POS0562 AUTOANTIBODIES TO JOINT PROTEINS AS NOVEL BIOMARKERS FOR THE DIAGNOSIS OF UNTREATED EARLY RHEUMATOID ARTHRITIS

Background

Autoantibodies to citrullinated protein (ACPA; measured as anti-CCP; aCCP) and rheumatoid factor (RF) appear years before clinical onset of RA and are essential tools in today’s classification criteria for RA. In animal models, antibodies to joint specific proteins (JP) can induce arthritis, and they are also present at onset of RA [1]. As there is a need for increased precision for early diagnosis of RA as well as identification of different subtypes of the disease, we aim to assess whether autoantibodies to native or modified JP can be used for early and precise diagnosis of RA.

Objectives

To study whether antibodies to JP, alone or in combination with ACPA/RF, could increase the diagnostic sensitivity and specificity in untreated early (ue)RA patients.

Methods

Antibodies to JP were analysed in serum from patients in three independent ueRA cohorts as well as from population controls without rheumatic diseases (WINGA, Gothenburg and MFM-ÅUS, Malmö n=1062). ERAp (n=66), the smallest and most recent cohort was chosen for screening, and BARFOT and TIRA-2 (n=1939) for validation. We have developed a bead-based multianalyte flow immunoassay [2] and screened approx. 350 peptides derived from JPs of interest. We included monoclonal antibodies as assay calibrators and determined limit of detection (LoD). To assess positivity for autoantibodies to JP of interest above LoD, we used 5MAD (median absolute deviation) of the control populations as the cut-off.

Results

In the ERAp cohort, 5 autoantibodies discriminated RA patients from controls with 81% sensitivity and 100% specificity (Table 1). The same autoantibodies had 68% sensitivity and 98% specificity in the combined BARFOT and TIRA-2 cohorts. Together with RF and aCCP, only 2 of the 5 autoantibodies added statistically significant diagnostic value, increasing the sensitivity from 48% to 61% with 99% specificity. In aCCP- and RF-negative ueRA patients (n=536), the novel biomarkers identified 22.5% of the patients with 99% specificity compared to controls.

Table 1.

Diagnostic capacity of the joint-specific antibodies

Test panelPerformanceGroup of patientsaCCP+RF+JP+SensitivitySpecificityAUC(ROC)ERApAll patients (n=66)--X81%100%89%RF and aCCP-neg patients (n=7)1------BARFOT and TIRA-2, combined dataAll patients (N=1939)--X68%98%86%All patients (N=1939)X--58%99%78%All patients (N=1939)2XX-48%100%84%All patients (N=1939)2, 3XXX61%99%86%RF and/or aCCP-pos patients (N=1403)--X84%99%93%RF and aCCP-neg patients (N=536)--X22%99%67%RA, literature valuesAnti-CCP testXN/AN/A53–71%95–96%N/A

1Not analysed due to lack of power

2This patient population is both aCCP+ and RF+

3Only 2 of the 5 autoantibodies added statistically significant to the diagnostic value

AUC, Area under the curve; ROC, receiver operating characteristic curve; N/A, not applicable. Controls without rheumatic diseases: N=935 for BARFOT / TIRA-2 and N=27 for ERAp.

Conclusion

Autoantibodies to JP discriminate ueRA patients better then aCCP and RF alone and add an increased diagnostic value in particular for seronegative patients.

References

[1]Holmdahl, R., V. Malmstrom, and H. Burkhardt, Autoimmune priming, tissue attack and chronic inflammation - the three stages of rheumatoid arthritis. Eur J Immunol, 2014. 44(6): p. 1593-9.

[2]Viljanen, J., et al., Synthesis of an Array of Triple-Helical Peptides from Type II Collagen for Multiplex Analysis of Autoantibodies in Rheumatoid Arthritis. ACS Chem Biol, 2020. 15(9): p. 2605-2615. Correction: ACS Chem Biol, 2020. 15(11): p. 3072

Acknowledgements

BARFOT study group.

Disclosure of Interests

Erik Lönnblom: None declared, Monica Leu Agelii: None declared, Outi Sareila Employee of: Part time employee in Vacara AB, Ingiäld Hafström: None declared, Maria Andersson: None declared, Lei Cheng: None declared, Göran Bergström: None declared, Anna-Karin H Ekwall: None declared, Anna Rudin: None declared, Alf Kastbom: None declared, Christopher Sjowall: None declared, Bingze Xu: None declared, Lennart T.H. Jacobsson: None declared, Johan Viljanen: None declared, Jan Kihlberg: None declared, Inger Gjertsson: None declared, Rikard Holmdahl Shareholder of: Rikard Holmdahl the founder of Vacara AB.

Disease activity trajectories in rheumatoid arthritis: a tool for prediction of outcome

Objective: Predicting treatment response and disease progression in rheumatoid arthritis (RA) remains an elusive endeavour. Identifying subgroups of patients with similar progression is essential for understanding what hinders improvement. However, this cannot be achieved with response criteria based on current versus previous Disease Activity Scores, as they lack the time component. We propose a longitudinal approach that identifies subgroups of patients while capturing their evolution across several clinical outcomes simultaneously (multi-trajectories). Method: For exploration, the RA cohort BARFOT (n = 2829) was used to identify 24 month post-diagnosis simultaneous trajectories of 28-joint Disease Activity Score and its components. Measurements were available at inclusion (0), 3, 6, 12, 24, and 60 months. Multi-trajectories were found with latent class growth modelling. For validation, the TIRA-2 cohort (n = 504) was used. Radiographic changes, assessed by the modified Sharp van der Heijde score, were correlated with trajectory membership. Results: Three multi-trajectories were identified, with 39.6% of the patients in the lowest and 18.9% in the highest (worst) trajectory. Patients in the worst trajectory had on average eight tender and six swollen joints after 24 months. Radiographic changes at 24 and 60 months were significantly increased from the lowest to the highest trajectory. Conclusion: Multi-trajectories constitute a powerful tool for identifying subgroups of RA patients and could be used in future studies searching for predictive biomarkers for disease progression. The evolution and shape of the trajectories in TIRA-2 were very similar to those in BARFOT, even though TIRA-2 is a newer cohort.

SAT0612 TEAM-REHABILITATION BENEFITS BODY COMPOSITION AND FUNCTIONAL OUTCOME BEYOND TIME OF THE REHABILITATION PERIOD IN INFLAMMATORY ARTHRITIS, OF WHICH BODY COMPOSITION IS LINKED TO CHANGE IN LEVEL OF CARDIORESPIRATORY FITNESS, WHEREAS MUSCLE MASS AND STRENGTH ARE LINKED TO PHYSICAL FUNCTIONING

Background:

Low physical activity, accumulated disability and disease chronicity contribute to adverse body composition and reduced cardiorespiratory fitness in patients with chronic inflammatory diseases. In the general population, physical exercise improves body composition, muscle strength and aerobic capacity but in inflammatory diseases it is not well established.

Objectives:

To investigate whether 1) exercise intervention in patients with arthritis affects body composition, physical and aerobic capacity, and whether 2) body composition and physical capacity could explain outcomes as HAQ and aerobic capacity.

