1
|
Jamnitski A, Krieckaert CL, Nurmohamed MT, Hart MH, Dijkmans BA, Aarden L, Voskuyl AE, Wolbink GJ. Patients non-responding to etanercept obtain lower etanercept concentrations compared with responding patients. Ann Rheum Dis 2011; 71:88-91. [PMID: 21914626 DOI: 10.1136/annrheumdis-2011-200184] [Citation(s) in RCA: 108] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
ObjectiveTo investigate the relationship between serum etanercept levels and clinical response.MethodsIn 292 etanercept-treated patients with rheumatoid arthritis clinical and pharmacological data were determined at baseline and after 1, 4 and 6 months of etanercept treatment. Differences in etanercept levels between good, moderate and European League Against Rheumatism (EULAR) non-responders were assessed after 6 months of therapy.ResultsAfter 6 months of therapy etanercept levels were significantly higher in good responders (median (IQR) 3.78 (2.53–5.17)) compared with both moderate 3.10 (2.12–4.47) and EULAR non-responders 2.80 (1.27–3.93) (all p<0.05). There was a significant association between clinical response and serum etanercept levels (regression coefficient 0.54, 95% CI 0.21 to 0.86, p=0.001). When patients were categorised into quartiles according to the height of etanercept levels, the lowest quartile (etanercept level <2.1 mg/l) comprised 40% of all non-responders. The highest quartile (etanercept level >4.7 mg/l) comprised 35% of all good EULAR responders. Anti-etanercept antibodies were detected in none of the sera.ConclusionThe authors demonstrated that lower etanercept levels were associated with non-response. Therapeutic drug monitoring and the possibility of the adjusted dosing regimes in the selected groups of patients should be investigated further as a possible tool to optimise treatment with etanercept.
Collapse
Affiliation(s)
- A Jamnitski
- Jan van Breemen Research Institute/Reade, Amsterdam, The Netherlands
| | | | | | | | | | | | | | | |
Collapse
|
2
|
Klarenbeek NB, Allaart CF, Kerstens PJSM, Huizinga TWJ, Dijkmans BAC. The BeSt story: on strategy trials in rheumatoid arthritis. Curr Opin Rheumatol 2009; 21:291-8. [DOI: 10.1097/bor.0b013e32832a2f1c] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
3
|
Jansen G, van der Heijden JW, Dijkmans BAC. Folate receptor β: a novel target for therapeutic intervention in rheumatoid arthritis? ACTA ACUST UNITED AC 2009. [DOI: 10.2217/ijr.09.6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
|
4
|
Bultink IEM, Hamann D, Seelen MA, Hart MH, Dijkmans BAC, Daha MR, Voskuyl AE. Deficiency of functional mannose-binding lectin is not associated with infections in patients with systemic lupus erythematosus. Arthritis Res Ther 2007; 8:R183. [PMID: 17166254 PMCID: PMC1794530 DOI: 10.1186/ar2095] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2006] [Revised: 09/09/2006] [Accepted: 12/13/2006] [Indexed: 11/12/2022] Open
Abstract
Infection imposes a serious burden on patients with systemic lupus erythematosus (SLE). The increased infection rate in SLE patients has been attributed in part to defects of immune defence. Recently, the lectin pathway of complement activation has also been suggested to play a role in the occurrence of infections in SLE. In previous studies, SLE patients homozygous for mannose-binding lectin (MBL) variant alleles were at an increased risk of acquiring serious infections in comparison with patients who were heterozygous or homozygous for the normal allele. This association suggests a correlation between functional MBL level and occurrence of infections in SLE patients. We therefore investigated the biological activity of MBL and its relationship with the occurrence of infections in patients with SLE. Demographic and clinical data were collected in 103 patients with SLE. Functional MBL serum levels and MBL-induced C4 deposition were measured by enzyme-linked immunosorbent assay using mannan as coat and an MBL- or C4b-specific monoclonal antibody. The complete MBL-dependent pathway activity was determined by using an assay that measures the complete MBL pathway activity in serum, starting with binding of MBL to mannan, and was detected with a specific monoclonal antibody against C5b-9. Charts were systematically reviewed to obtain information on documented infections since diagnosis of SLE. Major infections were defined as infections requiring hospital admission and intravenous administration of antibiotics. In total, 115 infections since diagnosis of lupus, including 42 major infections, were documented in the 103 SLE patients (mean age 41 ± 13 years, mean disease duration 7 ± 4 years). The percentage of SLE patients with severe MBL deficiency was similar to that in 100 healthy controls: 13% versus 14%, respectively. Although deposition of C4 to mannan and MBL pathway activity were reduced in 21% and 43% of 103 SLE patients, respectively, neither functional MBL serum levels nor MBL pathway activity was associated with infections or major infections in regression analyses. In conclusion, SLE patients frequently suffer from infections, but deficiency of functional MBL does not confer additional risk.
Collapse
Affiliation(s)
- Irene EM Bultink
- Department of Rheumatology, VU University Medical Center, Postbox 7057, Amsterdam 1007 MB, The Netherlands
- Slotervaart Hospital, Louwesweg 6, Amsterdam 1066 EC, The Netherlands
- Jan van Breemen Institute, Dr J. van Breemenstraat 2, Amsterdam 1056 AB, The Netherlands
| | - Dörte Hamann
- Sanquin Research at CLB, Plesmanlaan 125, Amsterdam 1066 CX, The Netherlands
| | - Marc A Seelen
- Department of Nephrology, Leiden University Medical Center, Postbox 9600, Leiden 2300 RC, The Netherlands
| | - Margreet H Hart
- Sanquin Research at CLB, Plesmanlaan 125, Amsterdam 1066 CX, The Netherlands
| | - Ben AC Dijkmans
- Department of Rheumatology, VU University Medical Center, Postbox 7057, Amsterdam 1007 MB, The Netherlands
- Slotervaart Hospital, Louwesweg 6, Amsterdam 1066 EC, The Netherlands
- Jan van Breemen Institute, Dr J. van Breemenstraat 2, Amsterdam 1056 AB, The Netherlands
| | - Mohamed R Daha
- Department of Nephrology, Leiden University Medical Center, Postbox 9600, Leiden 2300 RC, The Netherlands
| | - Alexandre E Voskuyl
- Department of Rheumatology, VU University Medical Center, Postbox 7057, Amsterdam 1007 MB, The Netherlands
| |
Collapse
|
5
|
van Halm VP, Nurmohamed MT, Twisk JWR, Dijkmans BAC, Voskuyl AE. Disease-modifying antirheumatic drugs are associated with a reduced risk for cardiovascular disease in patients with rheumatoid arthritis: a case control study. Arthritis Res Ther 2007; 8:R151. [PMID: 16984661 PMCID: PMC1779436 DOI: 10.1186/ar2045] [Citation(s) in RCA: 190] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2006] [Revised: 08/21/2006] [Accepted: 09/20/2006] [Indexed: 11/23/2022] Open
Abstract
Rheumatoid arthritis (RA) is characterized by inflammation and an increased risk for cardiovascular disease (CVD). This study investigates possible associations between CVD and the use of conventional disease-modifying antirheumatic drugs (DMARDs) in RA. Using a case control design, 613 RA patients (5,649 patient-years) were studied, 72 with CVD and 541 without CVD. Data on RA, CVD and drug treatment were evaluated from time of RA diagnosis up to the first cardiovascular event or the end of the follow-up period. The dataset was categorized according to DMARD use: sulfasalazine (SSZ), hydroxychloroquine (HCQ) or methotrexate (MTX). Odds ratios (ORs) for CVD, corrected for age, gender, smoking and RA duration, were calculated per DMARD group. Patients who never used SSZ, HCQ or MTX were used as a reference group. MTX treatment was associated with a significant CVD risk reduction, with ORs (95% CI): 'MTX only', 0.16 (0.04 to 0.66); 'MTX and SSZ ever', 0.20 (0.08 to 0.51); and 'MTX, SSZ and HCQ ever', 0.20 (0.08 to 0.54). The risk reductions remained significant after additional correction for the presence of rheumatoid factor and erosions. After correction for hypertension, diabetes and hypercholesterolemia, 'MTX or SSZ ever' and 'MTX, SSZ and HCQ ever' showed significant CVD risk reduction. Rheumatoid factor positivity and erosions both increased CVD risk, with ORs of 2.04 (1.02 to 4.07) and 2.36 (0.92 to 6.08), respectively. MTX and, to a lesser extent, SSZ were associated with significantly lower CVD risk compared to RA patients who never used SSZ, HCQ or MTX. We hypothesize that DMARD use, in particular MTX use, results in powerful suppression of inflammation, thereby reducing the development of atherosclerosis and subsequently clinically overt CVD.
