Biological modifier therapy for the treatment of rheumatoid arthritis

Neutralizing Anti-IL20 Antibody Treatment Significantly Modulates Low Grade Inflammation without Affecting HbA1c in Type 2 Diabetic db/db Mice

Low grade inflammation is present in pre-clinical and human type 2 diabetes. In this process, several cytokines like IL-1β and inflammatory cells like macrophages are activated and demonstrated to participate to the disease initiation and progression. IL-20 is a cytokine known to play non-redundant roles in progression of several inflammatory diseases. To address the therapeutic effect of inhibiting the IL-20 pathway in diabetes, diabetic db/db mice were treated with neutralizing anti-IL20 antibodies in vivo and both metabolic and inflammatory parameters were followed. Diabetic islets expressed the IL-20 cytokine and all IL-20 receptor components in elevated levels compared to resting non-diabetic islets. Islets were responsive to ex vivo IL-20 stimulation measured as SOCS induction and KC and IL-6 production. Neutralizing anti-IL20 treatment in vivo had no effect on HbA1c or weight although the slope of blood glucose increase was lowered. In contrast, anti-IL20 treatment significantly reduced the systemic low-grade inflammation and modulated the local pancreatic immunity. Significant reduction of the systemic IL-1β and MCP-1 was demonstrated upon anti-IL20 treatment which was orchestrated with a reduced RANTES, IL-16 and IL-2 but increased TIMP-1, MCP-1 and IL-6 protein expression locally in the pancreas. Interestingly, anti-IL20 treatment induced an expansion of the myeloid suppressor CD11bGr1int macrophage while reducing the number of CD8 T cells. Taken together, anti-IL20 treatment showed moderate effects on metabolic parameters, but significantly altered the low grade local and systemic inflammation. Hence, future combination therapies with anti-IL20 may provide beneficial therapeutic effects in type 2 diabetes through a reduction of inflammation.

The Role of Inflammatory Cytokines, the RANKL/OPG Axis, and the Immunoskeletal Interface in Physiological Bone Turnover and Osteoporosis

Although it has long been recognized that inflammation, a consequence of immune-driven processes, significantly impacts bone turnover, the degree of centralization of skeletal and immune functions has begun to be dissected only recently. It is now recognized that formation of osteoclasts, the bone resorbing cells of the body, is centered on the key osteoclastogenic cytokine, receptor activator of NF- κ B ligand (RANKL). Although numerous inflammatory cytokines are now recognized to promote osteoclast formation and skeletal degradation, with just a few exceptions, RANKL is now considered to be the final downstream effector cytokine that drives osteoclastogenesis and regulates osteoclastic bone resorption. The biological activity of RANKL is moderated by its physiological decoy receptor, osteoprotegerin (OPG). New discoveries concerning the sources and regulation of RANKL and OPG in physiological bone turnover as well as under pathological (osteoporotic) conditions continue to be made, opening a window to the complex regulatory processes that control skeletal integrity and the depth of integration of the skeleton within the immune response. This paper will examine the interconnection between bone turnover and the immune system and the implications thereof for physiological and pathological bone turnover.

[Adult onset septic coxitis : etiology, diagnostics, indication for and technique of open revision of the hip]

Septic arthritis of the hip can be caused via a hematogenous route, by penetration of periarticular infections, open hip trauma, injections or operations. Ultrasound, hip puncture and elevation of inflammatory parameters lead to the diagnosis. Differentiation of septic arthritis from gout and chondrocalcinosis may be difficult. Nevertheless, early revision of the hip has to be performed to avoid joint destruction. Open revision is the therapy of choice in the majority of cases.

Treatment of pain in juvenile idiopathic arthritis: A survey of pediatric rheumatologists

OBJECTIVE

To assess the opinions and current practice of pediatric rheumatologists regarding treatment of chronic pain in children with juvenile idiopathic arthritis (JIA).

METHODS

Standardized questionnaires were distributed to pediatric rheumatologists who are members of the Children's Arthritis and Rheumatology Research Alliance. Demographic data, opinions, and attitudes were solicited about pain assessment, current treatment of JIA with residual pain, and actual use of opioids to treat pain in children with JIA.

RESULTS

Of 99 rheumatologists who were contacted, 53 responses were received (53.5%). No significant demographic differences were found in attitudes about pain management and use of opioids. A total of 77.3% of respondents agreed that there are patients who continue to have significant pain despite adequate treatment. However, 59.6% disagreed with the use of opioid analgesics for treatment of those patients. Cross tabulations showed significant relationships between attitudes about opioid use and concerns for side effects, including drowsiness, fatigue, and constipation (chi(2) = 1.16, P > 0.05), as well as addiction (chi(2) = 5.51, P = 0.019). Thirty percent of those who strongly disagreed with opioid use and 52.4% of those who disagreed had in fact prescribed opioids in the past year. The most commonly prescribed opioids were codeine and oxycodone. Practitioners' perceived knowledge of the drugs significantly affected their likelihood to prescribe them.

