Effect of high-dose methylprednisolone administration on immune functions in multiple sclerosis patients

Targeting Chemokines and Chemokine Receptors in Multiple Sclerosis and Experimental Autoimmune Encephalomyelitis

Multiple sclerosis (MS) is an immune-mediated and neurodegenerative disorder that results in inflammation and demyelination of the central nervous system (CNS). MS symptoms include walking difficulties, visual weakening, as well as learning and memory impairment, thus affecting the quality of the patient's life. Chemokines and chemokine receptors are expressed on the immune cells as well as the CNS resident cells. Several sets of chemokine receptors and their ligands tend to be pathogenic players in MS, including CCL2, CCL3, CCL4, CCL5, CCL7, CCL8, CCL11, CCL17, CCL19, CCL21, CCL22, CXCL1, CXCL8, CXCL9, CXCL10, CXCL11, and CXCL16. Furthermore, current modulatory drugs that are used in the treatment of MS and its animal model, the experimental autoimmune encephalomyelitis (EAE), affect the expression of several chemokine and chemokine receptors. In this review, we highlight the pathogenic roles of chemokines and their receptors as well as utilizing them as potential therapeutic targets through selective agents, such as specific antibodies and receptor blockers, or indirectly through MS or EAE immunomodulatory drugs.

Vaccinations in patients with multiple sclerosis: A Delphi consensus statement

BACKGROUND

Patients with multiple sclerosis (MS) are at increased risk of infection. Vaccination can mitigate these risks but only if safe and effective in MS patients, including those taking disease-modifying drugs.

METHODS

A modified Delphi consensus process (October 2017-June 2018) was used to develop clinically relevant recommendations for making decisions about vaccinations in patients with MS. A series of statements and recommendations regarding the efficacy, safety and timing of vaccine administration in patients with MS were generated in April 2018 by a panel of experts based on a review of the published literature performed in October 2017.

RESULTS

Recommendations include the need for an 'infectious diseases card' of each patient's infectious and immunisation history at diagnosis in order to exclude and eventually treat latent infections. We suggest the implementation of the locally recommended vaccinations, if possible at MS diagnosis, otherwise with vaccination timing tailored to the planned/current MS treatment, and yearly administration of the seasonal influenza vaccine regardless of the treatment received.

CONCLUSION

Patients with MS should be vaccinated with careful consideration of risks and benefits. However, there is an urgent need for more research into vaccinations in patients with MS to guide evidence-based decision making.

Matrix metalloproteinase, vitamin A and methylprednisolone effects on experimentally induced amyloid arthropathy

We evaluated the role of some matrix metalloproteinases (MMPs) in enhancing the effect of vitamin A and the inhibiting effect of methylprednisolone on amyloid arthropathy in brown layer chicks. We used 100 one-day-old Isa brown layer chicks. The chicks were allocated to one of four groups as follows: negative control group (I), vitamin A group (II), positive control group (III) and methylprednisolone group (IV). Amyloid arthropathy was induced by injections of complete Freund's adjuvant into the left intertarsal joints of the chicks. Serum vitamin A and tissue MMP (MMP-1, MMP-2, MMP-9) levels were measured and differences among the groups were investigated. Serum vitamin A rates (μg/dl) were: 63.57 ± 4.10, 47.13 ± 10.62, 53.26 ± 10.79, 98.48 ± 8.20 in groups I, II, III and IV, respectively (p < 0.001). MMP-1, MMP-2 and MMP-9 levels were evaluated in tissues from the chickens with amyloid arthropathy. Methylprednisolone significantly suppressed the release of MMP-1 and MMP-2, and increased the release of MMP-9 in birds with amyloid arthropathy. In addition, vitamin A significantly increased the release of MMP-1, MMP-2 and MMP-9.

