of TMPRSS2), low testosterone may stimulate a worse clinical course in the advanced COVID-19 infection as it could exacerbate or activate the cytokine storm. If testosterone levels play these different roles, it is necessary to carefully identify patients for any indicated testosterone manipulation.

Molecular Mechanisms of Sex-Related Differences in Arthritis and Associated Pain

Clinical conditions leading to chronic pain show important sex-related differences in the prevalence, severity, and degree of functional disability. Decades of epidemiological and clinical studies have demonstrated that women are more sensitive to pain than men. Arthritis, including rheumatoid arthritis (RA) and osteoarthritis (OA), is much more prevalent in females and accounts for the majority of pain arising from musculoskeletal conditions. It is therefore important to understand the mechanisms governing sex-dependent differences in chronic pain, including arthritis pain. However, research into the mechanisms underlying the sex-related differences in arthritis-induced pain is still in its infancy due to the bias in biomedical research performed largely in male subjects and animals. In this review, we discuss current advances in both clinical and preclinical research regarding sex-related differences in the development or severity of arthritis and associated pain. In addition, sex-related differences in biological and molecular mechanisms underlying the pathogenesis of arthritis pain, elucidated based on clinical and preclinical findings, are reviewed.

Clinical Characteristics in Patients with Rheumatoid Arthritis: Differences between Genders

Objective

To compare the clinical characteristics of a group of men and women with rheumatoid arthritis (RA) and determine the differences between genders.

Materials and Methods

A descriptive and comparative cross-sectional study was developed with a group of 50 men and a control group of 50 women with RA, from a rheumatology center in the city of Guayaquil, Ecuador. Data collected included clinical manifestations, comorbidities, treatment, and disease activity. Clinical and activity differences between sexes were analyzed.

Results

Women were more devoted to housework (66%), while men consumed more tobacco (34%) and alcohol (38%). Fatigue (60%), loss of appetite (54%), and weight loss (44%) were more common in women. No differences were found in comorbidities or treatment. Women had higher values of DAS-28 (3.4 vs 2.5), HAQ-DI (1.1 vs 0.4), ESR (33.0 vs 23.2), painful joints (8 vs 3), swollen joints (6 vs 2), and overall physician assessment (3 vs 2).

Conclusion

The results are similar to other publications that establish that women have a more aggressive disease with greater activity of the disease and disability.

Do Androgens Modulate the Pathophysiological Pathways of Inflammation? Appraising the Contemporary Evidence

The role of testosterone in the pathophysiology of inflammation is of critical clinical importance; however, no universal mechanism(s) has been advanced to explain the complex and interwoven pathways of androgens in the attenuation of the inflammatory processes. PubMed and EMBASE searches were performed, including the following key words: "testosterone", "androgens", "inflammatory cytokines", "inflammatory biomarkers" with focus on clinical studies as well as basic scientific studies in human and animal models. Significant benefits of testosterone therapy in ameliorating or attenuating the symptoms of several chronic inflammatory diseases were reported. Because anti⁻tumor necrosis factor therapy is the mainstay for the treatment of moderate-to-severe inflammatory bowel disease; including Crohn's disease and ulcerative colitis, and because testosterone therapy in hypogonadal men with chronic inflammatory conditions reduce tumor necrosis factor-alpha (TNF-α), IL-1β, and IL-6, we suggest that testosterone therapy attenuates the inflammatory process and reduces the burden of disease by mechanisms inhibiting inflammatory cytokine expression and function. Mechanistically, androgens regulate the expression and function of inflammatory cytokines, including TNF-α, IL-1β, IL-6, and CRP (C-reactive protein). Here, we suggest that testosterone regulates multiple and overlapping cellular and molecular pathways involving a host of immune cells and biochemical factors that converge to contribute to attenuation of the inflammatory process.

Association of serum testosterone and dehydroepiandrosterone sulfate with rheumatoid arthritis: a case control study

Background

It is supposed that hypoandrogenism may be involved in the pathogenesis of rheumatoid arthritis (RA). Testosterone and dehydroepiandrosterone sulfate (DHEAs) levels decrease in body fluids of patients with RA.

Objective

The aim of this study was to determine the association of serum testosterone and DHEAs with RA.

Methods

This case-control study was conducted on 59 patients with RA and 61 healthy gender- and age-matched controls at Qazvin University of Medical Sciences, Qazvin, Iran, in 2014. Serum free testosterone and DHEAs levels were measured and compared between two groups. Serum testosterone levels lower than 0.029 ng/ml in females and 2.49 ng/ml in males were considered as abnormal. DHEAs levels lower than 18.9 μg/dl in females and 88.9 μg/dl in males were considered as abnormal. Data were analyzed using independent sample T-test, Chi-square test, and logistic regression analysis by SPSS software, version 19.

Results

The mean testosterone level in females of the control group was significantly higher than females in the case group. The mean DHEAs in the control group was significantly higher than the case group. Abnormal testosterone and DHEAs level in the case group was significantly higher than the control group. Logistic regression analysis showed independent association only between DHEAs levels and RA, after adjusting for age and gender (OR: 0.966, 95% CI: 0.953–0.979; p<0.001).

