Scaffold Proteins in Autoimmune Disorders

Cells transmit information to the external environment and within themselves through signaling molecules that modulate cellular activities. Aberrant cell signaling disturbs cellular homeostasis causing a number of different diseases, including autoimmunity. Scaffold proteins, as the name suggests, serve as the anchor for binding and stabilizing signaling proteins at a particular locale, allowing both intra and intercellular signal amplification and effective signal transmission. Scaffold proteins play a critical role in the functioning of tight junctions present at the intersection of two cells. In addition, they also participate in cleavage formation during cytokinesis, and in the organization of neural synapses, and modulate receptor management outcomes. In autoimmune settings such as lupus, scaffold proteins can lower the cell activation threshold resulting in uncontrolled signaling and hyperactivity. Scaffold proteins, through their binding domains, mediate protein- protein interaction and play numerous roles in cellular communication and homeostasis. This review presents an overview of scaffold proteins, their influence on the different signaling pathways, and their role in the pathogenesis of autoimmune and auto inflammatory diseases. Since these proteins participate in many roles and interact with several other signaling pathways, it is necessary to gain a thorough understanding of these proteins and their nuances to facilitate effective target identification and therapeutic design for the treatment of autoimmune disorders.

Quality of Life and Disability in Chikungunya Arthritis

BACKGROUND

Chikungunya virus infection, transmitted by Aedes mosquito vectors, causes outbreaks of chikungunya fever (CHIKF), throughout the tropical and subtropical world. Following acute infection, many CHIKF patients develop a second phase, chronic and disabling arthritis.

OBJECTIVE

To evaluate the impact of chikungunya arthritis (CHIKA) on quality of life and disability in a cohort of Brazilian CHIKA patients.

METHODS

We conducted a descriptive, non-interventionist, retrospective cross-sectional study analysing data collected from the medical records of chikungunya virus-infected patients treated between June 1, 2022, and June 30, 2022, in the Brazilian rheumatology clinic of one of us (JKA). To assess disability, quality of life, and pain, patients were evaluated using the Health Assessment Questionnaire Disability Index (HAQ-DI), 12-Item Short-Form Health Survey (SF-12), and Visual Analog Scale (VAS) pain.

RESULTS

Forty-two women with a mean (± SD) age of 57.83 (± 13.05) years had CHIKF confirmed by chikungunya-specific serology. The mean (± SD) time between the onset of chikungunya symptoms and the first clinic visit was 55.19 (± 25.88) days. At this visit, the mean (± SD) VAS pain score and DAS28-ESR were 77.26 (± 23.71) and 5.8 (± 1.29), respectively. The mean (± SD) HAQDI score was 1.52 (± 0.67). The mean (± SD) SF-12 PCS-12 was 29.57 (± 8.62) and SF-12 MCS-12 was 38.42 (± 9.85).

CONCLUSION

CHIKA is often highly disabling. As the mosquito vectors that transmit this illness have spread to every continent except Antarctica, there is a potential for widespread public health impact from CHIKA and the need for more effective, early intervention to prevent CHIKA.

MiR-30e-5p deficiency exerts an inhibitory effect on inflammation in rheumatoid arthritis via regulating Atl2 expression

OBJECTIVES

This study aims to investigate the inflammatory effect of the microRNA (miRNA) miR-30e-5p on rheumatoid arthritis (RA) development in RA mice and fibroblast-like synoviocytes (FLS).

MATERIALS AND METHODS

MiR-30e-5p and atlastin GTPase 2 (Atl2) expression in RA tissues and RA-FLS was evaluated using real-time quantitative polymerase chain reaction. The function of miR-30e-5p in inflammation of RA mice and RA-FLS was analyzed by enzyme-linked immunosorbent assay (ELISA) and Western blotting. 5-ethynyl-2'-deoxyuridine (EdU) assay was used to detect RA-FLS proliferation. Luciferase reporter assay was to confirm the interaction between miR-30e-5p and Atl2.

RESULTS

MiR-30e-5p expression was upregulated in the tissues from RA mice. Silencing miR-30e-5p alleviated inflammation in RA mice and RA-FLS. MiR-30e-5p negatively modulated Atl2 expression. Atl2 knockdown exerted a proinflammatory effect on RA-FLS. Atl2 knockdown rescued the inhibitory effect of miR-30e-5p knockdown on proliferation and inflammatory response of RA-FLS.

CONCLUSION

MiR-30e-5p knockdown inhibited the inflammatory response in RA mice and RA-FLS through Atl2.

Central sensitization in osteoarthritic knee pain: A cross-sectional study

Objectives

The aim of this study was to investigate central sensitization and associated factors in knee osteoarthritis (OA) patients and compare them with rheumatoid arthritis (RA) patients and healthy controls.

Patients and methods

This cross-sectional study was conducted with 125 participants (7 males, 118 females; mean age: 57.2±8.2 years; range, 45 to 75 years) between January 2017 and December 2018. Sixty-two patients with symptomatic knee OA, 32 RA patients with knee pain, and 31 healthy controls constituted the participants. Central sensitization was investigated with the Central Sensitization Inventory (CSI) and pressure pain threshold (PPT) measurements. Pain, functional status, and psychosocial features were assessed with self-reported questionnaires.

Results

The OA and RA groups had significantly lower PPT values at local, peripheral, and remote regions compared to the healthy controls. Pressure hyperalgesia was shown at the knee with a 43.5% prevalence, 27.4% at the leg, and 8.1% at the forearm of OA patients. Pressure hyperalgesia was present at the knee, leg, and forearm in 37.5%, 25%, and 9.4% of RA patients, respectively. Pressure pain threshold values, CSI scores, frequency of pressure hyperalgesia, and frequency of central sensitization according to the CSI were not statistically different between the OA and RA groups. Psychosocial features and structural damage were not correlated with PPT values in the OA group.

Conclusion

The severity of chronic pain and functional status may be the clinical clues to recognizing patients with central sensitization since local joint damage does not play a direct role in the etiopathogenesis of central sensitization in OA patients and severe pain persisting in the chronic process is associated with central sensitization regardless of the pathogenesis.