Methods:

Consecutive patients with inflammatory arthritis and a clinical need for rehabilitation, ages 18-80 years, participated in a team-rehabilitation program for 4 weeks. Anthropometry, body composition assessed with bioelectrical impedance analysis, muscle force with hand grip strength and Times sit-to-stand test (TST), activity limitation with the HAQ score and cardiorespiratory fitness with the Åstrand 6-minute cycle test for VO2 max were measured pre-rehabilitation and after 3 and 12 months. The ANOVA model with Bonferroni correction, adjusted for age, sex and baseline measures, was used for the pairwise comparisons of repeated measures overtime. Association between body composition, physical functioning, and the course of HAQ and cardiorespiratory fitness for 12 months was determined with linear mixed models adjusted for age, gender and comorbidity.

Results:

The study evaluated 149 patients with rheumatoid arthritis (RA), psoriasis arthritis, spondylarthritis and juvenile idiopathic arthritis, aged mean (SD) 53(13) years, 74% women, disease duration 21(13) years, HAQ 1.1(0.6) at inclusion and DAS28 4.1(1.3) for those with RA.

There was a statistically significant reduction of BMI between pre-rehabilitation and after 3 months, reduction of waist circumference, body fat, fat mass and the fat mass index after 3 and 12 months, adjusted p<0.05. The muscle mass of total body, arms and legs did not change significantly post-rehabilitation compared to pre-rehabilitation. Hand grip strength and TST improved together with reduction of HAQ and increased VO2 max after 3 and 12 months, adjusted p<0.05 adjusted for age, sex and baseline measures.

The HAQ overtime was independently associated with total body muscle mass, legs muscle mass, hand grip strength, and TST pre-rehabilitation, but not to the change of body composition overtime.

The course of VO2 max overtime was independently associated with pre-rehabilitation BMI, waist circumference, muscle mass of total body, arms and legs, fat mass, body fat, the fat mass index and TST, as well as with change of BMI, waist circumference, fat mass and the fat mass index between pre-rehabilitation and after 3 and 12 months.

Conclusion:

We observed benefits of intervention with a team-rehabilitation program for 4 weeks on body composition profile, functioning, physical limitation and cardiorespiratory fitness, which were presented beyond the time of the rehabilitation period for up to 12 months. Different aspects of body composition and physical capacity were associated with levels of disability measured with HAQ and with cardiorespiratory fitness. This study indicates that in patients with inflammatory arthritis, muscle mass and strength were linked to HAQ over time, whereas the measures of body composition could be more linked to cardiorespiratory fitness than to HAQ.

Disclosure of Interests:

None declared

AB0129 PCSK9 IS ASSOCIATED WITH DISEASE ACTIVITY AND IMPLICATED IN IMMUNE ACTIVATION IN SYSTEMIC LUPUS ERYTHEMATOSUS

Background:

LDL-levels are increased by Proprotein convertase subtilisin kexin 9 (PCSK9) which targets the LDL-receptor (LDLR). We reported that PCSK9 has immune modulatory properties in addition to LDL-lowering and ameliorates dendritic cell (DC) activation by oxidized LDL (OxLDL)1, which is abundant in atherosclerotic plaques. OxLDL is also raised and associated with cardiovascular disease (CVD) in SLE.1-3

Objectives:

We here investigate the role of PCSK9 in SLE both in a clinical context and in experimental ex vivo studies. The objective is to investigate if PCSK9 and its inhibition could be of relevance in SLE in addition to LDL-level related properties

Methods:

PCSK9-levels were determined by ELISA among SLE patients (n=109) and age- and sex-matched population-based controls (n=91). Common carotid intima-media thickness (IMT) and plaque occurrence were determined by B-mode ultrasound. Plaques were graded by echogenicity. Human peripheral blood monocytes from SLE patients or controls were differentiated into DCs. Effects of PCSK9 and its inhibition by silencing were studied.

Results:

PCSK9-levels were non-significantly higher among SLE-patients as compared to controls but associated significantly with SLE disease activity, as determined by SLAM (0.020) or SLEDAI (0.0178). There was no association between PCSK9-levels and atherosclerosis as determined by IMT, prevalence of plaques or echolucent (potentially vulnerable) plaques. PCSK9 levels were significantly associated with CVD among SLE-patients but not after adjustment for age.

OxLDL induced PCSK9 in DCs and DC-maturation with increased expression of CD86 and HLA-DR. The effects were significantly stronger in DC from SLE patients than from controls. Silencing of PCSK9 abolished OxLDL-induced DC-maturation.

Conclusion:

PCSK9 is associated with disease activity in SLE. One underlying cause could be OxLDL, promoting DC-activation which depends on PCSK9. OxLDL induces PCSK9, an effect which is higher among SLE-patients.PCSK9 could play an unexpected immunological role in SLE and inhibition of PCSK9 could potentially play a role in disease amelioration, pending on clinical studies.

References:

[1]Liu A and Frostegard J. PCSK9 plays a novel immunological role in oxidized LDL-induced dendritic cell maturation and activation of T cells from human blood and atherosclerotic plaque.J Intern Med. 2018.

[2]Frostegard J, Svenungsson E, Wu R, Gunnarsson I, Lundberg IE, Klareskog L, Horkko S and Witztum JL. Lipid peroxidation is enhanced in patients with systemic lupus erythematosus and is associated with arterial and renal disease manifestations.Arthritis Rheum. 2005;52:192-200.

[3]Frostegard J. Immunity, atherosclerosis and cardiovascular disease.BMC Med. 2013;11:117.

Disclosure of Interests:

Anquan Liu: None declared, Mizanur Rahman: None declared, Ingiäld Hafström: None declared, Sofia Ajeganova: None declared, Johan Frostegård Grant/research support from: Unconditional competitive grant from Amgen, related only to PCSK9, not the topic of this abstract

SAT0026 HIGHER LEVELS OF NATURAL ANTI-PHOSPHORYLCHOLINE ANTIBODIES ARE ASSOCIATED WITH LOWER RISK OF INCIDENT CARDIOVASCULAR EVENTS IN YOUNGER PATIENTS WITH RHEUMATOID ARTHRITIS

Background:

The increased cardiovascular (CV) risk in rheumatoid arthritis (RA), especially in seropositive RA, is not fully explained by traditional risk factors. Immuno-inflammatory mechanisms and autoantibodies could be involved in the pathogenesis of atherosclerotic disease. Recent studies have suggested that anti-phosporylcholine antibodies (anti-PC) of IgM subclass counteract the generation of senescent and IL-17+ T-cells, have atheroprotective effects and may play a role in formation and stabilization of atherosclerotic plaque.

Objectives:

To investigate the association between IgM anti-PC antibodies with cardiovascular (CV) morbidity in patients with RA in age and sex groups and by serostatus.

Methods:

The study population was derived from the BARFOT early RA cohort, recruited in 1994-1999. The outcome was CV events i.e. AMI, angina pectoris, coronary intervention, ischemic stroke and TIA tracked through the Swedish Hospital Discharge and the National Cause of Death Registries. The RA-disease measures and traditional risk factors were assessed according to the protocol. Sera collected at inclusion and the 2-year visit were analyzed with ELISA to determine levels of anti-PC IgM (Athera CVDefine kit, Athera Biotechnologies AB). The Kaplan-Meier estimates and Cox proportional-hazards regression models were applied. Analysis were stratified by median level of IgM anti-PC and performed within strata of age, sex and RA-autoantibodies.

Results:

In all, 654 patients with early RA, 68% women, mean (SD) age 55(14.7) years, DAS28 5.2(1.3), 60% RF-positive and 60% ACPA-positive without prevalent CVD were included in this analysis. The level of IgM anti-PC at baseline was median (IQR) of 60.9(36.4-94.9) and at 2 years 56.0(32.3-84.2) U/ml. During follow-up of > 10 years, 141 incident CV events (21.6%) were registered. The levels of anti-PC both at inclusion and after 2 years of observation were lower in participants who experienced CV event than in those who did not, p=0.020 and p=0.012.