Conclusion

With regard to the results, abnormal testosterone and DHEAs level in patients with RA was significantly higher than the control group. This shows the anti-inflammatory effects of gonadal and adrenal androgens in RA.

Impact of sex disparities on the clinical manifestations in patients with systemic lupus erythematosus: A systematic review and meta-analysis

BACKGROUND

Systemic lupus erythematosus (SLE) is a chronic autoimmune multiorgan disorder of unknown etiology. It affects both men and women, but with different disease manifestations of differing disease severity and in varying proportion, with a female predominance of approximately 90%. There have been numerous studies addressing this issue, especially its implications in relation to optimal sex-tailored treatment and improvement of survival rate; however, further research is warranted. A meta-analysis of studies was performed to compare the impact of sex on the clinical outcomes of SLE in different populations.

METHODS

A literature search of the MEDLINE/PubMed and EMBASE databases (until January 2016) was conducted to identify relevant articles. Clinical manifestations reported in these patients were considered as endpoints for this meta-analysis. Two independent reviewers determined eligibility criteria. A fixed-effect model has been used where a small heterogeneity was observed, or else, a random-effect model has been used among the studies. Odd ratio (OR) with 95% confidence interval (CI) was used to express the pooled effect on dichotomous variables, and the pooled analyses were performed with RevMan 5.3.

RESULTS

Sixteen studies consisting of a total of 11,934 SLE patients (10,331 females and 1603 males) have been included in this meta-analysis. The average female-to-male ratio of all the included studies is around 9.3:1. Several statistically significant differences were found: alopecia, photosensitivity, and oral ulcers were significantly higher in female patients (OR 0.36, 95% CI 0.29-0.46, P < 0.00001; OR 0.72, 95% CI 0.63-0.83, P < 0.00001; and OR 0.70, 95% CI 0.60-0.82, P < 0.00001, respectively). Malar rash was significantly higher in female patients (OR 0.68, 95% CI 0.53-0.88, P = 0.003), and arthritis was significantly lower in male patients (OR 0.72, 95% CI 1.25-1.84, P < 0.00001). However, serositis and pleurisies were significantly higher in female patients (OR 1.52, 95% CI 1.25-1.84 P < 0.0001; and OR 1.26, 95% CI 1.07-1.48, P = 0.006, respectively). Renal involvement was higher in male patients (OR 1.51, 95% CI 1.31-1.75, P < 0.00001).

CONCLUSION

The results of this meta-analysis suggest that alopecia, photosensitivity, oral ulcers, arthritis, malar rash, lupus anticoagulant level, and low level of C3 were significantly higher in female lupus patients, whereas renal involvement, serositis and pleurisies, thrombocytopenia, and anti-double stranded deoxyribonucleic acid level were predominant in male patients.

Rapid Anti-Inflammatory Effects of Gonadotropin-Releasing Hormone Antagonism in Rheumatoid Arthritis Patients with High Gonadotropin Levels in the AGRA Trial

Objectives

Gonadotropin-releasing hormone (GnRH) and pituitary gonadotropins, which appear to be proinflammatory, undergo profound secretory changes during events associated with rheumatoid arthritis (RA) onset, flares, or improvement e.g. menopausal transition, postpartum, or pregnancy. Potential anti-inflammatory effects of GnRH-antagonists may be most pronounced in patients with high GnRH and gonadotropin levels. Therefore, we investigated the efficacy and safety of a GnRH-antagonist, cetrorelix, in RA patients with high gonadotropin levels.

Methods

We report intention-to-treat post hoc analyses among patients with high gonadotropin levels (N = 53), i.e. gonadotropin levels>median, from our proof-of-concept, double-blind AGRA-study (N = 99). Patients with active longstanding RA, randomized to subcutaneous cetrorelix (5mg days1–2; 3mg days 3–5) or placebo, were followed through day 15. Only predefined primary and secondary endpoints were analyzed.

Results

The primary endpoint, Disease Activity Score of 28-joint counts with C-reactive protein (DAS28-CRP), improved with cetrorelix compared with placebo by day 5 (-1.0 vs. -0.4, P = 0∙010). By day 5, more patients on cetrorelix achieved at least a 20% improvement in the American College of Rheumatology scale (44% vs. 19%, P = 0.049), DAS28-CRP≤3.2 (24% vs. 0%, P = 0.012), and European League against Rheumatism ‘Good-responses’ (19% vs. 0%, P = 0.026). Tumor necrosis factor-α, interleukin-1β, interleukin-10, and CRP decreased with cetrorelix (P = 0.045, P = 0.034, P = 0.020 and P = 0.042 respectively) compared with placebo by day 15. Adverse event rates were similar between groups.

Conclusions

GnRH-antagonism produced rapid anti-inflammatory effects in RA patients with high gonadotropin levels. GnRH should be investigated further in RA.