Circ_0088194 Regulates Proliferation, Migration, Apoptosis, and Inflammation by miR-30a-3p/ADAM10 Axis in Rheumatoid Arthritis Fibroblastic Synovial Cells

Dysregulation of circular RNAs (circRNAs) has been observed in multiple diseases including rheumatoid arthritis (RA), and we investigated the role of the circ_0088194/microRNA (miR)-30a-3p/a disintegrin and metalloproteinase 10 (ADAM10) axis in RA. Circ_0088194, miR-30a-3p, and ADAM10 contents in RA tissues and RA-fibroblast-like synoviocytes (RA-FLSs) were analyzed by real-time quantitative polymerase chain reaction (RT-qPCR) and western blot. Cell proliferation, migration, apoptosis, and inflammatory factor secretion of RA-FLSs were detected using 5-ethynyl-2'-deoxyuridine (EdU), wound healing assay, flow cytometry, and enzyme-linked immunosorbent assay (ELISA). Targeting relationship between miR-30a-3p and circ_0088194 or ADAM10 was validated by luciferase reporter system, RNA immunoprecipitation (RIP), and RNA pull-down assays. Circ_0088194 and ADAM10 levels were increased, while miR-30a-3p was decreased in RA tissues and RA-FLSs. Circ_0088194 knockdown suppressed the growth, migration, and inflammation of RA-FLSs, while the upregulation of circ_0088194 showed opposite effects. Circ_0088194 directly targeted miR-30a-3p, ADAM10 was a target of miR-30a-3p, and circ_0088194 regulated the expression of ADAM10 by sponging miR-30a-3p. MiR-30a-3p inhibition restored the inhibition effects of circ_0088194 knockdown or RA-FLSs. Moreover, miR-30a-3p re-expression repressed growth, migration, and inflammatory response in RA-FLSs, which were reversed by ADAM10 overexpression. Circ_0088194 acted on miR-30a-3p/ADAM10 axis to promote the proliferation, migration, and inflammatory response, and inhibit apoptosis in RA-FLSs.

An investigation of coronaphobia and physical activity among patients with rheumatoid arthritis

Objectives

This study aims to investigate coronaphobia and physical activity levels in patients with rheumatoid arthritis (RA).

Patients and methods

Between December 2021 and February 2022, a total of 68 RA patients (11 males, 57 females; mean age: 48.3±10.1 years; range, 29 to 78 years) and 64 age- and sex-matched healthy individuals (4 males, 60 females; mean age: 47.9±10.2 years; range, 23 to 70 years) were included in this cross-sectional study. Demographic, physical, lifestyle, and medical characteristics of all participants were recorded. The COVID-19 Phobia Scale (C19PS) and the International Physical Activity Questionnaire-Short Form (IPAQ-SF) were administered to all participants. The RA patients were divided into two groups as: patients treated with biological and non-biological agents. The Disease Activity Score-28 (DAS28) and Clinical Disease Activity Index (CDAI) were used to measure disease activity.

Results

The total and subgroup scores of the C19P-S were found to be statistically significantly higher in both the biological and non-biological RA groups than in the control group (p=0.001). However, there was no statistically significant difference between the RA groups in terms of total and subgroup C19P-S scores. The mean IPAQ score was significantly lower in the RA group using biological drugs than in the control group (p=0.002). A significant correlation was found between DAS28 and total C19P-S scores (r:0.63, p<0.05), and CDAI and total C19P-S scores (r:0.79, p<0.05).

Conclusion

Patients with RA have an increased risk of coronaphobia and disease activity is correlated with coronaphobia. Patients treated with biological agents seem to have lower activity levels compared to other RA patients and healthy controls. These results should be considered in the management of RA during COVID-19 pandemic and preventive intervention strategies should be formulated to cope with coronaphobia.

Serum BMP-2 and BMP-4 levels and their relationship with disease activity in patients with rheumatoid arthritis and ankylosing spondylitis

Objectives

This study aims to investigate the levels of bone morphogenic proteins (BMPs), one of the pathways affecting bone turnover in these diseases, and to investigate their relationship with disease activity.

Patients and methods

Between September 2013 and July 2015, a total of 100 ankylosing spondylitis (AS) patients (53 males, 48 females; median age: 40 years; range, 18 to 62 years), 58 rheumatoid arthritis (RA) patients (25 males, 33 females; median age: 40.5 years; range, 26 to 59 years), and 102 age- and sex-matched healthy controls (55 males, 47 females; median age: 38 years; range, 18 to 55 years) were included in the study. In all groups, serum BMP-2 and BMP-4 levels were measured using enzyme-linked immunosorbent assay (ELISA). Demographic data (age, sex, duration of disease) and acute phase reactants of the patients at the final visit were recorded. Disease activity was assessed through the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) and Ankylosing Spondylitis Disease Activity Score C-Reactive Protein (ASDAS-CRP) for AS patients and through the Disease Activity Score-28-CRP (DAS-28-CRP) for RA patients.

Results

The median BMP-2 values were found to be significantly higher in the RA group compared to the other groups and in the control group compared to the AS group (p<0.001 for both). There was no significant difference between the groups in terms of median BMP-4 values (p>0.05). No significant relationship was found between serum BMP-2 and BMP-4 levels and disease activity in both AS and RA patients, while there was a weak positive correlation between erythrocyte sedimentation rate and CRP levels with BMP-2 level in RA patients (p=0.014, r=0.320 and p=0.029, r=0.287, respectively).

Conclusion

Our study results suggest that the BMP pathway may have different dual effects in AS and RA patients depending on the underlying pathogenesis, and that local effects are more prominent than serum levels.

Grape seed proanthocyanidin extract induces apoptotic and autophagic cell death in rheumatoid arthritis fibroblast-like synoviocytes

Objectives

In this study, we aimed to evaluate the association between grape seed proanthocyanidin extract (GSPE) and rheumatoid arthritis-fibroblast-like synoviocytes (RA-FLSs) and to investigate whether GSPE induces cell death in RA-FLSs.

Materials and methods

The FLSs were isolated from RA synovial tissues. Cell viability and cell cycle staging were analyzed using a hemocytometer and flow cytometry. Caspase 3 and poly (ADP-ribose) polymerase (PARP) proteins were analyzed using Western blotting with z-VAD-fmk. Protein LC3 and polyubiquitin-binding protein p62 that were degraded by autophagy were evaluated using Western blotting with 3-methyladenine and chloroquine. Reactive oxygen species (ROS) were also evaluated.

Results

When RA-FLSs were treated with GSPE, cell viability decreased, the number of cells in sub-G1 and G2/M phases increased, and the expression of pro-PARP and pro-caspase 3 proteins decreased in a concentration-dependent manner. This result was offset, when the cells were co-treated with the pan-caspase inhibitor z-VAD-fmk. The reduced cell viability, increased expression of LC3-II protein, and reduced expression of p62 protein with GSPE treatment were offset, when RA-FLSs were co-treated with GSPE and autophagy inhibitors 3-methyladenine and chloroquine. The level of ROS in RA-FLSs treated with GSPE was significantly lower than treatment with N-acetyl-cysteine, a ROS inhibitor.

Conclusion

Our study results show that GSPE induces apoptotic and autophagic cell death and inhibites reactive oxygen species in RA-FLSs.

LncRNA cardiac autophagy inhibitory factor is downregulated in rheumatoid arthritis and suppresses the apoptosis of fibroblast-like synoviocytes by promoting the maturation of miRNA-20a

Objectives

In this study, we aimed to investigate the effects of LncRNA cardiac autophagy inhibitory factor (CAIF) and miR-20a on the apoptosis of synovial cells in rheumatoid arthritis (RA) and the regulatory mechanism.