Collapse
Affiliation(s)
- Vokko P van Halm
- Department of Rheumatology, VU University Medical Center, Boelelaan 1117, Amsterdam, 1085 HV, The Netherlands
| | - Michael T Nurmohamed
- Department of Rheumatology, Jan van Breemen Institute, Jan van Breemen straat 2, Amsterdam, 1056 AB, The Netherlands
| | - Jos WR Twisk
- Department of Clinical Epidemiology and Biostatistics, VU University Medical Center, Boelelaan 1117, Amsterdam, 1085 HV, The Netherlands
| | - Ben AC Dijkmans
- Department of Rheumatology, VU University Medical Center, Boelelaan 1117, Amsterdam, 1085 HV, The Netherlands
| | - Alexandre E Voskuyl
- Department of Rheumatology, VU University Medical Center, Boelelaan 1117, Amsterdam, 1085 HV, The Netherlands
| |
Collapse
|
6
|
Drossaers-Bakker KW, Hamburger HL, Bongartz EB, Dijkmans BA, van Soesbergen RM. [Treatment of the obstructive sleep-apnea syndrome in adults]. Ned Tijdschr Geneeskd 2004; 148:802; author reply 802. [PMID: 15129572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
|
7
|
Dinant HJ, Kuijk AWRV, Goedkoop AY, Kraan MC, De Rie MA, Dijkmans BAC, Vaishnaw AK, Krueger G, Tak PP. Alefacept selectively reduces memory-effector (CD45RO+) T cells and improves clinical outcomes in psoriasis and psoriatic arthritis. J Allergy Clin Immunol 2002. [DOI: 10.1016/s0091-6749(02)81916-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
8
|
Nurmohamed MT, Dijkmans BA, Dijkmans BA. Prevention of post-discharge venous thromboembolism in patients with rheumatoid arthritis undergoing knee or hip arthroplasty: a continuing matter of debate. Ann Rheum Dis 2001; 60:905-7. [PMID: 11557644 PMCID: PMC1753382 DOI: 10.1136/ard.60.10.905] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- M T Nurmohamed
- Department of Rheumatology, Free University Medical Centre and Jan van Breemen Institute, Amsterdam, The Netherlands.
| | | | | |
Collapse
|
9
|
Jansen LM, van der Horst-Bruinsma IE, van Schaardenburg D, Bezemer PD, Dijkmans BA. Predictors of radiographic joint damage in patients with early rheumatoid arthritis. Ann Rheum Dis 2001; 60:924-7. [PMID: 11557647 PMCID: PMC1753390 DOI: 10.1136/ard.60.10.924] [Citation(s) in RCA: 108] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To determine factors at diagnosis, associated with radiographic damage at diagnosis and after one year, in patients with early rheumatoid arthritis (RA). METHODS New patients with early RA were followed up for one year. Possible prognostic factors were duration of complaints, morning stiffness, disease activity score (DAS28), functional status (Health Assessment Questionnaire (HAQ) score), rheumatoid factor (IgM RF), and C reactive protein (CRP). Outcome was defined as radiographic damage of the hands and feet (Sharp/van der Heijde score). For the statistical analysis, one way analysis of variance and a forward stepwise logistic regression model was used. RESULTS 130 patients with RA (68% female; median age 64 years, range 21-86) were included. Despite the fact that the median duration of complaints was short (15 weeks, range 2-106) the radiographic damage at diagnosis was significantly correlated with the duration of complaints (p<0.05). Patients with a duration of complaints of >34 weeks had significantly more radiographic joint damage at diagnosis than patients with a shorter duration of complaints. Radiographic progression at one year was correlated with high radiographic joint damage, high CRP level, and a positive IgM RF at entry. CONCLUSIONS In early RA, the number of radiographic lesions was correlated with a longer duration of complaints at the first visit. Progression of these lesions was predicted by a high baseline joint damage, high CRP level, and a positive IgM RF. Further reduction of the delay in referral and early treatment may further decrease joint damage in patients with recent onset polyarthritis.
Collapse
Affiliation(s)
- L M Jansen
- Jan van Breemen Instituut, Amsterdam, The Netherlands
| | | | | | | | | |
Collapse
|
10
|
van Ede AE, Laan RF, Rood MJ, Huizinga TW, van de Laar MA, van Denderen CJ, Westgeest TA, Romme TC, de Rooij DJ, Jacobs MJ, de Boo TM, van der Wilt GJ, Severens JL, Hartman M, Krabbe PF, Dijkmans BA, Breedveld FC, van de Putte LB. Effect of folic or folinic acid supplementation on the toxicity and efficacy of methotrexate in rheumatoid arthritis: a forty-eight week, multicenter, randomized, double-blind, placebo-controlled study. Arthritis Rheum 2001. [PMID: 11465701 DOI: 10.1002/1529-0131(200107)44:7<1515::aid-art273>3.0.co;2-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To study the effect of folates on discontinuation of methotrexate (MTX) as single-drug antirheumatic treatment due to toxicity, to determine which type of adverse events are reduced, to study the effects on the efficacy of MTX, and to compare folic with folinic acid supplementation in a 48-week, randomized, double-blind, placebo-controlled trial. METHODS Patients with active RA (n = 434) were randomly assigned to receive MTX plus either placebo, folic acid (1 mg/day), or folinic acid (2.5 mg/week). The initial MTX dosage was 7.5 mg/week; dosage increases were allowed up to a maximum of 25 mg/week for insufficient responses. Folate dosages were doubled once the dosage of MTX reached 15 mg/week. The primary end point was MTX withdrawal because of adverse events. Secondary end points were the MTX dosage and parameters of efficacy and toxicity of MTX. RESULTS Toxicity-related discontinuation of MTX occurred in 38% of the placebo group, 17% of the folic acid group, and 12% of the folinic acid group. These between-group differences were explained by a decreased incidence of elevated liver enzyme levels in the folate supplementation groups. No between-group differences were found in the frequency of other adverse events or in the duration of adverse events. Parameters of disease activity improved equally in all groups. Mean dosages of MTX at the end of the study were lower in the placebo group (14.5 mg/week) than in the folic and folinic acid groups (18.0 and 16.4 mg/week, respectively). CONCLUSION Both folate supplementation regimens reduced the incidence of elevated liver enzyme levels during MTX therapy, and as a consequence, MTX was discontinued less frequently in these patients. Folates seem to have no effect on the incidence, severity, and duration of other adverse events, including gastrointestinal and mucosal side effects. Slightly higher dosages of MTX were prescribed to obtain similar improvement in disease activity in the folate supplementation groups.
Collapse
Affiliation(s)
- A E van Ede
- University Medical Center St Radboud, Nijmegen, The Netherlands
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
11
|
van Ede AE, Laan RF, Rood MJ, Huizinga TW, van de Laar MA, van Denderen CJ, Westgeest TA, Romme TC, de Rooij DJ, Jacobs MJ, de Boo TM, van der Wilt GJ, Severens JL, Hartman M, Krabbe PF, Dijkmans BA, Breedveld FC, van de Putte LB. Effect of folic or folinic acid supplementation on the toxicity and efficacy of methotrexate in rheumatoid arthritis: a forty-eight week, multicenter, randomized, double-blind, placebo-controlled study. Arthritis Rheum 2001. [PMID: 11465701 DOI: 10.1002/1529-0131(200107)44:73.0.co;2-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
OBJECTIVE To study the effect of folates on discontinuation of methotrexate (MTX) as single-drug antirheumatic treatment due to toxicity, to determine which type of adverse events are reduced, to study the effects on the efficacy of MTX, and to compare folic with folinic acid supplementation in a 48-week, randomized, double-blind, placebo-controlled trial. METHODS Patients with active RA (n = 434) were randomly assigned to receive MTX plus either placebo, folic acid (1 mg/day), or folinic acid (2.5 mg/week). The initial MTX dosage was 7.5 mg/week; dosage increases were allowed up to a maximum of 25 mg/week for insufficient responses. Folate dosages were doubled once the dosage of MTX reached 15 mg/week. The primary end point was MTX withdrawal because of adverse events. Secondary end points were the MTX dosage and parameters of efficacy and toxicity of MTX. RESULTS Toxicity-related discontinuation of MTX occurred in 38% of the placebo group, 17% of the folic acid group, and 12% of the folinic acid group. These between-group differences were explained by a decreased incidence of elevated liver enzyme levels in the folate supplementation groups. No between-group differences were found in the frequency of other adverse events or in the duration of adverse events. Parameters of disease activity improved equally in all groups. Mean dosages of MTX at the end of the study were lower in the placebo group (14.5 mg/week) than in the folic and folinic acid groups (18.0 and 16.4 mg/week, respectively). CONCLUSION Both folate supplementation regimens reduced the incidence of elevated liver enzyme levels during MTX therapy, and as a consequence, MTX was discontinued less frequently in these patients. Folates seem to have no effect on the incidence, severity, and duration of other adverse events, including gastrointestinal and mucosal side effects. Slightly higher dosages of MTX were prescribed to obtain similar improvement in disease activity in the folate supplementation groups.
