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Kralj-Hans I, Li K, Wesek A, Lamorgese A, Omar F, Ranasinghe K, McGee M, Brack K, Li S, Aggarwal R, Bulle A, Kodre A, Sharma S, Fluck D, John I, Sharma P, Belsey JD, Li L, Seshasai SRK, Li HL, Marczin N, Chen Z. Leflunomide treatment for patients hospitalised with COVID-19: DEFEAT-COVID randomised controlled trial. BMJ Open 2023; 13:e068179. [PMID: 37055207 PMCID: PMC10105917 DOI: 10.1136/bmjopen-2022-068179] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/15/2023] Open
Abstract
OBJECTIVE To evaluate the clinical efficacy and safety of leflunomide (L) added to the standard-of-care (SOC) treatment in COVID-19 patients hospitalised with moderate/critical clinical symptoms. DESIGN Prospective, open-label, multicentre, stratified, randomised clinical trial. SETTING Five hospitals in UK and India, from September 2020 to May 2021. PARTICIPANTS Adults with PCR confirmed COVID-19 infection with moderate/critical symptoms within 15 days of onset. INTERVENTION Leflunomide 100 mg/day (3 days) followed by 10-20 mg/day (7 days) added to standard care. PRIMARY OUTCOMES The time to clinical improvement (TTCI) defined as two-point reduction on a clinical status scale or live discharge prior to 28 days; safety profile measured by the incidence of adverse events (AEs) within 28 days. RESULTS Eligible patients (n=214; age 56.3±14.9 years; 33% female) were randomised to SOC+L (n=104) and SOC group (n=110), stratified according to their clinical risk profile. TTCI was 7 vs 8 days in SOC+L vs SOC group (HR 1.317; 95% CI 0.980 to 1.768; p=0.070). Incidence of serious AEs was similar between the groups and none was attributed to leflunomide. In sensitivity analyses, excluding 10 patients not fulfilling the inclusion criteria and 3 who withdrew consent before leflunomide treatment, TTCI was 7 vs 8 days (HR 1.416, 95% CI 1.041 to 1.935; p=0.028), indicating a trend in favour of the intervention group. All-cause mortality rate was similar between groups, 9/104 vs 10/110. Duration of oxygen dependence was shorter in the SOC+L group being a median 6 days (IQR 4-8) compared with 7 days (IQR 5-10) in SOC group (p=0.047). CONCLUSION Leflunomide, added to the SOC treatment for COVID-19, was safe and well tolerated but had no major impact on clinical outcomes. It may shorten the time of oxygen dependence by 1 day and thereby improve TTCI/hospital discharge in moderately affected COVID-19 patients. TRIAL REGISTRATION NUMBERS EudraCT Number: 2020-002952-18, NCT05007678.
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Affiliation(s)
| | - Kuo Li
- Imperial College, London, UK
| | | | | | - Fatima Omar
- Ashford and Saint Peter's Hospitals NHS Trust, Chertsey, UK
| | | | - Megan McGee
- Ashford and Saint Peter's Hospitals NHS Trust, Chertsey, UK
| | - Kieran Brack
- Ashford and Saint Peter's Hospitals NHS Trust, Chertsey, UK
| | - Shiliang Li
- East China University of Science and Technology, Shanghai, China
| | | | - Ajay Bulle
- Meditrina Institute of Medical Science, Nagpur, India
| | | | - Shashank Sharma
- St Peters Hospital Emergency Department, Ashford and Saint Peter's Hospitals NHS Trust, Chertsey, UK
| | - David Fluck
- Cardiology, Ashford and Saint Peter's Hospitals NHS Trust, Chertsey, UK
| | - Isaac John
- Ashford and Saint Peter's Hospitals NHS Trust, Chertsey, UK
| | | | | | - Ling Li
- Department of Engineering, City University, London, UK
| | | | - Hong Lin Li
- Shanghai Key Laboratory of New Drug Design, Shanghai, China
| | | | - Zhong Chen
- Ashford and Saint Peter's Hospitals NHS Trust, Chertsey, UK
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Freeman ML, Clagett BM, Moisi D, Yeh E, Morris CD, Ryu A, Rodriguez B, Stein JH, Deeks SG, Currier JS, Hsue PY, Anthony DD, Calabrese LH, Ribaudo HJ, Lederman MM. Methotrexate Inhibits T Cell Proliferation but Not Inflammatory Cytokine Expression to Modulate Immunity in People Living With HIV. Front Immunol 2022; 13:924718. [PMID: 35967371 PMCID: PMC9374564 DOI: 10.3389/fimmu.2022.924718] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 06/10/2022] [Indexed: 11/13/2022] Open
Abstract
Inflammation associated with increased risk of comorbidities persists in people living with HIV (PWH) on combination antiretroviral therapy (ART). A recent placebo-controlled trial of low-dose methotrexate (MTX) in PWH found that numbers of total CD4 and CD8 T cells decreased in the low-dose MTX arm. In this report we analyzed T cell phenotypes and additional plasma inflammatory indices in samples from the trial. We found that cycling (Ki67+) T cells lacking Bcl-2 were reduced by MTX but plasma inflammatory cytokines were largely unaffected. In a series of in vitro experiments to further investigate the mechanisms of MTX activity, we found that MTX did not inhibit effector cytokine production but inhibited T cell proliferation downstream of mTOR activation, mitochondrial function, and cell cycle entry. This inhibitory effect was reversible with folinic acid, suggesting low-dose MTX exerts anti-inflammatory effects in vivo in PWH largely by blocking T cell proliferation via dihydrofolate reductase inhibition, yet daily administration of folic acid did not rescue this effect in trial participants. Our findings identify the main mechanism of action of this widely used anti-inflammatory medicine in PWH and may provide insight into how MTX works in the setting of other inflammatory conditions.
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Affiliation(s)
- Michael L. Freeman
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, Case Western Reserve University/University Hospitals, Cleveland Medical Center, Cleveland, OH, United States
| | - Brian M. Clagett
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, Case Western Reserve University/University Hospitals, Cleveland Medical Center, Cleveland, OH, United States
| | - Daniela Moisi
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, Case Western Reserve University/University Hospitals, Cleveland Medical Center, Cleveland, OH, United States
| | - Eunice Yeh
- Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health, Boston, MA, United States
| | - Charles D. Morris
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, Case Western Reserve University/University Hospitals, Cleveland Medical Center, Cleveland, OH, United States
| | - Angela Ryu
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, Case Western Reserve University/University Hospitals, Cleveland Medical Center, Cleveland, OH, United States
| | - Benigno Rodriguez
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, Case Western Reserve University/University Hospitals, Cleveland Medical Center, Cleveland, OH, United States
| | - James H. Stein
- Division of Cardiovascular Medicine, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
| | - Steven G. Deeks
- Division of HIV, Infectious Diseases and Global Medicine, Department of Medicine, University of San Francisco School of Medicine, San Francisco, CA, United States
| | - Judith S. Currier
- Division of Infectious Diseases, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States
| | - Priscilla Y. Hsue
- Division of Cardiology, Department of Medicine, University of California, San Francisco School of Medicine, San Francisco, CA, United States
| | - Donald D. Anthony
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, Case Western Reserve University/University Hospitals, Cleveland Medical Center, Cleveland, OH, United States
- Louis Stokes Cleveland Veterans Affairs Medical Center, US Department of Veterans Affairs, Cleveland, OH, United States
- Division of Rheumatic Diseases, MetroHealth Medical Center, Cleveland, OH, United States
| | - Leonard H. Calabrese
- Fasenmyer Center for Immunology, Division of Rheumatic Diseases, Cleveland Clinic, Cleveland, OH, United States
| | - Heather J. Ribaudo
- Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health, Boston, MA, United States
| | - Michael M. Lederman
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, Case Western Reserve University/University Hospitals, Cleveland Medical Center, Cleveland, OH, United States
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den Braanker H, Wervers K, Mus AMC, Bangoer PS, Davelaar N, Luime J, Tchetverikov I, Hazes JMW, Vis M, Lubberts E, Kok MR. Achieving sustained minimal disease activity with methotrexate in early interleukin 23-driven early psoriatic arthritis. RMD Open 2021; 6:rmdopen-2020-001175. [PMID: 32669451 PMCID: PMC7425114 DOI: 10.1136/rmdopen-2020-001175] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Revised: 03/13/2020] [Accepted: 04/02/2020] [Indexed: 01/14/2023] Open
Abstract
Objectives Methotrexate (MTX) is currently the recommended first-line therapy for treating psoriatic arthritis (PsA), despite lacking clear evidence. No estimates of efficacy of MTX in usual care and no clear MTX responsive clinical or laboratory variables are currently available. This study describes the response to MTX monotherapy in newly diagnosed patients with PsA in usual care. Second, we compared clinical variables and cytokine profiles in patients responding and not responding to MTX monotherapy. Methods We used data collected in the Dutch southwest Early Psoriatic Arthritis cohoRt study to select patients with PsA with oligoarthritis or polyarthritis, and at least 1 year follow-up. We analysed disease activity at 6 months of patients who started MTX monotherapy and still used MTX monotherapy 1 year after diagnosis. Cytokine profiles were determined at baseline and after 3 and 6 months with a bead-based multi-immunoassay. Results We identified 219 patients of which 183 (84%) patients started MTX monotherapy within 6 months after diagnosis. 90 patients used MTX monotherapy throughout the first year of which 44 patients (24%) reached minimal disease activity(MDA) at 6 months, decreasing to 33 patients (18%) after 1 year. Non-responders had significantly higher concentrations of interleukin (IL) 23 and IL-10 before and during MTX therapy. Conclusions Our results showed that only 18% of patients with PsA are in sustained MDA after 1 year of MTX monotherapy and non-responders more often had IL-23-driven disease. Our results indicate the need for more treat-to-target and personalised therapy strategies in PsA.