Trial Registration

ClinicalTrials.gov NCT00667758

What is causing my arthritis, doctor? A glimpse beyond the usual suspects in the pathogenesis of rheumatoid arthritis

Rheumatoid arthritis (RA) is a common, but heterogeneous, disease. Usually, when it comes to the pathogenesis of RA the physician faces a complex network of cytokines and cells of the immune system-the so-called effector level. However, is this network 'the cause' of the disease? Or is this rather the level most physicians are somewhat familiar with, as modern anti-rheumatic medications are having their targets there? In this review, we are looking beyond the usual culprits from the physician's perspective and discuss how other factors, such as genes, epigenetics, environmental factors, local joint characteristics or processes of aging might influence the clinical phenomenon RA.

Androgen receptor genetic variants in male patients with ankylosing spondylitis in Taiwan

AIM

Ankylosing spondylitis (AS) is a chronic rheumatic disorder with gender differences. The aim of study was to investigate the association between polymorphisms of the androgen receptor (AR) gene and the susceptibility to AS in Taiwanese men of Han Chinese descent.

METHODS

We conducted a case-control study with 92 male AS patients and 108 healthy controls. Trinucleotide (CAG and GGC) repeats and seven single nucleotide polymorphisms (SNPs) rs962458, rs6152, rs1204038, rs5918757, rs2361634, rs6624304 and rs1337080 in the AR gene were genotyped.

RESULTS

We found that only one patient had polymorphic SNPs of the AR gene. None of the genotyped SNPs in the AR gene, originally found in Caucasians, was polymorphic in the Taiwanese men. Neither CAG nor GGC repeat lengths in the AR gene had a significant relationship with human leukocyte antigen (HLA)-B27 positivity or disease severity in AS.

CONCLUSION

There were no differences in CAG and GGC lengths in the AR gene between AS and the controls. None of the genotyped SNPs in AR gene are detected to be polymorphic in male Taiwanese, which indicates that the effect of AR gene on AS may be ethnic-specific and may be conserved in East Asians compared to Caucasian populations. Still, additional studies using large sets of subjects deserve further attention, since our sample size was small with limited statistical power and supporting evidence for association between the AR gene and AS risk in the Japanese population exists.

Differential metabolism of androst-5-ene-3β,17β-diol between rats, canines, monkeys and humans

The potent anti-inflammatory activity of exogenous dehydroepiandrosterone (DHEA) in rodents has not translated to humans. This disparity in pharmacological effects has been attributed to factors such as differences in expression and function of molecular targets and differential metabolism. Hepatocytes from rats, dogs, monkeys, and humans were used to measure species-specific metabolism of a related compound, androst-5-ene-3β,17β-diol (5-AED) using reversed-phase radio-HPLC, to explore the metabolic contribution to this interspecies disparity. We found that rat hepatocytes transformed 5-AED predominantly into an array of highly oxidized metabolites. Canine metabolites overlapped with rat, but contained a greater abundance of less hydrophilic species. Monkey and human metabolites were strikingly less hydrophilic, dominated by 5-AED and DHEA conjugates. From the accumulating evidence indicating that the DHEA anti-inflammatory activity may actually reside in its more highly oxidized metabolites, we advance a hypothesis that the virtual absence of these metabolites in humans is central to the failure of exogenous DHEA to produce a potent pharmacological effect in clinical investigations. Accordingly, emulation of its anti-inflammatory activity in humans will require administration of an active native metabolite or a synthetic pharmaceutical derivative.

Potential immunomodulatory role of VIP in the implantation sites of prediabetic nonobese diabetic mice

Among several factors known to modulate embryo implantation and survival, uterine quiescence and neovascularization, maternal immunotolerance through the Th1/Th2 cytokine balance towards a Th2 profile, local regulatory T-cell (Treg) activation, and high levels of progesterone were assigned a prominent role. Vasoactive intestinal peptide (VIP) is a neuroimmunopeptide that has anti-inflammatory effects, promotes Th2 cytokines and CD4+CD25+FOXP3+Treg activation, and stimulates exocrine secretion, smooth muscle relaxation, and vasodilatation favoring uterus quiescence. The goal of the present work was to explore the participation of VIP in the implantation sites of normal and pregnant prediabetic nonobese diabetic (NOD) females, a mouse strain that spontaneously develops an autoimmune exocrinopathy similar to Sjögren's syndrome. Our results indicate a reduction in litter size from the third parturition onwards in the NOD female lifespan with increased resorption rates. Progesterone systemic levels were significantly decreased in pregnant NOD mice compared with BALB/c mice, although the allogeneic response to progesterone by spleen cells was not impaired. VIP receptors,Vipr1andVipr2(Vpac1andVpac2), were expressed at the implantation sites and VIP induced leukemia inhibitory factor (LIF) and Treg marker expression in both strains; however, a reducedVipexpression was found in NOD implantation sites. We conclude that the reduced birth rate at 16-week-old NOD mice with a Th1 systemic cytokine profile involves resorption processes with a lower expression of VIP at the sites of implantation, which acts as a local inducer of pro-implantatory LIF and Treg activation.