The CV event-free survival differed between patients with levels of anti-PC above median compared with those with levels below, p=0.003 by log-rank test. The risk for incident CV event showed a 0.6-fold hazard (95% CI, 0.4-0.8) among patients with higher anti-PC levels as compared with those with lower levels, p=0.003. In the age groups, the risk for incident CV event was lower in patients aged <55 years at inclusion than in those who were older, hazard ratio (HR) 0.40 (0.17-0.94), p=0.036. This result persisted when adjusted for sex and all traditional risk factors, HR 0.36 (0.14-0.92), p=0.032. Also, the risk for incident CV events was lower in patients with higher anti-PC levels in females, HR 0.61 (0-39-0.45), and double RF- and ACPA- negative patients, 0.44 (0.21-0.90), in crude analyses.

The favourable effect of anti-PC at baseline and the CV outcome was not observed in ages >55 years, males, ACPA+ and RF+ patients. There were no significant association between anti-PC level at 2 years and outcome.

Conclusion:

These results suggest that higher levels of IgM anti-PC are associated with a lower risk of incident CV events over 10 years in younger patients. The favourable atheroprotective effect of IgM anti-PC may be a part of explanation of lower risk of atherosclerotic disease in younger persons, females and in those with seronegative RA.

Acknowledgments :

6th Framework Program of the European Union (grant LSHM-CT-2006-037227 CVDIMMUNE)

Disclosure of Interests:

Sofia Ajeganova: None declared, Maria Andersson: None declared, Johan Frostegård Grant/research support from: Unconditional competitive grant from Amgen, related only to PCSK9, not the topic of this abstract, Ingiäld Hafström: None declared

Rheumatoid arthritis phenotype at presentation differs depending on the number of autoantibodies present

Objectives

In rheumatoid arthritis (RA), seropositive and seronegative disease may be two entities with different underlying pathophysiological mechanisms, long-term outcomes and disease presentations. However, the effect of the conjoint presence of multiple autoantibodies, as proxy for a more pronounced humoral autoimmune response, on clinical phenotype remains unclear. Therefore, this study investigates the association between the number of autoantibodies and initial clinical presentation in two independent cohorts of patients with early RA.

Methods

Autoantibody status (rheumatoid factor, anticitrullinated protein antibodies and anticarbamylated protein antibodies) was determined at baseline in the Leiden Early Arthritis Cohort (n=828) and the Swedish BARFOT (Better Anti-Rheumatic Farmaco-Therapy, n=802) study. The association between the number of autoantibodies and baseline clinical characteristics was investigated using univariable and multivariable ordinal regression.

Results

In both cohorts, the following independent associations were found in multivariable analysis: patients with a higher number of RA-associated antibodies were younger, more often smokers, had a longer symptom duration and a higher erythrocyte sedimentation rate at presentation compared with patients with few autoantibodies.

Conclusions

The number of autoantibodies, reflecting the breadth of the humoral autoimmune response, is associated with the clinical presentation of RA. Predisease pathophysiology is thus reflected by the initial clinical phenotype.

Dietary micronutrient intake and atherosclerosis in systemic lupus erythematosus

Objective

The aim of this study was to investigate the role of dietary micronutrient intake in systemic lupus erythematosus (SLE).

Methods

This study included 111 SLE patients and 118 age and gender-matched controls. Data on diet (food frequency questionnaires) were linked with data on Systemic Lupus Activity Measure, Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) and carotid atherosclerotic/echolucent plaque (B-mode ultrasound). Dietary micronutrient intake were compared between SLE patients and controls and in relation to lupus activity and atherosclerosis in SLE. Associations between micronutrient intake and plaque were analyzed through logistic regression, adjusted for potential confounders.

Results

Micronutrient intake did not differ between patients and controls, and between lower and higher lupus activity, apart from the fact that phosphorus was associated with SLEDAI > 6. In SLE patients, some micronutrients were associated with atherosclerotic plaque, left side. Lower intake of riboflavin and phosphorus was associated with atherosclerotic plaque, left side (odds ratio (OR) 3.06, 95% confidence interval (CI) 1.12–8.40 and OR 4.36, 95% CI 1.53–12.39, respectively). Higher intake of selenium and thiamin was inversely associated with atherosclerotic plaque, left side (OR 0.28, 95% CI 0.09–0.89 and OR 0.26, 95% CI 0.08–0.80, respectively). In addition, higher intake of thiamin was inversely associated with echolucent plaque, left side (OR 0.22, 95% CI 0.06–0.84). Lower intake of folate was inversely associated with bilateral echolucent plaque (OR 0.36, 95% CI 0.13–0.99).

Conclusions

SLE patients did not have different dietary micronutrient intake compared to controls. Phosphorus was associated with lupus activity. Riboflavin, phosphorus, selenium and thiamin were inversely associated with atherosclerotic plaque, left side in SLE patients, but not in controls. Dietary micronutrients may play a role in atherosclerosis in SLE.

The association between anti-carbamylated protein (anti-CarP) antibodies and radiographic progression in early rheumatoid arthritis: a study exploring replication and the added value to ACPA and rheumatoid factor

Objective

Anti-carbamylated protein (anti-CarP) antibodies are reported to associate with more radiographic progression within the total rheumatoid arthritis (RA) population and anti-citrullinated peptide antibody (ACPA)-negative subgroup. We explored the association of anti-CarP with radiographic progression in RA and aimed to replicate the association and evaluate the added value of anti-CarP antibodies in relation to ACPA and rheumatoid factor (RF).

Methods

576 Swedish and 628 Dutch patients with RA (2394 and 3247 sets of radiographs, respectively) were longitudinally studied. Replication was restricted to the Swedish patients. In both cohorts, the association of anti-CarP with radiographic progression was determined in strata of patients with similar ACPA and RF status; results of both cohorts were combined in fixed-effect meta-analyses. The net percentage of patients for whom the radiographic progression in 5 years was additionally correctly classified when adding anti-CarP to a model including ACPA and RF was evaluated.

Results

Anti-CarP associated with radiographic progression in the total Swedish RA population (beta=1.11 per year, p=8.75×10−13) and in the ACPA-negative subgroup (beta=1.14 per year, p=0.034). Anti-CarP associated with more radiographic progression in the strata of ACPA-positive/RF-negative, ACPA-negative/RF-positive and ACPA-positive/RF-positive patients with RA (respective p values 0.014, 0.019 and 0.0056). A model including ACPA and RF correctly classified 54% and 57% of the patients; adding anti-CarP to this model did not increase these percentages (54% and 56% were correctly classified).

Conclusions

Anti-CarP antibodies associated with more severe radiographic progression in the total and ACPA-negative RA population. Anti-CarP-positivity had a statistically significant additive value to ACPA and RF, but did not improve correct classification of patients.

Persistently active disease is common in patients with rheumatoid arthritis, particularly in women: a long-term inception cohort study

OBJECTIVES

Despite improved treatment strategies for rheumatoid arthritis (RA), some patients do not respond satisfactorily. The aim of this study was to investigate the course and outcome of early RA diagnosed during the 1990s and followed for 8 years with a focus on those who did not respond well to treatment.

