Acute-phase serum amyloid A regulates tumor necrosis factor α and matrix turnover and predicts disease progression in patients with inflammatory arthritis before and after biologic therapy.

OBJECTIVE: To investigate the relationship between acute-phase serum amyloid A (A-SAA) and joint destruction in inflammatory arthritis. METHODS: Serum A-SAA and C-reactive protein (CRP) levels, the erythrocyte sedimentation rate (ESR), and levels of matrix metalloproteinase 1 (MMP-1), MMP-2, MMP-3, MMP-9, MMP-13, tissue inhibitor of metalloproteinases 1 (TIMP-1), vascular endothelial growth factor (VEGF), and type I and type II collagen-generated biomarkers C2C and C1,2C were measured at 0-3 months in patients with inflammatory arthritis commencing anti-tumor necrosis factor α (anti-TNFα) therapy and were correlated with 1-year radiographic progression. The effects of A-SAA on MMP/TIMP expression on RA fibroblast-like synoviocytes (FLS), primary human chondrocytes, and RA/psoriatic arthritis synovial explant cultures were assessed using real-time polymerase chain reaction, enzyme-linked immunosorbent assay, antibody protein arrays, and gelatin zymography. RESULTS: Serum A-SAA levels were significantly (P < 0.05) correlated with MMP-3, the MMP-3:TIMP-1 ratio, C1,2C, C2C, and VEGF. The baseline A-SAA level but not the ESR or the CRP level correlated with the 28-joint swollen joint count and was independently associated with 1-year radiographic progression (P = 0.038). A-SAA increased MMP-1, MMP-3, MMP-13, and MMP/TIMP expression in RA FLS and synovial explants (P < 0.05). In chondrocytes, A-SAA induced MMP-1, MMP-3, and MMP-13 messenger RNA and protein expression (all P < 0.01), resulting in a significant shift in MMP:TIMP ratios (P < 0.05). Gelatin zymography revealed that A-SAA induced MMP-2 and MMP-9 activity. Blockade of the A-SAA receptor SR-B1 (A-SAA receptor scavenger receptor-class B type 1) inhibited MMP-3, MMP-2, and MMP-9 expression in synovial explant cultures ex vivo. Importantly, we demonstrated that A-SAA has the ability to induce TNFα expression in RA synovial explant cultures (P < 0.05). CONCLUSION: A-SAA may be involved in joint destruction though MMP induction and collagen cleavage in vivo. The ability of A-SAA to regulate TNFα suggests that A-SAA signaling pathways may provide new therapeutic strategies for the treatment of inflammatory arthritis.

Acute serum amyloid A induces migration, angiogenesis, and inflammation in synovial cells in vitro and in a human rheumatoid arthritis/SCID mouse chimera model.

Serum amyloid A (A-SAA), an acute-phase protein with cytokine-like properties, is expressed at sites of inflammation. This study investigated the effects of A-SAA on chemokine-regulated migration and angiogenesis using rheumatoid arthritis (RA) cells and whole-tissue explants in vitro, ex vivo, and in vivo. A-SAA levels were measured by real-time PCR and ELISA. IL-8 and MCP-1 expression was examined in RA synovial fibroblasts, human microvascular endothelial cells, and RA synovial explants by ELISA. Neutrophil transendothelial cell migration, cell adhesion, invasion, and migration were examined using transwell leukocyte/monocyte migration assays, invasion assays, and adhesion assays with or without anti-MCP-1/anti-IL-8. NF-kappaB was examined using a specific inhibitor and Western blotting. An RA synovial/SCID mouse chimera model was used to examine the effects of A-SAA on cell migration, proliferation, and angiogenesis in vivo. High expression of A-SAA was demonstrated in RA patients (p < 0.05). A-SAA induced chemokine expression in a time- and dose-dependent manner (p < 0.05). Blockade with anti-scavenger receptor class B member 1 and lipoxin A4 (A-SAA receptors) significantly reduced chemokine expression in RA synovial tissue explants (p < 0.05). A-SAA induced cell invasion, neutrophil-transendothelial cell migration, monocyte migration, and adhesion (all p < 0.05), effects that were blocked by anti-IL-8 or anti-MCP-1. A-SAA-induced chemokine expression was mediated through NF-kappaB in RA explants (p < 0.05). Finally, in the RA synovial/SCID mouse chimera model, we demonstrated for the first time in vivo that A-SAA directly induces monocyte migration from the murine circulation into RA synovial grafts, synovial cell proliferation, and angiogenesis (p < 0.05). A-SAA promotes cell migrational mechanisms and angiogenesis critical to RA pathogenesis.

