Long-term safety and efficacy of infliximab for the treatment of ankylosing spondylitis

Cutaneous Conundrums in Cardiac Sarcoidosis: A Series on Skin Disease in Immunosuppression

Sarcoidosis is a complex systemic condition resulting in formation of non-caseating granulomas. Infiltrative disease in cardiac sarcoidosis can have significant ramifications on mortality and is one of the few indications for systemic immunosuppressive therapy. In the patient on immunosuppressive medication, resultant sequelae such as skin and soft tissue infections are common and must be differentiated from cutaneous forms of sarcoidosis and other skin pathologies. Patients with humoral or cellular immunodeficiencies may have cutaneous lesions secondary to endemic fungi, mycobacterium, viral diseases, parasites, or encapsulated organisms. We report a rare case of cardiac sarcoidosis on immunosuppressive therapy, with a series of cutaneous sequelae due to opportunistic infection.

Bone changes and curative effect of infliximab in patients with ankylosing spondylitis

OBJECTIVES

To study the bone changes and curative effect of infliximab in patients with ankylosing spondylitis (AS).

METHODS

AS patients diagnosed and treated in Wuwei People's Hospital from January 2017 to March 2018 were collected as the study subjects of this study, and the patients were divided into INF group (n=40) and MTX group (n=40) according to the random number table. The expression levels of TNF-α and IL-33 before and after treatment were detected by enzyme-linked immunosorbent assay (ELISA), and bone changes before and after treatment were compared between the two groups. The ROC curves of TNF-α and IL-33 for efficacy prediction of AS were drawn and analyzed.

RESULTS

After treatment, the expression levels of serum TNF-α and IL-33 in patients in INF group were significantly lower than those in MTX group (P<0.001), and the improvement of bone erosion and tendon thickening in INF group was markedly higher than that in MTX group (P<0.001). The receiver operating characteristic (ROC) curve revealed that the area under the curve (AUC) of TNF-α for predicting efficacy was 0.939, and that of IL-33 was 0.853.

CONCLUSIONS

Infliximab can significantly improve the bone status and has a positive effect in patients with AS, and TNF-α and IL-33 are expected to be used as efficacy predictors of AS.

Effect of Boswellia Serrata Extract on Acute Inflammatory Parameters and Tumor Necrosis Factor-α in Complete Freund's Adjuvant-Induced Animal Model of Rheumatoid Arthritis

Context

The worldwide prevalence of rheumatoid arthritis (RA) is about 1%, whereas in India, it is approximately 0.75%. The current therapy for RA includes nonsteroidal anti-inflammatory drugs corticosteroids, disease-modifying anti-rheumatic drugs and some recently developed biologic agents, but all of these are associated with adverse effects. Some herbal drugs, such as Boswellia serrata, have been reported to possess anti-inflammatory activity.

Aims

The aim of this study is to evaluate the anti-arthritic activity of Boswellia serrata extract (BSE) in complete Freund's adjuvant (CFA)-induced arthritis in rats.

Materials and Methods

Thirty-six Wistar rats were divided into six equal groups. RA was induced by intradermal injection of 0.1 ml CFA in hind paw. Body weight, ankle diameter, paw volume, arthritic index, tumor necrosis factor-α (TNF-α), and histopathological examination were assessed. The experimental data were statistically assessed by one-way analysis of variance (ANOVA).

Statistical Analysis Used

The recorded data were analyzed using paired t-test and ANOVA test using SPSS. The data were analyzed and represented as mean difference. Value of P < 0.05 was considered statistically significant.

Results

BSE at dose 180 mg/kg showed statistically significant improvement in body weight and decrease in ankle diameter and arthritic index (P < 0.05); however, there was insignificant change in paw volume (P = 0.056). This improvement was comparable with Indomethacin. The level of TNF-α did not show any statistically significant change (P = 0.076). Histopathological results also exhibited a reduction in inflammatory parameters.

Conclusions

BSE might have usefulness as an adjunct to conventional therapy of RA.

Verification between Original and Biosimilar Therapeutic Antibody Infliximab Using nSMOL Coupled LC-MS Bioanalysis in Human Serum

Background:

Infliximab (IFX) is a chimeric therapeutic monoclonal antibody targeting tumor necrosis factor alpha (TNFα)-mediated inflammatory immune diseases. However, despite of an initial good clinical response, decrease in response to long-term treatment is a common observation.

Objective:

Recent studies suggest that IFX level in circulation has a correlation with clinical bioavailabil-ity. Therefore, the management of IFX dosage for individual manifestation by IFX monitoring may be valuable for the improvement of therapeutic response and outcomes.

Method:

In order to develop a broad IFX therapeutic monitoring in human serum, we have developed the validated IFX bioanalysis for RemicadeTM and its biosimilar product using our nano-surface and molecu-lar-orientation limited proteolysis (nSMOL) technology coupled with liquid chromatography-tandem mass spectrometry (LC-MS/MS). The nSMOL chemistry has a unique property of Fab-selective prote-olysis, and makes it possible a global bioanalysis for many monoclonal antibodies.

Results:

The quantitation range of IFX in serum was from 0.293 to 300 μg/ml with good linearity. Quan-titation verification at the concentrations of 0.293, 0.879, 14.1 and 240 μg/ml was within 1.56-7.53% of precision and 98.9-111% of accuracy using H-chain signature peptide SINSATHYAESVK. Moreover, cross-verified bioanalysis of Remicade quantitation using biosimilar standard, and its opposite combina-tion, obtained an identical and inter-comparative results.