Multiple sclerosis, relapses, and the mechanism of action of adrenocorticotropic hormone

Relapses in multiple sclerosis (MS) are disruptive and frequently disabling for patients, and their treatment is often a challenge to clinicians. Despite progress in the understanding of the pathophysiology of MS and development of new treatments for long-term management of MS, options for treating relapses have not changed substantially over the past few decades. Corticosteroids, a component of the hypothalamic-pituitary-adrenal axis that modulate immune responses and reduce inflammation, are currently the mainstay of relapse treatment. Adrenocorticotropic hormone (ACTH) gel is another treatment option. Although it has long been assumed that the efficacy of ACTH in treating relapses depends on the peptide’s ability to increase endogenous corticosteroid production, evidence from research on the melanocortin system suggests that steroidogenesis may only partly account for ACTH influences. Indeed, the melanocortin peptides [ACTH and α-, β-, γ-melanocyte-stimulating hormones (MSH)] and their receptors (Melanocortin receptors, MCRs) exert multiple actions, including modulation of inflammatory and immune mediator production. MCRs are widely distributed within the central nervous system and in peripheral tissues including immune cells (e.g., macrophages). This suggests that the mechanism of action of ACTH includes not only steroid-mediated indirect effects, but also direct anti-inflammatory and immune-modulating actions via the melanocortin system. An increased understanding of the role of the melanocortin system, particularly ACTH, in the immune and inflammatory processes underlying relapses may help to improve relapse management.

Type I interferon signature is high in lupus and neuromyelitis optica but low in multiple sclerosis

OBJECTIVE

Neuromyelitis optica (NMO) is characterized by selective inflammation of the spinal cord and optic nerves but is distinct from multiple sclerosis (MS). Interferon (IFN)-β mitigates disease activity in MS, but is controversial in NMO, with a few reports of disease worsening after IFN-β therapy in this highly active disease. In systemic lupus erythematosus (SLE), IFNs adversely affect disease activity. This study examines for the first time whether serum IFN-α/β activity and IFN-β-induced responses in peripheral blood mononuclear cells (MNC) are abnormally elevated in NMO, as they are in SLE, but contrast to low levels in MS.

METHODS

Serum type I IFN-α/β activity was measured by a previously validated bioassay of 3 IFN-stimulated genes (RT-PCR sensitivity, 0.1 U/ml) rather than ELISA, which has lower sensitivity and specificity for measuring serum IFNs. IFN responses in PBMNC were assessed by in vitro IFN-β-induced activation of phospho-tyrosine-STAT1 and phospho-serine-STAT1 transcription factors, and MxA proteins using Western blots.

RESULTS

Serum IFN-α/β activity was highest in SLE patients, followed by healthy subjects and NMO, but was surprisingly low in therapy-naïve MS. In functional assays in vitro, IFN-β-induced high levels of P-S-STAT1 in NMO and SLE, but not in MS and controls. IFN-β-induced MxA protein levels were elevated in NMO and SLE compared to MS.

CONCLUSIONS

Serum IFN activity and IFN-β-induced responses in PBMNC are elevated in SLE and NMO patients versus MS. This argues for similarities in pathophysiology between NMO and SLE and provides an explanation for IFN-induced disease worsening in NMO.

A phase two randomised controlled double blind trial of high dose intravenous methylprednisolone and oral prednisolone versus intravenous normal saline and oral prednisolone in individuals with leprosy type 1 reactions and/or nerve function impairment

BACKGROUND

Leprosy Type 1 reactions are a major cause of nerve damage and the preventable disability that results. Type 1 reactions are treated with oral corticosteroids and there are few data to support the optimal dose and duration of treatment. Type 1 reactions have a Th1 immune profile: cells in cutaneous and neural lesions expressing interferon-γ and interleukin-12. Methylprednisolone has been used in other Th1 mediated diseases such as rheumatoid arthritis in an attempt to switch off the immune response and so we investigated the efficacy of three days of high dose (1 g) intravenous methylprednisolone at the start of prednisolone therapy in leprosy Type 1 reactions and nerve function impairment.

RESULTS

Forty-two individuals were randomised to receive methylprednisolone followed by oral prednisolone (n = 20) or oral prednisolone alone (n = 22). There were no significant differences in the rate of adverse events or clinical improvement at the completion of the study. However individuals treated with methylprednisolone were less likely than those treated with prednisolone alone to experience deterioration in sensory function between day 29 and day 113 of the study. The study also demonstrated that 50% of individuals with Type 1 reactions and/or nerve function impairment required additional prednisolone despite treatment with 16 weeks of corticosteroids.