METHOD

This study included 640 patients (66% women) who were enrolled in the BARFOT (Better Anti-Rheumatic PharmacOTherapy) RA inception cohort between the years 1993 and 1999. The 28-joint count Disease Activity Score (DAS28) < 2.6 criteria were used to assess remission. Persistent disease (PD) was defined as absence of remission at all predefined follow-up visits at 1, 2, 5, and 8 years. Function was assessed by Health Assessment Questionnaire (HAQ) and Signals of Functional Impairment (SOFI) scores and radiological joint damage by the Sharp/van der Heijde score (SHS).

RESULTS

Of the 640 patients, 214 (37%) had PD (43% of the women and 25% of the men). Over the 8 years of follow-up, patients with PD had significantly worse mean values for patient's global health measured on a visual analogue scale (VAS patGH), VAS pain, HAQ, SOFI, and SHS compared with those in the non-PD group. Multivariate logistic regression analyses revealed that female gender, current smoking, disease activity at baseline, and absence of remission at 6 months independently predicted PD.

CONCLUSIONS

Of the patients who entered the early RA inception cohort, 37% suffered a PD course over 8 years. The consequences of PD with regard to general health, pain, function, and joint damage were considerable. Of note, PD was more common in women than in men.

Anticitrullinated protein antibodies and rheumatoid factor are associated with increased mortality but with different causes of death in patients with rheumatoid arthritis: a longitudinal study in three European cohorts

OBJECTIVE

Patients with rheumatoid arthritis (RA)-related autoantibodies have an increased mortality rate. Different autoantibodies are frequently co-occurring and it is unclear which autoantibodies associate with increased mortality. In addition, association with different causes of death is thus far unexplored. Both questions were addressed in three early RA populations.

METHODS

2331 patients with early RA included in Better Anti-Rheumatic Farmaco-Therapy cohort (BARFOT) (n=805), Norfolk Arthritis Register (NOAR) (n=678) and Leiden Early Arthritis Clinic cohort (EAC) (n=848) were studied. The presence of anticitrullinated protein antibodies (ACPA), rheumatoid factor (RF) and anticarbamylated protein (anti-CarP) antibodies was studied in relation to all-cause and cause-specific mortality, obtained from national death registers. Cox proportional hazards regression models (adjusted for age, sex, smoking and inclusion year) were constructed per cohort; data were combined in inverse-weighted meta-analyses.

RESULTS

During 26 300 person-years of observation, 29% of BARFOT patients, 30% of NOAR and 18% of EAC patients died, corresponding to mortality rates of 24.9, 21.0 and 20.8 per 1000 person-years. The HR for all-cause mortality (95% CI) was 1.48 (1.22 to 1.79) for ACPA, 1.47 (1.22 to 1.78) for RF and 1.33 (1.11 to 1.60) for anti-CarP. When including all three antibodies in one model, RF was associated with all-cause mortality independent of other autoantibodies, HR 1.30 (1.04 to 1.63). When subsequently stratifying for death cause, ACPA positivity associated with increased cardiovascular death, HR 1.52 (1.04 to 2.21), and RF with increased neoplasm-related death, HR 1.64 (1.02 to 2.62), and respiratory disease-related death, HR 1.71 (1.01 to 2.88).

CONCLUSIONS

The presence of RF in patients with RA associates with an increased overall mortality rate. Cause-specific mortality rates differed between autoantibodies: ACPA associates with increased cardiovascular death and RF with death related to neoplasm and respiratory disease.

Diet and fatty acid pattern among patients with SLE: associations with disease activity, blood lipids and atherosclerosis

OBJECTIVE

As atherosclerosis is increased in systemic lupus erythematosus (SLE) we compared dietary habits in patients with SLE with controls, and in the patients studied associations of diet components, especially fatty acids (FAs), with disease activity, serum lipids and carotid plaque presence.

METHODS

In all 114 patients with SLE and 122 age- and sex-matched population-based controls answered a food frequency questionnaire (FFQ). Subcutaneous abdominal fat cell aspiration was analysed as to FA content and plaque occurrence was determined by B-mode ultrasound.

RESULTS

The total diet energy intake did not differ between patients and controls. However, the patients with SLE reported a higher intake of carbohydrate, lower fibre intake and lower intake of omega-3 and omega-6, than controls (p < 0.05). In the patients, eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) in adipose tissue (AT) correlated negatively with disease activity (SLEDAI), r = -0.36, p = < 0.001 and r = -0.33, p = < 0.001, respectively. AT omega-3 was further positively associated with serum apoA1, r = 0.29, p = 0.004, whereas AT omega-6 showed a negative association, r = -0.21, p = 0.040. These FAs also had opposite associations with plaque presence, EPA and were DHA negative, r = -0.32, p = 0.002 and r = -0.33, p = 0.001, respectively, and omega-6 positive, r = 0.22, p = 0.027. The carbohydrate intake was positively correlated to AT omega-6, r = 0.38, p < 0.001, and negatively with serum apoA1, r = -0.27, p = 0.005.

CONCLUSION

The macronutrient dietary pattern is different in SLE as compared with controls. The low intake of omega-3 and high intake of carbohydrate among patients with SLE appear to be associated with worse disease activity, adverse serum lipids and plaque presence.

Microcirculation as determined by iontophoresis in SLE-patients and controls

Background: The risk of cardiovascular disease (CVD), microangiopathy and prevalence of atherosclerotic plaques are increased in Systemic Lupus Erythematosus (SLE). As systemic endothelial dysfunction is one of the earliest signs of these vascular outcomes in the general population we assessed skin microvascular endothelial function in SLE patients. Methods: Endothelial function in skin was tested with local application of acetylcholine (inducing endothelium-dependent vasodilatation) and any concomitant increase in skin perfusion was measured with Laser Doppler Fluxmetry (LDF) in 84 SLE-patients (83% women, mean age 47 years) and 81 age and sex matched controls. Common carotid intima-media thickness (cIMT) and plaque occurrence were also determined using B-mode ultrasound. Results: There were no significant differences in skin microvascular endothelial function between SLE-patients and controls. In the SLE group, endothelial function did not vary in relation to skin manifestations, Raynaud's phenomenon, nephritis or plaque occurrence. In SLE patients with CVD, however, endothelial function was impaired. Conclusion: Skin microvascular endothelial function is associated with CVD but not with early signs of atherosclerosis in SLE-patients. The endothelial function is not different in SLE-patients as compared to controls.

Effects on joint destruction and remission, bone turnover and lack of influence on atherogenesis: a review of the BARFOT low-dose prednisolone studies on patients with early RA

As early as in 1948 a woman with severe rheumatoid arthritis (RA) was successfully treated with glucocorticoids. However, not until recently has the role of GCs in the treatment of RA been clarified and supported by scientific evidence in a limited number of randomised studies. The present article reviews four reports from the BARFOT (Better Anti-Rheumatic FarmacOTherapy) low-dose prednisolone study based on 250 patients with early RA. These patients were randomised to have either DMARDs only or DMARDs plus prednisolone 7.5 mg daily for two years. It was shown that low-dose prednisolone in addition to a DMARD was superior to DMARDs alone in the ability to inhibit joint damage and induce clinical remission. A follow-up study demonstrated that remission after 2 years with low-dose prednisolone was associated with reduced joint destruction also after 4 years. Prednisolone had no or minor effects on bone density and the frequency of adverse effects was small. A third article measuring markers of bone synthesis and resorption demonstrated that the suppressive effect on bone synthesis exerted by prednisolone was counteracted by the ability of prednisolone to hamper the inflammatory mediated increase in bone resorption. In a fourth article assessing intima-media thickness and endothelial function, no influence of prednisolone 7.5 mg daily on atherosclerosis was observed. Altogether, these four studies provide evidence for recommending low-dose prednisolone treatment in combination with DMARDs for at least two years to patients with recent onset RA.

