Effect of anti-inflammatory drugs on sulphated glycosaminoglycan synthesis in aged human articular cartilage

Outcomes of prolotherapy in chondromalacia patella patients: improvements in pain level and function

We retrospectively evaluated the effectiveness of prolotherapy in resolving pain, stiffness, and crepitus, and improving physical activity in consecutive chondromalacia patients from February 2008 to September 2009. Sixty-nine knees that received prolotherapy in 61 patients (33 female and 36 male) who were 18–82 years old (average, 47.2 years) were enrolled. Patients received 24 prolotherapy injections (15% dextrose, 0.1% procaine, and 10% sarapin) with a total of 40 cc in the anterior knee. At least 6 weeks after their last prolotherapy session, patients provided self-evaluation of knee pain upon rest, activities of daily living (ADL) and exercise, range of motion (ROM), stiffness, and crepitus. Symptom severity, sustained improvement of symptoms, number of pain pills needed, and patient satisfaction before treatment and improvement after treatment were recorded. Following prolotherapy, patients experienced statistically significant decreases in pain at rest, during ADL, and exercise. Stiffness and crepitus decreased after prolotherapy, and ROM increased. Patients reported improved walking ability and exercise ability after prolotherapy. For daily pain level, ROM, daily stiffness, crepitus, and walking and exercise ability, sustained improvement of over 75% was reported by 85% of patients. Fewer patients required pain medication. No side effects of prolotherapy were noted. The average length of time from last prolotherapy session was 14.7 months (range, 6 months to 8 years). Only 3 of 16 knees were still recommended for surgery after prolotherapy. Prolotherapy ameliorates chondromalacia patella symptoms and improves physical ability. Patients experience long-term improvement without requiring pain medications. Prolotherapy should be considered a first-line, conservative therapy for chondromalacia patella.

Anti-inflammatory glucocorticoid drugs: reflections after 60 years

This review considers the problem of the serious concomitant side effects of powerful anti-inflammatory drugs modelled upon the principal human glucocorticoid hormone, cortisol. The very nature of the original bio-assays to validate their cortisol-like hormonal and anti-inflammatory activities ensured that pleiotropic toxins were selected for clinical studies. Other complicating factors have been (1) considerable reliance on bio-assays conducted in laboratory animals that primarily secrete corticosterone, not cortisol, as their principal anti-inflammatory adrenal hormone; (2) some differences in the binding of xenobiotic cortisol analogues (vis á vis cortisol) to transport proteins, detoxifying enzymes and even some intra-cellular receptors; (3) the "rogue" properties of these hormonal xenobiotics, acting independently of--but still able to suppress--hormonal mechanisms regulating endogenous cortisol; and (4) problems of intrinsic/acquired "steroid resistance", diminishing their clinical efficacy, but not necessarily all their toxicities. The rather gloomy conclusion is that devising new drugs to reproduce the effect of multi-potent hormones may be a recipe for disaster, in contexts other than simply remedying an endocrine deficiency. Promising new developments include "designed" combination therapies that allow some reduction in total steroid doses (and hopefully their side effects); sharpening strategies to limit the actual duration of steroid administration; and resurgent interest in searching for more selective analogues (both steroidal and non-steroid) with less harmful side effects. Some oversights and neglected areas of research are also considered. Overall, it now seems timely to engage in some drastic rethinking about (retaining?) these "licensed toxins" as fundamental therapies for chronic inflammation.

Cyclooxygenase inhibition lowers prostaglandin E2 release from articular cartilage and reduces apoptosis but not proteoglycan degradation following an impact load in vitro

This study investigated the release of prostaglandin E₂ (PGE₂) from cartilage following an impact load in vitro and the possible chondroprotective effect of cyclooxygenase-2 (COX-2) inhibition using non-steroidal anti-inflammatory drugs (NSAIDs).

Explants of human articular cartilage were subjected to a single impact load in a drop tower, and then cultured for 6 days in the presence of either a selective COX-2 inhibitor (celecoxib; 0.01, 0.1, 1.0 and 10 μM) or a non-selective COX inhibitor (indomethacin; 0.1 and 10 μM). The concentrations of PGE₂ and glycosaminoglycans (GAGs), a measure of cartilage breakdown, were measured in the explant culture medium at 3 and 6 days post-impact. Apoptotic cell death was measured in frozen explant sections by the terminal deoxynucleotidyl transferase-mediated dUTP nick-end labelling (TUNEL) method.

PGE₂ levels were increased by more than 20-fold in the medium of explants at both 3 (p = 0.012) and 6 days (p = 0.004) following impact, compared with unloaded controls. In the presence of celecoxib and indomethacin, the PGE₂ levels were reduced in a dose-related manner. These inhibitors, however, had no effect in reducing the impact-induced release of GAGs from the cartilage matrix. Addition of celecoxib and indomethacin significantly reduced the number of trauma-induced apoptotic chondrocytes in cartilage explant sections.

In this study, a marked increase in PGE₂ was measured in the medium following an impact load on articular cartilage, which was abolished by the selective COX-2 inhibitor, celecoxib, and non-selective indomethacin. These inhibitors reduced chondrocyte apoptosis but no change was observed in the release of GAGs from the explants, suggesting that the COX/PGE₂ pathway is not directly responsible for cartilage breakdown following traumatic injury. Our in vitro study demonstrates that it is unlikely that COX-2 inhibition alone would slow down or prevent the development of secondary osteoarthritis.