Patients and methods

Between May 2018 and March 2020, a total of 62 RA patients (24 males, 38 females; mean age: 55.2±4.9 years; range, 42 to 68 years) and 62 controls (24 males, 38 females; mean age: 55.3±4.8 years; range, 41 to 68 years) were included in this study. Plasma samples were collected from all participants. The expression levels of CAIF, mature miR-20a, and miR-20a precursor in these plasma samples were determined by reverse transcription-quantitative polymerase chain reaction (RT-qPCR). Correlations were analyzed using linear regression analysis. Overexpression of CAIF was achieved in human fibroblast-like synoviocytes (HFLSs) and the expression levels of mature miR-20a and miR-20a precursor were determined using RT-qPCR. Cell apoptosis was analyzed by cell apoptosis assay.

Results

The CAIF was downregulated in RA and positively correlated with the expression of mature miR-20a. In HFLSs, LPS treatment resulted in downregulation of both CAIF and miR-20a in a dose-dependent manner. In HFLSs, overexpression of CAIF did not affect the expression of miR-20a precursor, but upregulated the expression of mature miR-20a. Cell apoptosis analysis showed that overexpression of CAIF and miR-20a inhibited the apoptosis of HFLSs induced by LPS. The combination of overexpression of CAIF and miR-20a showed a stronger effect.

Conclusion

The CAIF may suppress the apoptosis of HFLSs in RA by promoting the maturation of miR-20a.

Long Non-Coding RNA NEAT1 Knockdown Alleviates Rheumatoid Arthritis by Reducing IL-18 through p300/CBP Repression

Rheumatoid arthritis (RA) is chronic inflammatory autoimmune disease. The crucial role of long non-coding RNA (lncRNA) in the progression of RA has been highlighted. Hence, this study was designed to explore the specific downstream mechanism of lncRNA nuclear-enriched abundant transcript 1 (NEAT1) in RA. Initially, the expression of NEAT1, p-p65, p300, and IL-18 in clinical tissues and cells was determined. Then, interactions among p65, NEAT1, p300, CBP, and IL-18 were investigated by immunofluorescence staining, dual luciferase reporter gene assay, RT-qPCR assay ChIP assay, and RIP assay followed by the analysis of their effects on RA in vivo and in vitro after expression alteration. The expressions of NEAT1, p-p65, p300, and IL-18 were all upregulated in the synovial tissues from the mice and patients with RA. NEAT1 silencing reduced the infiltration of CD4⁺ T cells and macrophages in synovial tissues, downregulated expression of blood inflammatory factors, relieved RA severity, and lowered incidence of RA in mice. Further, p-p65 could increase the expression of NEAT1 by binding to the NEAT1 promoter region, NEAT1 could co-locate and interact with p300, thus regulating the expression of IL-18 by regulating histone acetylation modification in IL-18 promoter region. NEAT1 aggravated RA via p300/CBP/IL-18 axis, representing a promising therapeutic target in RA.

The Emerging Role of Exosomal Non-coding RNAs in Musculoskeletal Diseases

Exosomes are phospholipid bilayer-enclosed membrane vesicles derived and constitutively secreted by various metabolically active cells. They are capable of mediating hetero- and homotypic intercellular communication by transferring multiple cargos from donor cells to recipient cells. Nowadays, non-coding RNAs (ncRNAs) have emerged as novel potential biomarkers or disease-targeting agents in a variety of diseases. However, the lack of effective delivery systems may impair their clinical application. Recently, accumulating evidence demonstrated that ncRNAs could be efficiently delivered to recipient cells using exosomes as a carrier, and therefore can exert a critical role in musculoskeletal diseases including osteoarthritis, rheumatoid arthritis, osteoporosis, muscular dystrophies, osteosarcoma and other diseases. Herein, we present an extensive review of biogenesis, physiological relevance and clinical implication of exosome-derived ncRNAs in musculoskeletal diseases.

Evaluation of Serum Calprotectin Level and Disease Activity in Patients with Rheumatoid Arthritis

BACKGROUND

Rheumatoid Arthritis (RA) is the most common type of chronic inflammatory arthritis with unknown etiology marked by a symmetric, peripheral polyarthritis. Calprotectin also can be used as a biomarker of disease activity in inflammatory arthritis and other autoimmune diseases.

OBJECTIVES

In this study, we evaluated the association between serum calprotectin level and severity of RA activity.

METHODS

A cross-sectional study was conducted on 44 RA patients with disease flare-up. Serum samples were obtained from all patients to measure calprotectin, ESR, CRP prior to starting the treatment and after treatment period in the remission phase. Based on Disease Activity Score 28 (DAS28), disease activity was calculated.

RESULTS

Of 44 RA patients, 9(20.5%) were male and 35(79.5%) were female. The mean age of our cases was 53±1.6 years. Seventeen (38.6%) patients had moderate DAS28 and 27(61.4%) had high DAS28. The average level of calprotectin in the flare-up phase was 347.12±203.60 ng/ml and 188.04±23.58 ng/ml in the remission phase. We did not find any significant association between calprotectin and tender joint count (TJC; P=0.22), swollen joint count (SJC; P=0.87), and general health (GH; P=0.59), whereas significant associations were found between the calprotectin level and ESR (p=0.001) and DAS28 (p=0.02). The average calprotectin level in moderate DAS28 (275.21±217.96 ng/ml) was significantly lower than that in high DAS28 (392.4±183.88 ng/ml) (p=0.05).

CONCLUSION

We showed that the serum level of calprotectin can be a useful and reliable biomarker in RA activity and its severity. It also can predict treatment response.

A Pilot Study to Evaluate the Effects of Oral N-Acetyl Cysteine on Inflammatory and Oxidative Stress Biomarkers in Rheumatoid Arthritis

BACKGROUND

Rheumatoid Arthritis (RA) is a common inflammatory disease of the joints. Due to the importance of inflammation and oxidative stress in the pathogenesis of RA, drugs that have anti-oxidant and anti-inflammatory properties, such as N-acetyl Cysteine (NAC), can be used as adjunctive therapy in patients with RA.

AIMS

The aim of this study was to evaluate the effects of oral NAC on inflammatory cytokines and oxidative stress in patients with RA.

METHODS

Adjunct to standard treatment, the NAC group (23 patients) received 600 mg of NAC twice daily and the placebo group (19 patients) received identical placebo twice daily for 12 weeks. Serum levels of Total Oxidant Status (TOS), Total Antioxidant Capacity (TAC), nitric oxide (NO), Total Thiol Groups (TTG), Malondialdehyde (MDA), tumor necrosis factor-alpha (TNF-α), interleukin- 6 (IL-6), C-reactive Protein (CRP), and Erythrocyte Sedimentation Rate (ESR) were measured at baseline and at the end of the study.

RESULTS

Results showed that in the NAC group, the serum levels of MDA, NO, IL-6, TNF-α, ESR and CRP were significantly lower than the baseline. Also, the serum level of TAC and TTG, as antioxidant parameters, increased significantly. However, only NO, MDA and TTG showed a significant difference in the NAC group as compared to the placebo group at the end of study.