Collapse
Affiliation(s)
- A E van Ede
- University Medical Center St Radboud, Nijmegen, The Netherlands
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
12
|
Reijnierse M, Dijkmans BA, Hansen B, Pope TL, Kroon HM, Holscher HC, Breedveld FC, Bloem JL. Neurologic dysfunction in patients with rheumatoid arthritis of the cervical spine. Predictive value of clinical, radiographic and MR imaging parameters. Eur Radiol 2001; 11:467-73. [PMID: 11288854 DOI: 10.1007/s003300000557] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The aim of this study was to evaluate if subjective symptoms, radiographic and especially MR parameters of cervical spine involvement, can predict neurologic dysfunction in patients with severe rheumatoid arthritis (RA). Sequential radiographs, MR imaging, and neurologic examination were performed yearly in 46 consecutive RA patients with symptoms indicative of cervical spine involvement. Radiographic parameters were erosions of the dens or intervertebral joints, disc-space narrowing, horizontal and vertical atlantoaxial subluxation, subluxations below C2, and the diameter of the spinal canal. The MR features evaluated were presence of dens and atlas erosion, brainstem compression, subarachnoid space encroachment, pannus around the dens, abnormal fat body caudal to the clivus, cervicomedullary angle, and distance of the dens to the line of McRae. Muscle weakness was associated with a tenfold increased risk of neurologic dysfunction. Radiographic parameters were not associated. On MR images atlas erosion and a decreased distance of the dens to the line of McRae showed a fivefold increased risk of neurologic dysfunction. Subarachnoid space encroachment was associated with a 12-fold increased risk. Rheumatoid arthritis patients with muscle weakness and subarachnoid space encroachment of the entire cervical spine have a highly increased risk of developing neurologic dysfunction.
Collapse
Affiliation(s)
- M Reijnierse
- Department of Radiology, University Hospital Leiden, The Netherlands
| | | | | | | | | | | | | | | |
Collapse
|
13
|
van Ede AE, Laan RF, Rood MJ, Huizinga TW, van de Laar MA, van Denderen CJ, Westgeest TA, Romme TC, de Rooij DJ, Jacobs MJ, de Boo TM, van der Wilt GJ, Severens JL, Hartman M, Krabbe PF, Dijkmans BA, Breedveld FC, van de Putte LB. Effect of folic or folinic acid supplementation on the toxicity and efficacy of methotrexate in rheumatoid arthritis: a forty-eight week, multicenter, randomized, double-blind, placebo-controlled study. Arthritis Rheum 2001; 44:1515-24. [PMID: 11465701 DOI: 10.1002/1529-0131(200107)44:7<1515::aid-art273>3.0.co;2-7] [Citation(s) in RCA: 237] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To study the effect of folates on discontinuation of methotrexate (MTX) as single-drug antirheumatic treatment due to toxicity, to determine which type of adverse events are reduced, to study the effects on the efficacy of MTX, and to compare folic with folinic acid supplementation in a 48-week, randomized, double-blind, placebo-controlled trial. METHODS Patients with active RA (n = 434) were randomly assigned to receive MTX plus either placebo, folic acid (1 mg/day), or folinic acid (2.5 mg/week). The initial MTX dosage was 7.5 mg/week; dosage increases were allowed up to a maximum of 25 mg/week for insufficient responses. Folate dosages were doubled once the dosage of MTX reached 15 mg/week. The primary end point was MTX withdrawal because of adverse events. Secondary end points were the MTX dosage and parameters of efficacy and toxicity of MTX. RESULTS Toxicity-related discontinuation of MTX occurred in 38% of the placebo group, 17% of the folic acid group, and 12% of the folinic acid group. These between-group differences were explained by a decreased incidence of elevated liver enzyme levels in the folate supplementation groups. No between-group differences were found in the frequency of other adverse events or in the duration of adverse events. Parameters of disease activity improved equally in all groups. Mean dosages of MTX at the end of the study were lower in the placebo group (14.5 mg/week) than in the folic and folinic acid groups (18.0 and 16.4 mg/week, respectively). CONCLUSION Both folate supplementation regimens reduced the incidence of elevated liver enzyme levels during MTX therapy, and as a consequence, MTX was discontinued less frequently in these patients. Folates seem to have no effect on the incidence, severity, and duration of other adverse events, including gastrointestinal and mucosal side effects. Slightly higher dosages of MTX were prescribed to obtain similar improvement in disease activity in the folate supplementation groups.
Collapse
Affiliation(s)
- A E van Ede
- University Medical Center St Radboud, Nijmegen, The Netherlands
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
14
|
|
15
|
Molenaar ET, Voskuyl AE, Familian A, van Mierlo GJ, Dijkmans BA, Hack CE. Complement activation in patients with rheumatoid arthritis mediated in part by C-reactive protein. ACTA ACUST UNITED AC 2001; 44:997-1002. [PMID: 11352263 DOI: 10.1002/1529-0131(200105)44:5<997::aid-anr178>3.0.co;2-c] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Complement activation in patients with rheumatoid arthritis (RA) is considered to be triggered by immune complexes. Recently, it was shown that C-reactive protein (CRP) can activate the complement system in vivo. We therefore hypothesized that part of the complement activation in RA is due to CRP. The aim of this study was to investigate CRP-mediated complement activation in RA, and to assess its correlation with disease activity. METHODS Complexes between CRP and the activated complement components C3d (C3d-CRP) and C4d (C4d-CRP), which reflect CRP-mediated complement activation, as well as the overall levels of activated C3 and C4 were measured in the plasma of 107 patients with active RA and 177 patients with inactive RA. Inactive RA was defined according to the American College of Rheumatology criteria for clinical remission. Disease activity was assessed by the modified Disease Activity Score (DAS28). RESULTS Plasma levels of C3d-CRP and C4d-CRP were increased in the majority of the patients, and were significantly higher in patients with active disease versus those with inactive RA (P < 0.001). In patients with active RA, the plasma concentrations of C3d-CRP and C4d-CRP correlated significantly with the DAS28 (Spearman's rho 0.61 and 0.55, respectively; P < 0.001), whereas these correlations were less pronounced in patients with inactive RA (Spearman's rho 0.28 [P < 0.001] and 0.25 [P = 0.001], respectively). Levels of activated C3 and C4 were also increased in the majority of the patients, particularly in patients with active RA. CONCLUSION Part of the activation of complement in RA is mediated by CRP and is correlated with disease activity. We suggest that this activation is involved in the pathogenesis of RA.
Collapse
Affiliation(s)
- E T Molenaar
- Vrije Universiteit Medical Center, Amsterdam, The Netherlands
| | | | | | | | | | | |
Collapse
|
16
|
Abstract
It has become clear that early suppression of rheumatoid arthritis disease activity is important in preventing progressive joint destruction and functional decline. To achieve this goal, many rheumatologists today advocate a more aggressive approach, using combinations of classic disease-modifying antirheumatic drugs-often including methotrexate-or new drugs. During the last 2 years, the combination of methotrexate, sulfasalazine, hydroxychloroquine, and prednisolone has been demonstrated to be more beneficial than monotherapy in patients with early rheumatoid arthritis. In addition, the superior efficacy of the combination of new tumor necrosis factor-alpha blocking agents plus methotrexate to methotrexate alone in patients with chronic disease is very promising. Most studies of combination therapy focus on the efficacy of a combination compared with monotherapy, rather than on the efficacy of a treatment strategy. Although these studies of combination therapy provide useful information about the possible synergistic action of combinations of drugs, many questions remain unanswered, and studies evaluating different treatment strategies are needed before a new approach can be suggested.
Collapse
Affiliation(s)
- Y P Goekoop
- Department of Rheumatology, Vr&OV0451;e Universiteit Medical Center, Amsterdam, The Netherlands
| | | | | | | |
Collapse
|
17
|
Steen KS, Lems WF, Aertsen J, Bezemer D, Dijkmans BA. Incidence of clinically manifest ulcers and their complications in patients with rheumatoid arthritis. Ann Rheum Dis 2001; 60:443-7. [PMID: 11302864 PMCID: PMC1753645 DOI: 10.1136/ard.60.5.443] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Non-steroidal anti-inflammatory drugs (NSAIDs) are often prescribed in patients with rheumatoid arthritis (RA). Because of its frequency and severity, NSAID gastropathy is the most important side effect. The clinical spectrum of NSAID gastropathy includes gastrointestinal complaints, ulcers and their complications. To reduce NSAID gastropathy, rheumatologists in greater Amsterdam decided in January 1997 that prophylactic agents should be prescribed for patients with RA at high risk for NSAID gastropathy, defined as age 60 or older or a history of gastrointestinal (GI) ulcers, or both. OBJECTIVE To determine the incidence of clinically manifest ulcers and their complications in patients with RA at high risk for NSAID gastropathy during a period in which prophylaxis was recommended. Published reports show that the incidence of clinically manifest ulcers and their complications varies from 1.3% to 5%. PATIENTS AND METHODS Within one year, three questionnaires were sent to all outpatients with RA of our clinic (n=2680). The patients were asked if they had had a gastroscopy and/or complication of an ulcer in the preceding months. When a GI event (ulcer or complication) had occurred an analysis was carried out to determine whether the event was possibly related to a compliance failure or a policy failure-for example, no prophylaxis prescribed when it was recommended. RESULTS The response rate for the three questionnaires was 88%, 76%, and 77%, respectively. All three questionnaires were returned by 1856 patients; NSAIDs were used in 1246 (67%) of them. Of the NSAID users 731 (59%) were in the high risk group. Clinically manifest ulcers occurred in seven high risk NSAID users (four gastric ulcers, two duodenal ulcers, and in one patient both types of ulcer). Complications of ulcers were diagnosed in eight (other) patients: seven (upper) GI bleedings and one perforation. Thus the incidence during one year of clinically manifest ulcers in the high risk group was 1.0% and of complications of ulcers 1.1%, together 2.1%. In the group of 15 patients with GI events, only one patient had not taken the adequately prescribed gastroprotective drugs (compliance failure). Misguidedly, gastroprotective drugs were not prescribed in seven patients (policy failure), but in the remaining seven patients gastroprotective drugs were adequately prescribed and used. CONCLUSION The incidence of clinically manifest ulcers and of complications of ulcers in patients with RA at high risk for NSAID gastropathy is relatively low, and might be related to our strategy to prescribe prophylactic agents in these patients.