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Affiliation(s)
- Hannah den Braanker
- Department of Rheumatology and Clinical Immunology, Maasstad Hospital, Rotterdam, Netherlands.,Department of Rheumatology, Erasmus Medical Centre, Rotterdam, Netherlands
| | - Kim Wervers
- Department of Rheumatology, Erasmus Medical Centre, Rotterdam, Netherlands
| | - Adriana M C Mus
- Department of Rheumatology, Erasmus Medical Centre, Rotterdam, Netherlands
| | - Priyanka S Bangoer
- Department of Rheumatology, Erasmus Medical Centre, Rotterdam, Netherlands
| | - Nadine Davelaar
- Department of Rheumatology, Erasmus Medical Centre, Rotterdam, Netherlands
| | - Jolanda Luime
- Department of Rheumatology, Erasmus Medical Centre, Rotterdam, Netherlands
| | - Ilja Tchetverikov
- Department of Rheumatology, Albert Schweitzer Ziekenhuis, Dordrecht, Netherlands
| | - J M W Hazes
- Department of Rheumatology, Erasmus Medical Centre, Rotterdam, Netherlands
| | - Marijn Vis
- Department of Rheumatology, Erasmus Medical Centre, Rotterdam, Netherlands
| | - Erik Lubberts
- Department of Rheumatology, Erasmus Medical Centre, Rotterdam, Netherlands
| | - Marc R Kok
- Department of Rheumatology and Clinical Immunology, Maasstad Hospital, Rotterdam, Netherlands
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Sokolik R, Iwaszko M, Świerkot J, Wysoczańska B, Korman L, Wiland P, Bogunia-Kubik K. Relationship Between Interleukin-6 -174G/C Genetic Variant and Efficacy of Methotrexate Treatment in Psoriatic Arthritis Patients. PHARMACOGENOMICS & PERSONALIZED MEDICINE 2021; 14:157-166. [PMID: 33536774 PMCID: PMC7850562 DOI: 10.2147/pgpm.s264555] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 11/11/2020] [Indexed: 12/13/2022]
Abstract
Introduction The purpose of the study was to investigate whether single-nucleotide polymorphisms (SNPs) IL-6 −174 G/C and IL-6R Asp358Ala are associated with susceptibility to psoriatic arthritis (PsA) or affect response to treatment with methotrexate (MTX). Patients and Methods Seventy-four patients diagnosed with PsA and qualified for MTX treatment were enrolled to the study. The control group consisted of 120 healthy individuals. Polymorphisms IL-6 −174 G/C and IL-6R Asp358Ala were genotyped using a polymerase chain reaction (PCR) amplification employing LightSNiP assays. Results A significant association between the IL-6 −174 CC genotype and an improved clinical outcome of MTX therapy was observed. A good response was more frequently observed among PsA patients bearing the IL-6 −174 CC genotype than patients with the GC or GG genotypes (P = 0.007). On the other hand, patients carrying the IL-6 −174 GC genotype less frequently responded to MTX treatment as compared to patients with other genotypes (P = 0.006). With respect to the IL-6R Asp358Ala SNP, there were no significant differences in genotype and allelic frequencies in relation to clinical outcome of MTX treatment. No association was found between the IL-6 −174 G/C or IL-6R Asp358Ala SNPs and PsA susceptibility. Conclusion Results from this study provide evidence that the IL-6 −174 G/C polymorphism might influence efficacy of MTX treatment.
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Affiliation(s)
- Renata Sokolik
- Department of Rheumatology and Internal Medicine, Wrocław Medical University, Wrocław, Poland
| | - Milena Iwaszko
- Laboratory of Clinical Immunogenetics and Pharmacogenetics, Hirszfeld Institute of Immunology and Experimental Therapy, Polish Academy of Sciences, Wrocław, Poland
| | - Jerzy Świerkot
- Department of Rheumatology and Internal Medicine, Wrocław Medical University, Wrocław, Poland
| | - Barbara Wysoczańska
- Laboratory of Clinical Immunogenetics and Pharmacogenetics, Hirszfeld Institute of Immunology and Experimental Therapy, Polish Academy of Sciences, Wrocław, Poland
| | - Lucyna Korman
- Department of Rheumatology and Internal Medicine, Wrocław Medical University, Wrocław, Poland
| | - Piotr Wiland
- Department of Rheumatology and Internal Medicine, Wrocław Medical University, Wrocław, Poland
| | - Katarzyna Bogunia-Kubik
- Laboratory of Clinical Immunogenetics and Pharmacogenetics, Hirszfeld Institute of Immunology and Experimental Therapy, Polish Academy of Sciences, Wrocław, Poland
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Wang Z, Wu J, Li D, Tang X, Zhao Y, Cai X, Chen X, Chen X, Huang Q, Huang R. Traditional Chinese medicine Biqi capsule compared with leflunomide in combination with methotrexate in patients with rheumatoid arthritis: a randomized controlled trial. Chin Med 2020; 15:36. [PMID: 32336980 PMCID: PMC7178961 DOI: 10.1186/s13020-020-00319-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 04/16/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Biqi capsule is a traditional Chinese medicine widely used as a complementary and alternative treatment for rheumatoid arthritis (RA). The objective is to understand the efficacy, safety and mechanism of Biqi combined with methotrexate (MTX) in RA. METHODS We present a randomized, controlled pilot trial on Biqi combined with MTX against patients with active RA. Seventy patients were randomized 1:1 to receive Biqi + MTX or Leflunomide (LEF) + MTX for 24 weeks, and were assessed at baseline, 4, 12 and 24 weeks. Serum and urine samples were collected for metabolomics. RESULTS Overall, 81.2% patients in Biqi group achieved ACR20 at 24 weeks. No statistically significant differences were observed in primary or secondary outcomes between the two groups. A better safety profile was observed for Biqi with significantly fewer adverse effects reported (11.4%) compared to LEF group (40%, P < 0.05). Comparison between treatment responders and non-responders indicated a unique urine metabolic profile of enriched fatty acids and decreased acylcarnitines associated with Biqi responders, indicating a restored energy homeostasis in response to Biqi. The gene targets of these metabolites were significantly enriched in interleukin-4 and interleukin-13 pathways, implying that Biqi could ameliorate Th2-derived inflammatory response. Multivariate network analysis indicated that patient morning stiffness and SJC were key factors associated with metabolomics in Biqi-treated patients, whereas CRP was the main factor in LEF group. Therefore, Biqi and LEF likely work by influencing different patient clinical parameters. CONCLUSIONS Our study suggests that Biqi capsule can be a promising alternative option in combination with MTX for RA treatment, and demonstrates the capability of using metabolomics to interrogate mechanism of action for traditional Chinese medicine.Trial registration This trial is registered with ChiCTR, No. ChiCTR-IPR-16009029. Registered August 15, 2016. http://www.chictr.org.cn/showprojen.aspx?proj=15034.