An orally bioavailable synthetic analog of an active dehydroepiandrosterone metabolite reduces established disease in rodent models of rheumatoid arthritis

Dehydroepiandrosterone (DHEA) treatment provides diverse anti-inflammatory benefits in rodent models of diseases, including rheumatoid arthritis (RA), but only limited benefits to patients. In rodents, DHEA is metabolized to (among others) androstene-3beta,7beta,17beta-triol (AET), which retains potent anti-inflammatory activity. 17Alpha-ethynyl-5-androstene-3beta,7beta,17beta-triol (HE3286) is a novel, metabolically stabilized, orally bioavailable derivative of AET. In the DBA mouse model of collagen-induced arthritis (CIA), once-daily oral treatments (gavage) with HE3286 (40 mg/kg), beginning at onset of disease, significantly decreased disease. Benefit was associated with reduction in joint inflammation, erosion, and synovial proliferation as measured by histological analysis and mRNA of proinflammatory cytokines, including tumor necrosis factor-alpha, interleukin (IL)-6, IL-1beta, and IL-23. Significant benefit was also observed in the CIA model even when treatments were delayed until 7 days after the onset of arthritis. Furthermore, dose-dependent benefit was observed in the DBA mouse model of collagen antibody-induced arthritis, as well as reductions in IL-6 and matrix metalloproteinase-3 mRNA levels in joints at the peak of disease and at the end of the study. HE3286, in contrast to dexamethasone, was not immune-suppressive in several classic animal models of immune function. Instead, HE3286 treatment was associated with reduced nuclear factor-kappaB activation and in our previous studies, with increased regulatory T cells. We hypothesize that HE3286 may represent a novel, perhaps first-in-class, anti-inflammatory agent and may more fully translate the benefits of DHEA, heretofore largely limited to rodents, into treatments for human diseases, including autoimmune disorders such as RA.

Prospective study to assess short-term intra-articular and tenosynovial changes in the aromatase inhibitor-associated arthralgia syndrome

PURPOSE

Arthralgia is an adverse class effect of aromatase inhibitors (AIs). To date, its exact mechanism remains unclear. The purpose of this study was to investigate the changes in clinical rheumatologic features and magnetic resonance imaging (MRI) of hands and wrists in AI and tamoxifen users.

PATIENTS AND METHODS

This is a prospective single-center study including 17 consecutive postmenopausal patients with early breast cancer receiving either tamoxifen (n = 5) or an AI (n = 12). At baseline and after 6 months, patients filled in a rheumatologic history questionnaire and a rheumatologic examination including a grip strength test was done. At the same time points, MRI of both hands and wrists was performed. The primary end point was tenosynovial changes from baseline on MRI. Secondary end points were changes from baseline for morning stiffness, grip strength, and intra-articular fluid on MRI. Wilcoxon signed ranks was used to test changes from baseline and the Spearman correlation coefficient to assess the association between rheumatologic and MRI changes from baseline.

RESULTS

At 6 months, patients on AI had a decrease in grip strength (P = .0049) and an increase in tenosynovial changes (P = .0010). The decrease in grip strength correlated well with the tenosynovial changes on MRI (P = .0074). Only minor changes were seen in patients on tamoxifen. AI users reported worsening of morning stiffness and showed an increase in intra-articular fluid on MRI.

CONCLUSION

The functional impairment of hands in the AI-associated arthralgia syndrome is characterized by tenosynovial changes on MRI correlating with a significant decrease in hand grip strength.

The many faces of testosterone

Testosterone is more than a “male sex hormone”. It is an important contributor to the robust metabolic functioning of multiple bodily systems. The abuse of anabolic steroids by athletes over the years has been one of the major detractors from the investigation and treatment of clinical states that could be caused by or related to male hypogonadism. The unwarranted fear that testosterone therapy would induce prostate cancer has also deterred physicians form pursuing more aggressively the possibility of hypogonadism in symptomatic male patients. In addition to these two mythologies, many physicians believe that testosterone is bad for the male heart. The classical anabolic agents, 17-alkylated steroids, are, indeed, potentially harmful to the liver, to insulin action to lipid metabolism. These substances, however, are not testosterone, which has none of these adverse effects. The current evidence, in fact, strongly suggests that testosterone may be cardioprotective. There is virtually no evidence to implicate testosterone as a cause of prostate cancer. It may exacerbate an existing prostate cancer, although the evidence is flimsy, but it does not likely cause the cancer in the first place. Testosterone has stimulatory effects on bones, muscles, erythropoietin, libido, mood and cognition centres in the brain, penile erection. It is reduced in metabolic syndrome and diabetes and therapy with testosterone in these conditions may provide amelioration by lowering LDL cholesterol, blood sugar, glycated hemoglobin and insulin resistance. The best measure is bio-available testosterone which is the fraction of testosterone not bound to sex hormone binding globulin. Several forms of testosterone administration are available making compliance much less of an issue with testosterone replacement therapy.