Anti-apoA-1 IgG and oxidized LDL are raised in rheumatoid arthritis (RA): potential associations with cardiovascular disease and RA disease activity

OBJECTIVE

To determine whether emerging cardiovascular risk factors such as anti-apolipoprotein A-1 (anti-apoA-1) immunoglobulin (Ig)G and oxidized low density lipoprotein (oxLDL) are associated with cardiovascular disease (CVD), carotid intima-media thickness (IMT), and disease activity in rheumatoid arthritis (RA).

METHOD

We determined the aforementioned associations in 69 RA patients with disease duration of 5 years and 46 controls matched by age, sex, and smoking status. Anti-apoA-1 IgG and oxLDL were measured by enzyme-linked immunosorbent assay (ELISA). Carotid arteries were examined by ultrasound. Disease Activity Score calculated on 28 joints (DAS28) was used to assess disease activity.

RESULTS

CVD prevalence was higher among RA patients than controls (17% vs. 2%, p = 0.01) but there was no difference in IMT (median: 0.67 vs. 0.66, p = 0.33). RA patients had a higher anti-apoA-1 IgG prevalence than controls (20% vs. 0%, p = 0.001). Anti-apoA-1 IgG and oxLDL levels were higher in cases than controls [median: 0.33 vs. 0.175 optical density (OD), p = 0.03; and 121 vs. 37.2 U/L, p = 0.0001, respectively]. Anti-apoA-1 IgG-positive patients had higher levels of oxLDL (median: 140.5 vs. 112 U/L, p = 0.01) than those tested negative. Receiver operating characteristic (ROC) curve analysis showed that only anti-apoA-1 IgG was a modest but significant predictor of CVD [area under the curve (AUC) = 0.65, p = 0.03] in RA patients. oxLDL was significantly associated with RA disease activity, whereas anti-apoA-1 IgG was not.

CONCLUSIONS

Anti-apoA-1 IgG could be a marker of CVD in RA, whereas oxLDL levels seem to reflect RA disease activity. Other causes of CVD than a general increase in atherosclerosis (as determined by IMT measurements) including plaque stability may therefore be of importance to explain the increased incidence of CVD in RA.

Influence of gender on assessments of disease activity and function in early rheumatoid arthritis in relation to radiographic joint damage

OBJECTIVE

To evaluate gender differences in score on 28-joint Disease Activity Score (DAS28), Health Assessment Questionnaire (HAQ) and Signals Of Functional Impairment (SOFI) and to relate these scores to radiographic joint destruction.

METHODS

In all, 549 patients with early RA (62% women) from the BARFOT (for "Better Anti-Rheumatic FarmacOTherapy") study were included. At baseline, 1, 2 and 5 years DAS28, HAQ and SOFI scoring, and radiographs of hands and feet were performed. The radiographs were scored using the van der Heijde-Sharp score.

RESULTS

In women the DAS28 was significantly higher than in men due to higher scores for general health and tender joints. Likewise, HAQ and VAS pain were rated significantly higher in women. The SOFI score was worse in men during the first 2 years, depending on higher upper limb scores. Total Sharp score (TotSharp), erosion score and joint space narrowing score did not differ between the sexes at any time point. The DAS28 area under the curve (AUC) correlated significantly with TotSharp at 5 years in both genders (r = 0.316, r = 0.313) mainly owing to swollen joints and erythrocyte sedimentation rate (ESR). The SOFI AUC correlated significantly with TotSharp in women (r = 0.135 to 0.220) but not in men.

CONCLUSIONS

Despite a similar degree of radiographic joint destruction women had, compared with men, worse scores for DAS28 and HAQ, possibly due to higher pain perception and less muscular strength and perhaps because men overestimate their functional capacity.

Effects of human interferon preparations on neutrophil function

We have studied effects of two partially purified human leukocyte (alpha) interferon (IFN) preparations (PIF-A and PIF-B) and a highly purified fibroblast (beta) IFN on the functional activity of normal human neutrophils (PMNs). In vitro, PIF-B conferred a significant and dose-dependent enhancement of chemiluminescence (CL) induced both by phagocytosis and a soluble stimulus, f-Met-Leu-Phe, and decreased killing of Staph. aureus. In contrast, PIF-A caused only a slight inhibition of bactericidal activity and had no effects on CL. beta-IFN had no effects on either bactericidal activity or CL. Migration under agarose was decreased with all of the IFN but phagocytosis and release of enzymes was not affected. PMNs from seven patients treated with PIF-A for multiple myeloma exhibited increased CL responses but no other PMN functions were affected. The findings that human IFN preparations affect PMN functions indicate that high-dose IFN therapy of immunocompromised patients should be carefully evaluated for the possibility of increased infectious complications.

Remission achieved after 2 years treatment with low-dose prednisolone in addition to disease-modifying anti-rheumatic drugs in early rheumatoid arthritis is associated with reduced joint destruction still present after 4 years: an open 2-year continuation study

Objective:

To evaluate if remission induced by low-dose prednisolone during the first 2 years of rheumatoid arthritis (RA) in the BARFOT glucocorticoid (GC) study had a sustained effect on radiological damage for a total of 4 years.

Methods:

A total of 150 of 211 eligible patients with RA who had been randomised to the 7.5 mg prednisolone group (P) or no prednisolone group (NoP) in addition to the initial disease-modifying antirheumatic drugs were included. Radiographs of hands and feet were scored using the Sharp–van der Heijde scoring method. A patient was considered to be in remission if the 28-joint count disease activity score was <2.6.

Results:

Mean (SD) age was 53 (14) and 57 (12) years for the patients in the P and NoP groups, respectively. 64% were female, 64% rheumatoid factor positive, and disease duration at baseline was 6 months. At 2 years the proportion of patients in remission in the P and NoP groups was 55 vs 30%, p = 0.003. Longitudinal analysis showed that over the entire course of the disease, patients on prednisolone had a higher probability of being in remission. Patients in remission at 2 years, compared with those not in remission, had significantly lower total Sharp score, erosion score and joint space narrowing score at 2 and 4 years. The changes in bone mineral density during the 4 years did not differ between those in remission and those with active disease, and were similar in the two treatment groups.

Conclusions:

Prednisolone 7.5 mg daily in addition to disease-modifying anti-rheumatic drugs increases the rate of remission in patients with early RA, which has a beneficial and sustained effect on radiological damage.

Randomized withdrawal of long-term prednisolone treatment in rheumatoid arthritis: effects on inflammation and bone mineral density

OBJECTIVE

Short-term, low-dose glucocorticoid (GC) treatment has anti-inflammatory and disease-modifying effects in rheumatoid arthritis (RA). However, scientific support for long-term, low-dose GC treatment, although widespread, is poor, and information on the effects on bone density is scarce. The aim of this study was to investigate how long-term GC treatment in RA affects inflammation as well as bone density, and also to investigate the feasibility of withdrawal of GC.

PATIENTS AND METHODS

Fifty-eight patients with RA treated with 5-7.5 mg prednisolone daily for at least 2 years were randomized either to withdraw or to continue GC treatment. The patients were followed prospectively for 2 years with respect to disease activity [using the Disease Activity Score calculated for 28 joints, (DAS28)], functional ability [using the Health Assessment Questionnaire (HAQ) score] and bone mineral density (BMD) of the lumbar spine and hip.