A role for the high-density lipoprotein receptor SR-B1 in synovial inflammation via serum amyloid-A.

Acute phase apoprotein Serum Amyloid A (A-SAA), which is strongly expressed in rheumatoid arthritis synovial membrane (RA SM), induces angiogenesis, adhesion molecule expression, and matrix metalloproteinase production through the G-coupled receptor FPRL-1. Here we report alternative signaling through the high-density lipoprotein receptor scavenger receptor-class B type 1 (SR-B1). Quantitative expression/localization of SR-B1 in RA SM, RA fibroblast-like cells (FLCs), and microvascular endothelial cells (ECs) was assessed by Western blotting and immunohistology/fluorescence. A-SAA-mediated effects were examined using a specific antibody against SR-B1 or amphipathic alpha-Helical Peptides (the SR-B1 antagonists L-37pA and D-37pA), in RA FLCs and ECs. Adhesion molecule expression and cytokine production were quantified using flow cytometry and ELISA. SR-B1 was strongly expressed in the RA SM lining layer and endothelial/perivascular regions compared with osteoarthritis SM or normal control synovium. Differential SR-B1 expression in RA FLC lines (n = 5) and ECs correlated closely with A-SAA, but not tumor necrosis factor alpha-induced intercellular adhesion molecule-1 upregulation. A-SAA-induced interleukin-6 and -8 production was inhibited in the presence of anti-SR-B1 in human microvascular endothelial cells and RA FLCs. Moreover, D-37pA and L-37pA inhibited A-SAA-induced vascular cell adhesion molecule-1 and intercellular adhesion molecule expression from ECs in a dose-dependent manner. As SR-B1 is expressed in RA synovial tissue and mediates A-SAA-induced pro-inflammatory pathways, a better understanding of A-SAA-mediated inflammatory pathways may lead to novel treatment strategies for RA.

The impact of a revised EQ-5D population scoring on preference-based utility scores in an inflammatory arthritis cohort.

BACKGROUND AND OBJECTIVE: It is well established that there are problems with the EQ-5D. This is due to the original scoring methods used and how negative time trade-off (TTO) values were treated. A revised scoring method has been published. This article applies this to an inflammatory arthritis cohort. The objective is to examine the impact of a revised scoring system for the EQ-5D (UK) TTO on the utility estimates and in the case of rheumatoid arthritis, to explore the impact of using different utility metrics on the incremental cost-effectiveness ratio (ICER) results of an economic model. METHODS: A total of 504 patients with inflammatory arthritis were rescored using revised EQ-5D scoring, which uses an episodic random utility model to deal with negative TTO values. Differences in utility scores were compared and the new mapping coefficients were obtained. These were then used in an economic model to examine the impact on the ICER. RESULTS: In rheumatoid arthritis, the overall change is less for the revised EQ-5D scoring than with the original EQ-5D (TTO) but greater than the SF-6D: EQ-5D UK -0.22 (95% confidence interval [CI] -0.30 to -0.15), revised EQ-5D UK -0.16 (95% CI -0.21 to -0.10) and SF-6D -0.08 (95% CI -0.11 to -0.05). A similar trend is seen in the psoriatic arthritis group. The economic model produced different ICERs, when different utility measures were used; EQ-5D (TTO) €42,402, SF-6D €111,788, and revised EQ-5D (TTO) €57,747. CONCLUSION: In the context of inflammatory arthritis, this article demonstrates that a revised scoring for EQ-5D may have a significant impact on utility estimates and on the output of the economic model.

Synovial tissue and serum biomarkers of disease activity, therapeutic response and radiographic progression: analysis of a proof-of-concept randomised clinical trial of cytokine blockade.