Conclusion:

The nSMOL strategy has the potential as a practical therapeutic monitoring technology in IFX therapeutic applications.

Targeting cytokines for treatment of neuropathic pain

BACKGROUND

Neuropathic pain is a challenging condition often refractory to existing therapies. An increasing number of studies have indicated that the immune system plays a crucial role in the mediation of neuropathic pain. Exploration of the various functions of individual cytokines in neuropathic pain will provide greater insight into the mechanisms of neuropathic pain and suggest potential opportunities to expand the repertoire of treatment options.

METHODS

A literature review was performed to assess the role of pro-inflammatory and anti-inflammatory cytokines in the development of neuropathic pain. Both direct and indirect therapeutic approaches that target various cytokines for pain were reviewed. The current understanding based on preclinical and clinical studies is summarized.

RESULTS AND CONCLUSIONS

In both human and animal studies, neuropathic pain has been associated with a pro-inflammatory state. Analgesic therapies involving direct manipulation of various cytokines and indirect methods to alter the balance of the immune system have been explored, although there have been few large-scale clinical trials evaluating the efficacy of immune modulators in the treatment of neuropathic pain. TNF-α is perhaps the widely studied pro-inflammatory cytokine in the context of neuropathic pain, but other pro-inflammatory (IL-1β, IL-6, and IL-17) and anti-inflammatory (IL-4, IL-10, TGF-β) signaling molecules are garnering increased interest. With better appreciation and understanding of the interaction between the immune system and neuropathic pain, novel therapies may be developed to target this condition.

TNFα blockers followed by continuation of sulfasalazine and methotrexate combination: a retrospective study on cost saving options of treatment in Spondyloarthritis

High cost deters continuous use of tumor necrosis factor α blockers (TNFi) in developing countries. The objective of this study was to evaluate outcome and expenditure incurred in Spondyloarthritis (SpA) patients beyond a year of follow-up after receiving four doses of infliximab (IFX) over and above background therapy of methotrexate (MTX) and sulfasalazine (SSZ) combination. Electronic medical records were screened for patients with SpA satisfying the Assessment of Spondyloarthritis International Society (ASAS) criteria between 2008 and 2014. Patients who completed at least 1 year of follow-up after receiving four doses of IFX (5 mg/kg at 0, 2, 6, and 14 weeks) on a background therapy of MTX (10-25 mg/week) and SSZ (2-3 g/day) combination were enrolled after obtaining an informed consent. Primary outcome assessed was "time to disease flare". Changes in acute phase reactants, patient reported outcomes (BASDAI, BASFI), and cost were also assessed. Forty-five patients were enrolled. Mean (SD) duration of follow up after fourth IFX dose was 28.9 (18.7) months. Disease flare occurred in 33.3% (15/45) after a mean (SD) duration of 14.5 (10.8) months as compared to 4-6 months described in literature on discontinuing TNFi. Reduction in ESR, CRP, BASDAI and BASFI continued to be statistically significant at follow-up as compared to baseline. As compared to continuous IFX therapy, this treatment reduced cost by 57.1% for each patient-month of follow-up. Short course IFX dosing followed by continuation of MTX and SSZ combination can prolong time to disease flare and decrease requirement for additional IFX dose in SpA. This regimen could be a cost saving option for patients with SpA.

Clinical Gait Analysis on a Patient Undergoing Surgical Correction of Kyphosis from Severe Ankylosing Spondylitis

BACKGROUND

Ankylosing spondylitis (AS) is a chronic inflammatory disease primarily affecting the axial skeleton, including the sacroiliac joints, costovertebral joints, and the spine. Patients with AS found to have an alter gait pattern. The purpose of this study was to investigate biomechanical alterations in gait after surgical correction in a patient with severe kyphosis from AS.

METHODS

A case report in controlled laboratory study, a pretest-posttest design. A 20 year-old male presented with severe sagittal imbalance and inability to stand erect due to AS. He presented with thoracic kyphosis of 70°, lumbar kyphosis of 25°, and pelvic incidence of 43°. The patient had a complex spinal reconstruction with 84° of sagittal correction, normalizing his sagittal alignment. Gait analysis was performed the day before surgery and one month post surgery, including three-dimensional kinematics, ground reaction forces, and electromyography outcomes.

RESULTS

Normalization of spinal alignment minimally increased walking speed and cadence. Lower extremity ranges of motion angles increased, but were not symmetrical even one month post surgery. Postoperatively, trunk flexion, neck extension and head orientation angles decreased compared with preoperative values, but was not symmetrical even one month post surgery. The trunk muscles were activated earlier in the post surgery condition compared to the pre surgery condition while lower extremity muscles presented later muscle activation.

CONCLUSIONS

Surgical correction of spinal alignment improved spine function and efficiency. Changes in gait abnormality parameters observed imply that the patient used less energy to ambulate after surgery than before surgery. Although pre-surgery data showed compensation in the spine kinematics, post-surgery data supported significant changes in the spine and the lower extremity values.

CLINICAL RELEVANCE

Formal gait and motion analysis can provide a method to assess the impact of severe spinal deformity on function and changes after treatment.