CONCLUSIONS

The study lends further support to the use of more prolonged courses of corticosteroid to treat Type 1 reactions and the investigation of risk factors for the recurrence of Type 1 reaction and nerve function impairment during and after a corticosteroid treatment.

TRIAL REGISTRATION

Controlled-Trials.com ISRCTN31894035.

The role of chicken IL-1beta, IL-6 and TNF-alpha in the occurrence of amyloid arthropathy

In this study, the roles of IL-1beta, IL-6 and TNF-alpha in amyloid arthropathic chickens with variable amounts (severe, moderate and mild) of amyloid accumulation were investigated. The presence and the levels of cytokines were evaluated in serum and in joint tissues by using ELISA and immunohistochemistry, respectively. One hundred brown layer chicks were allocated into four groups and intra-articular injections of Freund's adjuvant were used to induce amyloid arthropathy in Groups II, III and IV. Vitamin A in group II, and methylprednisolone in Group IV were added to enhance and to reduce the severity of amyloidosis, respectively. At the end of the study, a positive correlation was observed among the incidence and severity of amyloidosis, the serum amyloid A levels and the IL-1beta values both in the serum and tissues. Elevation in the tissue TNF-alpha levels in parallel with the severity of amyloidosis has also been noted. As a conclusion, IL-1beta appears to play an important role in avian AA amyloidosis either alone or in combination with TNF-alpha. Further investigation is needed for understanding the role of the pro-inflammatory cytokines in avian AA amyloidosis.

Glucocorticoids regulate innate immunity in a model of multiple sclerosis: reciprocal interactions between the A1 adenosine receptor and beta-arrestin-1 in monocytoid cells

Desensitization of seven transmembrane receptors (7TMRs), which are modulated by the beta-arrestins, leads to altered G protein activation. The A1 adenosine receptor (A1AR) is an antiinflammatory 7TMR exhibiting reduced expression and activity in both multiple sclerosis (MS) and the murine MS model, experimental autoimmune encephalomyelitis (EAE) in monocytoid cells. Herein, we report that beta-arrestin-1 expression was increased in brains of MS patients relative to non-MS brains, whereas A1AR expression was concomitantly reduced. This inverse relationship between beta-arrestin-1 and A1AR was confirmed in cultured monocytoid cells as beta-arrestin-1 overexpression resulted in a down-regulation of A1AR together with the internalization of the surface receptor. Moreover, a physical interaction between beta-arrestin-1 and A1AR was demonstrated in monocytoid cells. Proinflammatory cytokines regulated the A1AR/beta-arrestin-1 interactions, while A1AR activation also modulated proinflammatory cytokines expression. During EAE, beta-arrestin-1 and A1AR expression in the spinal cord displayed a similar pattern compared to that observed in MS brains. EAE-induced neuroinflammation and neurobehavioral deficits were suppressed by glucocorticoid treatments, accompanied by concurrent reduced beta-arrestin-1 and enhanced A1AR expression. Thus, the interplay between beta-arrestin-1 and A1AR in the central nervous system during neuroinflammation represents a reciprocal regulatory mechanism through which neuroprotective therapeutic strategies for neuroinflammatory diseases might be further developed.

Corticosteroids for multiple sclerosis: II. Application for disease-modifying effects

Physicians who treat multiple sclerosis (MS) face the challenge of patients exhibiting ongoing disease activity, including exacerbations, loss of functional capabilities, intellectual decline, and radiologic progression, despite being on a disease-modifying agent (DMA). After searching for factors that might at least in part explain these changes--such as nonadherent drug-taking behavior, or the presence of interferon-neutralizing antibodies--some providers may ultimately decide to switch the patient to another DMA. In most circumstances, patients likely derive only partial effects from these agents, even in the absence of compromising factors. Thus, a number of factors must be considered in order to intensify the treatment regimen in response to disease progression. In the context of an inadequate treatment response to a DMA, some clinicians will convert the patient to an alternative therapy, and others will instead use a second agent in combination with the first (the so-called platform agent). In the first of this two-part series, we explored the use of anti-inflammatory CS and ACTH to treat MS exacerbations. Although we underscored the limited availability of evidence-based studies to support specific regimens for this purpose, there is an even greater paucity of data to support the routine use of these agents in order to achieve chronic disease-modifying effects in those who continue to deteriorate clinically, radiographically, or both. Without doubt, a number of factors influence the formulation of combination treatment plan for MS. Nevertheless, we will focus on the rationale and practical schemes that can be considered for using corticosteroids (CS) (and perhaps even ACTH) in an attempt to modify various domains of ongoing disease activity.