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Affiliation(s)
- Zhang Wang
- Institute of Ecological Sciences, School of Life Sciences, South China Normal University, Guangzhou, China
| | - Jiaqi Wu
- Section Rheumatology Research, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), Guangzhou, China
| | - Dongyun Li
- Section Rheumatology Research, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), Guangzhou, China
| | - Xuan Tang
- Section Rheumatology Research, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), Guangzhou, China
| | - Yue Zhao
- Section Rheumatology Research, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), Guangzhou, China
- Guangdong Provincial Key Laboratory of Clinical Research on Traditional Chinese Medicine Syndrome, and State Key Laboratory of Dampness Syndrome of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Xiao Cai
- Section Rheumatology Research, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), Guangzhou, China
| | - Xianghong Chen
- Section Rheumatology Research, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), Guangzhou, China
| | - Xiumin Chen
- Section Rheumatology Research, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), Guangzhou, China
| | - Qingchun Huang
- Section Rheumatology Research, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), Guangzhou, China
| | - Runyue Huang
- Section Rheumatology Research, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), Guangzhou, China
- Guangdong Provincial Key Laboratory of Clinical Research on Traditional Chinese Medicine Syndrome, and State Key Laboratory of Dampness Syndrome of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
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Sardana K, Gupta A. A recalcitrant case of ulcerative lichen planus responsive to leflunomide. Clin Exp Dermatol 2019; 45:340-341. [PMID: 31389078 DOI: 10.1111/ced.14069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/05/2019] [Indexed: 11/26/2022]
Affiliation(s)
- K Sardana
- Department of Dermatology, Postgraduate Institute of Medical Education and Research and Dr Ram Manohar Lohia Hospital, New Delhi, India
| | - A Gupta
- Department of Dermatology, Postgraduate Institute of Medical Education and Research and Dr Ram Manohar Lohia Hospital, New Delhi, India
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Sardana K, Gupta A, Gupta PK. Leflunomide: an unlikely trigger and mechanistically a beneficial drug for alopecia areata. Clin Rheumatol 2019; 38:2957-2958. [PMID: 31332691 DOI: 10.1007/s10067-019-04669-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Revised: 06/21/2019] [Accepted: 06/27/2019] [Indexed: 10/26/2022]
Affiliation(s)
- Kabir Sardana
- Department of Dermatology, Post Graduate Institute of Medical Education and Research, Dr. Ram Manohar Lohia Hospital, Baba Kharak Singh Road, New Delhi, 110001, India
| | - Aastha Gupta
- Department of Dermatology, Post Graduate Institute of Medical Education and Research, Dr. Ram Manohar Lohia Hospital, Baba Kharak Singh Road, New Delhi, 110001, India.
| | - Pulin Kumar Gupta
- Department of Medicine, Post Graduate Institute of Medical Education and Research, Dr. Ram Manohar Lohia Hospital, Baba Kharak Singh Road, New Delhi, 110001, India
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Development of methotrexate-loaded cubosomes with improved skin permeation for the topical treatment of rheumatoid arthritis. APPLIED NANOSCIENCE 2019. [DOI: 10.1007/s13204-019-00976-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Sardana K, Gupta A, Gautam RK. Recalcitrant alopecia areata responsive to leflunomide and anthralin-Potentially undiscovered JAK/STAT inhibitors? Pediatr Dermatol 2018; 35:856-858. [PMID: 30318623 DOI: 10.1111/pde.13688] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Several treatment modalities are available for the management of alopecia areata (AA); however, no therapy is universally effective and treatment can be frustrating in severe cases, with low response and high recurrence rates. Recent studies show that the JAK/STAT pathway plays a central role in the pathogenesis of this disease by determining the crosstalk between the infiltrating CD8+ T cells and the hair follicles, suggesting a role of JAK inhibitors in the treatment of AA. However, reports on the off-label use of these more expensive targeted agents have shown variable results. We present a case of a child with recalcitrant ophiasis-pattern AA who had failed steroid therapy and was treated successfully with leflunomide and anthralin, possibly by the synergistic effect on the JAK/STAT pathway inhibition, and we propose this combination could be a cost-effective therapeutic option for recalcitrant AA.
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Takasugi K, Nishida K, Natsumeda M, Yamashita M, Yamamoto W, Ezawa K. IL-6 is an independent predictive factor of drug survival after dose escalation of infliximab in patients with rheumatoid arthritis. Mod Rheumatol 2017; 28:452-460. [DOI: 10.1080/14397595.2017.1361802] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Koji Takasugi
- Department of Internal Medicine, Rheumatoid Arthritis Center, Kurashiki Sweet Hospital, Kurashiki, Japan
| | - Keiichiro Nishida
- Department of Orthopaedic Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Masamitsu Natsumeda
- Department of Internal Medicine, Rheumatoid Arthritis Center, Kurashiki Sweet Hospital, Kurashiki, Japan
| | - Misuzu Yamashita
- Department of Internal Medicine, Rheumatoid Arthritis Center, Kurashiki Sweet Hospital, Kurashiki, Japan
| | - Wataru Yamamoto
- Department of Clinical Information Management, Rheumatoid Arthritis Center, Kurashiki Sweet Hospital, Kurashiki, Japan
| | - Kazuhiko Ezawa
- Department of Internal Medicine, Rheumatoid Arthritis Center, Kurashiki Sweet Hospital, Kurashiki, Japan
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12
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Sainas S, Pippione AC, Giorgis M, Lupino E, Goyal P, Ramondetti C, Buccinnà B, Piccinini M, Braga RC, Andrade CH, Andersson M, Moritzer AC, Friemann R, Mensa S, Al-Karadaghi S, Boschi D, Lolli ML. Design, synthesis, biological evaluation and X-ray structural studies of potent human dihydroorotate dehydrogenase inhibitors based on hydroxylated azole scaffolds. Eur J Med Chem 2017; 129:287-302. [DOI: 10.1016/j.ejmech.2017.02.017] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2016] [Revised: 02/06/2017] [Accepted: 02/07/2017] [Indexed: 11/25/2022]
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Matsuno H, Okada M, Sakai Y, Abe C, Katayama K, Sagawa A, Yamasaki K, Kondo M, Funahashi K, Matsubara T. The usefulness of a new triple combination treatment utilizing methotrexate, salazosulfapyridine, and bucillamine in rheumatoid arthritis. Mod Rheumatol 2016; 26:51-6. [PMID: 26052803 DOI: 10.3109/14397595.2015.1059984] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
OBJECTIVES Combination treatment with methotrexate, salazosulfapyridine and bucillamine as an alternative to treatment with TNF-inhibiting biologics in rheumatoid arthritis was investigated. METHODS Twenty-six facilities allied with the Japan Association of Rheumatologists in Private Practice participated in this study. One hundred and twelve patients enrolled in this study, all of whom were within 3 years of diagnosis with rheumatoid arthritis for whom treatment with one DMARD or a combination of two DMARDs had failed (DAS28 > 3.2). Patients chose their own treatment. The triple DMARDs combination group was comprised of 72 patients; the TNF-inhibiting biologics treatment group was comprised of 40 patients. RESULTS DAS28 scores for the triple DMARDs combination group and the TNF-inhibiting biologics treatment groups were 4.84 ± 0.96 and 5.23 ± 1.26, and there was no significant difference between the two groups. From the 6th month, average disease activities of both groups were reduced, and there was no difference between the two groups at 12 months (DAS28, 3.39 ± 1.43 and 3.05 ± 1.43, p = 0.39). Furthermore, there was no significant difference in the degree of bone destruction between the two groups at 12 months. CONCLUSIONS The triple DMARD combination therapy provided a new treatment option for those patients for whom treatment with biologics is difficult.
