The Effects of 5-year Etanercept Therapy on Cardiovascular Risk Factors in Patients with Psoriatic Arthritis

Cytokine modulation by etanercept ameliorates metabolic syndrome and its related complications induced in rats administered a high-fat high-fructose diet

The aim of the present study was to investigate the effect of etanercept (ETA)-an anti-tumor necrosis factor α (TNF-α) monoclonal antibody-on metabolic disorders such as obesity, hypertension, dyslipidemia, and insulin resistance associated with the metabolic syndrome (MS). MS was induced in rats via high-fat high-fructose (HFHF) administration for 8 weeks. Rats were divided into three groups: negative control, HFHF model, and ETA-treated groups [HFHF + ETA (0.8 mg/kg/twice weekly, subcutaneously) administered in the last 4 weeks]. ETA effectively diminished the prominent features of MS via a significant reduction in the percent body weight gain along with the modulation of adipokine levels, resulting in a significant elevation of serum adiponectin consistent with TNF-α and serum leptin level normalization. Moreover, ETA enhanced dyslipidemia and the elevated blood pressure. ETA managed the prominent features of MS and its associated complications via the downregulation of the hepatic inflammatory pathway that induces nonalcoholic steatohepatitis (NASH)-from the expression of Toll-like receptor 4, nuclear factor kappa B, and TNF-α until that of transforming growth factor-in addition to significant improvements in glucose utilization, insulin sensitivity, and liver function parameter activity and histopathological examination. ETA was effective for the treatment of all prominent features of MS and its associated complications, such as type II diabetes mellitus and NASH.

Elevated ApoB/ApoA-I ratio is associated with acute anti-N-Methyl-D-aspartate receptor encephalitis, but not disease outcomes

Objective

The purpose of the present study is to clarify the relationship between the apolipoprotein B100/apolipoprotein A-I (ApoB/ApoA-I) ratio and anti-N-methyl-D-aspartate receptor (anti-NMDAR) encephalitis.

Methods

A total of 71 patients with anti-NMDAR encephalitis were included in this study, and their ApoB/ApoA-I ratios in baseline and follow-up were retrospectively analyzed.

Results

The ApoB/ApoA-I ratio was closely correlated with the baseline-modified Rankin scale (mRS) score of >3 in patients with anti-NMDAR encephalitis. A subgroup analysis showed obvious differences between the high and low ApoB/ApoA-I ratio groups. The ApoB/ApoA-I ratio was positively correlated with intensive care unit (ICU) treatment, length of hospital stay, baseline mRS score, C-reactive protein (CRP), and erythrocyte sedimentation rate (ESR). The ratios of the high and low ApoB/ApoA-I groups both improved in the follow-up.

Conclusion

The increased ApoB/ApoA-I ratio is associated with acute anti-NMDAR encephalitis, but not disease outcomes. Serum ApoB/ApoA-I ratio was related to inflammation and immunity in peripheral blood. The findings might provide a new idea for further exploration of the pathogenesis and treatment of anti-NMDAR encephalitis.

Choosing the Appropriate Target for the Treatment of Psoriatic Arthritis: TNFα, IL-17, IL-23 or JAK Inhibitors?

Psoriatic arthritis (PsA) is a highly heterogenous disease. Apart from arthritis and psoriasis, other manifestations can also occur, including enthesitis, dactylitis, axial-, nail-, eye- and bowel- involvement. Comorbidities are also frequent in the setting of PsA, with cardiovascular disease and mental-health disorders being the most frequent. The Rheumatologist's arsenal has many different treatment options for treating PsA. Despite their effectiveness, there are some differences in terms of efficacy and safety that might affect clinician's decision for one or the other drug. Comparing biologic DMARDs and JAK-inhibitors, one could say that they have similar effectiveness in terms of musculoskeletal manifestations. However, anti-IL-17 and anti-IL-23 drugs seem to be more effective for skin manifestations. In contrast, JAK-inhibitors and etanercept might be less effective for these manifestations. Inflammatory bowel disease and uveitis are non-responsive to etanercept and anti-IL-17 drugs. As regards to comorbidities, data are scarce, but future studies will shed light on possible differential effect of bDMARDs or JAK-inhibitors. Safety is always an important drive for choosing the appropriate treatment. Infections are the most common adverse event of these drugs. Etanercept and anti-IL-17 drugs are safer for patients having latent tuberculosis, while herpes zoster is more common in individuals receiving JAK-inhibitors. Finally, venous thromboembolism risk, should be taken into account when JAK-inhibitors are used. In this review, we comparatively present, as outlined above, the various aspects that could affect the choice of the appropriate bDMARD or JAK-inhibitor for the treatment of a PsA patient.