High dose methylprednisolone induces FcγRI on granulocytes in MS-patients

Immune complexes impinge on receptors for the Fc domain of IgG (FcgammaR) and may thus influence the disease course in multiple sclerosis (MS). We analyzed FcgammaR distribution on monocytes and granulocytes in twenty relapsing-remitting MS patients at baseline, immediately after a five day course of high dose intravenous methylprednisolone (IVMP) treatment and after two months. After a five day course of IVMP the proportion of granulocytes with FcgammaRI was increased, P=0,002. There was no change in FcgammaRII and FcgammaRIII expression. The effect of IVMP on FcgammaRI expression could be important for the clearance of immune complexes in MS.

Corticosteroids and Multiple Sclerosis: To Treat or Not to Treat?

Although a rare disease, multiple sclerosis (MS) has a high prevalence rate in Canada and affects many Canadians and their families. An autoimmune disease of the central nervous system, it results in the destruction of the myelin sheath that surrounds the nerve axons. High-dose IV steroid therapy is often used to treat an acute exacerbation in MS. Steroids have immunosuppressant effects that work to decrease the autoimmune pathology component of the disease and to reduce the inflammation around the nerve axon, thereby promoting closer contact of the damaged myelin and subsequently partially restoring adequate electrical nerve conduction to reduce symptoms.

The high prevalence rate of MS in Canada makes it vital for pharmacists to become more aware of the different aspects of the disease and how these relate to therapy. The pharmacist should be aware of the adverse effects and impact of high-dose IV steroids in MS patients. The purpose of this review is threefold: 1) to provide a better understanding of MS pathology; 2) to contribute a systematic review of steroids; and 3) to assist in the clinical decision-making process and in the counselling requirements for patients on high-dose steroids.

The effects of vitamin A, pentoxyfylline and methylprednisolone on experimentally induced amyloid arthropathy in brown layer chicks

The effects of vitamin A, pentoxyfylline and methylprednisolone on experimentally induced amyloid arthropathy were investigated. In this study, 175 1-day-old brown layer chicks were used. Throughout the study Group II (vitamin A) received high doses of vitamin A (75,000 IU/kg), whereas Group I (negative control), Group III (positive control), Group IV (pentoxyfylline) and Group V (methylprednisolone) received normal levels of vitamin A in the diet. At the fifth week, the experimental Groups II, III, IV and V were injected with Freund's adjuvant intra-articularly to induce amyloid arthropathy. Group IV received pentoxyfylline and Group V received methylprednisolone (10 mg/kg, intramuscularly) once. Joint and blood samples were examined 13 weeks after the injections. The values in Groups I, II, III, IV and V, respectively, were as follows: amyloid arthropathy formation (%), 0, 100, 87, 76, 66; serum amyloid A (ng/ml), 166+/-17, 607+/-40, 423+/-39, 342+/-27, 293+/-22; serum retinol (microg/dl): 59.75+/-3.8, 42.72+/-3, 59.24+/-3.6, 102+/-9.1, 101.3+/-12.3; heterophil/lymphocyte ratio: 0.504, 0.75, 0.75, 0.087, 0.44. In conclusion, it was observed that vitamin A enhanced the development of amyloid arthropathy and there were positive associations between amyloidosis, increased levels of serum amyloid A and increased numbers of tissue infiltrating macrophages. Methylprednisolone had a more successful inhibitory effect on amyloid arthropathy than pentoxyfylline.