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Affiliation(s)
| | - Masato Okada
- b Immuno-Rheumatology Center, St. Luke's International Hospital , Tokyo , Japan
| | - Yoshitada Sakai
- c Division of Rehabilitation Medicine, Kobe University Graduate School of Medicine , Kobe , Japan
| | | | - Kou Katayama
- e Katayama Orthopedic Rheumatology Clinic , Toyooka, Asahikawa , Japan
| | - Akira Sagawa
- f Sagawa Akira Rheumatology Clinic , Sapporo , Japan
| | | | - Masakazu Kondo
- h Kondo Clinic of Rheumatology and Orthopaedic Surgery , Fukuoka , Japan
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Rheumatoid Arthritis Pharmacotherapies: Do They Have Anti-Atherosclerotic Activity? Curr Rheumatol Rep 2016; 18:27. [DOI: 10.1007/s11926-016-0578-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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15
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Chemopreventive effect of leflunomide against Ehrlich's solid tumor grown in mice: Effect on EGF and EGFR expression and tumor proliferation. Life Sci 2015; 141:193-201. [DOI: 10.1016/j.lfs.2015.10.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2015] [Revised: 08/07/2015] [Accepted: 10/02/2015] [Indexed: 02/07/2023]
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Pigott E, DuHadaway JB, Muller AJ, Gilmour S, Prendergast GC, Mandik-Nayak L. 1-Methyl-tryptophan synergizes with methotrexate to alleviate arthritis in a mouse model of arthritis. Autoimmunity 2014; 47:409-18. [PMID: 24798341 DOI: 10.3109/08916934.2014.914507] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Rheumatoid arthritis (RA) is an inflammatory autoimmune disease with no known cure. Current strategies to treat RA, including methotrexate (MTX), target the later inflammatory stage of disease. Recently, we showed that inhibiting indoleamine-2,3-dioxygenase (IDO) with 1-methyl-tryptophan (1MT) targets autoantibodies and cytokines that drive the initiation of the autoimmune response. Therefore, we hypothesized that combining 1MT with MTX would target both the initiation and chronic inflammatory phases of the autoimmune response and be an effective co-therapeutic strategy for arthritis. To test this, we used K/BxN mice, a pre-clinical model of arthritis that develops joint-specific inflammation with many characteristics of human RA. Mice were treated with 1MT, MTX, alone or in combination, and followed for arthritis, autoantibodies, and inflammatory cytokines. Both 1MT and MTX were able to partially inhibit arthritis when used individually; however, combining MTX + 1MT was significantly more effective than either treatment alone at delaying the onset and alleviating the severity of joint inflammation. We went on to show that combination of MTX + 1MT did not lower inflammatory cytokine or autoantibody levels, nor could the synergistic co-therapeutic effect be reversed by the adenosine receptor antagonist theophylline or be mimicked by inhibition of polyamine synthesis. However, supplementation with folinic acid did reverse the synergistic co-therapeutic effect, demonstrating that, in the K/BxN model, MTX synergizes with 1MT by blocking folate metabolism. These data suggest that pharmacological inhibition of IDO with 1MT is a potential candidate for use in combination with MTX to increase its efficacy in the treatment of RA.
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Affiliation(s)
- Elizabeth Pigott
- The Lankenau Institute for Medical Research , Wynnewood, PA , USA
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Lee SY, Park SH, Lee SW, Lee SH, Son MK, Choi YH, Chung WT, Yoo YH. Synoviocyte apoptosis may differentiate responder and non-responder patients to methotrexate treatment in rheumatoid arthritis. Arch Pharm Res 2014; 37:1286-94. [PMID: 24988987 DOI: 10.1007/s12272-014-0365-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2013] [Accepted: 03/03/2014] [Indexed: 11/24/2022]
Abstract
We aimed to evaluate whether methotrexate (MTX) in vitro induces apoptosis in synoviocytes obtained from rheumatoid arthritis patients and whether the apoptosis inducing effect of MTX to synoviocytes is correlated with the clinical responsiveness to MTX in patients with rheumatoid arthritis (RA). We evaluated 18 patients with RA taking MTX 15-20 mg/week as the subject group (nine responders and nine non-responders) and ten patients with osteoarthritis (OA) and nine patients with ankylosing spondylitis (AS) as the control group. Synoviocytes, cultured from the synovial fluid of the knee joint of each subject, were used for experiments between passages 4 and 6, and were treated with MTX. The induction of apoptosis was determined by the quantification of DNA hypoploidy by flow cytometry, nuclear morphology, caspases activation, DNA electrophoresis, and mitochondrial membrane potential measurements. The viability of synoviocytes treated with MTX was different between the MTX responders and nonresponders. MTX induced apoptosis in cultured synoviocytes by mitochondria- and caspase-dependent manners in the MTX responders but did not in the MTX non-responder, OA, and AS patients. The apoptotic responsiveness of the synoviocytes to MTX predicts the sensitivity to MTX treatment and provides a method determine the early application of an anti-tumor necrosis factor-α agent in RA treatment.
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Affiliation(s)
- Sang Yeob Lee
- Division of Rheumatology Department of Internal Medicine, Dong-A University, Pusan, Republic of Korea,
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Coffey G, Betz A, Graf J, Stephens G, Hua Lin P, Imboden J, Sinha U. Methotrexate and a spleen tyrosine kinase inhibitor cooperate to inhibit responses to peripheral blood B cells in rheumatoid arthritis. Pharmacol Res Perspect 2013; 1:e00016. [PMID: 25505569 PMCID: PMC4186432 DOI: 10.1002/prp2.16] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2013] [Accepted: 10/09/2013] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Selective disruption of the spleen tyrosine kinase (Syk) represents a novel strategy to control B-cell functional responses by inhibition of B-cell antigen receptor (BCR) signaling. PRT062607 (P505-15) is a highly selective small molecule Syk inhibitor that potently suppresses B-cell function in human and rodent blood, and reduces inflammation in rodent models of rheumatoid arthritis (RA). AIMS In this study, we sought to determine the potency of Syk inhibition by PRT062607 in whole blood from RA patients, and elucidate covariates that affect the potency of immune-regulation by this compound. MATERIALS AND METHODS Whole blood was collected from 30 patients diagnosed with RA as part of a single-center outpatient study. Disease severity, serum protein markers of inflammation, and co-medications were related to each other, and to PRT062607 activity in ex vivo Syk-mediated immune function assays. RESULTS We report here that PRT062607 exhibited greater potency in suppressing BCR mediated B-cell functional responses in whole blood from RA patients who received stable methotrexate (MTX) therapy. We demonstrate that the B-cell functional response to BCR ligation is influenced by cytokines and JAK/STAT signaling. DISCUSSION MTX is a known cytokine modulating agent, and this mechanism may act in concert with PRT062607 to control B-cell function. CONCLUSION These data have important implications for the co-administration of Syk inhibitors and MTX for the treatment of RA.