Skeletal developmental effects of selective and nonselective cyclooxygenase-2 inhibitors administered through organogenesis and fetogenesis in Wistar CRL:(WI)WUBR rats

Cyclooxygenase (COX) inhibitors are the most commonly ingested drugs. The aim of the study was to evaluate the prenatal skeletal effect of selective (DFU) and nonselective (tolmetin, ibuprofen, piroxicam) COX-2 inhibitors. All the tested compounds were administered intragastrically to pregnant Wistar rats from 7 to 21 gestation day. The initial dose was set at 8.5mg/kg/dose for tolmetin and ibuprofen, 0.3 and 0.2mg/kg/dose for piroxicam and DFU. The middle dose was increased 10-times. The highest dose, except for ibuprofen, was elevated 100-times. The highest dose for ibuprofen was set at 200mg/kg/dose. Tolmetin and ibuprofen were administered three times a day. Piroxicam and DFU were dosed once daily. After routine teratological examinations, extremities of randomly selected 21-day-old fetuses were taken for histological, immunohistochemical and molecular studies. The proximal femoral epiphyses were separated and their ultrastructure evaluated. The expression of genes coding cytokines (IL-1alpha, IL-1beta, IL-6, TNF-alpha, TNF-beta) and proteins (COX-1, COX-2, cathepsin K, collagen types I, II and X; osteocalcin, osteopontin) was evaluated in femoral epiphyses by RNase Protection Assay and/or immunohistochemically. The articulate development was checked histologically and found undisturbed in any of the experimental groups. The epiphysis of the 21-day-old fetuses, presented physiological expression of COX-1 and COX-2, as well as cathepsin K, collagen types I, II and X; osteopontin, osteocalcin and TNF-alpha. Increased developmental skeletal variation was noted in groups exposed to the highest dose of nonselective drugs. Unlike the increased number of skeletal variations observed in fetuses exposed to highest doses of nonselective compounds, both groups of COX inhibitors did not disturb joint formation and morphology of femoral epiphyses when administered even in high maternal toxic doses.

Physiological levels of hydrocortisone maintain an optimal chondrocyte extracellular matrix metabolism

OBJECTIVE

To investigate the effects of physiological doses of hydrocortisone on synthesis and turnover of cell associated matrix (CAM) by human chondrocytes obtained from normal articular cartilage.

METHODS

Human articular cartilage cells were obtained from visually intact cartilage of the femoral condyles of five donors and maintained in culture for one week to reach equilibrium in accumulated CAM compounds. 0, 0.05, 0.20, and 1.0 micro g/ml hydrocortisone was added to the nutrient media during the entire culture period. Cells were liberated and levels of CAM aggrecan, type II collagen, and fibronectin, of intracellular IGF-1, IL1alpha and beta, and of their respective plasma membrane bound receptors IGFR1, IL1RI, and the decoy receptor IL1RII, were assayed by flow cytometry.

RESULTS

In comparison with controls, hydrocortisone treated chondrocytes, at all concentrations, expressed significantly higher plasma membrane bound IGFR1. Intracellular IGF-1 levels remained unchanged. Together with these changes, reflecting an increased ability to synthesise extracellular matrix (ECM) macromolecules, hydrocortisone treated cells expressed significantly higher amounts of the plasma membrane bound decoy IL1RII. Concurrently, intracellular IL1alpha and beta levels and membrane bound IL1RI were down regulated. Levels of CAM aggrecan, type II collagen, and fibronectin were significantly up regulated in the chondrocytes treated with hydrocortisone.

CONCLUSION

0.05 micro g/ml hydrocortisone treated chondrocytes had decreased catabolic signalling pathways and showed an enhanced ability to synthesise ECM macromolecules. Because IL1 activity was decreased and the expression of IL1RII decoy receptor enhanced, more of the ECM macromolecules produced remained accumulated in the CAM of the chondrocytes. The effects were obtained at doses comparable with physiological plasma levels of hydrocortisone in humans.

Systemic use of pentosan polysulphate in the treatment of osteoarthritis

Forty dogs diagnosed as having chronic osteoarthritis took part in a double-blind clinical dose-response study using the antiarthritic agent pentosan polysulphate (PPS). After complete physical examination to ensure good general health, dogs received four subcutaneous injections at intervals of one week 0, 1, 3 or 5 mg/kg PPS from code-numbered bottles. At weekly intervals and four weeks after the last injection, weakness, stiffness, pain on joint manipulation, willingness to exercise, body condition and overall response were scored. There were no differences between groups in baseline data, but dogs receiving PPS had a favourable response compared to dogs receiving a placebo for lameness, body condition, pain on joint manipulation and willingness to exercise. The 3 mg/kg dose rate gave the best improvement, the 1 mg/kg dose was partially effective and the 5 mg/kg group was least effective. The use of PPS at a dose rate of 3 mg/kg for the treatment of clinical osteoarthritis in dogs is indicated by our study.

Ochronotic arthropathy: rapid destructive hip osteoarthritis associated with metabolic disease

Ochronosis is a musculoskeletal manifestation of alkaptonuria, an inherited metabolic disorder associated with various systemic abnormalities related to the deposition of homogentisic acid pigment in connective tissues. This report describes a 58-year-old woman with ochronotic arthropathy who, in addition to the typical clinical features of the disorder, presented with rapidly progressive hip osteoarthritis. The destruction of the joint architecture and the severe functional impairment necessitated a total hip replacement which resulted in a satisfactory outcome.