Protein electrophoresis and immunoglobulin analysis in HIV-infected patients

We studied the prevalence and nature of immunoglobulin abnormalities in HIV-1-infected patients in the era of highly active antiretroviral therapy. Protein electrophoreses (PEP) were performed on and quantitative immunoglobulin levels obtained in samples from 320 consecutive HIV-1-infected patients. Samples with possible PEP abnormalities underwent immunofixation. The PEP pattern was normal in 83.8% of samples, 8.1% had subtle oligoclonal banding, and 4.4% had a low-concentration (<5% of total protein) monoclonal band. Hypogammaglobulinemia and polyclonal hypergammaglobulinemia accounted for 1.9% each. In multivariate analysis, younger age (odds ratio [OR], 1.06 with each decreasing year of life; 95% confidence interval [CI], 1.02-1.11; P = .016), female sex (OR, 2.4; 95% CI, 1.13-5.11; P = .02), viral load (OR, 1.50 with each increasing logarithmic viral load of 1.0; 95% CI, 1.14-1.98; P = .004), and CD4 cell count (> or =350 vs <350/microL [0.35 x 10(9)/L]) (OR, 2.71; 95% CI, 1.09-6.75; P = .032) were associated with monoclonal or oligoclonal banding. These results suggest that younger HIV-1-infected patients with a more robust immune system (higher CD4 cell count), which is stimulated by uncontrolled viremia, are most likely to have an augmented B-cell response to HIV infection. One manifestation of this B-cell response is low-concentration monoclonal banding in 4.4% of the patients studied.

Reduced nitric oxide synthase and cyclo-oxygenase activity in the uterus of non-obese diabetic mice

A functional interaction between progesterone, Th2 cytokines and a suitable balance between nitric oxide and prostaglandins in the uterus is considered to have a major role in the success of embryo implantation and pregnancy. Non-obese diabetic (NOD) mice offer a suitable model to study the modulatory role of Th1 cytokines on uterus signalling and function, since at the prediabetic stage they develop a spontaneous Th1 autoimmune response against exocrine glands similar to Sjögren's syndrome. Vasoactive intestinal peptide (VIP) is a vasoactive neuro- and immunopeptide that promotes Th2 profiles and contributes to the smooth muscle relaxation and vasodilation. The aim of the present study was to investigate the activities of nitric oxide synthase and cyclo-oxygenase and the effect of VIP in the uterus of NOD mice with an emerging Th1 cytokine response. We present evidence of a reduced basal and VIP-stimulated activity of both enzymes in the uterus of NOD mice compared with normal BALB/c mice in proestrus. An altered functional interaction between both enzymes is also present in NOD mice at the time when increased levels of serum interleukin (IL)-12 and tumour necrosis factor-alpha but not interferon (IFN)-gamma or IL-10 were detected. We conclude that signalling alterations in uteri of NOD mice are simultaneous to the onset of a systemic Th1 cytokine response.

Male hypogonadism in systemic disease

Hypogonadism is often observed in the presence of common acute and chronic illnesses in men. Low testosterone levels in these patients can be associated with loss of lean body mass and bone mass density, decline in mood, loss of energy, and sexual dysfunction. The mechanisms explaining hypogonadism and various systemic diseases are not completely understood, but these conditions are likely caused by a combination of stress, nonspecific weight loss, inflammation, and medication. Testosterone replacement can be considered in this population to improve lean body mass, bone mass density, and quality of life. More information is needed regarding the risk benefits of testosterone treatment on health outcomes in men who have systemic illness.

The in vitro effects of dehydroepiandrosterone on chondrocyte metabolism

OBJECTIVE

To investigate the in vitro effects of dehydroepiandrosterone (DHEA) on neonatal rat chondrocytes.

DESIGN

Chondrocytes isolated from neonatal rat cartilage were cultured in three-dimensionally agarose beads and were treated with DHEA.

METHODS

Primary culture of chondrocytes was harvested from newborn Wistar rats. The DHEA effects on chondrocyte activities were evaluated by analyzing chondrocyte proliferation, matrix protein synthesis, gene expressions of collagen, matrix metalloproteinase-1, -3 and -13 (MMP-1, -3 and -13), and cyclooxygenase-2 (COX-II), and protein synthesis of interleukin-6 (IL-6), prostaglandin E2 (PGE2) and tissue inhibitor of metalloproteinase-1 (TIMP-1).

RESULTS

The DHEA treatment did affect chondrocyte proliferation and glycosaminoglycan (GAG) synthesis. DHEA suppressed the expression of MMP-1, -3 and -13 genes and PGE2 protein synthesis enhanced by lipopolysaccharide (LPS) while the COX-II and inducible nitric oxide synthase (iNOS) gene expressions were down-regulated by DHEA.

CONCLUSIONS

Our study demonstrates that DHEA has an ability to modulate the imbalance between MMPs and PGE2 in the neonatal chondrocytes which suggest that it has a potential protective role against articular cartilage damage.