Collapse
Affiliation(s)
- K S Steen
- Department of Rheumatology, Academic Hospital Vrije Universiteit, Slotervaart Hospital, and Jan van Breemen Institute, Amsterdam, The Netherlands
| | | | | | | | | |
Collapse
|
18
|
van Asselt KM, Lems WF, Bongartz EB, Hamburger HL, Drossaers-Bakker KW, Dijkmans BA, van Soesbergen RM. Outcome of cervical spine surgery in patients with rheumatoid arthritis. Ann Rheum Dis 2001; 60:448-52. [PMID: 11302865 PMCID: PMC1753638 DOI: 10.1136/ard.60.5.448] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES Cervical spine instability in patients with rheumatoid arthritis (RA) may lead to cervical myelopathy or occipital neuralgia, or both. Morbidity and mortality in patients with RA treated with cervical spine surgery during two years of follow up were evaluated. METHODS Between 1992 and 1996 55 patients with RA underwent cervical spine surgery because of occipital neuralgia or cervical myelopathy, or both. Patients were classified according to the Ranawat criteria for pain and neurological assessment before operation and three months and two years postoperatively. For occipital neuralgia a successful operation was defined as complete relief of pain and for cervical myelopathy as neurological improvement. RESULTS Occipital neuralgia was present in 17 patients, cervical myelopathy in 14 patients, and 24 had both. Surgical treatment in the patients with symptoms of occipital neuralgia who were still alive two years after surgery was successful in 18/29 (62%). In the surviving patients with cervical myelopathy neurological improvement of at least one Ranawat class was seen in 16/24 (67%). Postoperative mortality within six weeks was 3/51 (6%). Within two years after the operation 14 /51 (27%) of the patients had died; in most patients the cause of death was not related to surgery. The highest mortality (50%) was found in the group of six patients with quadriparesis and very poor functional capacity (Ranawat IIIB). CONCLUSION Cervical spine surgery in patients with RA performed because of occipital neuralgia or cervical myelopathy, or both, is successful in most patients who are alive two years after surgery. However, the mortality rate during these two years is relatively high, which seems to be largely related to the severity of the underlying disease and not to the surgery itself.
Collapse
Affiliation(s)
- K M van Asselt
- Department of Rheumatology, Slotervaart Hospital, Jan van Breemen Institute and the Academic Hospital Vrije Universiteit in Amsterdam, The Netherlands
| | | | | | | | | | | | | |
Collapse
|
19
|
van Rossum MA, Fiselier TJ, Franssen MJ, ten Cate R, van Suijlekom-Smit LW, Wulffraat NM, van Luijk WH, Oostveen JC, Kuis W, Dijkmans BA, van Soesbergen RM. Effects of sulfasalazine treatment on serum immunoglobulin levels in children with juvenile chronic arthritis. Scand J Rheumatol 2001; 30:25-30. [PMID: 11252688 DOI: 10.1080/030097401750065283] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
This article describes the effects of sulfasalazine (SSZ) treatment on serum immunoglobulin (Ig) levels in 6 children with oligoarticular- or polyarticular onset juvenile chronic arthritis (JCA). None of the children who developed dysimmunoglobulinemia during treatment showed clinical symptoms of this adverse event, in particular none developed severe infections. All patients regained normal immunoglobulin levels after discontinuing SSZ treatment. One patient with a partial IgA deficiency at the start of SSZ treatment showed a slow increase in the IgA level during treatment. During follow-up (4-6 years), one patient spontaneously developed a dysimmunoglobulinemia and one patient developed diabetes mellitus. Based on these case reports and review of the literature we advocate monitoring of serum immunoglobulin levels while on SSZ treatment.
Collapse
Affiliation(s)
- M A van Rossum
- Department of Paediatrics, Leiden University Medical Centre, The Netherlands
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
20
|
Bultink IE, Lems WF, van de Stadt RJ, Dinant HJ, Leyte A, Park DS, de Koning MH, Dijkmans BA. Ferritin and serum transferrin receptor predict iron deficiency in anemic patients with rheumatoid arthritis. Arthritis Rheum 2001; 44:979-81. [PMID: 11315939 DOI: 10.1002/1529-0131(200104)44:4<979::aid-anr157>3.0.co;2-h] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- I E Bultink
- Academic Hospital Vrije Universiteit, Amsterdam, The Netherlands
| | | | | | | | | | | | | | | |
Collapse
|
21
|
Abstract
Dutch rheumatologists were given a questionnaire on NSAID gastropathy, in which older age (>60 years) and previous ulcers were mentioned by them as being the most important risk factors. Dutch rheumatologists follow different strategies for the prevention of NSAID gastropathy, with a slight preference for proton pump inhibitors and the use of COX-2 selective NSAIDs.
Collapse
Affiliation(s)
- K S Steen
- Department of Rheumatology, Academic Hospital, Vrije Universiteit, Slotervaart Hospital and Jan van Breemen Institute, Amsterdam, The Netherlands
| | | | | |
Collapse
|
22
|
Baudoin P, van der Horst-Bruinsma IE, Dekker-Saeys AJ, Weinreich S, Bezemer PD, Dijkmans BA. Increased risk of developing ankylosing spondylitis among first-born children. Arthritis Rheum 2000; 43:2818-22. [PMID: 11145041 DOI: 10.1002/1529-0131(200012)43:12<2818::aid-anr23>3.0.co;2-f] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Studies in mice have demonstrated an increased risk of ankylosing enthesopathy in earlier litters compared with later-born offspring. In humans, birth order and maternal age as risk factors for ankylosing spondylitis (AS) have not been investigated previously. This study was undertaken to investigate whether first-born children have a higher risk of AS than later-born children and whether maternal age at delivery is another risk factor. METHODS The birth order of 162 AS patients was compared with that of their healthy siblings, both for the total group and with stratification for maternal age at first delivery. Maternal age at the time of delivery of AS patients who were first-born children was compared with the mean maternal age at first delivery in the Dutch population. RESULTS The number of first-born children with AS was significantly higher than would be expected in case of an equal risk between first-born and later-born children (26 versus 20 for families with 2 children [P = 0.029] and 63 versus 47.6 for all families [P = 0.004]). Also, the mean maternal age at first delivery was lower in mothers of AS patients (24.8 years) compared with mothers of healthy controls (26.1 years). CONCLUSION Low birth order is a risk factor for AS in humans.
Collapse
Affiliation(s)
- P Baudoin
- University Hospital, Vrije Universiteit, Amsterdam, The Netherlands
| | | | | | | | | | | |
Collapse
|
23
|
Hulshof MM, Bouwes Bavinck JN, Bergman W, Masclee AA, Heickendorff L, Breedveld FC, Dijkmans BA. Double-blind, placebo-controlled study of oral calcitriol for the treatment of localized and systemic scleroderma. J Am Acad Dermatol 2000; 43:1017-23. [PMID: 11100017 DOI: 10.1067/mjd.2000.108369] [Citation(s) in RCA: 87] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Various treatments including corticosteroids, nonsteroidal anti-inflammatory drugs, D-penicillamine, interferon gamma, cyclosporine, and cytostatic drugs have been used with limited success in both morphea and systemic sclerosis (SSc). OBJECTIVE We investigated the effect of treatment with oral calcitriol in patients with localized or systemic scleroderma. METHODS A randomized, double-blind, placebo-controlled study of 9 months' duration with a 6-month follow-up was performed at the Department of Dermatology. A total of 27 patients (7 patients with SSc and 20 with morphea) were selected on a minimal skin score of 3 for patients with morphea and 12 for those with SSc. Each patient received calcitriol (0.75 microg/day for 6 months plus 1.25 microg/day for 3 months) or placebo for 9 months. Efficacy parameters included skin score, measurement of serum markers of collagen synthesis and degradation and, additional for the patients with SSc, oral aperture measurements, lung function studies, and esophagus motility. RESULTS The skin score in patients with morphea after 9 months' treatment showed no significant difference between the placebo and calcitriol groups (mean percentage reduction [SD] in skin score in the placebo group was -29.3 [57.9]; in the calcitriol group it was -19.4 [46.6]). The small group of patients with SSc was inadequate to allow us to draw any conclusions regarding efficacy. No significant change was found in the serum markers of collagen metabolism. CONCLUSION In this study calcitriol was not more effective than placebo in patients with morphea. Because of the small group of patients with SSc treated, no conclusions regarding efficacy in SSc can be drawn.