CONCLUSION

Pediatric rheumatologists are divided in their attitudes regarding treatment of residual pain in children with JIA. Concern for side effects appears to be a major factor in the decision to prescribe these analgesics. More data are needed to facilitate clearer cost-benefit analyses in the decision to prescribe opioids to this clinical population.

Perioperative management of patients with rheumatoid arthritis in the era of biologic response modifiers

PURPOSE OF REVIEW

This article provides guidelines for the perioperative management of the most commonly used antirheumatic drugs being used to treat patients with rheumatoid arthritis, with an emphasis on the relatively new addition of biologic response modifiers.

RECENT FINDINGS

Few clinical data exist examining the perioperative management of the biologic drugs, which include the inhibitors of tumor necrosis factor-alpha (etanercept, infliximab, and adalimumab), the interleukin-1 receptor antagonist anakinra, and to a much lesser extent the CD20 inhibitor rituximab. The only human data available in that regard is based on the use of the tumor necrosis factor-alpha inhibitor infliximab in surgical patients with Crohn disease. Although quite limited, that data appeared favorable in finding that infliximab did not result in an increased risk of postoperative complications in that setting.

SUMMARY

Perioperative guidelines have never been well established for a majority of the traditional antirheumatic drugs in use today. Recommendations for the perioperative use of nonsteroidal antiinflammatory drugs and glucocorticoids have the most evidence-based support. Data for the use of methotrexate are also available from which to generate reasonable guidelines; however, for the remaining antirheumatic drugs in current use, the available data cannot support any clear evidence-based recommendations. To provide reasonable guidelines for the use of the biologics, perhaps the best we can do is to extrapolate from the very limited data coming from the concurrent use of infliximab in patients with Crohn disease who have undergone surgery. Beyond that, we are left with animal and tissue culture data from which any recommendations would be rather tenuous.

Glucosamine and chondroitin sulfate: biological response modifiers of chondrocytes under simulated conditions of joint stress

OBJECTIVE

To test the hypothesis that chondrocytes are more responsive to the chondroprotective agents, glucosamine (glcN) and chondroitin sulfate (CS), under in vitro conditions simulating in vivo joint stress.

DESIGN

Synthetic and anticatabolic activities of bovine articular cartilage were assayed using 35-sulfate labeling and assaying the specific activity of glycosaminoglycans (GAGs) under the conditions of enzyme-induced matrix depletion, heat stress, mechanical compression and cytokine stress.

RESULTS

The response of cartilage to simulated conditions of in vivo stress varies, depending on the type stress and age of the animal. Cartilage from aged animals was more responsive to stress and to glcN and CS. Pronase-induced matrix depletion and mechanical stress increased proteoglycan synthetic activity. Exposure to glcN and CS significantly enhanced this stress response from 85 to 191% and from 40 to 1000%, respectively. Heat stress and stromelysin digestion decreased synthetic activity, which was reversed or normalized on exposure to glcN and CS. Cartilage from young joints was somewhat refractory to the level of stress imposed and to treatment with glcN and CS.

CONCLUSION

The metabolic response of cartilage from aged animals to glcN and CS under simulated conditions of in vivo stress is significantly greater than that seen in nonstressed or young tissue. By enhancing the "protective" metabolic response of chondrocytes to stress, glcN and CS may improve its ability for repair and regeneration. These observations suggest that these compounds function as biological response modifiers (BRMs), agents which boost natural protective responses of tissues under adverse environmental conditions.

New indications for treatment of chronic inflammation by TNF-alpha blockade

The impressive anti-inflammatory effects of the tumor necrosis factor (TNF)alpha blockers etanercept and infliximab have led to their use in multiple inflammatory diseases besides their original indication, rheumatoid arthritis (RA). The well-studied clinical effects of both agents in RA are the reduction of signs and symptoms of joint inflammation as well as the arrest of bone destruction. Infliximab has also been Food and Drug Administration-approved in the treatment of Crohn disease; etanercept is now FDA-approved for juvenile chronic arthritis and psoriatic arthritis. Favorable initial clinical trials have been reported in other rheumatic diseases, including ankylosing spondylitis and adult Still disease. In addition, TNF alpha blockade is being studied in the treatment of uveitis, myelodysplastic syndromes, and graft-versus-host disease. Studies in sepsis and septic shock have identified small subsets of patients that may benefit from TNF alpha blockade, but broader use in septic patients has not improved survival. The TNF alpha blockers have had relatively infrequent serious side effects, especially compared with the immunosuppressive and cytotoxic agents otherwise employed to treat these diseases. Further studies of optimal dosing, combination with other therapies, and long-term benefits and side effects will emerge from future trials.