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Affiliation(s)
- Greg Coffey
- Portola Pharmaceuticals, Inc. South San Francisco, California, 94080
| | - Andreas Betz
- Portola Pharmaceuticals, Inc. South San Francisco, California, 94080
| | - Jonathan Graf
- University of California San Francisco, School of Medicine San Francisco, California, 94143
| | - Gillian Stephens
- Portola Pharmaceuticals, Inc. South San Francisco, California, 94080
| | - Pei Hua Lin
- Portola Pharmaceuticals, Inc. South San Francisco, California, 94080
| | - John Imboden
- University of California San Francisco, School of Medicine San Francisco, California, 94143
| | - Uma Sinha
- Portola Pharmaceuticals, Inc. South San Francisco, California, 94080
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Ball EMA, Gibson DS, Bell AL, Rooney MR. Plasma IL-6 levels correlate with clinical and ultrasound measures of arthritis in patients with systemic lupus erythematosus. Lupus 2013; 23:46-56. [PMID: 24243775 DOI: 10.1177/0961203313512882] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE The objective of this paper is to elucidate the role of specific cytokines in lupus (SLE) arthritis. METHODS Fifty SLE and 40 RA patients had an ultrasound (US) scan of their hand as per standardized protocols. US scores were expressed per joint and as a total 'US activity' score, (sum of power Doppler (PD) and grey-scale synovial hypertrophy scores in all joints) and a total erosion score. SLE disease activity was assessed (BILAG and SELENA-SLEDAI). Plasma levels of IL-6, TNF-alpha and BLyS were measured using sandwich ELISA kits (Quantikine kits, R & D). RESULTS On the basis of the US results SLE patients were divided into three groups: erosive arthritis (n = 20), non-erosive arthritis (n = 18) and those with a normal US scan (n = 12). Across the SLE groups plasma IL-6 levels correlated with CRP (p < 0.001), hand deformity scores (p = 0.005), BILAG musculoskeletal score (p = 0.009), wrist PD score (p = 0.01), the presence of tenosynovitis (p = 0.008) and total US activity score (p < 0.001) (which remained constant when corrected for total BILAG score). Neither TNF-alpha nor BLyS levels correlated with US or clinical measures of lupus arthritis; however, TNF-alpha correlated with total BILAG score (p < 0.001). CONCLUSION This is the first study to examine levels of specific cytokines in a cohort of SLE patients stratified in terms of joint disease by US, where the most significant finding is that IL-6 levels correlated both with clinical and US measures of arthritis disease activity.
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Affiliation(s)
- E M A Ball
- 1Centre for Infection & Immunity, Queen's University, Belfast, UK
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Liu J, Sun Y. How does Chinese medicine target cytokine imbalance in rheumatoid arthritis? Chin J Integr Med 2013; 19:874-80. [PMID: 24170633 DOI: 10.1007/s11655-013-1620-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2012] [Indexed: 11/24/2022]
Abstract
Rheumatoid arthritis (RA) manifests as an imbalance between pro- and anti-inflammatory cytokines. Cytokine imbalance is suggested to play critical roles in the development of RA. Currently, various treatments for RA, including biological agents such as antibodies against inflammation mediators, or Chinese herbal medicines, intervene the disease by restoring the balance of cytokines. Chinese medicine (CM) can not only suppress the expression of pro-inflammatory cytokines, but also induce the expression of cytokines with anti-inflammatory and immunomodulatory effects. Thus, Chinese medicine can effectively reduce inflammatory cell infiltration into synovial tissue, pannus formation, and degradation of the extracellular matrix surrounding cartilage cells, thereby reducing subchondral bone damage. This paper reviews the changes of cytokine profiling during development of RA and discuss the mechanisms by which Chinese medicine restores the cytokine balance.
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Affiliation(s)
- Jian Liu
- Department of Rheumatism Immunity, First Affiliated Hospital, Anhui University of Chinese Medicine, Hefei, 230031, China,
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Nishina N, Kaneko Y, Kameda H, Kuwana M, Takeuchi T. Reduction of plasma IL-6 but not TNF-α by methotrexate in patients with early rheumatoid arthritis: a potential biomarker for radiographic progression. Clin Rheumatol 2013; 32:1661-6. [DOI: 10.1007/s10067-013-2309-0] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2012] [Revised: 03/24/2013] [Accepted: 05/27/2013] [Indexed: 10/26/2022]
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Ćalasan MB, Thurlings RM, Wulffraat NM, Prakken BJ. Translational medicine from bedside to bench and back again: methotrexate revisited. ACTA ACUST UNITED AC 2013. [DOI: 10.2217/ijr.13.13] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Yao Y, Ding CZ, Fang Y. Combination of MTX and LEF attenuates inflammatory bone erosion by down-regulation of receptor activator of NF-kB ligand and interleukin-17 in type II collagen-induced arthritis rats. Rheumatol Int 2013; 33:1845-53. [PMID: 23334376 DOI: 10.1007/s00296-013-2674-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2012] [Accepted: 01/08/2013] [Indexed: 12/23/2022]
Abstract
The objectives of this study were to determine the effect of combination of methotrexate (MTX) and leflunomide (LEF) on type II collagen-induced arthritis rats and its mechanism. Curative effect was confirmed on CIA rats, which were randomized and divided into model, MTX, LEF and MTX + LEF group. Weights and joint swelling scores of rats were recorded. Interleukin (IL)-17, receptor activator of NF-κB ligand (RANKL) and osteoprotegerin (OPG) concentration in serum were determined by ELISA. H&E dyeing of joint was used to estimate the inflammation and osteoclasia extent. The mechanism was investigated through fibroblast-like synoviocytes isolated from RA patients. The effect of MTX and LEF on cell viability, and RANKL and OPG expression were indicated through MTT and RT-PCR analysis, respectively. Combination therapy would be effective in treating CIA rats. Joint swelling scores and IL-17 and RANKL level in serum were decreased obviously (P < 0.05), while OPG level was elevated (P < 0.05). Anti-inflammatory and anti-osteoclasia effect would be indicated by H&E dyeing results. Moreover, FLS cell viability was inhibited by combination treatment in vitro (P < 0.05), and expression of osteoclasia-related genes (RANKL and OPG) was modified (P < 0.05). Combination therapy would relive the synovium hypertrophy through depressing cell viability and osteoclasia through decreasing RANKL and increasing OPG expression. Otherwise, combination was superior to monotherapy.
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Affiliation(s)
- Yao Yao
- Department of Pharmacy, The Affiliated Drum Tower Hospital of Nanjing University Medical School, 321 Zhong Shan Road, Nanjing 210008, Jiang Su, China
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Kim JY, Lim MK, Sheen DH, Kim C, Lee SY, Park H, Lee MJ, Lee SK, Yang YS, Shim SC. Gene Expression Profile of T-cell Receptors in the Synovium, Peripheral Blood, and Thymus during the Initial Phase of Collagen-induced Arthritis. Immune Netw 2011; 11:258-67. [PMID: 22194709 PMCID: PMC3243000 DOI: 10.4110/in.2011.11.5.258] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2011] [Revised: 09/06/2011] [Accepted: 09/19/2011] [Indexed: 12/19/2022] Open
Abstract
Background Current management strategies attempt to diagnose rheumatoid arthritis (RA) at an early stage. Transcription profiling is applied in the search for biomarkers for detecting early-stage disease. Even though gene profiling has been reported using several animal models of RA, most studies were performed after the development of active arthritis, and conducted only on the peripheral blood and joint. Therefore, we investigated gene expression during the initial phase of collagen-induced arthritis (CIA) before the arthritic features developed in the thymus in addition to the peripheral blood and synovium. Methods For gene expression analysis using cDNA microarray technology, samples of thymus, blood, and synovium were collected from CIA, rats immunized only with type II collagen (Cll), rats immunized only with adjuvant, and unimmunized rats on days 4 and 9 after the first immunization. Arrays were scanned with an Illumina bead array. Results Of the 21,910 genes in the array, 1,243 genes were differentially expressed at least 2-fold change in various organs of CIA compared to controls. Among the 1,243 genes, 8 encode T-cell receptors (TCRs), including CD3ζ, CD3δ, CD3ε, CD8α, and CD8β genes, which were down-regulated in CIA. The synovium was the organ in which the genes were differentially expressed between CIA and control group, and no difference were found in the thymus and blood. Further, we determined that the differential expression was affected by adjuvant more than Cll. The differential expression of genes as revealed by real-time RT-PCR, was in agreement with the microarray data. Conclusion This study provides evidence that the genes encoding TCRs including CD3ζ, CD3δ, CD3ε, CD8α, and CD8β genes were down-regulated during the initial phase of CIA in the synovium of CIA. In addition, adjuvant played a greater role in the down-regulation of the CD3 complex compared to CII. Therefore, the down-regulation of TCR gene expression occurred dominantly by adjuvant could be involved in the pathogenesis of the early stage at CIA.