Nonsteroidal anti-inflammatory drugs

NSAIDs' mechanism of action by inhibiting the synthesis of prostanoids accounts for both their therapeutic and toxic effects. They are commonly used in acute and chronic musculoskeletal and soft-tissue conditions. Adverse reactions include gastrointestinal disturbances and hypoproteinemia. Their pharmacologic effect seems to have a longer duration than their plasma concentrations indicate. This gives implications on current regulations for competing horses and the relevance of permitted levels has been questioned. The NSAIDs do not appear to enhance performance, but rather allow the horse to run up to its potential by reducing pain and lameness. There is concern over the possible hazards to the horse by this kind of therapeutic use. In conclusion, NSAIDs have well justifiable therapeutic uses in equine practice. They should, however, be used when there is a clear clinical indication, in safe dose rates and without jeopardizing the welfare of the performance horse.

In vitro effect of nonsteroidal antiinflammatory drugs on proteoglycanase and collagenase activity in human osteoarthritic cartilage

The effects of several nonsteroidal antiinflammatory drugs, used at concentrations achievable in synovial fluid, on human osteoarthritic (OA) cartilage metallo-protease activity in vitro was studied. Acetaminophen and ketoprofen had no effect; sodium salicylate, indomethacin, and diclofenac slightly decreased proteoglycanase activity. Piroxicam and tenoxicam suppressed proteoglycanase activity by 48.2% and 68.3%, respectively, and suppressed collagenase activity by 19.1% and 36.8%, respectively. Use of these NSAIDs may help to decrease cartilage catabolism in patients with OA.

Comparison of the effects of non-steroidal anti-inflammatory drugs (NSAIDs) on proteoglycan synthesis by articular cartilage explant and chondrocyte monolayer cultures

Experiments were conducted to study proteoglycan biosynthesis by rabbit articular chondrocytes cultured in the presence of NSAIDs and 35SO4(2-) for up to 8 days. Both articular cartilage explants and confluent chondrocyte monolayer culture models were used. Medium was changed every 2 days and the [35SO4]proteoglycans which had accumulated in the medium and the extracellular matrix during the culture intervals were assayed separately. In long-term experiments, drugs were removed on day 8, and proteoglycan production during a 10-12 day culture interval also was assayed. The drugs studied were diclofenac, indomethacin, ketoprofen, piroxicam and tiaprofenic acid, at concentrations of 0, 0.1, 1, 10, 50 and 100 micrograms/mL. Whereas proteoglycan production by cell cultures was maximal early in the culture period, explants produced more proteoglycans as time progressed. The highest concentrations of all of the drugs, especially diclofenac and indomethacin, inhibited proteoglycan secretion by both cell and explant cultures. However, after removal of the drugs from the cultures, suppressed proteoglycan production reversed to levels equivalent to, or higher than controls in the cell cultures, but largely persisted in explant cultures. About 70-80% of proteoglycans produced by explants were retained in the matrix, whereas about 80-90% of proteoglycans produced by cell cultures were secreted into the medium. Where drugs inhibited proteoglycan production, the levels were reduced by approximately the same proportions in both extracellular matrix and culture medium fractions. Of the NSAIDs examined only ketoprofen demonstrated a stimulatory effect on PG synthesis in explant cultures at a physiological concentration (0.1 microgram/mL).

In vitro influence of ketoprofen on the proteoglycan metabolism of human normal and osteoarthritis cartilage

We investigated the influences of ketoprofen on the proteoglycan (PG) turnover of human articular cartilage explants in three groups: normal young with a high basal PG synthesis, normal adult and osteoarthritis cartilage, both with a low basal PG synthesis. Ketoprofen had no influence on the mean PG synthesis rate of normal adult and OA cartilage after 4 days of culture nor on the cartilage PG content after 8 days of culture. There was no relation between the histological grade of OA and effects of ketoprofen. In normal young cartilage ketoprofen induced an increase of the PG synthesis rate when added to the culture in a concentration of 10(-4) M. No correlation existed between the effect of ketoprofen and the basal PG synthesis of normal cartilage.

Sulfate homeostasis. III. Effect of chronic naproxen or sulindac treatment on inorganic sulfate disposition in arthritic patients with renal impairment

The purpose of the present investigation was to examine the influence of chronic naproxen (500 mg twice daily) or sulindac (200 mg twice daily) therapy on the disposition of inorganic sulfate in arthritic subjects with impaired renal function. Subjects were studied during a control period (after a 7-day NSAID washout) and after 14 days of treatment with either naproxen or sulindac. During the control period subjects in this investigation exhibited higher serum sulfate concentrations and lower sulfate renal clearance values than reported for younger subjects with normal renal function. Treatment with either sulindac or naproxen significantly decreased creatinine clearance. Sulindac therapy also increased the serum sulfate concentration and decreased the clearance of sulfate; a similar trend was observed after naproxen therapy but the average change was smaller and not statistically significant. There were significant correlations between the creatinine and the sulfate clearances or serum concentrations. The glomerular filtration rate of inorganic sulfate was not altered by drug treatment and there was no impairment of reabsorption. The serum concentrations and renal clearance of other electrolytes (sodium, potassium, magnesium, calcium, phosphorus) were largely unaffected. Therefore, chronic treatment with naproxen or sulindac decreases the renal clearance of endogenous sulfate in humans: this appears to be a consequence of the decrement in renal function observed in subjects with preexisting mild renal impairment.