CONCLUSION

According to the results of this study, oral NAC can significantly reduce the several oxidative stress factors and inflammatory cytokines. These results need to be confirmed in larger studies while considering clinical outcomes of RA patients.

Anti-Arthritic Effect of Garcinol Enriched Fraction Against Adjuvant Induced Arthritis

Background:

Garcinia indica also known as kokum is used in traditional system of medicine for relieving inflammation and rheumatic pain. Garcinol, a benzophenone obtained from its fruit rind is reported to have anti-inflammatory effect via modulating arachidonic acid metabolism, suppressing iNOS expression, NF-κB activation and COX-2 expression. It has also been studied for antioxidant and anti-cancer activity. Apart from these, few patents claim that garcinol also has anti-obesity and hepatoprotec-tive effect and has a potential to be used for the treatment of renal disorders, endometriosis and cardiac dysfunction.

Objective:

Garcinol Enriched Fraction (GEF) from the fruit rind of Garcinia indica should be effective in the treatment of arthritis, one of the chronic inflammatory disorder owing to its anti-inflammatory property as indicated by earlier experiments.

Methods:

GEF was prepared from the fruit rind of Garcinia indica and quantified using LC-MS/MS. It was found to contain 89.4% w/w of garcinol. GEF was evaluated at the dose of 10mg/kg for its efficacy against Complete Freund’s Adjuvant (CFA) induced arthritis in Wistar albino rats. Paw volumes of both sides were measured by Plethysmometer and body weight was recorded on 0, 1, 5, 12 and 21^st day. The hyperalgesic response was also measured by motility test and stair climbing test.

Results:

GEF showed a significant reduction in paw swelling (p < 0.0001) and arthritis index (p < 0.0001) exhibiting anti-inflammatory potential. It also improves the motility and stair climbing ability of experimental animals (p < 0.05), thus reducing hyperalgesia.

Conclusion:

Garcinol enriched fraction shows anti-arthritic activity in experimental animals.

Nanotherapeutics for the Treatment of Cancer and Arthritis

BACKGROUND

Nanotechnology is gaining significant attention worldwide for the treatment of complex diseases such as AIDS (acquired immune deficiency syndrome), cancer and rheumatoid arthritis. Nanomedicine is the application of nanotechnology used for diagnosis and treatment for the disease that includes the preservation and improvement of human health by covering an area such as drug delivery using nanocarriers, nanotheranostics and nanovaccinology. The present article provides an insight into several aspects of nanomedicine such as usages of multiple types of nanocarriers, their status, advantages and disadvantages with reference to cancer and rheumatoid arthritis.

METHODS

An extensive search was performed on the bibliographic database for research article on nanotechnology and nanomedicine along with looking deeply into the aspects of these diseases, and how all of them are co-related. We further combined all the necessary information from various published articles and briefed to provide the current status.

RESULTS

Nanomedicine confers a unique technology against complex diseases which includes early diagnosis, prevention, and personalized therapy. The most common nanocarriers used globally are liposomes, polymeric nanoparticles, dendrimers, metallic nanoparticles, magnetic nanoparticles, solid lipid nanoparticles, polymeric micelles and nanotubes among others.

CONCLUSION

Nanocarriers are used to deliver drugs and biomolecules like proteins, antibody fragments, DNA fragments, and RNA fragments as the base of cancer biomarkers.

Study of Monocytes/Macrophages Stimuli as the Targets of Treating Inflammatory Bone Diseases

Inflammation is the most common pathology in many orthopedic diseases, such as: rheumatoid arthritis (RA), osteoarthritis (OA) and other reasons caused osteolysis. The leading factor of inflammation was considered as the differentiation of monocyte and the polarization of macrophage. However, cytokines and different cell models could regulate this progress in some aspects. Therefore, in the current review, we summarize several cytokines and cell models, which could lead to inflammatory orthopedic diseases via regulating monocytes and macrophages. In order to extensively explore the potential therapeutic and medicine targets for inflammation-induced bone diseases.

Th1/Th17 Cytokine Profile is Induced by Macrophage Migration Inhibitory Factor in Peripheral Blood Mononuclear Cells from Rheumatoid Arthritis Patients

BACKGROUND

Macrophage migration inhibitory factor (MIF) is an immunoregulatory cytokine that plays a crucial role as a regulator of the innate and adaptive immune responses and takes part in the destructive process of the joint in rheumatoid arthritis (RA) by promoting angiogenesis and inducing proinflammatory cytokines and matrix metalloproteinases (MMP). We evaluated if recombinant human MIF (rhMIF) induces the production of TNF-α, IFN-γ, IL-1β, IL-6, IL-10, IL-17A, and IL- 17F in peripheral blood mononuclear cells (PBMC) from RA patients and control subjects (CS).

METHODS

The PBMC from RA patients and CS were stimulated for 24 hours with combinations of LPS, rhMIF or the MIF antagonist ISO-1. Cytokine profiles were measured using a multiplex immunoassay and, macrophage migration inhibitory factor (MIF) was determined by ELISA kit.

RESULTS

The PBMC of CS and RA produced Th1 and Th17 cytokines under stimulation with rhMIF, however, this effect was higher in the cells of RA patients. The rhMIFstimulated PBMC from RA patients produced higher levels of Th1 and Th17 cytokines in comparison with unstimulated cells: TNF-α (538.81 vs. 5.02 pg/mL, p<0.001), IFN-γ (721.90 vs. 8.40 pg/mL, p<0.001), IL-1β (150.14 vs. 5.17 pg/mL, p<0.05), IL-6 (19769.70 vs. 119.85 pg/mL, p<0.001), IL-17A (34.97 vs. 0.90 pg/mL, p<0.01) and IL-17F (158.43 vs. 0.92 pg/mL, p<0.001).

CONCLUSION

These results highlight the potential role of MIF in the establishment of the chronic inflammatory process in RA via Th1 and Th17 cytokine profile induction and provide new evidence of the role of MIF to stimulate the IL-17A and IL-17F expression in PBMC from RA and CS.

Metformin one in a Million Efficient Medicines for Rheumatoid Arthritis Complications: Inflammation, Osteoblastogenesis, Cardiovascular Disease, Malignancies

BACKGROUND

Rheumatoid arthritis is a widespread autoimmune disease and inflammation and bone destruction are two main issues in rheumatoid arthritis.

OBJECTIVE

To discussing metformin effects on rheumatoid arthritis complications.

METHODS

We conducted a narrative literature search including clinical trials, experimental studies on laboratory animals and cell lines. Our search covered Medline, PubMed and Google Scholar databases from 1999 until 2018. We used the terms" Metformin; Rheumatoid arthritis; Cardiovascular disease; Cancer; Osteoblastogenesis.