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Affiliation(s)
- Ji-Young Kim
- Department of Medicine, Eulji Medi-Bio Research Institute, Eulji University, Daejeon 302-799, Korea
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Lang VR, Englbrecht M, Rech J, Nüsslein H, Manger K, Schuch F, Tony HP, Fleck M, Manger B, Schett G, Zwerina J. Risk of infections in rheumatoid arthritis patients treated with tocilizumab. Rheumatology (Oxford) 2011; 51:852-7. [PMID: 21865281 DOI: 10.1093/rheumatology/ker223] [Citation(s) in RCA: 83] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
OBJECTIVES To investigate the occurrence and risk factors for infections in RA patients treated with tocilizumab. METHODS A cohort of all RA patients (n = 112) starting tocilizumab therapy between October 2008 and March 2010 in Northern Bavaria was screened for infections. Mild/moderate and severe infections were recorded. Multivariate logistic regression analysis was used to define risk factors for infection. RESULTS Overall, 26 patients developed infections [23.2%; 58.0/100 patient-years (py)], 18 of them were mild to moderate (16.1%, 40.1/100 py) and 8 were severe (17.9/100 py). Concomitant use of LEF and prednisone, high disease activity and previous therapy with rituximab were associated with the occurrence of mild/moderate infections. Severe infections were related to longer disease duration, exposure to more than three previous DMARDs and concomitant therapy with proton-pump inhibitors. CONCLUSION The rate of infection in RA patients treated with tocilizumab in clinical practice is higher than in the clinical trial populations. Increased attention should especially be given to patients with longer disease duration, previous exposure to multiple DMARDs, i.e. previous exposure to rituximab and those receiving concomitant LEF, prednisone or proton-pump inhibitor treatment.
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Affiliation(s)
- Veronika R Lang
- Department of Internal Medicine 3, University of Erlangen-Nuremberg, Krankenhausstrasse 12, 91054 Erlangen, Germany
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Pilot study of safety and effect of combined intravitreal bevacizumab and methotrexate for neovascular age-related macular degeneration. Eur J Ophthalmol 2011; 21:77-82. [PMID: 20872362 DOI: 10.5301/ejo.2010.5696] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/09/2010] [Indexed: 11/20/2022]
Abstract
PURPOSE To evaluate the safety and effect of combined intravitreal methotrexate and bevacizumab on choroidal neovascularization in age-related macular degeneration (AMD). METHODS Seven eyes of 7 patients (4 female; mean age 65.43±5.96 years) with choroidal neovascularization secondary to AMD were studied. Patients received intravitreal injection of methotrexate and bevacizumab and were examined every 1.5 months. Reinjections were performed with bevacizumab only. RESULTS Three patients had 3 months, 3 had 4.5 months, and 1 had 8 months of follow-up. Mean number of reinjections was 2.0. In all patients, best-corrected visual acuity (BCVA) improved compared to baseline. Central macular thickness (CMT) decreased in all but one patient who had no reduced visual acuity. Mean BCVA (logMAR) was 1.27±0.43 D at baseline, 1.1±0.38 D at week 6, and 0.93±0.31 D at month 3. Mean BCVA in 3 patients at 4.5 months was 1.1±0.15 D. There were statistically significant differences between BCVA before injection and at week 6 (p=0.017), 3 months (p=0.005), and 4.5 months (p=0.04). Mean baseline CMT was 389±177 µm, 371±154 µm at 6 weeks, and 317±108 µm at 3 months. Mean CMT in 3 patients at 4.5 months was 266±66 µm. There were no statistically significant differences between baseline CMT and after treatment. No scar formation, increase of scar, or adverse reaction to methotrexate injection were seen. CONCLUSIONS Addition of intravitreal methotrexate to bevacizumab was safe in 7 eyes of 7 patients. It may enhance the therapeutic effect in regression of neovascularization in AMD and may reduce development of a fibrous component and disciform scar formation.
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Targońska-Stępniak B, Dryglewska M, Majdan M. Influence of long-term leflunomide treatment on serum amyloid concentration in rheumatoid arthritis patients. Pharmacol Rep 2011; 62:719-25. [PMID: 20885012 DOI: 10.1016/s1734-1140(10)70329-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2009] [Revised: 12/07/2009] [Indexed: 10/25/2022]
Abstract
Rheumatoid arthritis (RA) is a chronic, inflammatory disease that requires intervention with disease-modifying antirheumatic drugs (DMARDs) to stop disease progression. Leflunomide (LEF) is a DMARD with anti-inflammatory and immunomodulatory properties. As its primary mode of action, LEF reversibly inhibits dihydroorotate dehydrogenase, a key enzyme in de novo biosynthesis of pyrimidine in cells. Serum amyloid A protein (SAA) is elevated in inflammatory states and high SAA levels indicate a risk of developing secondary amyloidosis. The aim of this study was to investigate the effects of long-term LEF treatment on SAA levels and disease activity in a group of RA patients. The study group consisted of 50 consecutive RA patients (43 F, 7 M) treated with leflunomide. All patients had a clinical evaluation and SAA measurements taken at two consecutive visits during months 0, 1, 3, 6 and 12. Mean SAA concentrations decreased significantly in the first months of LEF therapy (up to the 6th month) with a more pronounced effect in patients with higher SAA levels. However, by the 12(th) month of treatment, the mean SAA level did not differ significantly from the SAA level at the start of treatment. At the same time though, other clinical and laboratory parameters of RA activity indicated that the disease activity decreased. Results demonstrated that in patients with active RA LEF therapy provided a significant, long-term reduction of inflammatory activity, as measured by the classic parameters of disease activity. During the treatment, SAA concentrations decreased significantly, followed by a slight increase, in spite of a reduction in other classical indicators of inflammatory response.
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Affiliation(s)
- Bożena Targońska-Stępniak
- Department of Rheumatology and Connective Tissue Diseases, Medical University of Lublin, Jaczewskiego 8, PL 20-950 Lublin, Poland
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Xinqiang S, Fei L, Nan L, Yuan L, Fang Y, Hong X, Lixin T, Juan L, Xiao Z, Yuying S, Yongzhi X. Therapeutic efficacy of experimental rheumatoid arthritis with low-dose methotrexate by increasing partially CD4+CD25+Treg cells and inducing Th1 to Th2 shift in both cells and cytokines. Biomed Pharmacother 2010; 64:463-71. [DOI: 10.1016/j.biopha.2010.01.007] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2009] [Accepted: 01/25/2010] [Indexed: 02/06/2023] Open
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Abstract
Rheumatoid arthritis is a chronic and highly morbid disease affecting approximately 1% of the world's population. With the advent of disease-modifying antirheumatic drugs, patients are increasingly able to maintain control of their arthritis and prevent joint destruction. However, not all patients respond adequately to any single disease-modifying antirheumatic drug, and many newer parenteral therapies are cost prohibitive. Leflunomide, an inhibitor of pyrimidine biosynthesis, is the first oral disease-modifying antirheumatic drug to have been approved for rheumatoid arthritis in the USA in the last 15 years, and is now widely used in over 70 countries around the world. Leflunomide is efficacious when used as monotherapy or in combination with methotrexate to treat patients with rheumatoid arthritis, and is generally well tolerated. As clinical use increases, new ways to use leflunomide in order to minimize toxicity and maximize efficacy are being explored.