OBJECTIVES: To evaluate synovial tissue and serum biomarkers of disease activity, therapeutic response and radiographic progression during biological therapy for rheumatoid arthritis (RA). METHODS: Patients with active RA entered a randomised study of anakinra 100 mg/day, administered as monotherapy or in combination with pegsunercept 800 microg/kg twice a week. Arthroscopic synovial tissue biopsies were obtained at baseline and two further time points. Following immunohistochemical staining, selected mediators of RA pathophysiology were quantified using digital image analysis. Selected mediators were also measured in the serum. RESULTS: Twenty-two patients were randomly assigned: 11 received monotherapy and 11 combination therapy. American College of Rheumatology 20, 50 and 70 response rates were 64%, 64% and 46% with combination therapy and 36%, 9% and 0% with monotherapy, respectively. In synovial tissue, T-cell infiltration, vascularity and transforming growth factor beta (TGFbeta) expression demonstrated significant utility as biomarkers of disease activity and therapeutic response. In serum, interleukin 6 (IL-6), matrix metalloproteinase (MMP) 1, MMP-3 and tissue inhibitor of metalloproteinase 1 (TIMP-1) were most useful in this regard. An early decrease in serum levels of TIMP-1 was predictive of the later therapeutic outcome. Pretreatment tissue levels of T-cell infiltration and the growth factors vascular endothelial growth factor/TGFbeta, and serum levels of IL-6, IL-8, MMP-1, TIMP-1, soluble tumour necrosis factor receptor types I and II and IL-18 correlated with radiographic progression. CONCLUSIONS: Synovial tissue analysis identified biomarkers of disease activity, therapeutic response and radiographic progression. Biomarker expression in tissue was independent of the levels measured in the serum.

CCR5 blockade in rheumatoid arthritis: a randomised, double-blind, placebo-controlled clinical trial.

OBJECTIVE: C-C chemokine receptor type 5 (CCR5), a chemokine receptor expressed on T cells and macrophages, and its ligands are found in inflamed synovial tissue (ST) of patients with rheumatoid arthritis (RA). The rationale for testing CCR5 blockade in patients with RA was supported by the effects of a CCR5 antagonist in collagen-induced arthritis in rhesus monkeys. The effects of CCR5 blockade in patients with active RA were explored. METHODS: In this phase Ib randomised, placebo-controlled trial, treatment with an oral CCR5 inhibitor (SCH351125) in patients with active RA was evaluated. Clinical efficacy was assessed using European League Against Rheumatism and American College of Rheumatology response criteria. ST biopsies were taken before and after 28 days of treatment, and analysed for CCR5+ cells. In a subset of patients, MRIs of an inflamed joint were obtained before and after treatment. RESULTS: In all, 32 patients were included; 20 received SCH351125 and 12 placebo. Three patients who received SCH351125 did not complete the study due to adverse events; none of these were serious. No improvement was observed in the active treatment group compared to placebo. Results were consistent for clinical evaluation, ST analysis and MRI. CONCLUSION: This proof of concept study does not support the use of CCR5 blockade as a therapeutic strategy in patients with active RA.

Fatigue is an independent outcome measure and is sensitive to change in patients with psoriatic arthritis.

OBJECTIVES: This pilot study examined sensitivity to change and relative independence of fatigue as an outcome measure in patients with psoriatic arthritis (PsA) following anti-TNF therapy. METHODS: Patients with PsA commencing anti-TNF therapy were evaluated at baseline and at 3 months. Fatigue was measured using a 0-10 numeric rating scale (NRS). This was a one-dimensional 11-point NRS with anchors of 0 (none) and 10 (a great deal). The words 'none' and 'a great deal' were placed under the NRS corresponding to the anchors 0 and 10, respectively. Sensitivity to change of fatigue was compared with recognised core outcomes and determined by calculating the standardised response means. Multiple regression analysis was employed to determine predictors of fatigue and their independent variance. RESULTS: Forty-one patients were evaluated. Mean (SD) fatigue levels were 5.6 (2.3) and 3.6 (2.2) (p=0.001) at baseline and at 3-months, respectively. Using the SRM, fatigue ranked sixth relative to the other measures demonstrating a moderate sensitivity to change. Noteworthy was the observation that fatigue was ranked higher than CRP. The relative independent variance in fatigue of 27% was greater than that of the core clinical measures: HAQ 21%, TJC 14%, Pain 4%, SJC 0.4%, GH 0.4%, and less than that of the laboratory measure CRP 33%. CONCLUSIONS: This study demonstrated that fatigue is an independent outcome measure and is sensitive to change in patients with PsA.

Synovial tissue rank ligand expression and radiographic progression in rheumatoid arthritis: observations from a proof-of-concept randomized clinical trial of cytokine blockade.