The effect of chronic paracetamol administration to rats on the glycosaminoglycan content of patellar cartilage

Male Wistar rats were treated with paracetamol (200 mg/kg twice a day) for 2, 3, 4 and 9 weeks. During the first four weeks of paracetamol administration the serum sulfate concentration was significantly decreased. However, during the fourth until the ninth week, the serum sulfate concentration was only diminished to a small and insignificant extent. The paracetamol administration did not lead to serious liver or renal toxicity, as determined by alanine aminotransferase and creatinine levels in the serum of the rats. The paracetamol-induced serum sulfate depletion, observed during the first four weeks of the experiment, led to a significantly lower glycosaminoglycan content of the patellar cartilage of the rats after three and four weeks paracetamol treatment. When after the fourth week the serum sulfate concentration rose to nearly normal levels also the glycosaminoglycan content in the rat patellar cartilage reached control levels. These data indicate that the serum sulfate depletion might be the causative factor for the observed reduction in glycosaminoglycan content of rat patellar cartilage.

Studies on the metabolism of glycosaminoglycans under the influence of new herbal anti-inflammatory agents

The in vivo effect of an herbal based, non-steroidal anti-inflammatory product, salai guggal, prepared from the gum resin exudate of Boswellia serrata and its active principle "boswellic acids" on glycosaminoglycan metabolism has been studied in male albino rats. The biosynthesis of sulfated glycosaminoglycans, as evaluated by the uptake of [35S]sulfate, and the content of glycosaminoglycans were measured in specimens of skin, liver, kidney and spleen. Statistical analysis of the data obtained with respect to the boswellic acids and salai guggal were compared with those of ketoprofen. A significant reduction in glycosaminoglycan biosynthesis was observed in rats treated with all of the drugs. Glycosaminoglycan content was found to be decreased in the ketoprofen-treated group, whereas that of the boswellic acids or salai guggal treated groups remained unaltered. The catabolism of glycosaminoglycans was followed by estimating the activities of lysosomal glycohydrolases, namely beta-glucuronidase, beta-N-acetylglucosaminidase, cathepsin B1, cathepsin B2 and cathepsin D, in tissues and by estimating the urinary excretion and hexosamine and uronic acid. The degradation of glycosaminoglycans was found to be reduced markedly in all drug-treated animals as compared to controls. The potential significance of boswellic acids and salai guggal was discussed in the light of changes in the metabolism of glycosaminoglycans.

Evaluation of the effect of antiarthritic drugs on the secretion of proteoglycans by lapine chondrocytes using a novel assay procedure

A new method is described for separating free 35SO4-- from 35SO4 labelled proteoglycans synthesised by rabbit articular chondrocytes cultured in the presence of excess 35SO4--. The procedure uses the low solubility product of barium sulphate to remove, by precipitation, free 35SO4-- from culture medium. Optimum recovery of 35SO4 labelled proteoglycans was achieved after papain digestion to release 35SO4-glycosaminoglycans, and addition of chondroitin sulphate before the precipitation step. Using this assay, we studied the effect of six drugs-indomethacin, diclofenac, sodium pentosan polysulphate, glycosaminoglycan polysulphate ester, tiaprofenic acid, and ketoprofen-on the secretion into the medium of labelled proteoglycans by lapine chondrocytes. The six drugs were tested at 0.1, 1, 10, 50, and 100 micrograms/ml over four consecutive 48 hour culture periods. A consistent concentration-response pattern was found for the four non-steroidal anti-inflammatory drugs (NSAIDs) studied. Generally they inhibited proteoglycan secretion at 50 and 100 micrograms/ml but had no effect at lower concentrations. Inhibition of secretion was strongest with indomethacin and diclofenac at 50 and 100 micrograms/ml. In contrast with the NSAIDs studied, the two sulphated polysaccharides (sodium pentosan polysulphate and glycosaminoglycan polysulphate ester) at low concentrations increased proteoglycan secretion by chondrocytes, with maximal stimulation occurring at 1 microgram/ml. Sodium pentosan polysulphate, but not glycosaminoglycan polysulphate ester, showed inhibitory activity at 50 and 100 micrograms/ml.

Inhibition of glycosaminoglycan synthesis in anatomically intact rat patellar cartilage by paracetamol-induced serum sulfate depletion

We have studied the effect of low sulfate concentrations on the glycosaminoglycan synthesis in rat patellar cartilage in vivo as well as in vitro. The oral administration of 200 mg/kg paracetamol to male Wistar rats resulted in a significant reduction of the serum sulfate concentration. Reduced serum sulfate availability resulted in a 34% decrease of glycosaminoglycan synthesis in patellar cartilage. This is due to sulfate depletion since paracetamol had no direct effects on glycosaminoglycan synthesis and a slight but significant inhibitory effect on the catabolism of radiolabeled glycosaminoglycans in vitro. The glycosaminoglycans synthesized at low sulfate concentrations in vivo were similar to the glycosaminoglycans synthesized at physiological sulfate concentrations. Studying the effect of sulfate availability in vitro on glycosaminoglycan synthesis in patellar cartilage we found that incubation of rat patellae in medium containing less than 0.5 mM inorganic sulfate led to a decreased sulfate incorporation. The use of potential sulfate decreasing drugs can lead to inhibition of glycosaminoglycan synthesis. This argues for a reconsideration of the use of these drugs in patients with already dysfunctioning cartilage metabolism as in rheumatoid arthritis and osteoarthrosis.