Collapse
Affiliation(s)
- M M Hulshof
- Department of Dermatology, Leiden University Medical Center, Leiden, The Netherlands
| | | | | | | | | | | | | |
Collapse
|
24
|
Nurmohamed MT, Soesan M, van Oers MH, Dijkmans BA, van Soesbergen RM. Cyclosporin for sulphasalazine-induced aplastic anaemia in a patient with early rheumatoid arthritis. Rheumatology (Oxford) 2000; 39:1431-3. [PMID: 11136894 DOI: 10.1093/rheumatology/39.12.1431] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
|
25
|
Giltay EJ, Popp-Snijders C, van Denderen JC, van Schaardenburg D, Gooren LJ, Dijkmans BA. Phenylbutazone can spuriously elevate unextracted testosterone assay results in patients with ankylosing spondylitis. J Clin Endocrinol Metab 2000; 85:4923-4. [PMID: 11134168 DOI: 10.1210/jcem.85.12.7076-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
|
26
|
Abstract
A role for sex steroids in the pathogenesis of AS is suggested by the male predominance, the peak age of onset in young adults, the increased number of first manifestations and flares after pregnancy, and the fact that sex steroids may modulate immune functions. There is a theoretic possibility that (normal levels of) androgens are indeed relevant in the male sex skew of AS. It has been reported that men with AS have higher than normal androgen levels; however, the evidence that serum testosterone levels are elevated in patients with AS is not robust. Elevated DHEAS and 17 alpha-hydroxyprogesterone levels have been reported in male AS patients; these may be secondary to inflammation and stress but may theoretically also be causally related to AS. These elevations might result from a partial late onset 11 beta- or 21-hydroxylase deficiency. Current data on sex steroid hormones provide no straightforward explanation for the male predominance in AS. It is fair to say that present data in patients with long-standing AS are too limited to suggest a role for androgens in the perpetuation of the disease, but a role in the initiation and the early stages of AS cannot be excluded. Such information can only be obtained from prospective studies. Cross-sectional studies cannot clearly distinguish causal relation from secondary disease effects, because blood sampling to test these hypotheses only takes place many years after the onset of disease. The impact of sex steroids on these features of AS is still unresolved. There is as yet no rationale for the use of medication that modifies sex steroid hormones in the management of AS. Alternative explanations for the higher male prevalence of AS may be found in the different chromosomal configuration and body composition of men and women.
Collapse
Affiliation(s)
- L J Gooren
- Department of Endocrinology, University Hospital Vrije Universiteit, Amsterdam, The Netherlands.
| | | | | | | |
Collapse
|
27
|
Lems WF, Dijkmans BA. [Effect of anti-osteoporosis agents on the incidence of vertebral fractures]. Ned Tijdschr Geneeskd 2000; 144:1941-5. [PMID: 11048556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
Abstract
In the early nineties of the last century, increase in bone mineral density (BMD) was usually the primary endpoint in studies observing the effect of anti-osteoporotic medication. Recently, several large studies have been published with the number of new vertebral deformities as the primary endpoint. This should be preferred, since fractures are generally associated with clinical signs and symptoms, while changes in BMD are not. In all these studies of the effects of alendronate, risedronate, raloxiphen and calcitonin in postmenopausal women with osteoporosis there was a striking discrepancy between a small increase in BMD of the lumbar spine, varying from +2 tot +8%, and a much larger reduction in the number of patients with new vertebral fractures: -36 to -49%. This difference could be related to an effect on bone quality, an independent effect on bone resorption, or to technical limitations of BMD measurements that underestimate true effects of antiresorptive therapy. The number of patients needing to be treated to prevent one fracture depended on background risk and on the effectiveness of the therapy.
Collapse
Affiliation(s)
- W F Lems
- Academisch Ziekenhuis Vrije Universiteit, afd. Reumatologie, Amsterdam.
| | | |
Collapse
|
28
|
Kvien TK, Haugeberg G, Uhlig T, Falch JA, Halse JI, Lems WF, Dijkmans BA, Woolf AD. Data driven attempt to create a clinical algorithm for identification of women with rheumatoid arthritis at high risk of osteoporosis. Ann Rheum Dis 2000; 59:805-11. [PMID: 11005782 PMCID: PMC1753011 DOI: 10.1136/ard.59.10.805] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To examine relations between osteoporosis and low bone mass and demographic and clinical variables in patients with rheumatoid arthritis (RA), in an attempt to develop a data driven clinical tool for identification of patients at high risk of osteoporosis. METHODS All patients were recruited from a county based register and were examined cross sectionally with a variety of clinical and health status measures as well as bone density measures (anteroposterior spine L2-4, total hip, and femoral neck). Associations between osteoporosis (T score < or = -2.5SD) and low bone mass (T score < or = -1SD), on the one hand, and demographic and clinical measures, on the other, were examined bivariately and by logistic regression analyses. RESULTS 394 patients with a mean age of 54.8 years were examined. The percentages having osteoporosis/low bone mass were 16.8/45.8, 14.7/54.5 and 14.7/55.5 in spine L2-4, total hip, and femoral neck, respectively. Osteoporosis and low bone mass were bivariately related to age, body mass index (BMI), disease duration, disease process measures, presence of deformed joints, physical disability, current use of corticosteroids, and history of non-vertebral fracture. In multivariate analyses, age >60 years, low BMI, and current use of corticosteroids were consistently related to osteoporosis and to low bone mass at all sites. The presence of deformed joints was associated with osteoporosis at the total hip, and a history of previous non-vertebral fracture with osteoporosis at the femoral neck. The Modified Health Assessment Questionnaire (MHAQ) > or = 1.5 and non-vertebral fracture were also independently associated with low bone mass at the hip. The logistic regression analyses models could, however, only predict osteoporosis with a sensitivity of about 50-60% and a specificity of 80-90% at the various measurement sites, and low bone mass with a sensitivity and specificity of about 70%. CONCLUSION Consideration of demographic and disease markers may be of some help in predicting presence of osteoporosis or low bone mass, but a combination of markers cannot be used as a clinical tool with sufficient sensitivity and specificity for the identification of osteoporosis or low bone mass in patients with RA.
Collapse
Affiliation(s)
- T K Kvien
- Oslo City Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway.
| | | | | | | | | | | | | | | |
Collapse
|
29
|
van Dieten HE, Korthals-de Bos IB, van Tulder MW, Lems WF, Dijkmans BA, Boers M. Systematic review of the cost effectiveness of prophylactic treatments in the prevention of gastropathy in patients with rheumatoid arthritis or osteoarthritis taking non-steroidal anti-inflammatory drugs. Ann Rheum Dis 2000; 59:753-9. [PMID: 11005773 PMCID: PMC1753000 DOI: 10.1136/ard.59.10.753] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
A systematic review on the cost effectiveness of prophylactic treatments of non-steroidal anti-inflammatory drug (NSAID) induced gastropathy in patients with osteoarthritis or rheumatoid arthritis was conducted. Two reviewers conducted the literature search and the review. Both full and partial economic evaluations published in English, Dutch, or German were included. The criteria list published in the textbook of Drummond was used to determine the quality of the economic evaluations. The methodological quality of three randomised controlled trials (RCTs) in which the economic evaluations obtained probability estimates of NSAID induced gastropathy and adverse events was assessed by a list of internal validity criteria. The conclusions were based on a rating system consisting of four levels of evidence. Ten economic evaluations were included; three were based on RCTs. All evaluations studied misoprostol as prophylactic treatment: in one evaluation misoprostol was studied as a fixed component in a combination with diclofenac (Arthrotec). All economic evaluations comprised analytical studies containing a decision tree. The three trials were of high methodological quality. Nine economic evaluations were considered high quality and one economic evaluation was considered of low methodological quality. There is strong evidence (level "A") that the use of misoprostol for the prevention of NSAID induced gastropathy is cost effective, and limited evidence (level "C") that the use of Arthrotec is cost effective. Although the levels of evidence used in this review are arbitrary, it is believed that a qualitative analysis is useful: quantitative analyses in this field are hampered by the heterogeneity of economic evaluations. Existing criteria to evaluate the methodological quality of economic evaluations may need refinement for use in systematic reviews.