Metabolic Syndrome and Its Components in Psoriatic Arthritis

Psoriatic arthritis (PsA) is a well-known inflammatory disorder with a wide variety of phenotypes that extend beyond the joints. It has been defined as an immune-mediated disorder in which Th-1 and Th-17 cells play a key role. It has been associated with an elevated risk of metabolic syndrome (MetS), which is characterized by abdominal obesity, hypertension, hyperglycemia, and hyperlipidemia. While the exact pathophysiology of the link between PsA and MetS has yet to be precisely determined, persistence of inflammatory abnormalities, with overexpression of pro-inflammatory cytokines, might be the cause. Studies have consistently emphasized the strong association between elevated risk of developing cardiovascular disease and MetS in individuals with underlying PsA. The literature has also shown an association between the increased PsA severity and the increased frequency of MetS components. This association has important clinical consequences when treating patients with PsA. Therefore, screening programs should be implemented for PsA patients to evaluate whether they have MetS, and appropriate treatment should be given to manage cardiometabolic risk factors. Patients should also be closely monitored for potential adverse treatment effects on co-morbidities. This article summarizes the evidence of associations between several components of MetS and PsA and analyzes the impact of treatment on these factors.

Effect of Biologics on Cardiovascular Inflammation: Mechanistic Insights and Risk Reduction

It is increasingly recognized that atherosclerosis and consequently cardiovascular disease (CVD) are closely linked with inflammatory processes. The latter is in the center of the pathogenic mechanism underlying autoimmune rheumatic diseases (ARD). It follows then, that optimal control of inflammation in ARDs may lead to a decrease of the accompanied CVD risk. Major trials (eg, CANTOS, CIRT), aimed at examining the possible benefits of immunomodulatory treatments in CVD, demonstrated conflicting results. On the other hand, substantial evidence is accumulating about the possible beneficial effects of biologic disease modifying antirheumatic drugs (bDMARDs) in patients with ARDs, particularly those with rheumatoid arthritis (RA). It seems that bDMARDs (some more than others) alter the lipid profile in RA patients but do not adversely affect, in most cases, the TC/HDL ratio. Favorable effects are noted for arterial stiffness and endothelial function. This is reflected in the lower risk for CVD events, seen in observational studies of RA patients treated with bDMARDs. It should be stressed that more data exist for the TNF-inhibitors than for other bDMARDs, such as tocilizumab, abatacept and rituximab. As regards the spondyloarthropathies (SpA), data are less robust. For TNF-inhibitors, effects appear to be on par with those seen in RA but no conclusions can be drawn for newer biologic drugs used in SpA (eg, IL-17 blockers). Finally, there is accumulating evidence for a beneficial effect of immunosuppressive treatment in cardiac inflammation and function in several ARDs. Introduction of newer therapeutic options in clinical practice seem to have a positive impact on CVD in the setting of ARD. This is probably due to better control of inflammation, but direct improvement in vascular pathology is also a valid hypothesis. Most data are derived from observational studies and, therefore, randomized controlled trials are needed to assess the possible favorable effect of bDMARDs on CVD outcomes.

Cardiovascular Disease in Spondyloarthritides

The spondyloarthritides are a group of chronic systemic inflammatory joint diseases, the main types being ankylosing spondylitis (AS) and psoriatic arthritis (PsA). Evidence accumulating during the last decades suggests that patients with AS or PsA carry an increased risk for cardiovascular disease and cardiovascular death. This risk appears to be mediated by systemic inflammation over and above classical cardiovascular risk factors. The excess cardiovascular risk in those patients has been formally acknowledged by scientific organizations, which have called physicians' attention to the matter. The application by Rheumatologists of new effective anti-rheumatic treatments and treat-to-target strategies seems to benefit patients from a cardiovascular point of view, as well. However, more data are needed in order to verify whether anti-rheumatic treatments do have an effect on cardiovascular risk and whether there are differences among them in this regard. Most importantly, a higher level of awareness of the cardiovascular risk is needed among patients and healthcare providers, better tools to recognize at-risk patients and, ultimately, commitment to address in parallel both the musculoskeletal and the cardiovascular aspect of the disease.

Clinical approach to the inflammatory etiology of cardiovascular diseases

Inflammation is an obligatory marker of arterial disease, both stemming from the inflammatory activity of cholesterol itself and from well-established molecular mechanisms. Raised progenitor cell recruitment after major events and clonal hematopoiesis related mechanisms have provided an improved understanding of factors regulating inflammatory phenomena. Trials with inflammation antagonists have led to an extensive evaluation of biomarkers such as the high sensitivity C reactive protein (hsCRP), not exerting a causative role, but frequently indicative of the individual cardiovascular (CV) risk. Aim of this review is to provide indication on the anti-inflammatory profile of agents of general use in CV prevention, i.e. affecting lipids, blood pressure, diabetes as well nutraceuticals such as n-3 fatty acids. A crucial issue in the evaluation of the benefit of the anti-inflammatory activity is the frequent discordance between a beneficial activity on a major risk factor and associated changes of hsCRP, as in the case of statins vs PCSK9 antagonists. In hypertension, angiotensin converting enzyme inhibitors exert an optimal anti-inflammatory activity, vs the case of sartans. The remarkable preventive activity of SLGT-2 inhibitors in heart failure is not associated with a clear anti-inflammatory mechanism. Finally, icosapent ethyl has been shown to reduce the CV risk in hypertriglyceridemia, with a 27 % reduction of hsCRP. The inflammation-based approach to arterial disease has considerably gained from an improved understanding of the clinical diagnostic strategy and from a better knowledge on the mode of action of numerous agents, including nutraceuticals.