The objective of the study was to evaluate synovial tissue receptor activator of nuclear factor-κß ligand (RANKL) and osteoprotegerin (OPG) as biomarkers of disease activity, progressive joint damage, and therapeutic response, during cytokine blockade in rheumatoid arthritis (RA). Patients with active RA entered a randomized open-label 12-month study of anakinra 100 mg/day, administered as monotherapy or in combination with pegsunercept 800 µg/kg twice weekly. Arthroscopic synovial tissue biopsies were obtained at baseline, at 4 weeks and at the final time point. Following immunohistochemical staining, RANKL and OPG expression was quantified using digital image analysis. Radiographic damage was evaluated using the van der Heijde modification of the Sharp scoring system. Twenty-two patients were randomized. Baseline expression of RANKL, but not OPG, correlated significantly with baseline CRP levels (r = 0.61, P < 0.01). While a significant reduction in OPG expression following treatment was observed in clinical responders at the final time point (P < 0.05 vs. baseline), RANKL levels did not change, and the RANKL:OPG ratio remained unaltered, even at the highest levels of clinical response. When potential predictors of radiographic outcome were evaluated, baseline RANKL expression correlated with erosive progression at 1 year (r = 0.71, P < 0.01). Distinct, though related, pathophysiologic processes mediate joint inflammation and destruction in RA. Elevated synovial tissue RANKL expression is associated with progressive joint erosion, and may be independent of the clinical response to targeted therapy. The potential therapeutic importance of modulating RANKL in RA is highlighted, if radiographic arrest is to be achieved.

Fatigue is a reliable, sensitive and unique outcome measure in rheumatoid arthritis.

OBJECTIVE: Fatigue is an important symptom in patients with RA. Measurement of fatigue in clinical trials and in clinical practice requires scales that are reproducible, sensitive to change and practical. This study examined the reliability and sensitivity to change of fatigue and its relative independence as an outcome measure in RA. METHODS: Successive patients referred to the rheumatology clinic at St Vincent's University Hospital and Our Lady's Hospice were evaluated. Clinical assessments were undertaken at baseline and 3 months after commencing TNF-alpha blockade. Fatigue was measured using an 11-point numeric rating scale (NRS). Sensitivity to change when compared with current core set outcome measures was determined by calculation of the standardized response mean (SRM). Multiple regression analysis was employed to determine the independent variance of fatigue scores relative to the core set. RESULTS: Forty-nine patients were evaluated. At baseline, mean (s.d.) fatigue scores were 6.7 +/- 2.1. At 3 months, fatigue scores had fallen to 4.3 +/- 2.6 (P < 0.001). Test-retest intraclass correlation coefficient for the NRS was 0.79 (P < 0.008). Fatigue was ranked third for relative sensitivity to change as shown by SRM: pain, 1.37; tender joint count (TJC), 1.09; fatigue, 0.92; swollen joint count (SJC), 0.86; HAQ, 0.82; CRP, 0.69; and patient global health (GH), 0.25. The relative independent variance in fatigue of 22% was higher than that of the core set: TJC, 20%; pain, 19%; SJC, 16%; GH, 8%; HAQ, 7%; and CRP, 8%. CONCLUSIONS: This study demonstrates that measures of fatigue are reliable and sensitive to change, and should be considered for inclusion as a core outcome measure in RA.

Tuberculosis reactivation during immunosuppressive therapy in rheumatic diseases: diagnostic and therapeutic strategies.

PURPOSE OF REVIEW: Biological agents used to treat rheumatologic conditions have made a significant impact on these difficult to treat autoimmune diseases. The tradeoff has been an increase in infections, and particularly tuberculosis with tumor necrosis factor blocker use. Because reactivation of latent tuberculosis infection is preventable, new data have demonstrated that these agents can be made safer when the clinician addresses latent tuberculosis infection. RECENT FINDINGS: Research that supports the screening and treatment of rheumatology patients with latent tuberculosis infection is reviewed, and the emerging consensus on how best to do this is discussed. The limitations of testing to rule out latent tuberculosis infection in this group is emphasized, as this often prevents the tumor necrosis factor blocker prescriber from offering the patient complete reassurance with regard to tuberculosis risk. SUMMARY: Findings to date support the close screening and treatment for tumor necrosis factor in this uniquely vulnerable group. Such vigilance should probably be applied to future drugs that interfere with cytokines known to play a role in tuberculosis immunity.