RESULTS

Only 11 patients out of 26 randomized to stop GC treatment and available for outcome measures succeeded in stopping the GC medication within 1 year. Fifteen patients failed withdrawal of GC because of increased joint symptoms. A higher mean DAS28 during the study was associated with loss of bone mass in the trochanter. The group that continued with unchanged GC treatment did not deteriorate in BMD during the 2 years but in fact Z-scores improved significantly.

CONCLUSION

Our results indicate that low-dose GC treatment after several years has persisting anti-inflammatory effects in RA and no further negative impact on BMD. It thus seems to be more important to control disease activity than withdraw low-dose GC treatment in this population considering bone health.

Malnutrition in women with rheumatoid arthritis is not revealed by clinical anthropometrical measurements or nutritional evaluation tools

OBJECTIVE

To evaluate diagnostic instruments for assessment of nutritional status in patients with rheumatoid arthritis (RA) in relation to objective body composition data.

SUBJECTS AND METHODS

Study subjects include 60 in-ward patients (83% women, median age 65 years). Anthropometric measures and the nutritional tools Mini Nutritional Assessment (MNA), Subjective Global Assessment (SGA), Malnutrition Universal Screening Tool (MUST) and Nutritional Risk Screening tool 2002 (NRS-2002). Body composition was determined by dual-energy X-ray absorptiometry and fat-free mass index (FFMI; kg/m(2)) and fat mass index (FMI; kg/m(2)) were calculated.

RESULTS

Mean body mass index (BMI) for RA women and men were 24.4 and 26.9 kg/m(2), respectively. Twelve per cent of the women and none of the few men had BMI<18.5 kg/m(2), that is, the cutoff value for malnutrition. FFMI indicated 52% of the women and 30% of the men to be malnourished. The sensitivity and specificity for BMI to detect malnutrition according to FFMI were 27 and 100%, whereas for arm muscle circumference the sensitivity was 36% and the specificity 89% and for triceps skin fold 43 and 93%, respectively. For MNA, sensitivity was 85% and specificity 39% and for SGA 46 and 82%. Both MUST and NRS-2002 had sensitivity of 45% and specificity of 19%.

CONCLUSION

A large proportion of in-ward RA patients had reduced FFMI. Concurrent elevation of fat mass made BMI a non-reliable tool to detect malnutrition. Of the tested clinical evaluation tools, MNA might be used as a screening instrument, but because of its low specificity it should be followed by body composition determination.

Sex: a major predictor of remission in early rheumatoid arthritis?

BACKGROUND

The treatment goal of early rheumatoid arthritis is remission. This study reports remission rates in clinical practice using a cohort of patients with early rheumatoid arthritis.

METHODS

698 patients with early rheumatoid arthritis were included. Mean age at inclusion was 58 years and mean disease duration was 6.4 months; 64% of the patients were women, 56% were positive for antibodies to cyclic citrullinated peptide and 60% were positive for rheumatoid factor. Remission was defined as a disease activity score <2.6, with or without ongoing treatment with drugs for rheumatoid arthritis.

RESULTS

After 2 years, 261 of 689 patients were in remission (37.9%), and after 5 years, the remission rate was 38.5%. However, only 26.1% were in remission at both these time points. Multiple logistic regression analyses found sex to be a main predictor for remission. Thus, significantly fewer women were in remission after 2 years (32.1% v 48%, p = 0.001) after 5 years (30.8% v 52.4%, p = 0.001) and at both these time points (19.1% v 39.3%, p = 0.001). Although disease activity was not with certainty more pronounced in women at onset of disease, the disease course became markedly worse in women. The disparity in remission frequency between women and men could not be explained by differences in disease duration, age or treatment with disease modifying antirheumatic drugs or glucocorticoids.

CONCLUSIONS

Early remission of rheumatoid arthritis by 28-joint Disease Activity Score<2.6 was as frequent or more frequent in this study than in most previous reports. Importantly, women had more severe disease with a considerably lower remission rate than men, although the disease activity before treatment seemed similar.

Prediction of radiological outcome in early rheumatoid arthritis in clinical practice: role of antibodies to citrullinated peptides (anti-CCP)

OBJECTIVE

To investigate the role of anti-cyclic citrullinated peptide antibody (anti-CCP) for the prediction of radiological outcome in patients with early rheumatoid arthritis.

METHODS

Anti-CCP was assessed at baseline in 379 patients with early rheumatoid arthritis (disease duration <1 year). Radiological joint damage and progression were assessed by Larsen score after two years of follow up (end point) and used as outcome variables. The prognostic value of anti-CCP and other demographic and disease related baseline variables were assessed by univariate and multivariate analyses, including calculation of odds ratios (OR), predictive values, and multiple logistic regression models.

RESULTS

The presence of anti-CCP was associated with significantly higher Larsen score both at baseline and at end point. Univariate predictor analysis showed that anti-CCP had the highest significant OR for radiological joint damage and progression after baseline Larsen score, followed by rheumatoid factor, erythrocyte sedimentation rate (ESR), C reactive protein, age, smoking status, and sex. In stepwise multiple regression analyses, baseline Larsen score, anti-CCP, and ESR were selected as significant independent predictors of the radiological outcomes.

CONCLUSIONS

There is good evidence for an association of anti-CCP with radiological joint changes in rheumatoid arthritis. Anti-CCP is an independent predictor of radiological damage and progression. Though prediction in early rheumatoid arthritis is still far from perfect, the use of anti-CCP in clinical practice should make it easier for rheumatologists to reach judicious treatment decisions.

Long term efficacy and safety of cyclosporin versus parenteral gold in early rheumatoid arthritis: a three year study of radiographic progression, renal function, and arterial hypertension

OBJECTIVE

To compare the three year safety and efficacy of cyclosporin and parenteral gold in the treatment of early, active, severe rheumatoid arthritis (RA), and to study the reversibility of cyclosporin associated renal dysfunction in patients who discontinued cyclosporin treatment.

METHODS

The patients continued to receive cyclosporin or parenteral gold in an 18 month open extension to an 18 month randomised, parallel group study. The main efficacy variable was blinded evaluation of radiographic progression of joint damage. Safety variables included serum creatinine, calculated creatinine clearance, and blood pressure.

RESULTS

Radiographic progression during follow up was similar in both groups. About 60% of the patients in the intention to treat groups (n=272) and about half of the patients in the completer groups (n=114) had definite radiographic progression in joint damage (increases >6 in the Larsen-Dale score), and about one in three also had substantial progression (>18 increase in Larsen-Dale score). Both systolic and diastolic blood pressure were significantly increased in the cyclosporin group compared with the gold group, and 12/139 (9%) versus 3/139 (2%) (p=0.03) had notably raised blood pressure. The mean serum creatinine increased by 28% at the treatment end point in the cyclosporin group as compared with 7% in the gold group. The mean calculated creatinine clearance was reduced by 16% and increased by 1% in the cyclosporin and gold groups, respectively, at the end of the study. At the final follow up visit after discontinuation of cyclosporin (at least three months after treatment was stopped) the mean serum creatinine was increased by 15% and creatinine clearance reduced by 16%. Sustained increases in serum creatinine at this post-treatment end point were mostly seen in patients with a raised serum creatinine during treatment of at least 50%.

CONCLUSION

Three year changes in radiographic damage during cyclosporin and parenteral gold were similar in patients with early, active RA. Abnormal renal function and raised blood pressure were often seen in the cyclosporin treated patients.

Bioavailable testosterone in men with rheumatoid arthritis-high frequency of hypogonadism

OBJECTIVES

To study bioavailable testosterone (T) in men with rheumatoid arthritis (RA) by determining non-sex hormone-binding globulin (SHBG)-bound T (NST) under standardized conditions and to investigate if NST is related to disease variables.