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Affiliation(s)
- Gary Kunkel
- Division of Rheumatology, Department of Medicine, University of Utah, 30 North 1900 East, Salt Lake City, UT 84132, USA.
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Härle P, Straub RH, Fleck M. Perioperative management of immunosuppression in rheumatic diseases—what to do? Rheumatol Int 2009; 30:999-1004. [DOI: 10.1007/s00296-009-1323-7] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2009] [Accepted: 11/29/2009] [Indexed: 12/21/2022]
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Abstract
This article examines the therapeutic potential of methotrexate (MTX) in the treatment of cholestatic liver disease, with specific reference to its use in primary biliary cirrhosis (PBC) and primary sclerosing cholangitis (PSC). In PBC patients, evidence suggests that a particular subset of patients may benefit, either biochemically or symptomatically, from the addition of MTX to their therapeutic regimen. How best to define these potential MTX responders remains unclear, but may warrant a "therapeutic trial" in some patients with more aggressive disease or in patients with refractory and disabling PBC-related symptoms. In contrast, PSC continues to be an immensely challenging disease to effectively treat, and the role of MTX for treating PSC patients remains dubious.
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Affiliation(s)
- Kerri Novak
- Division of Gastroenterology, Liver Unit, University of Calgary, 3330 Hospital Dr., NW, Health Sciences Center, Calgary, Alberta, Canada T2N 4N1
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Uppal SS, Raghupathy R, Hayat SJ, Chowdhury RI, Abraham M, Rawoot P. Patient demographics and disease variables correlate with distinct cytokine patterns in mitogen-stimulated peripheral blood mononuclear cells from rheumatoid arthritis patients. Rheumatol Int 2007; 28:533-9. [DOI: 10.1007/s00296-007-0495-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2007] [Accepted: 11/09/2007] [Indexed: 10/22/2022]
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van Woerkom JM, Kruize AA, Geenen R, van Roon EN, Goldschmeding R, Verstappen SMM, van Roon JAG, Bijlsma JWJ. Safety and efficacy of leflunomide in primary Sjögren's syndrome: a phase II pilot study. Ann Rheum Dis 2007; 66:1026-32. [PMID: 17223657 PMCID: PMC1954693 DOI: 10.1136/ard.2006.060905] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND For invalidating symptoms in primary Sjögren's syndrome (pSS), there is still a need for easy-to-administer, cost-effective and well-tolerated systemic treatment. Leflunomide (LEF) is structurally unrelated to other immunomodulatory drugs and might be efficacious in pSS, given its characteristic immunoregulatory modes of action. OBJECTIVE To investigate the safety and efficacy of LEF in pSS in a phase II open-label pilot study. METHODS 15 patients with pSS with early and active disease received LEF 20 mg once daily for 24 weeks. Tolerability, safety and efficacy of LEF were evaluated every 8 weeks. Additional safety visits were performed every fortnight. RESULTS Mild gastrointestinal discomfort (including diarrhoea) and hair loss were mainly reported. Five patients developed lupus-like skin lesions on the face, arms or trunk, responding well to topical corticosteroids, nevertheless causing the withdrawal of one patient. Two patients with pre-existing hypertension had to increase dosages of anti-hypertensive drugs. Increased levels of alanine aminotransferase normalised after dose reduction in two patients. A decrease in general fatigue and an increase in physical functioning were observed after 24 weeks. Serum IgG levels decreased from 8 weeks onwards. Schirmer test values increased, not reaching statistical significance, whereas sialometry values did not change. In four of five repeated biopsies, the lymphocytic focus score decreased at the rate of 1 focus/4 mm(2). A remarkable amelioration of leucocytoclastic vasculitis was observed in three patients. CONCLUSIONS Although the safety profile seems fairly acceptable, the observed indications for efficacy were modest and may be doubtful in justifying a randomised controlled trial of LEF in pSS.
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Affiliation(s)
- J M van Woerkom
- Department of Rheumatology & Clinical Immunology, F 02.127, University Medical Center, PO Box 85500, 3508 GA Utrecht, The Netherlands
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Landewé R, van der Heijde D, Klareskog L, van Vollenhoven R, Fatenejad S. Disconnect between inflammation and joint destruction after treatment with etanercept plus methotrexate: results from the trial of etanercept and methotrexate with radiographic and patient outcomes. ACTA ACUST UNITED AC 2006; 54:3119-25. [PMID: 17009230 DOI: 10.1002/art.22143] [Citation(s) in RCA: 120] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE To determine the relationship between disease activity and radiographic progression of joint destruction in patients with rheumatoid arthritis (RA) treated with methotrexate (MTX), those treated with etanercept, and those treated with the combination of MTX plus etanercept. METHODS Baseline, 12-month, and 24-month data from the Trial of Etanercept and Methotrexate with Radiographic and Patient Outcomes database were analyzed. The dependent variable was the 1-year change in the modified Sharp/van der Heijde score (Sharp score); therefore, 2 interval changes per patient were available. Interval change in the Sharp score was modeled by time (years), treatment, disease activity, and the interaction (disease activity x treatment). Disease activity was reflected by the time-averaged Disease Activity Score (taDAS) and the time-averaged C-reactive protein (taCRP) level, which were calculated per 1-year interval. Generalized mixed linear modeling (GMLM) was used to adjust for within-patient correlation. RESULTS GMLM confirmed a significant interaction between treatment and the taCRP level and taDAS with respect to the change in Sharp score (P = 0.012 and P = 0.03, respectively). In patients treated with MTX alone, radiographic progression increased with an increasing taCRP level or taDAS, although progression rates were low in patients whose disease was in remission and in those with low-to-moderate disease activity. This relationship was less clear in patients treated with etanercept and was absent in those who received combination therapy. CONCLUSION Combination therapy with MTX plus etanercept uncouples the classic relationship between disease activity and radiographic progression in patients with RA.
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Affiliation(s)
- Robert Landewé
- University Hospital Maastricht, Maastricht, The Netherlands.
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Abstract
Autoimmune diseases affect 3% of the world population, yet the diagnosis and classification of autoimmune diseases remain based on clinical examination combined with traditional laboratory tests and imaging studies. The development of genomic and proteomic technologies provides an unprecedented ability to identify novel biosignatures to diagnose, classify, and guide therapeutic decision making in patients with autoimmune disease. In this article, we review recent advances in proteomics technologies and their application to autoimmune disease.
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Affiliation(s)
- Wolfgang Hueber
- Department of Medicine, Division of Immunology and Rheumatology, Stanford University School of Medicine, CA, USA.