Measurement of periarticular bone mineral density in the hands of patients with early inflammatory arthritis using dual energy x-ray absorptiometry.

Hand bone densitometry is more sensitive than standard radiology in the measurement of disease-related bone damage in early arthritis. Most studies employing dual energy x-ray absorptiometry (DXA) have evaluated the whole hand. The aim of this study was to evaluate a method that quantified bone density in regions of interest that were confined to the juxta-articular areas of metacarpo-phalangeal (MCP) and proximal interphalangeal (PIP) joints. Patients with inflammatory arthritis affecting the hands were selected for study. Postero-anterior (PA) scans of selected juxta-articular sub-regions were acquired using a Hologic 4500 Elite bone densitometer and forearm software. Each hand was scanned three times in immediate succession with repositioning between scans. The six selected sub-regions included the periarticular regions of the second, third, and fourth MCP and PIP joints. Sub-regions of different dimensions (4 and 5 mm proximal and distal to the joint space) were assessed at each joint. Coefficients of variation (CV) were calculated for bone mineral density (BMD) and bone mineral content (BMC) of each selected sub-region. Eighty four individual hand joints in seven patients were evaluated three times. Precision values ranged between 0.89% and 2.37% for BMD and between 1.38 and 3.26 for BMC measurements. BMD measurements of MCP joints were more precise than PIP joints. BMD measurements of 10-mm sub-regions were more precise than 8-mm sub-regions. The precision value for the net average BMD measurement of the six sub-regions evaluated was 0.78% for 8-mm sub-regions and 0.73% for 10-mm sub-regions. Net average BMC measurements had CV values of 1.11% and 1.08%, respectively. DXA can be used to reliably measure periarticular BMD and BMC of small joints in the hands in patients with early inflammatory arthritis. Precision values for quantifying juxta-articular bone approximated BMD measurements of the spine.

Microscopic measurement of inflammation in synovial tissue: inter-observer agreement for manual quantitative, semiquantitative and computerised digital image analysis.

OBJECTIVES: To evaluate inter-observer agreement for microscopic measurement of inflammation in synovial tissue using manual quantitative, semiquantitative and computerised digital image analysis. METHODS: Paired serial sections of synovial tissue, obtained at arthroscopic biopsy of the knee from patients with rheumatoid arthritis (RA), were stained immunohistochemically for T lymphocyte (CD3) and macrophage (CD68) markers. Manual quantitative and semiquantitative scores for sub-lining layer CD3+ and CD68+ cell infiltration were independently derived in 6 international centres. Three centres derived scores using computerised digital image analysis. Inter-observer agreement was evaluated using Spearman's Rho and intraclass correlation coefficients (ICCs). RESULTS: Paired tissue sections from 12 patients were selected for evaluation. Satisfactory inter-observer agreement was demonstrated for all 3 methods of analysis. Using manual methods, ICCs for measurement of CD3+ and CD68+ cell infiltration were 0.73 and 0.73 for quantitative analysis and 0.83 and 0.78 for semiquantitative analysis, respectively. Corresponding ICCs of 0.79 and 0.58 were observed for the use of digital image analysis. All ICCs were significant at levels of p<0.0001. At each participating centre, use of computerised image analysis produced results that correlated strongly and significantly with those obtained using manual measurement. CONCLUSION: Strong inter-observer agreement was demonstrated for microscopic measurement of synovial inflammation in RA using manual quantitative, semiquantitative and computerised digital methods of analysis. This further supports the development of these methods as outcome measures in RA.

Perceptions of the Cause, Impact and Management of Persistent Fatigue in Patients with Rheumatoid Arthritis Following Tumour Necrosing Factor Inhibition Therapy.