17alpha-hydroxylase/C17-20 lyase cytochrome P450 mRNA expressions and enzyme activities during the development of arthritis in collagen-induced arthritis mice

In our previous study, we have investigated the serum levels of dehydroepiandrosterone (DHEA) in type II collagen (CII)-induced arthritis (CIA) mice. During the study, we found that in normal control mice, serum levels of DHEA in the latter half of the experimental period (13-16 weeks old) were significantly lower than those at the beginning of the experiment (10 weeks old). However, in CIA mice, such decreases were not observed by CII treatment. To examine the cause of the retention of DHEA during the development of arthritis in CIA mice in this study, 17alpha-hydroxylase/C17-20 lyase P450 (CYP17) mRNA expressions were measured by real time RT-PCR and the CYP17 enzyme activities were investigated in the liver and testis on days 6, 13, 28 and 48 after CII treatment in DBA/1J mice. There were no significant differences of CYP17 expressions in the liver between control and CIA mice at each experimental day, while a significant increase of expression in the testis of CIA mice was observed on day 48. On the other hand, CYP17 enzyme activities on days 28 and 48 in testis microsome (Mc) from the CIA mice were significantly higher than those of the control on the same day, while no significant differences of activities in liver Mc were observed between the CIA and control mice. These findings suggested that the cause of the retention of DHEA on days 28 and 48 after CII treatment may be the increase of CYP17 expression and the enzyme activities in the testis.

Rheumatoid Arthritis: Neuroendocrine Immune Integrated Physiopathogenetic Perspectives and Therapy

Current concepts of neuroendocrine immune (NEI) aspects of rheumatoid arthritis (RA) are reviewed and recent clinical trials of glucocorticoids and sex steroids are summarized. A novel physiopathogenetic perspective is presented. Data are provided of amplified NEI interactions and dysregulation, many years before symptomatic onset of RA. Chronic imbalances between the NEI, vascular endothelial, neural, and other vital counterregulatory intertwined networks are proposed to cause RA and influence its disease activity. Future research may reveal means of diminishing the onset risk as well as disease activity of RA by controlling these imbalances of NEI and other vital networks.

Pilot clinical trial of dehydroepiandrosterone (DHEA) versus placebo for Sjögren's syndrome

OBJECTIVE

To screen for potential efficacy and assess feasibility and safety of dehydroepiandrosterone (DHEA) as a treatment for Sjögren's syndrome (SS).

METHODS

A 24-week randomized, double-blinded, pilot trial of oral DHEA (200 mg/day) versus placebo was conducted. The primary comparison was to a hypothesized 20% placebo response rate. If 14 consecutive subjects on DHEA did not respond, a Phase III trial would be considered futile. A placebo group of 14 subjects was planned to verify placebo response rate and estimate sample size required for a definitive trial. Response criteria required 20% improvement in at least 2 of 3 domains. Analysis of covariance was used to adjust for baseline differences and for stratified randomization. Outcome measures included visual analog scale questionnaires for dry eye and dry mouth symptoms, lissamine green ocular dye staining and Schirmer I tests, stimulated salivary flow, IgG, and erythrocyte sedimentation rate (ESR).

RESULTS

Randomization resulted in 14 DHEA and 14 placebo group subjects. At baseline, mean +/- SD for DHEA versus placebo groups were Schirmer I tests 4.5 +/- 4.5 versus 5.4 +/- 6.1 mm/5 minutes; Van Bijsterveld score 5.3 +/- 2.1 versus 5.5 +/- 2.2; unstimulated saliva 0.03 +/- 0.05 versus 0.04 +/- 0.10 ml/minute; IgG 1,699 +/- 749 versus 1,712 +/- 621 g/dl; and ESR 40 +/- 31 versus 44 +/- 28 mm/hour. Apart from changes over the trial in dry mouth symptoms, no significant differences were noted between the DHEA and placebo groups for dry eye symptoms, objective measures of ocular dryness, stimulated salivary flow; IgG, or ESR. Four DHEA and one placebo group patient dropped out because of adverse effects. Although 7 subjects met response criteria in the DHEA group, 5 met the criteria in the placebo group, and there was no significant difference between groups.

CONCLUSION

DHEA showed no evidence of efficacy in SS. Without evidence for efficacy, patients with SS should avoid using unregulated DHEA supplements, since long-term adverse consequences of exposure to this hormone are unknown.

Effect of sex hormones on experimental autoimmune uveoretinitis (EAU)

PURPOSE

Sex hormones have been associated with the prevalence, susceptibility, and severity of autoimmune disease. Although the exact mechanism is unknown, sex hormones are reported to influence cytokine production, specifically by affecting the balance of Th1 and Th2 effector cells. We evaluated the effect of estrogen, progesterone, and testosterone in autoimmune uveoretinitis (EAU), a rodent model of human ocular autoimmune disease.

METHODS

Lewis rats implanted with either beta-estradiol (estrogen), 5-dihydrotestosterone (5-DHT), norgestrel (progesterone), or estrogen plus progesterone were immunized with the retinal antigen interphotoreceptor retinoid binding protein (IRBP) peptide. Evaluation of EAU was based on histology of the eyes and measurement of peripheral immunological responses of DTH and lymphocyte proliferation to S-antigen. Quantitative RT-PCR was used to measure IFN-gamma and IL-10 mRNA in the eyes.

RESULTS

In female rats 5-DHT significantly decreased, estrogen slightly enhanced, but progesterone or estrogen + progesterone did not affect EAU. In contrast, in male rats 5-DHT slightly decreased, estrogen moderately decreased, progesterone did not effect, but, estrogen + progesterone slightly decreased EAU. The results correlated with the ocular levels of Th1 (IFN-gamma) and Th2 (IL-10) cytokine messengers.