Anti-rheumatic drugs and cartilage

In this chapter an attempt has been made to draw together the known biology of cartilage and some of the mechanisms thought to be responsible for its failure in arthritis. The picture is far from complete but we are now in a good position to use this information to help appraise the pros and cons of the wide range of drugs now available to treat articular disorders. For convenience, these drugs were classified as NSAIDs, corticosteroids and chondroprotective agents. The influence of each of these classes on the metabolism of cartilage was examined in the light of published laboratory and clinical studies. It has been clearly shown that not all NSAIDs are the same. While many of the older drugs provided no benefit to cartilage metabolism, and in some instances suppressed it, the more recently discovered molecules appear to be free of these undesirable effects. Tiaprofenic acid, diclofenac and piroxicam emerged as drugs with little or no harmful effects on cartilage metabolism when used at concentrations within the human therapeutic range. For all NSAIDs, their potential effects on cartilage must be weighed against their respective anti-inflammatory potency, half-life, and effects on the gastric mucosa and other tissues. Other chapters in this book have addressed these important problems. The long-acting corticosteroids, betamethasone and triamcinolone hexacetonide, also appear to offer some benefit in the management of OA; however, as in RA, their use should be restricted to short-term applications. In terms of cartilage metabolism the chondroprotective agents pentosan polysulphate, Arteparon and Rumalon have been the most extensively studied class of drugs. While the laboratory studies have provided convincing evidence of their chondroprotective efficacy, it has been difficult to prove this clinically. This dichotomy of opinion (laboratory versus clinical) stems largely from the inadequacy of the methodologies currently available for the objective clinical assessment of patient response to anti-rheumatic drug therapy. With the advent of nuclear magnetic resonance imaging techniques and monoclonal antibodies to detect specific proteoglycan breakdown fragments in synovial fluid and plasma, the prospects for a unified research approach for the evaluation of these agents may now be possible.

NSAIDs and cartilage metabolism

Data from experimental studies on the influence of non-steroidal anti-inflammatory drugs (NSAIDs) on cartilage is reviewed. There is evidence from this data that some NSAIDs exert a harmful effect, but also that other NSAIDs do not influence cartilage metabolism or could even have a moderate beneficial effect. So far the experimental data must be interpreted with great caution to the clinical situation and no firm conclusions could be drawn from the few clinical reports available. However, the high frequency of other side effects of NSAIDs in the elderly calls a restrictive prescription of these drugs to osteoarthritic patients.

Effects of tiaprofenic acid and other NSAIDs on proteoglycan metabolism in articular cartilage explants

Using in vitro methods, we have determined the effects of four NSAIDs on the biosynthesis and turnover of proteoglycans in articular cartilage explants. Over the concentration ranges examined (5 X 10(-7) to 10(-5) mol/L for tiaprofenic acid, naproxen and indomethacin; 5 X 10(-5) to 10(-3) mol/L for aspirin), all the drugs examined, except tiaprofenic acid, reduced the rate of proteoglycan synthesis compared with control tissue. All of the compounds examined reduced the turnover rate of newly synthesised proteoglycans. The products of turnover of explants treated with the various NSAIDs did not appear to be significantly different from those produced by control tissue, as assessed by gel chromatography and electrophoresis. There were some indications, however, of quantitative differences in distribution on both these analytical systems. These results indicate that with the exception of tiaprofenic acid all the NSAIDs examined produced a general reduction in chondrocyte metabolic activity. Thus it seems unlikely that tiaprofenic acid would have a direct detrimental effect on articular cartilage during long term administration.

Systemic administration of glycosaminoglycan polysulphate (arteparon) provides partial protection of articular cartilage from damage produced by meniscectomy in the canine

Bilateral medial meniscectomy was undertaken in 14 mature beagles. Another two underwent arthrotomy (sham-operated controls). One week after surgery, six of the meniscectomised animals were administered glycosaminoglycan polysulphate (Arteparon) (2 mg/kg) subcutaneously three times a week for 3 weeks, then twice weekly until killed 23 weeks later. Two months before death all animals were given Na2(35)SO4 (1.0 mCi/kg) intravenously. At autopsy, articular cartilage (AC) from the medial and lateral compartments, as well as from the femoral trochlear groove and femoral head, was sampled. Proteoglycans (PGs) were isolated by 4.0 M Guanidine hydrochloride (GuHCl) extraction of AC and purified by ultracentrifugation. The PG monomers were assayed for hexuronic acid, protein, and hexosamines (galactosamine/glucosamine), and their ability to aggregate. The results indicated that Arteparon provided some protective effect to AC in the meniscectomised compartment as demonstrated histologically by reduced surface fibrillation, diminished chondrocyte cloning, and maintenance of alcianophilia. The levels of PGs and hexuronate-protein ratios in medial AC of drug-treated meniscectomised animals were found to be comparable to sham controls, whereas these parameters in the nondrug-treated meniscectomized group were depressed.

Articular cartilage response to arthroscopic surgery: a review of current knowledge

This review is intended to point out the many variables affecting articular cartilage around the time of arthroscopic surgery. Despite the rapid clinical recovery of arthroscopic surgery patients, there may be considerable articular cartilage inhibition related to preoperative, intraoperative, and postoperative factors. Risks to the patient and his joint can be minimized by careful management of these known variables.