INTRODUCTION: Fatigue is a major symptom of rheumatoid arthritis (RA), the most common chronic inflammatory joint disease. The present study explored patients' experiences of RA fatigue to elucidate unique elements and management strategies. METHODS: This single site study recruited tumour necrosis factor-α inhibitor (TNFi)-treated RA patients with a moderate/good response in disease activity and persistent moderate/greater fatigue on a five-point verbal rating scale. This qualitative descriptive design used semi-structured questions, individual interviews and content analysis of narrative data. RESULTS: Ten patients were interviewed (six women), with age and disease duration ranges of 44-75 and 6-36 years, respectively. Perceptions of the RA fatigue experience generated four categories (experiencing a distinct, yet seldom discussed RA symptom; seeking an explanation for fatigue; being in an incapacitating state; and trying to manage) and eight subcategories. Fatigue was newly identified as a distinct part of the entity of RA. While patients proposed many plausible root causes, the only rational explanation for the nature of this fatigue was that it was integral to their RA. Singularly, fatigue contributed considerably to RA-imposed lifestyle restrictions. Patients had learnt to accommodate and self-manage fatigue in the absence of professional input. Novel management strategies proposed included patients talking about the nature of RA fatigue with others and the need for staff to alert patients to this distinct symptom of RA. CONCLUSION: Fatigue, branded as a distinct symptom of RA, exerted an identifiable impact on patients. Fatigue is potentially amenable to modification; talking about fatigue was proposed as a novel management strategy. Copyright © 2016 John Wiley & Sons, Ltd.

Resolution of endothelial activation and down-regulation of Tie2 receptor in psoriatic skin after infliximab therapy.

BACKGROUND: Psoriasis is a common dermatosis characterized by erythematous skin plaques and associated arthritis. Microvessels of the papillary dermis in psoriatic lesions are elongated, tortuous, and dilated, which contributes significantly to the proinflammatory response. Angiopoietin (Ang) 1 and 2 and their receptor, Tie2, are a family of growth factors recognized in inflammatory lesions to be critical for new blood vessel growth and maintenance, with recent studies suggesting tumor necrosis factor (TNF)-alpha-induced angiogenesis is in part mediated by the Tie2 receptor. The aim of this study was to evaluate the effect of anti-TNF-alpha therapy on angiogenic growth factor expression and on the cellular infiltrate in psoriatic lesional skin. METHODS: Sixteen patients with moderate to severe psoriasis and associated psoriatic arthritis (n = 13) received infliximab infusions (3-5 mg/kg) at baseline and at 2 and 6 weeks. Clinical assessments and skin biopsies were undertaken at baseline, and at 2 and 12 weeks. Ang 1, Ang 2, Tie2, and TNF-alpha messenger RNA expression were quantified by real-time polymerase chain reaction. Protein expression of vascular endothelial growth factor, Ang 2, Tie2, TNF-alpha, and the inflammatory infiltrate was determined using immunohistology. We conducted clinical assessments including Psoriasis Area and Severity Index, percentage body surface area, Arthritis Disease Activity Score, and Health Assessment Questionnaire. RESULTS: At baseline expression of Ang 1/2, vascular endothelial growth factor, Tie2, and TNF-alpha messenger RNA and protein were greater in preinvolved skin compared with uninvolved skin (P < .05). Infliximab produced a significant reduction in protein expression of Ang 2, vascular endothelial growth factor, and Tie2 (P < .001) along with a decrease in messenger RNA expression of Ang 1 (P < .045) and Tie2 (P < .021). This was paralleled by a significant reduction in the inflammatory infiltrate scores (P < .001) and platelet-endothelial cell adhesion molecule (CD31) expression (P = .001), suggesting deactivation of endothelial cell. There was a 93% mean reduction in Psoriasis Area and Severity Index (P = .001), and a significant reduction in Disease Activity Score 28 (P = .012) and mean Health Assessment Questionnaire scores by week 12. LIMITATIONS: This study involves a small number of patients. CONCLUSION: These results suggest infliximab is both effective and well tolerated in severe psoriasis, resulting in deactivation of endothelium and down-regulation of growth factor and cytokine expression, leading to a decrease in the cellular infiltrate and clinical improvement in psoriasis. Furthermore, the effect of infliximab on growth factor expression, in particular Tie2, supports previous in vitro work suggesting TNF-alpha may be a major regulator of the Ang/Tie2 pathway.

Factors that influence fatigue status in patients with severe rheumatoid arthritis (RA) and good disease outcome following 6 months of TNF inhibitor therapy: a comparative analysis.