METHODS

Basal serum concentrations of total T, SHBG and luteinizing hormone (LH) were measured in 104 men with RA, and the levels of NST as well as the quotient T/SHBG were calculated. The data were compared with those of 99 age-matched healthy men. The results were analysed separately for the age groups 30-49, 50-59 and 60-69 yr.

RESULTS

The RA men had lower NST levels than the healthy men in all age groups. T levels and the T/SHBG ratio were lower only in the age group 50-59 yr. SHBG did not differ significantly. LH was significantly lower in the patients than in the controls. Thirty-three of the 104 patients were considered to have hypogonadism compared with seven of the 99 healthy men. The only clinical variable apart from age that had a significant impact on NST was the Stanford Health Assessment Questionnaire (HAQ).

CONCLUSION

Men with RA had lower levels of bioavailable T and a large proportion were considered hypogonadal. The low levels of LH suggested a central origin of the relative hypoandrogenicity.

Bone mineral density in women and men with early rheumatoid arthritis

OBJECTIVE

To study bone mineral density (BMD) in patients with early rheumatoid arthritis.

METHODS

Dual x-ray absorptiometry was performed in 227 patients, 149 women and 78 men, with rheumatoid arthritis (RA) of no more than 12 months duration.

RESULTS

Women, as well as men above 60 years of age, had a BMD at spine and hip comparable with age and sex matched reference populations. Men younger than 60 years had a tendency to lower BMD. Although the proportion of female patients with osteoporosis was not higher than in the reference, population the proportion of patients with reduced bone mass was increased, and this was found also in men. There was no significant association between BMD and disease duration, disease activity or disability.

CONCLUSION

Untreated patients with early RA have a BMD in spine and hip not significantly different from that of normal reference populations. However, an increased number of the patients had reduced bone mass already at disease onset.

A vegan diet free of gluten improves the signs and symptoms of rheumatoid arthritis: the effects on arthritis correlate with a reduction in antibodies to food antigens

OBJECTIVE

Whether food intake can modify the course of rheumatoid arthritis (RA) is an issue of continued scientific and public interest. However, data from controlled clinical trials are sparse. We thus decided to study the clinical effects of a vegan diet free of gluten in RA and to quantify the levels of antibodies to key food antigens not present in the vegan diet.

METHODS

Sixty-six patients with active RA were randomized to either a vegan diet free of gluten (38 patients) or a well-balanced non-vegan diet (28 patients) for 1 yr. All patients were instructed and followed-up in the same manner. They were analysed at baseline and after 3, 6 and 12 months, according to the response criteria of the American College of Rheumatology (ACR). Furthermore, levels of antibodies against gliadin and beta-lactoglobulin were assessed and radiographs of the hands and feet were performed.

RESULTS

Twenty-two patients in the vegan group and 25 patients in the non-vegan diet group completed 9 months or more on the diet regimens. Of these diet completers, 40.5% (nine patients) in the vegan group fulfilled the ACR20 improvement criteria compared with 4% (one patient) in the non-vegan group. Corresponding figures for the intention to treat populations were 34.3 and 3.8%, respectively. The immunoglobulin G (IgG) antibody levels against gliadin and beta-lactoglobulin decreased in the responder subgroup in the vegan diet-treated patients, but not in the other analysed groups. No retardation of radiological destruction was apparent in any of the groups.

CONCLUSION

The data provide evidence that dietary modification may be of clinical benefit for certain RA patients, and that this benefit may be related to a reduction in immunoreactivity to food antigens eliminated by the change in diet.

[New drugs against rheumatoid arthritis. Improved treatment options place new demands on health care organization]

During the present year more new drugs will be introduced for the treatment of rheumatoid arthritis than have been for several decades. In order to make the widening range of therapeutic options truly available in daily clinical care, certain changes will be required in the organization of treatment resources for rheumatic patients. Several articles in the present issue of Läkartidningen describe the new drugs. Besides introducing these new drugs, it is shown that combinations of "old" antirheumatic drugs (DMARD's) given in high doses and in an earlier phase of disease than previously also exert positive effects on disease course. Taken together, new strategies have been developed for the treatment of patients with RA. One such strategy, endorsed by the Swedish Rheumatology Association, is described in this paper, together with a description of a new national surveillance system for the new drugs.

Progression of joint damage in early active severe rheumatoid arthritis during 18 months of treatment: comparison of low-dose cyclosporin and parenteral gold

OBJECTIVE

This study compared the progression of joint damage in patients with early active severe rheumatoid arthritis (RA) treated with cyclosporin or parenteral gold.

METHODS

In this open, randomized, multicentre study with a blinded radiological endpoint, 375 patients who had suffered from active severe RA for <3 yr were randomized to be treated for 18 months with low-dose cyclosporin or parenteral gold. The groups were stratified with regard to corticosteroid use. Primary efficacy variables were numbers of erosions, erosion score and the Larsen-Dale joint damage score.

RESULTS

Joint damage progressed at similar rates in both treatment arms. In both groups, patients receiving corticosteroids had less X-ray progression. Rheumatoid factor positivity, high swollen joint count, high erythrocyte sedimentation rate and pre-existing X-ray abnormalities predicted progression of joint damage. Although numbers of serious adverse events were similar, more gold patients (n = 65) than cyclosporin patients (n = 45) withdrew from study medication because of adverse events.

CONCLUSION

Cyclosporin was comparable to parenteral gold in retarding progression of joint damage and was better tolerated in terms of adherence to therapy. The open label design should be kept in mind when assessing this difference.

Availability of iron and degree of inflammation modifies the response to recombinant human erythropoietin when treating anemia of chronic disease in patients with rheumatoid arthritis

Forty-six patients with rheumatoid arthritis (RA) and documented anemia of chronic disease (Hb < 100/110 g/l) were randomized to receive either human recombinant erythropoietin (r-HuEPO, n = 36, 300 U/kg body weight) or placebo (n = 10) for 12 weeks in a multicenter study. An adequate response was defined as elevation of Hb > or = 120 g/l. Relevant clinical and laboratory assessments were made to evaluate efficacy and secure safety. A significant elevation in Hb from week 10 onwards was noted in twenty-six patients (five drop-outs) out of nine patients receiving placebo (one drop-out) (12 +/- 1.2 g/l vs 4 +/- 0.5 g/l; Hb elevation from 95 g/l to 107 g/l vs 93 g/l to 97 g/l, P < 0.05). Only 14.6%, however, were considered responders according to preset criteria. In the responders a lower initial CRP, a significant reduction in ESR but not in CRP was seen compared to the remaining r-HuEPO group. A significant elevation of energy level was noted in the r-HuEPO group; otherwise, no differences in clinical variables were seen. No serious adverse effects were noted. When analyzing patients receiving oral iron in combination with r-HuEPO and adding five additional, openly selected patients receiving both adequate iron supplementation and r-HuEPO, there was a significant weekly elevation of Hb from week 8 onwards in favor of combination therapy over the ones only receiving r-HuEPO (18 +/- 1.1 g/l vs 7 +/- 1.1 g/l, P < 0.05). The initial six responders had now reached ten of whom seven belonged to the combination therapy group. Response to r-HuEPO in RA patients appears to be dependent on availability of iron and on the degree of inflammation. If r-HuEPO treatment is considered, iron deficiency should always be corrected and strenuous efforts should have been made to control the disease itself.