DISCUSSION

Inflammatory pro-cytokines such as Interlukin-6 play important roles in T. helper 17 cell lineage differentiation. Interlukin-6 and Tumor Necrosis Factor-α activate Janus kinase receptors signal through signaling transducer and activator of transcription signaling pathway which plays important role in inflammation, bone destruction and cancer in rheumatoid arthritis patients. Interlukin-6 and Tumor Necrosis Factor-α synergistically activate signaling transducer and activator of transcription and Nuclear Factor-kβ pathways and both cytokines increase the chance of cancer development in rheumatoid arthritis patients. Metformin is AMPK activators that can suppress mTOR, STAT3 and HIF-1 so AMPK activation plays important role in suppressing inflammation and osteoclastogenesis and decreasing cancer.

CONCLUSION

Metformin effect on AMPK and mTOR pathways gives the capability to change Treg/Th17 balance and decrease Th17 differentiation and inflammation, osteoclastogenesis and cancers in RA patients. Metformin can be useful in protecting bones especially in first stages of RA and it can decrease inflammation, CVD and cancer in RA patients so Metformin beside DAMARs can be useful in increasing RA patients' life quality with less harm and cost.

In vivo, Extract from Withania somnifera Root Ameliorates Arthritis via Regulation of Key Immune Mediators of Inflammation in Experimental Model of Arthritis

BACKGROUND

Rheumatoid Arthritis (RA) is a devastating disease characterized by continual addition of leukocytes and T cells within the articular cavity causing inflammation and cartilage destruction. Withania somnifera is one of the most precious medicinal herbs, reported to have antioxidant, anti-inflammatory, and immunomodulatory properties.

OBJECTIVE

The purpose of this study was to evaluate anti-inflammatory activity of aqueous extract of Withania somnifera roots (WSAq) in Collagen Induced Arthritic (CIA) rats.

METHODS

To achieve this, we assessed the level of inflammatory cytokines such as Tumor Necrosis Factor (TNF)-α, IL-1β, IL-6 and IL-10 in CIA rats. Further, transcription factor, oxidative stress parameters and CD+8 expressions were also analyzed in CIA rats.

RESULTS

Arthritic rats showed a greater increase in the levels of pro inflammatory cytokines such as TNF-α, IL-1β, IL-6, transcription factor NF-κB and a decrease in IL-10 concentration than controls rats. Oral administration of WSAq at a dose of 300mg/kg.wt. (WSAq300) appreciably attenuated the production of these pro inflammatory cytokines. This anti-inflammatory activity of WSAq300 might be partly mediated through an increase in the secretion of IL-10 and inhibition of NF-κB activity. Further, arthritic rats also show increased oxidative stress as compared to control rats. This increased oxidative stress in the arthritic rats appears to be the outcome of both an activated pro-oxidant and a poor antioxidant defense system. Treatment with WSAq300 strongly ameliorates all these ROS parameters significantly to near normal. Additional, metalloproteinase MMP-8 levels were also measured and found to be increased in CIA rats, which after treatment with WSAq300 came down to near normal.

CONCLUSION

From the above results, it can be concluded that the use of WSAq300 may be a valuable supplement which can improve human arthritis.

Body Mass Index Impact on Disease Activity, Clinical and Sonographic Remission Rates in Patients with Rheumatoid Arthritis

AIM

To investigate the impact of body mass index (BMI) on clinical disease activity indices and clinical and sonographic remission rates in patients with rheumatoid arthritis (RA).

PATIENTS AND METHODS

Sixty-three patients with RA were categorized according to BMI score into three groups: normal (BMI<25), overweight (BMI 25-30) and obese (BMI≥30). Thirty-three of them were treated with conventional synthetic disease-modifying anti-rheumatic drugs (csDMARDs), and 30 with biologic DMARDs (bDMARDs). Patients underwent clinical and laboratory assessment and musculoskeletal ultrasound examination (MSUS) at baseline and at 6 months after initiation of therapy. We evaluated the rate of clinical and sonographic remission (defined as Power Doppler score (PD) = 0) and its correlation with BMI score.

RESULTS

In the csDMARDs group, 60% of the normal weight patients reached DAS28 remission; 33.3% of the overweight; and 0% of the obese patients. In the bDMARDs group, the percentage of remission was as follows: 60% in the normal weight subgroup, 33.3% in the overweight; and 15.8% in the obese. Within the csDMARDs treatment group, two significant correlations were found: BMI score-DAS 28 at 6th month, rs = .372, p = .033; BMI score-DAS 28 categories, rs = .447, p = .014. Within the bDMARDs group, three significant correlations were identified: BMI score-PDUS at sixth month, rs = .506, p =.004; BMI score-DAS 28, rs = .511, p = .004; BMI score-DAS 28 categories, rs = .592, p = .001. Sonographic remission rates at 6 months were significantly higher in the normal BMI category in both treatment groups.

CONCLUSION

BMI influences the treatment response, clinical disease activity indices and the rates of clinical and sonographic remission in patients with RA. Obesity and overweight are associated with lower remission rates regardless of the type of treatment.

Gray Scale and Power Doppler Ultrasonographic Findings in the Assessment of Disease Activity and Their Correlation with Disease Activity Parameters in Rheumatoid Arthritis

OBJECTIVES

To study the utility of gray scale and power Doppler ultrasonography in assessing the disease activity and correlation of ultrasonographic findings with disease activity parameters in Rheumatoid Arthritis (RA).

MATERIALS AND METHODS

This cross-sectional study was conducted on 100 RA patients diagnosed as per 2010 classification criteria. Rheumatoid Factor (RF), serum Anti-cyclic Citrullinated Peptide Antibodies (ACPA), Erythrocyte Sedimentation Rate (ESR), C-reactive Protein (CRP), disease activity score with 28-joint counts and ESR (DAS28-ESR), Visual Analogue Scale (VAS) for global disease activity and Gray Scale Ultrasonography (GSUS) and Power Doppler Ultrsonography (PDUS) scores in hands and wrists were determined.

RESULTS

Of 100 RA patients with clinically active arthritis, GSUS detected disease activity in all and PDUS in 95 (95%) patients. Of total 2200 joints assessed, disease activity was seen by clinical assessment in 51.31% (1116/2200), GSUS in 57.36% (1262/2200) and PDUS in 48.36% (1064/2200) joints. For detecting active arthritis, clinical assessment showed 79.5% sensitivity and 76.2% specificity while GSUS showed 100% sensitivity and 82.5% specificity using PDUS as a gold standard. GSUS findings of synovitis, joint effusion and bone erosions and PDUS score showed significant correlations with the swollen joint count, tender joint count, ESR and DAS28- ESR (p<0.05 each) but not with VAS, CRP, RF and ACPA (p>0.05 each). Multivariate analysis showed that swollen joint count was independently associated with synovitis (p=0.029) and tender joint count with PDUS score (p=0.036).

CONCLUSIONS

GSUS and PDUS findings are useful in ascertaining the disease activity and correlate with clinical disease activity in joints in RA.