Collapse
Affiliation(s)
- H E van Dieten
- Department of Clinical Epidemiology and Biostatistics, Vrije Universiteit, Van de Boechorststraat 7, 1081 BT Amsterdam, The Netherlands.
| | | | | | | | | | | |
Collapse
|
30
|
Lodder MC, Bakker SM, Dijkmans BA, Kvien TK, Woolf AD, Lems WF. Osteoporosis in patients with rheumatoid arthritis: tip of the iceberg? Scand J Rheumatol 2000; 29:203. [PMID: 10898079 DOI: 10.1080/030097400750002148] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
|
31
|
van den Ende CH, Breedveld FC, le Cessie S, Dijkmans BA, de Mug AW, Hazes JM. Effect of intensive exercise on patients with active rheumatoid arthritis: a randomised clinical trial. Ann Rheum Dis 2000; 59:615-21. [PMID: 10913058 PMCID: PMC1753212 DOI: 10.1136/ard.59.8.615] [Citation(s) in RCA: 125] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To investigate the effects of a dynamic, intensive exercise regimen on pain, disease activity, and physical functioning in active rheumatoid arthritis (RA). METHODS 64 patients with RA with a mean age of 60 (13) years and mean disease duration of 8 (8) years, admitted to hospital because of active disease, were randomly assigned to an intensive exercise programme or to a conservative exercise programme during their period in hospital with a mean length of 30 (14) days. The intensive exercise programme consisted of knee and shoulder dynamic and isometric muscle strengthening exercises against resistance five times a week and conditioning bicycle training three times a week and was supplemental to the conservative exercise programme of range of motion and isometric exercises. Indices of disease activity, pain, muscle strength, and functional ability were assessed at 0, 3, 6, 12, and 24 weeks by a blinded observer. RESULTS The medical treatment during the study was the same in both groups. Both groups improved in measures of disease activity, differences between groups were not statistically significant. The mean improvement in disease activity score at 24 weeks in the intensive and conservative exercise group was -1.4 (1. 5) and -0.7 (1.4), respectively. Measures of physical functioning improved significantly for patients in the intensive exercise group, and differences between groups were statistically significant for measures of muscle strength. CONCLUSION A short term intensive exercise programme in active RA is more effective in improving muscle strength than a conservative exercise programme and does not have deleterious effects on disease activity.
Collapse
Affiliation(s)
- C H van den Ende
- Department of Rheumatology, Leiden University Medical Centre, Leiden, The Netherlands.
| | | | | | | | | | | |
Collapse
|
32
|
Molenaar ET, Lems WF, Dijkmans BA, de Koning MH, van de Stadt RJ, Voskuyl AE. Levels of markers of bone resorption are moderately increased in patients with inactive rheumatoid arthritis. Rheumatology (Oxford) 2000; 39:742-4. [PMID: 10908692 DOI: 10.1093/rheumatology/39.7.742] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE Clinical remission occurs in 10-20% of patients with rheumatoid arthritis (RA). However, it is questionable whether clinical remission corresponds to the complete absence of the inflammatory process. To answer this question we measured collagen degradation products (which are known to be increased in active disease) in patients with inactive RA and in healthy controls. PATIENTS AND METHODS The urinary levels of bone resorption markers (pyridinoline, deoxypyridinoline, N-terminal telopeptide and C-terminal telopeptide) were measured in 184 patients with inactive RA, as defined by the preliminary criteria of clinical remission of the American College of Rheumatology, and in 118 healthy individuals. RESULTS After adjusting for age, concentrations of all four bone resorption markers were found to be significantly higher in patients with inactive RA than in healthy controls. CONCLUSION The urinary excretion of bone resorption markers is increased in patients classified as having inactive RA. These results suggest that the inflammatory process is not completely absent.
Collapse
Affiliation(s)
- E T Molenaar
- Department of Rheumatology, University Hospital Vrije Universiteit, Amsterdam, The Netherlands
| | | | | | | | | | | |
Collapse
|
33
|
Abstract
Methotrexate, an antirheumatic drug that may increase serum homocysteine, significantly increases mortality in patients with rheumatoid arthritis and cardiovascular comorbidity.
Collapse
|
34
|
van der Paardt M, van Denderen JC, van den Brule AJ, Morré SA, van der Horst-Bruinsma IE, Bezemer PD, Dijkmans BA. Prevalence of Chlamydia trachomatis in urine of male patients with ankylosing spondylitis is not increased. Ann Rheum Dis 2000; 59:300-2. [PMID: 10733479 PMCID: PMC1753118 DOI: 10.1136/ard.59.4.300] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To compare the prevalence of Chlamydia trachomatis infections in ankylosing spondylitis (AS) patients with controls, using DNA amplification assays in urine specimens. METHODS The prevalence of C trachomatis infections was assessed in 32 male AS patients and 120 age and sex matched controls. Urine specimens were tested by ligase chain reaction and polymerase chain reaction. In addition, blood samples of AS patients were tested on serum antibodies to C trachomatis (IgA and IgG) by a specific peptide based solid phase enzyme immunoassay. A questionnaire was used to assess the differences in sexual behaviour and ethnic origin between the two groups. AS patients were also asked about disease characteristics. RESULTS No significant differences were found between cases and controls in the prevalence of C trachomatis infections. No associations were found between C trachomatis antibodies and disease characteristics, except for acute anterior uveitis (AAU). Four of eight (50%) AS men positive for IgG had a history of AAU in comparison with three of 24 (12.5%) IgG negative men (OR = 7.0; 95% confidence intervals: 1.1, 44.1). CONCLUSION The prevalence of Chlamydia trachomatis infections, as detected by commercially available DNA amplification assays in urine specimens, in AS patients is not higher compared with male controls of the same age. However, there seems to be an association between specific antibodies to C trachomatis and AAU.
Collapse
|
35
|
Jansen LM, van Schaardenburg D, van Der Horst-Bruinsma IE, Bezemer PD, Dijkmans BA. Predictors of functional status in patients with early rheumatoid arthritis. Ann Rheum Dis 2000; 59:223-6. [PMID: 10700432 PMCID: PMC1753094 DOI: 10.1136/ard.59.3.223] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To find disease parameters that can predict the functional capacity of patients with early rheumatoid arthritis (RA) at the first visit to the rheumatologist and one year after entry. METHODS Patients referred to the outpatients clinic between 1995 and 1996, with a symptom duration of less than three years and fulfilling the American Rheumatism Association 1987 revised criteria for RA within one year after entry were included. Assessments of the duration of morning stiffness, the Disease Activity Score (DAS: a composite score based on erythrocyte sedimentation rate (ESR), number of painful and swollen joints and patient global assessment), pain (Visual Analogue Scale), the Arthritis Impact Measurement Scale (AIMS) and the Health Assessment Questionnaire (HAQ) were performed every three months. Possible predictors of the HAQ at entry and after one year were analysed by logistic regression. RESULTS 133 patients were included in the study. The median duration of complaints was three months (range 0-35) and the median HAQ score at entry was 1.12 (range 0-3). There was no correlation between duration of complaints and the HAQ at entry (r = 0.01). An HAQ score under the 50th percentile at entry could be predicted correctly for 74% of the patients by entry DAS and C reactive protein concentration, and at one year could be predicted correctly for 73% of the patients by entry HAQ and pain score. CONCLUSION Disease activity is strongly correlated with a lower functional capacity at entry, whereas disease duration is not. The functional status at entry is a good predictor for functional status at one year. Severity rather than duration of arthritis prompts referral in this cohort.
Collapse
Affiliation(s)
- L M Jansen
- Jan van Breemen Instituut, Amsterdam, The Netherlands
| | | | | | | | | |
Collapse
|
36
|
Dekker-Saeys BJ, Dijkmans BA, Tytgat GN. Treatment of spondyloarthropathy with 5-aminosalicylic acid (mesalazine): an open trial. J Rheumatol 2000; 27:723-6. [PMID: 10743816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
OBJECTIVE Ankylosing spondylitis (AS) and spondyloarthropathy (SpA) are inflammatory diseases of unknown etiology. Various exogenous and endogenous (inherited) factors play a role in their development. Sulfasalazine (SSZ) is generally accepted as a disease modifying drug in the treatment of AS and SpA. Which part of SSZ, 5-acetylsalicylic acid (5-ASA, mesalazine) or sulfapyridine (SP), is the effective moiety is unknown. As the bowel, colon, and the ileum play an important role in the development of AS and SpA, it may be possible that 5-ASA is the effective moiety, with a similar mode of action as in the treatment of inflammatory bowel disease. To determine the efficacy of 5-ASA an open pilot study was done in 2 groups of patients with SpA. METHODS Twenty patients with SpA, who were taking SSZ, were switched to 5-ASA (Pentasa), and 19 patients with active SpA were treated with 5-ASA without previous administration of SSZ. RESULTS In the first group, 17 (85%) patients responded with respect to the physician global clinical assessment compared to the previous SSZ treatment period; whereas in the second patient group a statistically significant improvement was obtained in erythrocyte sedimentation rate. CONCLUSION The results support our hypothesis that 5-ASA might be the active moiety of SSZ in the treatment of SpA.