CONCLUSION

The data support the hypothesis that sex hormones may affect autoimmune diseases by inducing changes in the cytokine balance. This suggests that sex hormone therapy could be considered as an adjunct to anti-inflammatory agents to treat ocular autoimmune diseases in humans.

Effects of dehydroepiandrosterone on articular cartilage during the development of osteoarthritis

OBJECTIVE

To investigate the in vivo effects of dehydroepiandrosterone (DHEA) on knee joints during the development of experimentally induced osteoarthritis (OA).

METHODS

Twenty-two mature NZW rabbits underwent bilateral anterior cruciate ligament transection (ACLT) and received 0.3-ml intraarticular injections of DHEA (at a concentration of 100 microM in phosphate buffered saline) and control solution in the right and left knees, respectively, beginning 4 weeks after ACLT and continuing once weekly for 5 weeks. All animals were killed 9 weeks after surgery, and the knee joints were assessed by gross morphologic, histologic, histomorphometric, and biochemical methods.

RESULTS

Gross morphologic inspection following India ink application showed that the right femoral condyles, which received DHEA, demonstrated less severe cartilage damage than did the contralateral condyles. The thickness, area, and roughness of the DHEA-treated femoral condyles provided evidence of a cartilage-protecting effect of DHEA following ACLT. These results were supported by gene expression analysis. Messenger RNA expression of a proinflammatory cytokine, interleukin-1beta, and catabolic enzymes, matrix metalloproteinases 1 and 3, was reduced in the cartilage of the DHEA-treated knee joints, and expression of tissue inhibitor of metalloproteinase 1 was increased.

CONCLUSION

Results of the present study demonstrate a cartilage-protecting effect of DHEA during the development of OA following ACLT in a rabbit model.

The in vitro effects of dehydroepiandrosterone on human osteoarthritic chondrocytes

OBJECTIVE

To investigate the in vitro effects of dehydroepiandrosterone (DHEA) on human osteoarthritic chondrocytes.

DESIGN

Chondrocytes isolated from human osteoarthritic knee cartilage were three-dimensionally cultured in alginate beads, except for cell proliferation experiment. Cells were treated with DHEA in the presence or absence of IL-1beta. The effects on chondrocytes were analyzed using a 3-(4,5-dimethylthiazol-2yl)-5-(3-carboxymethoxy-phenyl)-2-(4-sulfophenyl)-2H-tetrazolium inner salt (MTS) assay (for chondrocyte proliferation), a dimethylmethylene blue (DMB) assay (for glycosaminoglycan (GAG) synthesis), and an indole assay (for DNA amount). Gene expressions of type I and II collagen, metalloproteinase-1 and -3 (MMP-1 and -3), and tissue inhibitor of metalloproteinase-1 (TIMP-1) as well as the IL-1beta-induced gene expressions of MMP-1 and -3 were analyzed by reverse transcription-polymerase chain reaction (RT-PCR). The protein synthesis of MMP-1 and -3 and TIMP-1 was determined by Western blotting.

RESULTS

The treatment of chondrocytes with DHEA did not affect chondrocyte proliferation or GAG synthesis up to 100 micro M of concentration. The gene expression of type II collagen increased in a dose-dependent manner, while that of type I decreased. DHEA suppressed the expression of MMP-1 significantly at concentrations exceeding 50 micro M. The gene expression of MMP-3 was also suppressed, but this was without statistical significance. The expression of TIMP-1 was significantly increased by DHEA at concentrations exceeding 10 micro M. The effects of DHEA on the gene expressions of MMP-1 and -3 were more prominent in the presence of IL-1beta, in which DHEA suppressed not only MMP-1, but also MMP-3 at the lower concentrations, 10 and 50 micro M, respectively. Western blotting results were in agreement with RT-PCR, which indicates that DHEA acts at the gene transcription level.

CONCLUSIONS

Our study demonstrates that DHEA has no toxic effect on chondrocytes up to 100 micro M of concentration and has an ability to modulate the imbalance between MMPs and TIMP-1 during OA at the transcription level, which suggest that it has a protective role against articular cartilage loss.

Dehydroepiandrosterone therapy ameliorates experimental autoimmune myasthenia gravis in Lewis rats

To detect a possible effect of dehydroepiandrosterone (DHEA) in the pathogenesis of experimental autoimmune myasthenia gravis (EAMG), DHEA (0.5 mg/rat) was administrated intraperitoneally to Lewis rats every other day from day 4 postimmunization (p.i.) to day 35 p.i. with Torpedo acetylcholine receptor (AChR) and Freund's complete adjuvant. Rats treated with DHEA had a lower clinical score (mean clinic score, 2 versus 0.5 on day 37 p.i.) and a lower body weight loss (mean body weight, 169 versus 142 g on day 37 p.i.) compared with control EAMG rats. DHEA treatment decreased serum anti-AChR IgG and IgG2b antibody titers on days 7, 14, and 21 p.i. and inhibited the levels of anti-AChR IgG antibody secreting cells (60%), accompanied by decreased IL-4 (33%) and augmented TGF-beta1-positive cells (41%) among lymph node mononuclear cells. These results obtained from EAMG in Lewis rats further encourage us to study DHEA treatment in human MG.