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Sebastiani M, Giuggioli D, Vesprini E, Caruso A, Ferri C. Successful treatment with leflunomide of arthritis in systemic sclerosis patients. Rheumatology (Oxford) 2006; 45:1175-6. [PMID: 16820378 DOI: 10.1093/rheumatology/kei248] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Dimitrova P, Ivanovska N. Host resistance to Candida albicans infection of mice with collagen-induced arthritis treated with leflunomide. Res Microbiol 2006; 157:525-30. [PMID: 16797932 DOI: 10.1016/j.resmic.2005.12.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2005] [Revised: 11/02/2005] [Accepted: 12/08/2005] [Indexed: 10/25/2022]
Abstract
The dehydro-orotate dehydrogenase inhibitor leflunomide is used for the treatment of rheumatoid arthritis. In the present study, its influence on host resistance to Candida albicans infection in mice with collagen-induced arthritis (CIA) was investigated. Leflunomide administered at a dose of 5 mg/kg for 5 consecutive days in mice with CIA inhibited collagen-specific cellular and humoral responses. The drug did not change the severity of primary C. albicans infection evaluated by kidney and liver colonization. At the early stage of infection leflunomide inhibited IFN-gamma production and enhanced IL-4 secretion. The effect of the drug on IL-4 production was less pronounced at the late phase of infection. Leflunomide enhanced anti-Candida IgM antibody production and diminished anti-Candida IgG antibody synthesis. This correlated with impaired resistance to reinfection. Results demonstrate that leflunomide administration to mice with collagen-induced arthritis might affect mechanisms of the late immune response to C. albicans infection.
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Affiliation(s)
- Petya Dimitrova
- Department of Immunology, Institute of Microbiology, 26 G. Bonchev Str., 1113 Sofia, Bulgaria
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Havemose-Poulsen A, Sørensen LK, Stoltze K, Bendtzen K, Holmstrup P. Cytokine profiles in peripheral blood and whole blood cell cultures associated with aggressive periodontitis, juvenile idiopathic arthritis, and rheumatoid arthritis. J Periodontol 2006; 76:2276-85. [PMID: 16332240 DOI: 10.1902/jop.2005.76.12.2276] [Citation(s) in RCA: 76] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Cytokines play a key role in the pathogenesis of inflammatory diseases. An obvious question is whether patients with aggressive periodontitis, juvenile idiopathic arthritis, or rheumatoid arthritis share blood cytokine profiles distinguishing them from individuals free of disease. METHODS The study population consisted of Danish white adults, <35 years of age, diagnosed with localized aggressive periodontitis (LAgP; N = 18), generalized aggressive periodontitis (GAgP; N = 27), juvenile idiopathic arthritis (JIA; N = 10), or rheumatoid arthritis (RA; N = 23) and healthy individuals with no systemic or oral diseases (control [CTRL]; N = 25). Enzyme-linked immunosorbent assays were used to determine the levels of interleukin (IL)-1alpha, IL-1beta, IL-1 receptor antagonist (IL-1Ra), IL-6, IL-10, tumor necrosis factor (TNF)-alpha, and lymphotoxin (LT)-alpha in peripheral blood (plasma) and unstimulated and stimulated whole blood cell cultures from the same blood collection. Autoantibodies (aAb) to IL-1alpha and IL-6 were quantitated by radioimmunoassay. RESULTS Similar patterns of slightly higher IL-10 levels in plasma were found for GAgP and RA patients and in unstimulated cultures for GAgP, RA, and JIA patients. Interestingly, unstimulated cultures also demonstrated similar patterns of higher TNF-alpha levels for these three groups of patients. Similar group patterns of periodontitis patients (LAgP and GAgP) included increased IL-1Ra levels in stimulated cultures, which also showed similar group patterns of arthritis patients (JIA and RA) with respect to higher IL-1alpha and lower LT-alpha levels. Low titers of aAb to IL-1alpha and IL-6 were found in almost all individuals. CONCLUSION Patients with aggressive periodontitis and types of arthritis presented with similar components of blood cytokine profiles distinguishing them from individuals free of disease.
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Affiliation(s)
- Anne Havemose-Poulsen
- Department of Periodontology, School of Dentistry, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark.
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Djouad F, Fritz V, Apparailly F, Louis-Plence P, Bony C, Sany J, Jorgensen C, Noël D. Reversal of the immunosuppressive properties of mesenchymal stem cells by tumor necrosis factor alpha in collagen-induced arthritis. ACTA ACUST UNITED AC 2005; 52:1595-603. [PMID: 15880818 DOI: 10.1002/art.21012] [Citation(s) in RCA: 294] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Adult mesenchymal stem cells (MSCs) represent promising tools for therapeutic applications such as tissue engineering and cellular therapy. Recent data suggest that, due to their immunosuppressive nature, MSCs may be of interest to enhance allogeneic hematopoietic engraftment and prevent graft-versus-host disease. Using a murine model of rheumatoid arthritis (RA), this study investigated whether the immunosuppressive properties of MSCs could be of therapeutic value to inhibit reactive T cells in autoimmune diseases such as RA. METHODS In mice with collagen-induced arthritis (CIA), we injected various doses of C3 MSCs at the time of immunization or booster injection, and subsequently evaluated the clinical and immunologic parameters. The immunosuppressive properties of MSCs were determined in vitro in mixed lymphocyte reactions with or without the addition of tumor necrosis factor alpha (TNFalpha). RESULTS In the CIA model of arthritis, MSCs did not confer any benefit. Both the clinical and the immunologic findings suggested that MSCs were associated with accentuation of the Th1 response. Using luciferase-expressing MSCs, we were unable to detect labeled cells in the articular environment of the knee, suggesting that worsening of the symptoms was unlikely due to the homing of MSCs in the joints. Experiments in vitro showed that the addition of TNFalpha was sufficient to reverse the immunosuppressive effect of MSCs on T cell proliferation, and this observation was associated with an increase in interleukin-6 secretion. CONCLUSION Our data suggest that environmental parameters, in particular those related to inflammation, may influence the immunosuppressive properties of MSCs.
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Osiri M, Shea B, Robinson V, Suarez-Almazor M, Strand V, Tugwell P, Wells G. Leflunomide for treating rheumatoid arthritis. Cochrane Database Syst Rev 2003; 2002:CD002047. [PMID: 12535423 PMCID: PMC8437750 DOI: 10.1002/14651858.cd002047] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Rheumatoid arthritis (RA) is a chronic inflammatory joint disease. Leflunomide, as an inhibitor of pyrimidine synthesis, has a different mechanism of action than other existing disease modifying anti-rheumatic drugs (DMARD). OBJECTIVES To determine the efficacy and toxicity of leflunomide compared to placebo or other DMARDs in the treatment of RA. SEARCH STRATEGY We conducted a search in MEDLINE, EMBASE, Current Contents and the Cochrane Controlled Trial Register for trials up to December 2001. We also hand-searched reference lists and consulted content experts. SELECTION CRITERIA Two independent reviewers selected the trials that met predetermined inclusion criteria. DATA COLLECTION AND ANALYSIS Two independent reviewers extracted data and assessed methodologic quality using standardized forms. MAIN RESULTS Six trials were included in this review. Using the ACR20 improvement criteria, there was an absolute difference in improvement of 28% (95% confidence interval: 21 - 35%) favouring leflunomide (232 out of 413 leflunomide treated patients compared to 89 out of 311 placebo patients met the criteria). There was no difference in ACR20 response rate between the patients treated with leflunomide and SSZ or MTX at 6 and 12 months. Other clinical outcomes were improved significantly in the leflunomide group compared to placebo but not different from SSZ or MTX. Withdrawals due to adverse events with leflunomide were 10% greater than placebo (70 out of 416 compared to 18 out of 311 respectively). Important adverse events included gastrointestinal symptoms, elevated liver function tests, alopecia, and infections. Overall adverse events and withdrawals in the leflunomide group were not significantly different from SSZ or MTX. REVIEWER'S CONCLUSIONS Leflunomide appears to improve all clinical outcomes and delay radiologic progression at both 6 and 12 months of treatment compared to placebo. Its efficacy and adverse events at 2 years of treatment are comparable to SSZ and MTX. Long-term efficacy and toxicity remains to be established.
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Affiliation(s)
- M Osiri
- Medicine, Chulalongkorn University Hospital, Division of Rheumatology, Department of Medicine, Chulalongkorn University Hospital, Rama IV Road, Pathumwan, Bangkok, Thailand, 10330.
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