A reappraisal of 'analgesic hip'

Nineteen patients with hip radiographs typical of 'analgesic hip' (rapidly destructive, atrophic arthropathy involving both femoral and acetabular components) have been studied. Women predominated (14:5), and all were elderly (mean age 74 years, range 64-83 years). Destructive hip disease was unilateral in all but one case. The mean interval from symptom onset to typical x ray appearance was short (one year, range three to 24 months), and persistent pain unresponsive to drug therapy was characteristic. Screening showed no metabolic or neurological disease. Contrary to previous reports, non-steroidal anti-inflammatory drugs could not be incriminated in development of the disease. Clinical and radiographic similarity to apatite associated destructive arthritis of other large joints was striking, and occurrence of the latter, uncommon condition in five patients (five shoulders, two knees) suggests that both descriptions represent a common articular response at different joint sites.

Salicylate-induced depletion of endogenous inorganic sulfate. Potential role in the suppression of sulfated glycosaminoglycan synthesis in murine articular cartilage

Sodium salicylate has been shown to suppress glycosaminoglycan (GAG) synthesis by articular hyaline cartilage in vitro. We investigated the in vivo effect of sodium salicylate on murine patellar cartilage, using incorporation of intraperitoneally administered 35S-sulfate as a measure of sulfated GAG synthesis. Our results indicated that a single dose of sodium salicylate (200 mg/kg) inhibited in vivo sulfated GAG synthesis by 56%, compared with controls, and had no effect on sulfated GAG breakdown. A striking finding was that sodium sulfate treatment reduced the serum concentration of inorganic sulfate from 1.1 mM to approximately 0.3 mM, and that this serum reduction was associated with a twofold increase in urinary excretion of sulfate. Using anatomically intact patellar cartilage, in vitro studies clearly showed that, in concentrations reached in vivo (greater than or equal to 1 mM), salicylate suppressed murine chondrocyte GAG synthesis. However, in the presence of serum, the effects of 1 mM salicylate were abolished. We also found that sulfated GAG synthesis was clearly inhibited at low concentrations of sulfate (less than 0.5 mM). Our data indicate that sodium salicylate can suppress articular chondrocyte sulfated GAG synthesis in vivo, and that this effect may particularly be due to a drug-induced reduction of endogenous sulfate.

Tiaprofenic acid. A review of its pharmacological properties and therapeutic efficacy in rheumatic diseases and pain states

Tiaprofenic acid is a new non-steroidal anti-inflammatory agent advocated for use in rheumatoid arthritis, osteoarthritis, musculoskeletal disorders, soft-tissue injuries and inflammatory conditions and acute pain of varying origin. Published data suggest that tiaprofenic acid 600 mg daily in 2 or 3 divided doses is comparable in effectiveness with aspirin, diclofenac, ibuprofen, indomethacin, naproxen, piroxicam and sulindac in the treatment of rheumatoid arthritis and osteoarthritis. More controlled clinical trials are necessary to evaluate its potential in rheumatic conditions other than rheumatoid arthritis and osteoarthritis. In controlled studies in patients with acute pain following surgery or trauma, tiaprofenic acid was more effective than placebo and as effective as aspirin and indomethacin. While tiaprofenic acid produced fewer side effects than aspirin in rheumatoid arthritis treatment, and indomethacin in the treatment of osteoarthritis, results have generally shown the short term tolerability of tiaprofenic acid to be similar to that of other non-steroidal anti-inflammatory drugs. As no one of the non-steroidal anti-inflammatory agents is the most suitable drug for all patients requiring such therapy, tiaprofenic acid should be considered along with other drugs of this type in the therapy of arthritic conditions and of acute postoperative or posttraumatic pain.

Chemically induced renal papillary necrosis and upper urothelial carcinoma. Part 1

In the past, renal papillary necrosis (RPN) has been commonly associated with long-term abusive analgesic intake, but over recent years a wide variety of industrially and therapeutically used chemicals have been shown to induce this lesion experimentally or in man. Destruction of the renal papilla may result in: (1) secondary degenerative cortical changes which precede chronic renal failure or (2) a rapidly metastasizing upper urothelial carcinoma, which has a very poor prognosis. This article will briefly review the published data on the morphology, function, and biochemistry of the normal renal medulla and the pathology associated with RPN, together with the secondary changes which give rise to cortical degeneration or epithelial carcinoma. It will then examine in detail those chemicals which have been reported to cause RPN in an attempt to delineate structure-activity relationships. Finally, the many different theories that have been proposed to explain the pathophysiology of RPN will be examined and an hypothesis will be put forward to explain the primary pathogenesis of the lesion and its secondary consequences.

Effects of sodium diclofenac on glycosaminoglycan metabolism in experimental osteoarthritis in rabbits

The effect of diclofenac sodium (DS) on the metabolism of glycosaminoglycans (GAG) was studied in rabbits during the development of osteoarthritis of the knee induced by immobilization. Contents of hexosamines, uronic acid and sulphate-derived 35S-radioactivity in separated GAGs were determined. DS was given to 6 immobilized rabbits for 17 days at a dose of 1.5 mg/kg through a stomach tube. The controls consisted of 8 immobilized rabbits without medication and of 21 non-immobilized rabbits, 6 of which received DS for 17 days. DS did not inhibit in vivo metabolism of sulphated GAGs, according to measurements of [35S]-sulphate incorporation. Healthy rabbits given DS showed only marginal changes of GAG content in joint tissues. DS did not prevent the loss of GAG from the weight-bearing cartilages of the immobilized knees, but caused a further loss of chondroitin sulphates accompanied by an increased amount of hyaluronic acid in the tissues. DS prevented accumulation of the GAGs, which normally occurs during development of osteoarthritis in tissues of the tibial margin and in collateral ligaments. The findings indicate that the effect of DS on the GAG metabolism in connective tissues is somewhat different from that with other non-steroidal anti-inflammatory agents.