Methylprednisolone increases neuronal apoptosis during autoimmune CNS inflammation by inhibition of an endogenous neuroprotective pathway

Optic neuritis is one of the most common clinical manifestations of multiple sclerosis (MS), a chronic inflammatory disease of the CNS. High-dosage methylprednisolone treatment has been established as the standard therapy of acute inflammation of the optic nerve (ON). The rationale for corticosteroid treatment lies in the antiinflammatory and immunosuppressive properties of these drugs, as shown in experimental autoimmune encephalomyelitis (EAE), the animal model of MS. To investigate the influence of methylprednisolone therapy on the survival of retinal ganglion cells (RGCs), the neurons that form the axons of the ON, we used a rat model of myelin oligodendrocyte glycoprotein (MOG)-induced EAE. Optic neuritis was diagnosed by recording visual evoked potentials, and RGC function was monitored by measuring electroretinograms. Methylprednisolone treatment significantly increased RGC apoptosis during MOG-EAE. By Western blot analysis, we identified the underlying molecular mechanism: a suppression of mitogen-activated protein kinase (MAPK) phosphorylation, which is a key event in an endogenous neuroprotective pathway. The methylprednisolone-induced inhibition of MAPK phosphorylation was calcium dependent. Hence, we provide evidence for negative effects of steroid treatment on neuronal survival during chronic inflammatory autoimmune disease of the CNS, which should result in a reevaluation of the current therapy regimen.

Depression-like changes of the sleep-EEG during high dose corticosteroid treatment in patients with multiple sclerosis

Acute exacerbations of multiple sclerosis (MS) are commonly treated with high doses of corticosteroids that can influence sleep regulation and hypothalamo-pituitary-adrenal (HPA) activity. We examined the sleep-EEG (including conventional and spectral EEG analysis) in 9 female patients with relapsing-remitting MS (and no psychiatric disorder) just prior to and on days 2 and 10 of high dose corticosteroid treatment (500 mg/day methylprednisolone given IV for 5 days, then PO taper down) and age-matched healthy female controls. Before treatment with corticosteroids, MS patients compared to controls showed few changes of the sleep EEG, namely a significant increase in slow wave sleep (SWS) and a decrease in stage 2 sleep. In contrast, on day 10, but not day 2 of treatment, MS patients showed a number of sleep-EEG changes typically observed in patients with depression, including a reduction in REM latency, an increase in REM density, a decrease in the SWS and delta sleep ratio and a decrease in sigma EEG activity. However, no concomitant effect of treatment on mood was noted. In summary, unlike acute treatment with methylprednisolone, prolonged treatment induces several changes of the sleep-EEG in MS patients, that are also observed in patients with an acute depressive episode. Further prospective studies with longer-term follow-up are needed to examine the clinical relevance of our preliminary data.

Low interferon gamma producers are better treatment responders: a two-year follow-up of interferon beta-treated multiple sclerosis patients

As response to interferon beta (IFNB) treatment, a 50% reduction of the mean relapse rate compared to pretreatment values has been reported. However, individual responses vary considerably, ranging from no reduction in exacerbation frequency to complete suppression of relapses for at least two years. At the moment, valid predictors for IFNB response are lacking. Here we present a prospective evaluation of 33 patients with primary relapsing multiple sclerosis who were followed for two years of IFNB treatment A low interferon gamma (IFG) production before treatment predicted a two-year term without exacerbations in 68.8% of cases correctly, whereas a high pretreatment IFG production implied the risk of at least one relapse in the first two years in 70.6%. These preliminary results encourage further evaluation of IFG as predictor of an IFNB treatment response.

Production of IL-1beta and IL-1Ra as risk factors for susceptibility and progression of relapse-onset multiple sclerosis

Interleukin-1beta (IL-1beta) is present in multiple sclerosis (MS) lesions. Interleukin-1 receptor antagonist (IL-1Ra) moderates the induction of experimental autoimmune encephalomyelitis (EAE). Here, we show that families that are characterized by high IL-1beta over IL-1Ra production ratio are at 2.2-fold (95% CI, 1.0-4.8; p=0.05) increased risk to have a patient relative with relapse-onset MS than families with a low ratio. It is also related to the reduction of volumetric magnetization transfer ratio (MTR) histogram height, a measure of parenchymal integrity (p=0.04). Those families who combine a high IL-1beta over IL-1Ra ratio with a high tumor necrosis factor (TNF) over IL-10 production ratio have a 6.2-fold (95% CI, 1.8-21; p=0.002) increased risk. Innate production of IL-1beta and IL-1Ra is not related to the outcome of primary progressive MS. Taq1 polymorphism in the IL-1beta gene and the variable number of tandem repeats (VNTR) polymorphism of 86-base pairs within the IL-1Ra gene cannot explain these findings.