Current Status and Future Prospects of Small-molecule Protein-protein Interaction (PPI) Inhibitors of Tumor Necrosis Factor (TNF) and Receptor Activator of NF-κB Ligand (RANKL)

The overexpression of Tumor Necrosis Factor (TNF) is directly related to the development of several autoimmune diseases, such as rheumatoid and psoriatic arthritis, inflammatory bowel disease, Crohn's disease, refractory asthma, and multiple sclerosis. Receptor Activator of Nuclear Factor Kappa- B Ligand (RANKL) belongs to the TNF family and is the primary mediator of osteoclast-induced bone resorption through interaction with its receptor RANK. The function of RANKL is physiologically inhibited by the action of osteoprotegerin (OPG), which is a decoy receptor that binds to RANKL and prevents the process of osteoclastogenesis. Malfunction among RANK/RANKL/OPG can also result in bone loss diseases, including postmenopausal osteoporosis, rheumatoid arthritis, bone metastasis and multiple myeloma. To disrupt the unwanted functions of TNF and RANKL, current attempts focus on blocking TNF and RANKL binding to their receptors. In this review, we present the research efforts toward the development of low-molecular-weight pharmaceuticals that directly block the detrimental actions of TNF and RANKL.

Study in Treatment of Collagen-Induced Arthritis in DBA/1 Mice Model by Genistein

BACKGROUND

This work aimed to evaluate the effects of genistein treatment in Collagen Induced Arthritis (CIA) mouse model.

METHODS

CIA was elicited in DBA/1 Mice by an intradermal injection of 100 μL of an emulsion of bovine type II collagen (CII) in isovolumic incomplete Freund's adjuvant (IFA) at the base of the tail. Twenty-one days later, a second injection of CII in IFA was administered at the base of the tail. After the symptoms of arthritis showed in mouse model, we divided animals into two groups according to their clinical symptom scores. The treatment group was intraperitoneally injected daily with genistein (based on the pre-experiment data and literature reported, 5 mg/kg dose was selected and tested) for 12 days, while the control group was injected with phosphate buffered saline. Inflammatory cytokines titer, radiological, and histological observations were completed at different time's points after treatment. CT analysis was conducted 3 months after the treatment to observe the articular structures. Immunohistochemical analysis was performed to investigate the expression and distribution of VEGF in joint tissues.

RESULTS

Genistein suppressed the expressions of IL-1β, IL-6 and TNF-α in the serum. Radiological results showed that bone degradation was inhibited by the treatment. Moreover, hematoxylin and eosin staining showed that the degree of inflammation was relieved. In the cartilage area, TRAP stain-positive cells were detected, which was notably reduced in the treatment group compared to the control group. Micro-CT 3D images clearly exhibited that the joint adhered and structures destroyed in the control group with less destruction in the treatment group. Furthermore, genistein suppressed VEGF expression, and blocked angiogenesis in the synovial tissue.

CONCLUSION

Our work provides further data regarding the effects of genistein as a potential treatment drug for RA, as well as the role of genistein in the anti-inflammatory pathway in RA therapy.

Onset of Hypertension in Leflunamide Treated Low Socioeconomic Rheumatoid Arthritis Patients: An Unseen Iceberg

OBJECTIVE

To determine the frequency of new-onset hypertension in patients with Rheumatoid arthritis taking leflunomide, in comparison with methotrexate in Asian setting.

MATERIAL AND METHODS

Perspective case-control study was conducted in 2014 in a tertiary care hospital located in Karachi, Pakistan. Adult patients, having rheumatoid arthritis were randomly prescribed leflunomide or methotrexate. Patients having chronic hypertension, proteinuria and chronic kidney disease were excluded. Patients were monthly followed for blood pressure and heart rate measurements. Hypertension was defined using JNC 7 criteria.

RESULTS

Out of 144 patients enrolled, 80 patients received Leflunomide while 64 were started on methotrexate. Mean systolic blood pressure in leflunomide group at the start and at the end of study was 108.5 and 135.4mmHg, respectively while in methotrexate group, mean systolic BP was 109.8 and 110.5 mmhg, respectively. After one year follow up, 33 out of 80 (41%) patients were receiving leflunomide had pre-hypertension or hypertension, while only 3 out of 64 patients (4.7%) were receiving methotrexate had hypertension.

CONCLUSION

Risk of developing hypertension in patient receiving Leflunomide is much higher in Asian population like Pakistan as compared to western population.

Drug-Bearing Supramolecular Filament Hydrogels as Anti-Inflammatory Agents

We report here on the covalent conversion of the anti-inflammatory agent ketoprofen into self-assembling prodrugs that enable the effective purification of ketoprofen enantiomers, the improved selectivity and potency of ketoprofen, as well as the formation of one-component drug-bearing supramolecular hydrogels. We found that the ketoprofen hydrogelator could exhibit much-enhanced selectivity for cyclooxygenase 2 (COX-2) over COX-1, reduce the concentration of inflammatory cytokines (IL-1 and TNFα), and induce apoptosis in fibroblast-like synoviocytes while maintaining biocompatibility with healthy chondrocytes. In addition, these anti-inflammatory agent-containing hydrogels demonstrated the ability to retain the therapeutic within a joint cavity after intra-articular injection, exhibiting a slow, steady release into the plasma. We believe that upon further optimization these drug-based injectable supramolecular hydrogels could provide the basis for a local treatment strategy for rheumatoid arthritis and similar conditions.

Risk of Herpes Zoster in Individuals on Biologics, Disease-Modifying Antirheumatic Drugs, and/or Corticosteroids for Autoimmune Diseases: A Systematic Review and Meta-Analysis

Background.

Studies examining the risk of herpes zoster (HZ) associated with immunosuppressants, such as biologics, nonbiological disease-modifying antirheumatic drugs (nbDMARDs), or corticosteroids, have generated conflicting results.

Methods.

We conducted a systematic literature search from January 1946 to February 2016. Search terms related to HZ, rheumatoid arthritis, psoriasis, psoriatic arthritis, systemic lupus erythematous, or inflammatory bowel disease, biologics, nbDMARDS, and corticosteroids were used. We included randomized controlled trials (RCTs) and observational studies reporting associations between immunosuppressants and HZ outcomes in adults. For RCTs, we used the Mantel-Haenszel fixed-effects model to estimate pooled odds ratios (ORs) and 95% confidence intervals (CIs) for HZ risk. For observational studies, adjusted ORs were pooled separately using random-effects inverse variance models.

Results.

Data were pooled from 40 eligible RCTs (20136 patients) and 19 observational studies (810939 patients). Biologics were associated with a greater risk of HZ than control (RCTs: OR = 1.71, 95% CI = 1.11–2.64; observational studies: OR = 1.58, 95% CI = 1.39–1.81). In RCTs, the OR of non-tumor necrosis factor (TNF) blockers was 2.19 (95% CI 1.20–4.02), but that of TNF blockers was not significantly different from control. Increased risks of HZ with nbDMARDs (OR = 1.21; 95% CI = 1.15–1.28) and corticosteroids (OR = 1.73; 95% CI = 1.57–1.89) were observed in observational studies, but few RCTs examined these comparisons.