Chemically induced renal papillary necrosis and upper urothelial carcinoma. Part 2

In the past, renal papillary necrosis (RPN) has been commonly associated with long-term abusive analgesic intake, but over recent years a wide variety of industrially and therapeutically used chemicals have been shown to induce this lesion experimentally or in man. Destruction of the renal papilla may result in: (1) secondary degenerative cortical changes which precede chronic renal failure or (2) a rapidly metastasizing upper urothelial carcinoma, which has a very poor prognosis. This article will briefly review the published data on the morphology, function, and biochemistry of the normal renal medulla and the pathology associated with RPN, together with the secondary changes which give rise to cortical degeneration or epithelial carcinoma. It will then examine in detail those chemicals which have been reported to cause RPN in an attempt to delineate structure-activity relationships. Finally, the many different theories that have been proposed to explain the pathophysiology of RPN will be examined and an hypothesis will be put forward to explain the primary pathogenesis of the lesion and its secondary consequences.

Nonsteroidal anti-inflammatory drugs and modulation of cartilaginous changes in osteoarthritis and rheumatoid arthritis. Clinical implications

Nonsteroidal anti-inflammatory drugs have a potential for modifying the complex pathophysiologic events leading to cartilage destruction in various forms of arthritis. Following an evaluation of basic mechanisms in the pathogenesis of cartilaginous destructive lesions, the effects of nonsteroidal anti-inflammatory drugs on normal chondrocyte metabolism are discussed. Their capacity to modulate cartilage and bone lesions in experimental forms of arthritis is addressed, as is the manner in which they may modify the pathophysiology of cartilage destruction in human forms of arthritis. Different classes of nonsteroidal anti-inflammatory drugs produce different effects in certain in vivo or in vitro settings.

Ibuprofen in the prevention of experimentally induced postoperative adhesions

Using a five-dose 70 mg/kg regimen, of ibuprofen significantly reduced both overall adhesion formation and the severity of adhesions when given to rabbits in the immediate postoperative period. This reduction was apparently time- and dose-related, as animals given smaller doses of ibuprofen at subsequent intervals had a tendency toward more adhesions and also more severe adhesions. A positive correlation was found between the severity of adhesions and the formation of new glycosaminoglycans and collagens.

Effects of salicylate and indomethacin on glycosaminoglycan and prostaglandin E2 synthesis in intact canine knee cartilage ex vivo

The effects of salicylate and indomethacin on glycosaminoglycan synthesis by intact articular cartilage were examined ex vivo. Distal femora of normal dogs were transected at the diaphysis and incubated in medium containing sodium salicylate or indomethacin and 35SO4. Uronic acid contents of habitually loaded and habitually unloaded regions of the condyles averaged 4.2% and 3.1% of the tissue dry weight, respectively. Salicylate had no effect on glycosaminoglycan synthesis in cartilage from loaded sites but suppressed synthesis by 18% (P less than 0.01) in cartilage from unloaded sites, while indomethacin had no effect on glycosaminoglycan synthesis in either region. Evidence that the drugs indeed diffused into the cartilage, even when no effects on glycosaminoglycan metabolism were noted, was provided by measurements of prostaglandin E2. At the concentrations used, both indomethacin and salicylate markedly reduced prostaglandin E2 synthesis by the cartilage. In studies with 14C-acetylsalicylic acid or 14C-indomethacin, the concentration of each drug in cartilage was calculated to be about 3 logs lower than that in the culture medium. Furthermore, drug concentrations in cartilage from loaded zones were consistently lower than those in cartilage from unloaded sites.

Ibuprofen inhibition of postsurgical adhesion formation: a time and dose response biochemical evaluation in rabbits