Collapse
Affiliation(s)
- B J Dekker-Saeys
- Department of Rheumatology, Jan van Breemen Institute, and University of Amsterdam, The Netherlands
| | | | | |
Collapse
|
37
|
Jacobs JW, Blaauw AA, Dijkmans BA, van Riel PL, Bijlsma JW. [Pharmacotherapy of patients with (early) rheumatoid arthritis]. Ned Tijdschr Geneeskd 2000; 144:211-6. [PMID: 10682647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/15/2023]
Abstract
As soon as the diagnosis 'early rheumatoid arthritis (RA)' is made, a disease-modifying antirheumatic drug (DMARD) should be prescribed without delay. Methotrexate in dosages up to 30 mg once weekly is being used more frequently than in the past, also in early RA. Combination therapy with DMARDs is indicated in case of insufficient effect of a single DMARD. Combinations with methotrexate appear to be especially effective, like methotrexate and cyclosporin. A novel effective DMARD is leflunomide. In the near future promising biologicals will probably be applied in clinical daily practice, presumably in combination with conventional DMARDs. New non-steroidal anti-inflammatory drugs (NSAIDs) have been developed that are probably safer than conventional NSAIDs. If the recent finding that glucocorticoids are able to inhibit joint damage in (early) RA will be confirmed, prednisone might be used more often in (early) RA. Bone marrow transplantation in RA is still experimental.
Collapse
Affiliation(s)
- J W Jacobs
- Universitair Medisch Centrum, afd. Reumatologie en Klinische Immunologie, Utrecht
| | | | | | | | | |
Collapse
|
38
|
Dijkmans BA, Landewé RB, van den Borne BE, Breedveld FC. Combination cyclosporine and (hydroxy)chloroquine in rheumatoid arthritis. Clin Exp Rheumatol 1999; 17:S103-4. [PMID: 10589367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/14/2023]
Abstract
Antimalarials are attractive candidates for combination therapy. In vitro experiments have revealed a synergistic mode of action of cyclosporine and chloroquine which could not, however, be confirmed in a clinical trial.
Collapse
Affiliation(s)
- B A Dijkmans
- Rheumatology Department, Academic Hospital Vrije Universiteit, Amsterdam, The Netherlands.
| | | | | | | |
Collapse
|
39
|
van den Borne BE, Landewé RB, Rietveld JH, Goei The HS, Griep EN, Breedveld FC, Dijkmans BA. Chloroquine therapy in patients with recent-onset rheumatoid arthritis: the clinical response can be predicted by the low level of acute-phase reaction at baseline. Clin Rheumatol 1999; 18:369-72. [PMID: 10524550 DOI: 10.1007/s100670050121] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
If rheumatoid arthritis (RA) patients with a mild disease course could be identified early in the phase of the disease, therapy with less aggressive and probably less toxic antirheumatic drugs seems to be rational. The aim of this study was to investigate which factors at baseline could predict a clinical response (American College of Rheumatology preliminary response criteria) after treatment with chloroquine for 16 weeks. Two hundred and three early RA patients with active disease were treated with oral chloroquine sulphate (Nivaquine) at a daily dose of 300 mg during the first 4 weeks, 200 mg during the second 4 weeks and 100 mg thereafter. One hundred and eighty-three patients (90%) completed the study and 20 patients prematurely discontinued treatment. Of all the patients, 43 patients (21%) met the response criteria. A low level of C-reactive protein (CRP) was the only independent predictor for clinical response [relative risk: 0.97 (95% confidence interval: 0.95-0.98)]. It was concluded that a clinical response to chloroquine therapy in early RA patients can be predicted by a low CRP level at baseline.
Collapse
Affiliation(s)
- B E van den Borne
- Department of Rheumatology, Leiden University Medical Center, The Netherlands.
| | | | | | | | | | | | | |
Collapse
|
40
|
Giltay EJ, van Schaardenburg D, Gooren LJ, Kostense PJ, Dijkmans BA. Decreased serum biochemical markers of muscle origin in patients with ankylosing spondylitis. Ann Rheum Dis 1999; 58:541-5. [PMID: 10460186 PMCID: PMC1752948 DOI: 10.1136/ard.58.9.541] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
OBJECTIVES There is a lack of unanimity about (increased) serum levels of creatine kinase (CK) in patients with ankylosing spondylitis (AS), perhaps because of the inclusion of inappropriate controls. Therefore, serum levels of biochemical markers of muscle origin were assessed in AS patients compared with controls. METHODS In a comparative study serum levels of sarcoplasmic proteins indicating muscle cell leakage, creatinine, and C reactive protein (CRP) were measured. Fifty eight AS patients with a mean disease duration of 22 (SD 11) years and 58 age and sex matched controls (without back complaints) were included. RESULTS Lower serum levels in AS patients compared with controls were found for CK (mean (SD): 46 (21) v 76 (44) IU/l; p<0.001), aldolase (0.43 (0.36) v 0.58 (0. 32) IU/l; p=0.001), creatinine (91 (13) v 96 (11) micromol/l; p=0. 02), alanine aminotransferase (2.8 (1.5) v 4.1 (2.9) IU/l; p=0.001) and aspartate aminotransferase (7.0 (2.7) v 8.4 (3.5) IU/l; p=0.02). Also the lean body mass, as estimated by a formula using height, weight, age and sex, showed lower values in patients versus controls (56 (9) v 59 (9) kg; p=0.004), but creatinine clearance (by Cockcroft and Gault formula) was not different (p=0.48). Partial correlation coefficients adjusted for age and sex showed that CRP levels correlated negatively with CK and aldolase levels in AS patients (r= -0.48, p<0.001 and r= -0.37, p=0.005, respectively). CONCLUSION Serum levels of biochemical markers of muscle origin were lower in AS patients compared with controls. Patients with active AS, as reflected by high CRP levels, may have an increased protein degradation, predominantly in skeletal muscle.
Collapse
Affiliation(s)
- E J Giltay
- Institute of Endocrinology, University Hospital Vrije Universiteit, Amsterdam, The Netherlands
| | | | | | | | | |
Collapse
|
41
|
Steen KS, Lems WF, Dijkmans BA. [Effectiveness, safety, and costs of measures for prevention of gastropathy due to the use of nonsteroidal antiinflammatory drugs]. Ned Tijdschr Geneeskd 1999; 143:1649-52. [PMID: 10494299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/14/2023]
Abstract
NSAID gastropathy, because of its severity and prevalence, is the most important side effect of nonsteroidal anti-inflammatory drugs. Protective strategies are advocated in patients with high risk for NSAID gastropathy (age over 60 years and/or previous ulcer). Different strategies for the prevention of NSAID gastropathy are: using a cyclo-oxygenase (COX)-2 inhibitor, adding a prostaglandin analogue, an H2-receptor antagonist or a proton pump inhibitor or eradicating Helicobacter pylori. On the basis of efficacy, safety and costs prescription of a proton pump inhibitor as a prophylactic agent appears to be the best option; prescription of a prostaglandin analogue is a good alternative. The preliminary data on the COX-2 inhibitors are promising. The role of H. pylori in NSAID gastropathy is not yet elucidated.
Collapse
Affiliation(s)
- K S Steen
- Academisch Ziekenhuis Vrije Universiteit, afd. Reumatologie, Amsterdam
| | | | | |
Collapse
|
42
|
Nurmohamed MT, Lems WF, Dijkmans BA. Risk of post-discharge venous thromboembolism in patients with rheumatoid arthritis undergoing knee or hip arthroplasty. Is prolonged thromboprophylaxis warranted or dangerous? Ann Rheum Dis 1999; 58:392-5. [PMID: 10381480 PMCID: PMC1752914 DOI: 10.1136/ard.58.7.392] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- M T Nurmohamed
- Department of Rheumatology, Slotervaart Hospital and Jan van Breemen Institute, Amsterdam, the Netherlands
| | | | | |
Collapse
|
43
|
|
44
|
Affiliation(s)
- E J Giltay
- Institute of Endocrinology, Reproduction and Metabolism, Hospital Vrije Universiteit, Amsterdam, The Netherlands.
| | | | | | | |
Collapse
|
45
|
Giltay EJ, van Schaardenburg D, Gooren LJ, Popp-Snijders C, Dijkmans BA. Androgens and ankylosing spondylitis: a role in the pathogenesis? Ann N Y Acad Sci 1999; 876:340-64; discussion 365. [PMID: 10415629 DOI: 10.1111/j.1749-6632.1999.tb07658.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The frequency and severity of ankylosing spondylitis (AS) show a male preponderance, and androgenic steroids have been implicated in its etiology. Some reports have indicated that serum androgen levels are slightly elevated relative to estrogen levels in patients with AS as compared to controls. In more recent studies, however, serum testosterone, 17 beta-estradiol, and androstenedione levels did not significantly differ between AS patients and controls. Moreover, testosterone levels measured directly in serum can be spuriously elevated, especially in patients using phenylbutazone. Elevated serum levels of the adrenal steroids 17 alpha-hydroxyprogesterone and dehydroepiandrosterone (DHEA) sulfate have been found in patients with AS. These elevations might be explained by partial 11 beta- or 21-hydroxylase deficiencies, but may also be secondary to an enhanced stress response. In vitro studies as well as studies in animals and humans indicate that DHEA enhanced, and 17 beta-estradiol and progesterone inhibit, the cell-mediated immune response, which may play a role in the pathogenesis of AS. Oral estrogen therapy in female patients and human chorionic gonadotrophin injections in male patients with AS, increased the 17 beta-estradiol/testosterone ratio and resulted in a moderate clinical improvement. In conclusion, serum testosterone levels are not elevated in patients with AS. Therefore testosterone probably has no role in the perpetuation of long-standing AS and provides no basis for antiandrogenic treatment. Cross-sectional case-control studies, however, cannot clearly distinguish etiological factors from secondary disease effects, especially when blood sampling occurs many years after the onset of AS. Consequently, the role of sex steroids in the pathogenesis is still insufficiently elucidated.