Metabolic Syndrome and psoriatic arthritis: considerations for the clinician

Introduction: Metabolic Syndrome (MetS) is strictly interconnected with systemic inflammation, and increased evidence has described a close link between this condition and Psoriatic Arthritis (PsA).Areas covered: This review summarizes main studies exploring clinical aspects and prevalence of MetS in PsA cohorts. Further, there is accumulating evidence showing shared inflammatory pathways between MetS, its components, and PsA.Expert opinion: The high prevalence of MetS in PsA highlights the need for screening, evaluation, and close monitoring of MetS and its components (namely, diabetes mellitus, obesity, hypertension, and dyslipidemia) in psoriatic patients.Further studies should focus on the pathogenetic link between MetS and PsA. More studies are required to identify appropriate algorithms for the assessment and management of MetS in PsA patients.

Cardiovascular risk in ankylosing spondylitis and the effect of anti-TNF drugs: a narrative review

Introduction: Cardiovascular (CV) mortality is increased in patients with ankylosing spondylitis (AS), but little is known about CV morbidity beyond the fact that they have a two-fold higher prevalence of ischemic heart disease than controls due to the inflammatory pattern of the disease itself, and a higher prevalence of traditional CV risk factors than the general population. Anti-TNF drugs reduce inflammation and a number of studies have reported a reduction in sub-clinical atherosclerosis in AS patients treated with anti-TNF drugs, thus suggesting that inflammation contributes to their higher CV risk. Anti-TNF drugs also alter the lipid profiles of AS patients, although these changes may reflect their normalization secondary to inflammation control, and improve their other myocardial alterations.Areas covered: This review concentrates on the risk of cardiovascular morbidity and mortality among AS patients and the effect of anti-TNF drugs on this risk, with particular emphasis on the putative causes involved and the aspects that are relevant in clinical practice.Expert opinion: The growing evidence of CV disease in AS means that all clinicians need to know how to prevent it and treat patients appropriately. It is important to bear in mind the EULAR guidelines, which state that a rheumatologist is responsible for monitoring all AS patients for signs of CV involvement because this is essential in order to ensure that they are treated properly. As there is little clinical evidence concerning the effects of biological drugs other than anti-TNF agents, treatment should be decided on the basis of the clinical aspects of the type of AS and the CV co-morbidity: for example, patients who are hypertensive or dyslipidemic should immediately start treatment with an anti-hypertensive agent and/or a statin. All of the patients should be educated to prevent CV events by keeping to a balanced healthy diet, avoiding tobacco smoking, and maintaining normal blood pressure, LDL-cholesterol and glucose levels. Finally, all clinicians (but particularly rheumatologists) should always bear in mind CV complications in order to guarantee that the quality of life of AS patients is as good as possible.

Cardiovascular morbidity and mortality in ankylosing spondylitis and psoriatic arthritis

The cardiovascular burden in inflammatory rheumatic diseases is well recognized. Recently, this burden has been highlighted in ankylosing spondylitis (also known as radiographic axial spondyloarthritis) and psoriatic arthritis. We review the cardiovascular morbidity and mortality in these diseases, as well as the prevalence and incidence of traditional cardiovascular risk factors. We examine the contribution of anti-inflammatory therapy with nonsteroidal anti-inflammatory drugs, disease-modifying anti-rheumatic drugs, and TNF inhibitors on the cardiovascular risk profile. Finally, we examine the available recommendations for the management of cardiovascular comorbidity, as they apply to the spondyloarthritis population.

The Clinical Significance and Potential Role of C-Reactive Protein in Chronic Inflammatory and Neurodegenerative Diseases

C-reactive protein (CRP) is an acute-phase protein synthesized by hepatocytes in response to pro-inflammatory cytokines during inflammatory/infectious processes. CRP exists in conformationally distinct forms such as the native pentameric CRP and monomeric CRP (mCRP) and may bind to distinct receptors and lipid rafts and exhibit different functional properties. It is known as a biomarker of acute inflammation, but many large-scale prospective studies demonstrate that CRP is also known to be associated with chronic inflammation. This review is focused on discussing the clinical significance of CRP in chronic inflammatory and neurodegenerative diseases, such as cardiovascular disease, type 2 diabetes mellitus, age-related macular degeneration, hemorrhagic stroke, Alzheimer’s disease, and Parkinson’s disease, including recent advances on the implication of CRP and its forms specifically on the pathogenesis of these diseases. Overall, we highlight the advances in these areas that may be translated into promising measures for the diagnosis and treatment of inflammatory diseases.