Recently, a reduction in postoperative adhesion formation in rabbits which received high-dose ibuprofen (280 mg/kg/day) treatment in the perioperative interval was reported. Because these results could have resulted from a nonspecific effect of ibuprofen, the effects of ibuprofen on peritoneal injury in a time and dose response fashion was evaluated. Seventy rabbits were assigned to seven groups. All rabbits received a dose of ibuprofen 1 hr prior to surgery. The time of the second dose was either 8 or 12 hr after the surgical procedure; 8 hr for groups A, C, and E; 12 hr for groups B, D, and F (A, B: 70 mg/kg; C, D: 35 mg/kg; E, F: 17.5 mg/kg, respectively). Thereafter, rabbits received further dosing every 6 hr to complete a total 10-dose regimen. Group G served as a nontreatment control. Surgical injury was induced by either abrasion or ischemia of the right uterine horn. Immediately after closing the incision, 10 muCi of 14C-labeled glucosamine and 10 muCi of 14C-labeled proline were injected into each rabbit. All rabbits underwent a second laparotomy on the fifth postoperative day for evaluation of adhesion formation. Uterine tissue adjacent to the site of uterine healing was excised for determination of glycosaminoglycan and collagen concentration. In the nontreatment control group G, 5 of the 10 rabbits had severe grade 2 adhesions at the time of second laparotomy, 3 had grade 1 filmy adhesions, and 2 had no adhesions. This is in marked contrast (P less than 0.025) to the group that received ibuprofen at 70 mg/kg/day with the first postoperative dose 8 hr after surgery (group A). In this group, no rabbits had severe grade 2 adhesions, 3 rabbits had filmy grade 1 adhesions, and 7 rabbits were free of pelvic adhesions. A gradual tendency towards more adhesions and more severe adhesions was apparent in groups B-F as the dose of ibuprofen was decreased and the time of first postoperative injection was prolonged. The recovery of 14C-labeled glucosamine from the glycosaminoglycan extraction demonstrated a positive correlation between the cpm recovered and the severity of adhesions formed. Groups A and B had, overall, the lowest ratios of glucosamine (1.47 +/- 0.08 and 1.56 +/- 0.09, respectively) which were statistically different from the nontreatment control group G (1.76 +/- 0.11, P less than 0.05). There was also a positive correlation between the formation of severe adhesions and the ratio of 14C-labeled proline recovered by collagen extraction.(ABSTRACT TRUNCATED AT 400 WORDS)

Microinjury to the synovial membrane may cause disaggregation of proteoglycans in rabbit knee joint articular cartilage

Proteoglycans (PGs) isolated from articular cartilage (AC) of mature rabbits subjected to two or more consecutive intraarticular (IA) injections of sterile saline 24 h apart showed an aggregation defect in the presence of excess hyaluronic acid (HA). Although the PG contents of experimental and control cartilages were indistinguishable, a higher proportion of PGs were extractable from the 3 X IA tissues, as assessed by uronic acid analysis. Proteoglycans from experimental and control cartilages when examined by Sepharose CL-2B chromatography showed two subunit populations, the smaller (KAV = 0.70) containing more ketatan sulphate than the larger (KAV = 0.31). Cultures of AC from IA joints released more 35SO4-labelled PGs into the media over 72 h than control tissues and consisted mainly of PG degradation products although 20% could aggregate in the presence of HA. Examination of PG aggregation 2 weeks after 2 X IA or 3 X IA injections showed that the defect initiated was still present; however, cartilage of immature rabbits was not affected by the 2 X IA procedure.

Biochemical evaluation of postsurgical wound repair: prevention of intraperitoneal adhesion formation with ibuprofen

Proteins central to normal wound repair, including collagen and proteoglycans, were extracted during postoperative mesothelial regeneration, then the quantitation was correlated to macroscopic observations of normal peritoneal reepithelialization and/or postoperative adhesion formation. Sixty-three New Zealand white female rabbits of reproductive age were prospectively assigned to either Group A, untreated control; Group B, which received intramuscular injections of ibuprofen, 70 mg/kg per injection (immediately and 6 hr after surgery); or Group C, which received 5 intramuscular injections of ibuprofen (4 hr before surgery, and immediately, 6, 12, and 18 hr after surgery). The right uterine horn underwent one of three standardized surgical traumas: (1) abrasion of the peritoneal surface with a scalpel until punctate bleeding developed, (2) ischemia of the uterine horn by removal of the collateral blood supply (devascularization), (3) crushing of the uterine horn by cross clamping for 3 min with a Kelley hemostat. Thereafter, 10 microCi of C-14-labeled glucosamine and 10 microCi of C-14-labeled proline were injected into the marginal ear vein of each rabbit. All rabbits underwent a laparotomy on the fifth postoperative day for evaluation of adhesion formation and tissue biopsy for protein extraction. No reduction in adhesion formation was found using a 2-dose postoperative treatment regimen. However, using a 70 mg/kg X 5-doses regimen in the immediate perioperative interval, a significant reduction in both adhesion formation and severe adhesion formation (both P less than 0.025) were found following standardized surgical injury. The extent of adhesion formation was correlated with the extractable glycosaminoglycan and collagen concentrations. As determined by recovered glucosamine and proline, a positive correlation was apparent between the severity of adhesion grade and formation of new glycosaminoglycans or collagens. Thus, ibuprofen appears to inhibit adhesion formation through suppression of fibroproliferative inflammation.

Partial reversal by beta-D-xyloside of salicylate-induced inhibition of glycosaminoglycan synthesis in articular cartilage

While net 35S-glycosaminoglycan synthesis in normal canine articular cartilage was suppressed by 10(-3)M sodium salicylate to about 70% of the control value, addition of xyloside (10(-6)M-10(-3)M) to the salicylate-treated cultures led to a concentration-dependent increase in glycosaminoglycan synthesis, which rose to 120-237% of controls. Similar results were obtained when 3H-glucosamine was used to measure glycosaminoglycan synthesis, confirming that salicylate suppresses and xyloside stimulates net glycosaminoglycan synthesis, and not merely sulfation. Salicylate (10-3)M) did not affect the activity of xylosyl or galactosyl transferase prepared from canine knee cartilage, and net protein synthesis was unaltered by either salicylate or xyloside. The proportion of newly synthesized proteoglycans existing as aggregates when cartilage was cultured with xyloside was similar to that in controls, although the average hydrodynamic size of disaggregated proteoglycans and of sulfated glycosaminoglycans was diminished.