Apoptosis signals in atopy and asthma measured with cDNA arrays

A variety of studies have stressed the importance of the control of inflammatory cell longevity and the balance of pro-survival and pro-apoptotic signalling. Recently, asthma was found to be associated with reduced apoptosis of inflammatory cells in lung tissue. The aim of the study was to investigate the systemic activation of apoptosis pathways using cDNA array technology in atopy and asthma. Eighteen atopic asthmatics (AA), eight atopic non-asthmatic (AN) and 14 healthy control subjects (C) were included in the study. Peripheral blood mononuclear cells were separated with gradient centrifugation, mRNA purified and the reverse-transcribed probes hybridized to cDNA arrays. The signals were compared by standardizing to the 100 most expressed genes and group differences assessed with the Mann-Whitney U-test. We found a concerted up-regulation of several pro-survival cytokines and growth factors in AN and AA. FAS and FASL were not differentially expressed, but FAST kinase was over-expressed in AN and AA. The tumour necrosis factor pathway was activated in AN and AA with increased cytokine and receptor levels and increased TRAF2, an intracellular signalling product. There were indications of a down-regulated p53 system. In contrast, the Bcl-2 family of genes showed a net pro-apoptotic profile in AN and AA. The group of caspases showed a constant gene expression pattern in all groups. In conclusion, significant differences in the expression of apoptosis-related genes were found in peripheral blood of atopic individuals with and without asthma. cDNA array technology proved to be useful and may be complementary to DNA-based studies in order to analyse interactive and multidimensional pathways as shown here for apoptosis.

Increased interferon-gamma (IFN-gamma), IL-10 and decreased IL-4 mRNA expression in peripheral blood mononuclear cells (PBMC) from patients with systemic lupus erythematosus (SLE)

Cytokines are important regulators of lymphocyte function in SLE. However, the profile of Th1 and Th2 cytokines produced by circulating lymphocytes in human SLE has not been clearly elucidated. The aim of the present study was to characterize the gene expressions of the Th1-type cytokine IFN-gamma, and the Th2-type cytokines IL-10 and IL-4 in PBMC of 15 patients with SLE and 10 healthy individuals by a semiquantitative reverse transcriptase polymerase chain reaction (RT-PCR). Our results showed that expression of IFN-gamma (P = 0.0004) and IL-10 (P = 0.002) transcripts were significantly increased in PBMC of patients with SLE compared with healthy controls. By contrast, expression of IL-4 transcripts in PBMC of patients with SLE was significantly decreased compared with the healthy controls (P = 0.0008). Primary sources of IL-10 were B cells and monocytes, with variable contribution of T cells as detected in various fractions of PBMC of patients with SLE (P = 0.049). These findings support the hypothesis that the enhanced production of IFN-gamma by mononuclear cells may trigger inflammatory responses, together with the enhanced production of IL-10 resulting in autoantibody production by B cells in human SLE.

Increased cortisol levels in human umbilical cord blood inhibit interferon alpha production of neonates

Immunosuppressive effects of corticosteroids are generally known, but the mechanisms influencing the immune system are poorly understood. However, a correlation between cortisol levels and cytokine production has been reported by several investigators. In the present study we determined cortisol concentrations in human umbilical cord blood. Cord blood samples from healthy and normal term infants born by vaginal delivery and blood samples from healthy adult donors, respectively, were analysed. Our data revealed significantly increased cortisol levels in cord blood. In contrast, samples derived from infants born by caesarian section seem to be normal. Further experiments were performed to analyse the influence of cortisol on the production of interferon (IFN) alpha. Therefore, peripheral blood mononuclear cells (PBMC) were separated from peripheral blood of healthy adult volunteers. Cortisol was added to a final concentration of 30 micrograms/dl as measured in cord blood. Following stimulation with Newcastle disease virus (NDV) the IFN-alpha release was 50 to 60% reduced compared to untreated controls. These data suggest that increased levels of cortisol in cord blood might influence the IFN-alpha response of newborns. We propose that cortisol levels increase transiently after birth and may alter several physiological as well as immunological reactions. Since cord blood is commonly used to investigate features of the neonatal immune system, different behaviour as a result of temporarily increased cortisol concentrations should be considered.