Effect of sulphasalazine on gastrointestinal microflora and on mucosal heat shock protein expression in patients with rheumatoid arthritis

This study was performed in order to elucidate a possible association between mucosal heat shock protein expression, the gastrointestinal microflora and disease activity in 17 patients with RA before and after 16 weeks of sulphasalazine (SASP) treatment. The duodenal-jejunal mucosal binding of the monoclonal antibody ML30, recognizing the 65 kDa heat shock protein of mycobacteria, was increased (P = 0.048) in the untreated RA patients compared to controls, but did not correlate to disease, activity or microflora and was not altered by SASP therapy. There was no convincing evidence for bacterial overgrowth in the jejunum and the faecal microflora was normal. SASP treatment altered the faecal microflora, with significant reductions of the total aerobic bacteria, Escherichia coli and Bacteroides, and increased numbers of Bacillus. SASP had only minor effects on the jejunal microflora. A high carriage frequency of Candida albicans was found in saliva and the counts correlated negatively with the unstimulated whole salivary secretion rate. These results suggest that the gut may be involved in the aetiopathogenesis of RA but do not substantiate the hypothesis that the anti-rheumatic effects of SASP are mediated via its anti-microbial properties. However, the possibility that a micro-organism, not detected in this study, may be of crucial importance in RA, cannot be ruled out.

Evidence of a local intestinal immunomodulatory effect of sulfasalazine in rheumatoid arthritis

OBJECTIVE

To analyze whether the intestinal mucosa in rheumatoid arthritis (RA) is immunologically abnormal and whether sulfasalazine (SSZ) possesses any local intestinal immunoregulatory effect.

METHODS

Lymphocyte subpopulations and HLA-DR expression were evaluated in biopsy specimens from the duodenal-jejunal mucosa and in peripheral blood samples obtained from 17 patients with RA, both before and after 16 weeks of SSZ treatment. The same mucosal assays were also performed in 7 controls.

RESULTS

The mucosa of the small intestine in RA patients showed no differences in morphology, HLA-DR expression, or the amounts and distribution of CD3+, CD4+, CD8+, and gamma/delta + lymphocytes compared with the control group. However, there was a reduction in mucosal CD3+ and gamma/delta + lymphocyte numbers after SSZ therapy, which did not correspond to a change in peripheral blood CD3+ lymphocyte number. SSZ treatment also tended to diminish the peripheral blood CD4+:CD8+ cell ratio (P = 0.05).

CONCLUSION

No signs of inflammation or immunologic abnormalities were seen in RA duodenal-jejunal mucosa. In this part of the intestine, however, SSZ exerted immunoregulatory effects that were not encountered in the peripheral blood.

The effect of endothelin, neuropeptide Y, calcitonin gene-related peptide and substance P on neutrophil functions

Neuropeptides are putative mediators of inflammation. At physiological concentrations substance P has been shown to prime polymorphonuclear neutrophil granulocyte (PMN) chemiluminescence (CL). In the present study we show also that both endothelin and neuropeptide Y (NPY), but not calcitonin gene-related peptide (CGRP) are able to prime PMN oxidative metabolism. At similar nanomolar concentrations SP and endothelin (but not NPY) also primed formyl-methionyl-leucyl-phenylalanine (fMLP)-induced rises of cytosolic calcium. On the other hand, NPY caused a direct and dose-related increase of cytosolic calcium concentrations. None of the mentioned neuropeptides primed PMN aggregation or directly induced CL, aggregation or chemotaxis over a wide range of concentrations (1 fM-1 microM).

Effects of antirheumatic treatment on gastric secretory function and salivary flow in patients with rheumatoid arthritis

Many patients with rheumatoid arthritis have impaired gastric acid secretion and dysfunction of the lacrimal and salivary glands, conditions which have been proposed to be due to glandular atrophy. The hypothesis that the rheumatoid inflammation by itself has a depressive effect on these secretory functions was tested on 20 patients with active rheumatoid arthritis who underwent 16 weeks of sulphasalazine therapy. The patients responded well to the treatment, with reduction of joint indices and acute phase reactants. The resting and stimulated whole salivary secretion rate increased in 9/10 and 8/10 patients, respectively. The maximal gastric acid output increased in those patients who had a moderate reduction in acid output prior to treatment. When estimated by s-pepsinogen I, the gastric secretory capacity increased in all patients but one. In a group of auranofin treated patients, s-pepsinogen I rose only in those who responded to treatment with reduced disease activity. These results support the idea that the impaired secretory functions are at least partially reversible and probably also partly inflammatory mediated.

Antirheumatic effects of fasting

Total fasting induces within a few days a substantial reduction of joint pain, swelling, morning stiffness, and other arthritic symptoms in patients with rheumatoid arthritis. This remission subsides slowly after discontinuation of fasting. Its mechanisms are complex and involves diminished activation of neutrophils and lymphocytes and decreased generation of leukotrienes and of concentrations of serum complement factors, as well as of other proinflammatory systems. Moreover, ketosis and other metabolic and endocrine changes may be of significance for symptom expression and recognition.

Effect of sulphasalazine and sulphapyridine on neutrophil superoxide production: role of cytosolic free calcium

As the neutrophil granulocyte plays an important part in rheumatoid inflammation the effect of sulphasalazine on neutrophil function was studied. The results show that sulphasalazine, and its metabolite sulphapyridine, inhibit neutrophil superoxide production elicited by the receptor mediated stimulus N-formyl-methionyl-leucyl-phenyl-alanine (fMLP) and by the calcium ionophore A23187. This effect seems to be dependent on inhibition of intracellular Ca++ increase as both substances reduce this increase upon cell activation with fMLP and A23187. Sulphasalazine and sulphapyridine do not inhibit superoxide production after stimulation with the ester phorbol myristate acetate, a stimulus response coupling which is independent of intracellular Ca++ increase. The reported inhibition of superoxide generation may explain, at least partly, the antirheumatic property of sulphasalazine.

Dietary linoleate supplementation modulates formyl-peptide receptor expression and functional responses of rat neutrophils

We studied effects of dietary supplementation with the essential fatty acid (EFA) linoleic acid (LA) to see if neutrophil responses would be modulated. Neutrophils from rats maintained on a diet supplemented with EFA to 10% of the energy content--the high EFA (HEFA) group--showed a significantly higher LA concentration (but similar arachidonic acid content) compared with neutrophils from control rats maintained on a standard diet with 3% of the energy content as EFA. The HEFA group showed a significantly higher neutrophil oxidative metabolism compared with controls in response to N-formyl-methionyl-leucyl-phenylalanine (FMLP), but this response was equal to control values when stimulated by ionophore A23187, sodium fluoride, or phorbol myristate acetate. Similarly, FMLP conferred a more pronounced increase of intracellular Ca2+ in HEFA neutrophils, whereas this response to ionomycin was equal to that in controls. In contrast, HEFA rat neutrophil migration was decreased to 71% of the value in controls in response to FMLP. Similar results were observed for aggregation responses. On A23187 stimulation, HEFA and control neutrophils generated equal amounts of leukotriene B4 and other 5-lipoxygenase products as well as thromboxane B2 and 6-keto-prostaglandin F1 alpha. However, assessment of binding of FMLP labeled with tritium revealed an increase of the low affinity state of the FMLP receptor population. Thus an increased intake of one unsaturated fatty acid, LA, leading to its accumulation in neutrophils, conferred alterations in formyl-peptide-elicited responses, not associated with the formation of the assessed arachidonate-derived mediators, but most likely through the observed modulation of FMLP receptor subpopulations.