Conclusions.

Immunocompromised patients receiving biologics were associated with an increased risk of HZ. The risk is also increased with corticosteroids and nbDMARDs. These findings raise the issue of prophylaxis with zoster vaccine in patients initiating immunosuppressive therapy for autoimmune diseases.

Improving the power of clinical trials of rheumatoid arthritis by using data on continuous scales when analysing response rates: an application of the augmented binary method

Objective. In clinical trials of RA, it is common to assess effectiveness using end points based upon dichotomized continuous measures of disease activity, which classify patients as responders or non-responders. Although dichotomization generally loses statistical power, there are good clinical reasons to use these end points; for example, to allow for patients receiving rescue therapy to be assigned as non-responders. We adopt a statistical technique called the augmented binary method to make better use of the information provided by these continuous measures and account for how close patients were to being responders.

Methods. We adapted the augmented binary method for use in RA clinical trials. We used a previously published randomized controlled trial (Oral SyK Inhibition in Rheumatoid Arthritis-1) to assess its performance in comparison to a standard method treating patients purely as responders or non-responders. The power and error rate were investigated by sampling from this study.

Results. The augmented binary method reached similar conclusions to standard analysis methods but was able to estimate the difference in response rates to a higher degree of precision. Results suggested that CI widths for ACR responder end points could be reduced by at least 15%, which could equate to reducing the sample size of a study by 29% to achieve the same statistical power. For other end points, the gain was even higher. Type I error rates were not inflated.

Conclusion. The augmented binary method shows considerable promise for RA trials, making more efficient use of patient data whilst still reporting outcomes in terms of recognized response end points.

Meloxicam-loaded Phospholipid/solutol® HS15 Based Mixed Nanomicelles: Preparation, Characterization, and in vitro Antioxidant Activity

BACKGROUND

Rheumatoid arthritis (RA) is a debilitating disease which results in joint destruction, mainly due to chronic inflammation and oxidative stress. Meloxicam (MLX) is a preferential cyclooxygenase-2 (COX-2) inhibitor with potential free radical scavenging activity. Mixed nanomicelles (NMs) of MLX can augment its antioxidant effects.

OBJECTIVE

The present study aims to prepare, characterize, and evaluate the in vitro antioxidant effects of MLX-loaded mixed nanomicelles (MLXNMs).

METHOD

Conventional thin-film hydration method was employed to fabricate MLX-NMs. The formulations were characterized for particle size, zeta potential, entrapment efficiency (EE), and drug loading (DL). Additionally, the optimized formulation was characterized for small-angle neutron scattering (SANS), in vitro drug release, and morphology. MLX encapsulation in NMs was confirmed by Fourier Transform Infrared spectroscopy (FTIR), differential scanning calorimetry (DSC), 1H nuclear magnetic resonance (NMR), and X-ray diffraction (XRD), studies. The cell uptake of sulforhodamine B (SRB)- labeled NMs was studied in RAW 264.7 cells. The in vitro antioxidant activity of optimized MLX-NMs was studied by different antioxidant assays.

RESULTS

The optimized MLX-NMs exhibited average size and zeta potential of 88 ± 42 nm and -47.4 ± 16.2 mV, respectively. The EE and DL of MLX were 94.13 ± 1.01 % and 4.20 ± 0.05 %, respectively. Morphology studies confirmed the oblate ellipsoidal shape of MLXNMs. The in vitro release study exhibited a biphasic release pattern. MLX encapsulation into the micelle core was confirmed by FTIR, DSC, 1H NMR, and XRD studies. Additionally, SRB-labeled NMs demonstrated efficient in vitro cell uptake in RAW 264.7 cells. Furthermore, in vitro antioxidant studies exhibited superior free radical scavenging activity of MLXNMs as compared to free MLX.

CONCLUSION

The NMs potentiate the in vitro antioxidant effects of MLX.

Determinants of Disability in Rheumatoid Arthritis: A Community-Based Cohort Study

Longitudinal care of a community-based cohort of patients with rheumatoid arthritis (RA) was evaluated retrospectively. Candidate determinants of disability included visual analog scales (VAS) for patient global assessment and pain, comorbidities, and medications. The outcome was the 'patient-acceptable symptom state' for disability as defined by the Health Assessment Questionnaire (HAQ) disability index, using a cutoff of <1.04. Two-sample t tests and multivariable logistic regression were used to determine odds ratios (OR) for associations between predictor variables and disability. Out of a total of 99 patients, 28 (28%) patients had HAQ ≥1.04 at their last visit. The greatest odds of not attaining the patient-acceptable symptom state in a multivariable model was associated with corticosteroids (OR: 5.1; p=0.02), antidepressants (OR: 5.3; p=0.02), and female sex (OR: 6.5; p=0.05). In the era of biologic therapy, female sex, corticosteroids, and antidepressants remain profound determinants of disability highlighting the need to understand the underlying mechanisms.

Reverse Shoulder Arthroplasty in Rheumatoid Arthritis: A Systematic Review

Background:

Anatomical shoulder replacement for rheumatoid arthritis (RA) is complicated by a high incidence of rotator cuff tears and glenoid erosion. This can lead to poor function and early failure. Reverse shoulder arthroplasty (RSA) has gained popularity as an alternative. This systematic review attempts to further define the role of RSA in RA.

Methods:

A systematic review identified seven studies reporting outcomes of RSA in RA patients. Studies were critically appraised, and data on outcomes, complications and technical considerations were extracted and analysed.

Results:

One hundred and twenty one shoulders were included (mean follow up 46.9 months). Consistent improvements in the main outcome measures were noted between studies. Ninety five percent of patients described excellent to satisfactory outcomes. The minimum mean forward elevation reported in each study was 115 degrees. Symptomatic glenoid loosening (1.7%), deep infection (3.3%) and revision surgery (5%) rates were no higher than for a population of mixed aetiologies.

Discussion:

Previous concerns regarding high pre- and peri-operative complication and revision rates in RA patients were not shown to be valid by the results of this review. Although associated cuff tears are common and glenoid bone loss can increase the technical complexity of surgery, RSA provides consistent and predictable improvements in key outcome measures and the revision and complication rates do not appear to be higher than reported in a large population of mixed aetiologies.

Conclusion:

The contemporary literature shows that RSA is a safe, effective and reliable treatment option in RA patients.

Comparing Five Year Out-Come in Two Cohorts of Patients with Early Rheumatoid Arthritis - A BARFOT Study

The objective of the study was to compare disease characteristics over the first 5 years of disease in patients with RA, with disease onset in 1990s and 2000s, respectively.