Collapse
Affiliation(s)
- E J Giltay
- Institute of Endocrinology, Reproduction and Metabolism, Hospital Vrije Universiteit, Amsterdam, The Netherlands.
| | | | | | | | | |
Collapse
|
46
|
Abstract
New insights into the pathogenesis of rheumatoid arthritis (RA) and consequently new targets of therapy are covered in a broad overview fashion. Short-term significant beneficial effect on RA disease activity has been established in a small but rapidly growing number of double-blind placebo-controlled trials now including recombinant human IL-1 receptor antagonist, chimeric (mouse/human) monoclonal antibodies (mAb) against TNF alpha (cA2), humanised (human/mouse) anti-TNF alpha mAb (CDP571) and recombinant human TNF-receptor-Fc fusion protein (TNFR:Fc). Placebo-controlled trials of anti-T cells agents such as chimeric anti-CD4 mAb (cM-T412) and anti-CD5 immunoconjugate, did not demonstrate clinical benefit. A placebo-controlled study of the anti-T cell derived cytokine IL-2 (DAB486IL-2) showed only modes clinical improvement. Other anti-T cell approaches such as autologous T cell vaccination and induction of tolerance by oral type II collagen have been unsuccessful. The one controlled trial with an anti-inflammatory cytokine, recombinant human IFN-gamma, showed modest clinical benefits. Controlled trials with IL-4 and IL-10 and with anti-adhesion molecules are awaited.
Collapse
Affiliation(s)
- H J Dinant
- Department of Rheumatology, Jan van Breemen Institute, Amsterdam, The Netherlands
| | | |
Collapse
|
47
|
van den Borne BE, Landewé RB, Goei The HS, Breedveld FC, Dijkmans BA. Cyclosporin A therapy in rheumatoid arthritis: only strict application of the guidelines for safe use can prevent irreversible renal function loss. Rheumatology (Oxford) 1999; 38:254-9. [PMID: 10325664 DOI: 10.1093/rheumatology/38.3.254] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES To investigate (1) whether the increase in serum creatinine observed during cyclosporin A (CsA) therapy was reversible in a group of patients with rheumatoid arthritis (RA) treated before the current guidelines for safe use in RA were developed and (2) whether the application of these guidelines prevents serum creatinine increases in the long term. PATIENTS AND METHODS Eighty-three RA patients who had started low-dose CsA therapy between September 1990 and October 1992, and who were treated according to guidelines that allowed a 50% rise in serum creatinine, were tested for serum creatinine levels in December 1995 if they had discontinued CsA for at least 3 months. Predictors for irreversibility of renal function were determined by using multiple regression analysis. RESULTS The mean level of serum creatinine gradually increased from 69+/-14 (mean+/-S.D.) micromol/l when starting CsA therapy to 88+/-23 micromol/l (28% above baseline) at the moment of CsA discontinuation, and had decreased to 80+/-17 micromol/l (16% above baseline) at follow-up, 35+/-14 months after drug discontinuation. During CsA therapy, the mean level of serum creatinine had increased to 82+/-19 micromol/l (26% above baseline) at 6 months and to 87+/-22 micromol/1 (39% above baseline) at 42 months. The mean CsA dose had decreased from 3.1+/-0.9 mg/kg/day at 6 months to 1.9+/-0.8 mg/kg/day at 42 months. The absolute number of months that serum creatinine levels were > 30% above baseline was an independent predictor for a persistent increase of the serum creatinine after CsA discontinuation. More than 2 months with a serum creatinine increase of > or = 30% resulted in a higher percentage irreversible increase than for less than 2 months with a > or = 30% increase: 27 and 6%, respectively (P < 0.0001). CONCLUSION Long-term low-dose CsA administration in RA patients was associated with an increase in serum creatinine which was partially irreversible after drug discontinuation. The increase in serum creatinine was completely reversible in the patient group that was treated according to the current guidelines for safe use of CsA.
Collapse
Affiliation(s)
- B E van den Borne
- Department of Rheumatology, Leiden University Medical Centre, The Netherlands
| | | | | | | | | |
Collapse
|
48
|
van der Graaff WL, Prins AP, Niers TM, Dijkmans BA, van Lier RA. Quantitation of interferon gamma- and interleukin-4-producing T cells in synovial fluid and peripheral blood of arthritis patients. Rheumatology (Oxford) 1999; 38:214-20. [PMID: 10325659 DOI: 10.1093/rheumatology/38.3.214] [Citation(s) in RCA: 46] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE The balance between T cells able to produce interferon gamma (IFN-gamma) (type 1) and interleukin-4 (IL-4) (type 2) is considered to be important in the development of autoimmunity. In this study, we quantitated the percentage of both cell types in synovial fluid (SF) and peripheral blood (PB) of rheumatoid arthritis (RA) patients, non-rheumatoid arthritis patients and healthy controls. METHODS After short-term stimulation of synovial mononuclear cells with phorbol ester and ionomycin, cytokine-producing cells were quantitated using an intracellular staining technique and flow cytometric analysis. RESULTS Although no significant differences in CD8 + cells were found, significantly higher percentages of IFN-gamma-producing CD4 + (Th 1) and IL-4-producing CD4 + (Th2) cells were found in the peripheral blood of RA patients in comparison with healthy controls. However, the Th1/Th2 ratio was not different between the two groups. Comparative studies between PB and SF showed that in both RA and non-RA patients, percentages of Th1 cells were higher in SF than in PB, while Th2 cells were preferentially found in the PB, resulting in a higher Th1/Th2 ratio in the SF. The Th1/Th2 ratio in the SF correlated with disease activity as estimated by the erythrocyte sedimentation rate. CONCLUSION These results are in agreement with the hypothesis that Th1 cells preferentially home to inflamed joints in both RA and non-RA patients, but show that this does not result in an altered Th1/Th2 ratio in the PB of RA patients.
Collapse
Affiliation(s)
- W L van der Graaff
- CLB, Sanquin Blood Foundation, Department of Clinical Viro-Immunology, Academical Medical Centre, University of Amsterdam, Jan van Breemen Institute of Rheumatology and Rehabilitation, The Netherlands
| | | | | | | | | |
Collapse
|
49
|
Giltay EJ, Popp-Snijders C, van Schaardenburg D, Dekker-Saeys BJ, Gooren LJ, Dijkmans BA. Serum testosterone levels are not elevated in patients with ankylosing spondylitis. J Rheumatol 1998; 25:2389-94. [PMID: 9858435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
OBJECTIVE Studies in patients with ankylosing spondylitis (AS) describe slightly elevated serum testosterone levels, but these studies were not properly controlled for possible confounders. METHODS In a case-control study serum levels of sex steroids, luteinizing hormone, and sex hormone binding globulin (SHGB) were measured in patients with AS and in age and sex matched controls. The body mass index, smoking status, use of alcohol, and fat intake were recorded. RESULTS Testosterone levels measured in serum extracts did not differ in 50 male patients with AS compared to controls (mean +/- SD 16 +/- 4 vs 15 +/- 5 nmol/l, respectively; p = 0.54). In unextracted serum, however, male patients showed elevated testosterone (p < 0.001) and dehydroepiandrosterone sulfate levels (p = 0.003), even after controlling for confounders (p < 0.001). One of 10 female patients had an elevated testosterone level in unextracted serum. The 17 male users and one of the 2 female users of phenylbutazone had the highest testosterone levels in unextracted serum, and all showed a significant decline after extraction. Serum levels of other sex steroids, luteinizing hormone, and SHGB did not differ significantly between patients and controls. CONCLUSION Serum testosterone levels are not elevated in male patients with AS. Spuriously elevated testosterone levels in unextracted serum might be related to the use of phenylbutazone in our patient sample.
Collapse
Affiliation(s)
- E J Giltay
- Institute of Endocrinology, Reproduction and Metabolism, and the Department of Rheumatology, Vrije Universiteit Hospital, Amsterdam, The Netherlands
| | | | | | | | | | | |
Collapse
|
50
|
Giltay EJ, Verhoeven AC, van Schaardenburg D, Popp-Snijders C, Boers M, Gooren LJ, Dijkmans BA. Serum dehydroepiandrosterone sulphate levels in patients with early rheumatoid arthritis: positive association with C-reactive protein, but not with HLA-DR genotype. Br J Rheumatol 1998; 37:1254-6. [PMID: 9851286 DOI: 10.1093/rheumatology/37.11.1254] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
|