Age- and sex-related changes in susceptibility of Wistar rats to Strongyloides venezuelensis infection

The effects of host age and sex on susceptibility to Strongyloides venezuelensis in Wistar rats were examined by counting larvae recovered from the lungs of animals 3 days after infection. The susceptibility of female rats to S. venezuelensis rapidly decreased with age and elevated estrogen. Resistance in female rats inoculated at 6 and 10 weeks of age was nine and twenty-fold higher, respectively than that in the youngest group (3 weeks). In contrast, the susceptibility of male animals was lowest in the youngest group, then increased with age and elevated testosterone. Sex differences in susceptibility were not evident in the youngest group, but became apparent with age.

Androgens and estrogens modulate the immune and inflammatory responses in rheumatoid arthritis

Generally, androgens exert suppressive effects on both humoral and cellular immune responses and seem to represent natural anti-inflammatory hormones; in contrast, estrogens exert immunoenhancing activities, at least on humoral immune response. Low levels of gonadal androgens (testosterone/dihydrotestosterone) and adrenal androgens (dehydroepiandrosterone and its sulfate), as well as lower androgen/estrogen ratios, have been detected in body fluids (that is, blood, synovial fluid, smears, salivary) of both male and female rheumatoid arthritis patients, supporting the possibility of a pathogenic role for the decreased levels of the immune-suppressive androgens. Several physiological, pathological, and therapeutic conditions may change the sex hormone milieu and/or peripheral conversion, including the menstrual cycle, pregnancy, the postpartum period, menopause, chronic stress, and inflammatory cytokines, as well as use of corticosteroids, oral contraceptives, and steroid hormonal replacements, inducing altered androgen/estrogen ratios and related effects. Therefore, sex hormone balance is still a crucial factor in the regulation of immune and inflammatory responses, and the therapeutical modulation of this balance should represent part of advanced biological treatments for rheumatoid arthritis and other autoimmune rheumatic diseases.

Pregnancy in renal transplantation: immunologic evaluation of neonates from mothers with transplanted kidney

The occurrence of pregnancy in young female organ transplant recipients may sustain a high risk for prematurity and low rate of malformations in neonates. Therefore, it is necessary to counsel couples who want a child. In case of pregnancy, strict guidelines must be observed. Continuous exposure to CsA in utero seems to impair T-, B- and NK-cell development and function in neonates. This effect is prolonged throughout the first year of life. In addition, low levels of serum immunoglobulins occur at the same time. This leads to suggest a delayed administration of classical vaccinations (after the first 6 months of life) in view of the potential risks of both sub-optimal immunologic responses, and adverse events after the administration of live, attenuated vaccines in infants born from young female organ transplant recipients.

Age and sex steroid-related changes in glucocorticoid sensitivity of pro-inflammatory cytokine production after psychosocial stress

Aging is associated with an increased susceptibility to infections and chronic inflammatory diseases. This might be caused by dysregulations of the endocrine system with increased activity of the hypothalamus-pituitary-adrenal (HPA) axis and decreased levels of sex steroids. Therefore, we investigated the stress-response of the HPA axis and glucocorticoid (GC) sensitivity of pro-inflammatory cytokine production in elderly men, compared to testosterone-treated elderly men and young controls. Stress-induced increases in cortisol did not differ significantly between experimental groups (F=2.10; p>0.10), but GC sensitivity increased significantly in young controls and testosterone-treated elderly men, while a decrease was found in untreated elderly men (F=5.28; p<0.01). We conclude that the increase in GC sensitivity after stress serves to protect the individual from detrimental increases of pro-inflammatory cytokines, a mechanism that is disturbed in elderly men and partly restored by testosterone treatment.

Transcription factors

The regulation of gene expression by transcription factors is fundamental to the phenotype of all cells. The activated phenotype of cells engaged in inflammatory processes is characterized by induced expression of a diverse set of genes, including cytokines, enzymes and cell adhesion molecules. A relatively small number of inducible transcription factors, particularly NF-kappaB, AP-1, NFATs and STATs, are responsible for the expression of a wide variety of inflammatory phenotypic characteristics and therefore play a central role in the pathogenesis of rheumatic diseases. Each of these transcription factors can be modified by existing anti-rheumatic and anti-inflammatory drugs, although adverse effects and limited efficacy remain problems. The future development of therapeutic agents with specificity for transcription factors, especially NF-kappaB, might lead to safer and more effective treatment.

Neuroendocrine immune mechanisms in rheumatic diseases. An overview and future implications

A new physiopathogenetic paradigm may be proposed for RA and possibly its related systemic rheumatic diseases (i.e., mechanisms whereby multiple risk factors initially perturb the homeostasis of core physiologic components over an extended premorbid phase, which may progress to clinical disease in later decompensated stages). These complex interactive processes are likely to be individualized according to genetic, nongenomic somatic, developmental, behavioral, and environmental influences. Future research promises to further elucidate the roles of neuroendocrine mechanisms in the rheumatic diseases and offers promise for enhanced therapies and possible avenues for disease modification if not eventual prevention.