Anti-apoptotic roles for the mutant p53R248Q through suppression of p53-regulated apoptosis-inducing protein 1 in the RA-derived fibroblast-like synoviocyte cell line MH7A

We previously reported that somatic mutations in the p53 gene accumulated at a higher frequency in AID(activation induced cytidine deaminase)(+) RA-FLS, which may result in the malfunction of p53, causing the tumor-like properties of RA-FLS. Among the p53 mutations identified from 3 sources of AID(+) RA-FLS, we focused on the p53R248Q mutation because it was reported to enhance the invasiveness of lung cancer cells and to have dominant-negative activity for pro-apoptotic molecules. We obtained cDNA encoding the p53R248Q mutant and introduced it into the MH7A RA-FLS cell line. P53R248Q dramatically suppressed the expression of the pro-apoptotic molecule p53AIP1 even under oxidative stress, which normally upregulates p53AIP1, leading to apoptosis. Moreover, overexpression of p53AIP1 increased apoptosis, whereas p53AIP1 knockdown rescued the cells from apoptosis. Together, these studies indicate the critical role of p53AIP1 under DNA damaging stresses for cell fate determination in RA-FLS containing the p53R248Q mutation.

No Correlations Between the Development of Specific IgA and IgM Antibodies Against Anti-TNF Blocking Agents, Disease Activity and Adverse Side Reactions in Patients with Rheumatoid Arthritis

The use of tumour necrosis factor (TNF) antagonists (infliximab [IFN], etanercept [ETN], adalimumab [ADA]) has changed the course of many rheumatic diseases, including rheumatoid arthritis (RA). However, some questions concerning their safety have emerged since their approval because they can trigger immunisation, induce rare type I and III hypersensitivity, and cause acute and delayed reactions. The aim of this study was to evaluate the correlations between hypersensitivity reactions to biological agents, disease activity and the development of class-specific IgA and IgM antibodies against the three anti-TNF agents in patients with RA. This longitudinal observational study involved consecutive outpatients with active RA who started treatment with IFN (n=30), ETN (n=41) or ADA (n=28). Clinical data and systemic and local side effects were collected prospectively at baseline and after six months of anti-TNF treatment. Serum samples were taken at the same time points in order to measure antibodies against the TNF blockers, anti-nuclear (ANA) and anti-dsDNA antibodies. The IgA and IgM antibodies specific to all three anti-TNF-α agents were analysed using ImmunoCaP Phadia- Thermofisher especially developed in collaboration with the laboratory of Immunology and Allergy, San Giovanni di Dio, Florence. The mean age of the 99 patients (86% females) was 54.6±12.4 years, and the median disease duration was 11.2±.3.2 years (range 3-14.3). The three treatment groups were comparable in terms of age, gender, rheumatoid factor and anti-citrullinated peptide (CCP) antibody positivity, and baseline C-reactive protein levels, erythrocyte sedimentation rate, 28-joint disease activity scores, and concomitant medications. Twelve patients treated with INF (40%) had anti-IFN IgM, and two (6%) anti-IFN IgA; 19 patients treated with ADA (68%) had anti-ADA IgM, and four (6%) anti-ADA IgA; and 27 patients treated with ETN (66%) had anti-ETN IgM, and 24 (58%) anti-ETN IgA. There were five systemic reactions in the IFN group, and seven adverse local reactions in both the ADA and the ETN group. There was no correlation between drug-specific IgA and IgM antibodies (p=0.65). There was also no correlation between the antibodies and disease activity after six months of treatment (r=0.189;p=0.32). Our findings show that the development of antibodies against IFN, ADA or ETN of IgA and IgM class are not related to any decrease in efficacy or early discontinuation of anti-TNF treatment in RA patients, nor to systemic and local reactions. Further studies of larger series of RA patients are needed to confirm the relationships between the development of drug-specific antibodies, serum TNF blocker levels, and disease activity.

Targeted Therapy with Rituximab in Felty's Syndrome: A Case Report

Felty's syndrome is a rare, severe extra-articular manifestation of rheumatoid arthritis (RA). There is no standard therapy, and several disease-modifying antirheumatic drugs have been used with varying success. Only very few reports exist in literature on the use of biologicals in this indication and this with a variable efficacy. We report the case of a 53-year-old woman with severe refractory/partly undertreated RA who presented with Felty's syndrome and pancytopenia, in whom treatment with rituximab led to an marked increase of red blood cells, neutrophils and thrombocytes. In addition, the RA disease activity status improved dramatically and treatment with steroids could be reduced. The current sparse literature on this topic is reviewed.

c-Jun N-Terminal Kinase in Inflammation and Rheumatic Diseases

The c-Jun N-terminal kinases (JNKs) are members of the mitogen-activated protein kinase (MAPK) family and are activated by environmental stress. JNK is also activated by proinflammatory cytokines, such as TNF and IL-1, and Toll-like receptor ligands. This pathway, therefore, can act as a critical convergence point in immune system signaling for both adaptive and innate responses. Like other MAPKs, the JNKs are activated via the sequential activation of protein kinases that includes two dual-specificity MAP kinase kinases (MKK4 and MKK7) and multiple MAP kinase kinase kinases. MAPKs, including JNKs, can be deactivated by a specialized group of phosphatases, called MAP kinase phosphatases. JNK phosphorylates and regulates the activity of transcription factors other than c-Jun, including ATF2, Elk-1, p53 and c-Myc and non-transcription factors, such as members of the Bcl-2 family. The pathway plays a critical role in cell proliferation, apoptosis, angiogenesis and migration. In this review, an overview of the functions that are related to rheumatic diseases is presented. In addition, some diseases in which JNK participates will be highlighted.

Tolerability and patient/physician satisfaction with subcutaneously administered methotrexate provided in two formulations of different drug concentrations in patients with rheumatoid arthritis

Objectives:

To determine preference, satisfaction, usability and local tolerability by patients, physicians and study nurses of two subcutaneously administered methotrexate (MTX) formulations of different concentrations.

Methods:

This was an open-label, comparative, within-patient controlled, multicentre study of 132 patients with rheumatoid arthritis (RA). MTX treatment consisted of 20 mg/week administered as a medium-concentration formulation (MC) (2.0 ml of 10 mg/ml solution in prefilled syringe; separate needle) compared to a novel high-concentration formulation (HC) (0.4 ml of 50 mg/ml in prefilled syringe; pre-attached needle). Each treatment was given for three weeks. Questionnaires and visual analogue scales were used to measure outcomes.

Results:

At the end of the study, 93% of the patients preferred HC over MC as further treatment. Overall assessment of HC was “good” or “very good” in 90.6% vs 34.4% in MC-treated patients. Physician’s and patients global assessment of syringe usability showed highly statistically significant differences (P < 0.0001) in favour of HC. Overall assessment by study nurses’ and investigators’ was “good” (18.8%) or “very good” (81.2%) for HC and “good” in 31.3% or “very good” in 12.5% for MC, and no preference in 50%. Local tolerability improved slightly also with HC.

Conclusions:

The total smaller volume of administered drug and the improved usability of a pre-attached needle in combination with a smaller prefilled syringe resulted in preference of the patients of HC over MC. The slightly improved local tolerability may also have added to this preference. This assessment was confirmed by similar assessments made by healthcare professionals.

Eudra-CT number: 2007-003591-19.