The objective of the present study is to determine the factors associated with persistent fatigue in patients with severe rheumatoid arthritis (RA) and good disease response to 6 months of tumour necrosis factor inhibitor therapy. Eligible patients with either persistent (PF) or no fatigue (NF) were compared. Using validated questionnaires and bivariate analysis, this cross-sectional survey explored if clinical characteristics, pain, self-efficacy, sleep and mood/depression differed between groups. Patients with PF (PF; NF) (n = 28; 28) reported significantly more overall pain (11.3 ± 9.4 (0-33); 6.9 ± 8.9 (0-33)), more recent and current pain intensity (41.4 ± 26.6 (0-80) 24.4 ± 26.6 (0-100) and depression (11.8 ± 7.5 (1-35); 8.2 ± 6.6 (0-26)), than the NF group. There was no significant difference between groups in self-efficacy and both groups experienced poor sleep quality (Pittsburgh Sleep Quality Index >5). Despite having good disease response, the PF group had significantly higher rheumatoid factor incidence, disease activity score-28, early morning stiffness duration and lower incidence of ever-failing disease-modifying anti-rheumatic drugs than the NF group. These findings enhance the fatigue literature in patients with RA prescribed tumour necrosis factor (TNF) inhibition therapy, identifying the potentially modifiable factors of pain and depression, previously demonstrated to be strongly associated with fatigue in non-biologic populations. In addition, this study highlights the association between persistent fatigue and an on-going state of low disease activity. This infers that more judicious disease management could minimise the symptom burden of pain and depression and consequentially fatigue.

Identification of Naf1/ABIN-1 among TNF-alpha-induced expressed genes in human synoviocytes using oligonucleotide microarrays.

The cytokine tumor necrosis factor alpha (TNF-alpha) is a critical effector of the pathogenesis of rheumatoid arthritis (RA). We used oligonucleotide microarray (OM) analysis to assess TNF-alpha-modulated gene expression in cultured primary human synoviocytes in vitro. Genes identified include cytokines and inflammatory mediators, extracellular matrix and adhesion molecules, cell cycle and proliferation related proteins, transcription related proteins, and apoptotic mediators. OM identified 1185 differentially expressed genes in TNF-alpha-treated synoviocytes. The regulation of Nef-associated factor-1 (Naf1), an A20-binding, nuclear factor kappa B (NFkappaB) inhibitory protein was probed further given its putative role as an endogenous brake for the expression of some TNF-alpha-driven genes. Naf1 mRNA levels were higher in synovial biopsies from patients with active RA and seronegative arthropathy than in those from patients with osteoarthritis. These findings underscore the value of transcriptome analysis in cytokine-activated synoviocyte cultures in vitro as a means of identifying disease-associated genes in human arthritis, and implicate Naf1 as a potential modulator of TNF-alpha bioactivity in RA.

Inhibition of PGE2 production by nimesulide compared with diclofenac in the acutely inflamed joint of patients with arthritis.

OBJECTIVE: Cyclo-oxygenase (COX) exists in two isoforms, COX-1 and COX-2. COX-1 is responsible for homeostatic functions, whereas COX-2 is inducible and responsible for the inflammatory effects of prostaglandins. Nimesulide, a selective inhibitor of COX-2, has been shown to relieve pain rapidly in arthritis. We examined the effect of nimesulide on prostaglandin formation in arthritis, to evaluate if this compound gains access to the site of inflammation and whether this is required for analgesia. STUDY DESIGN: This was a single-dose, double-blind, double-dummy, parallel group study of nimesulide 100mg compared with diclofenac 50mg. METHODS: Serial sampling of synovial fluid, whole blood and plasma was performed at baseline and 0.5, 1, 2, 3 and 4 hours after drug administration. Synovial tissue was obtained by needle biopsy at completion of the study period. Synovial fluid prostaglandin E2 (PGE2) was measured by enzyme immunoassay. COX-1 and COX-2 activities in whole blood were estimated by serum thromboxane B2 (TxB2) and endotoxin-induced PGE2 concentrations respectively. Synovial tissue COX-1 and COX-2 mRNA and protein expression were studied by reverse transcriptase polymerase chain reaction and immunohistochemistry respectively. Twenty patients with acute knee inflammation on a background of arthritis of all types completed the study. RESULTS: Patients were allocated randomly to groups to receive nimesulide (n = 10) or diclofenac (n = 10). The mean (+/- SEM) plasma concentration of PGE2 in the nimesulide group decreased from 24.45 +/- 2.71 ng/mL at baseline to 1.74 +/- 2.71 ng/ mL at 2 hours. Diclofenac also inhibited PGE2, but at a later time point (28.15 +/- 2.86 ng/mL at baseline and 0.85 +/- 2.86 ng/mL at 4 hours). The mean (+/- SEM) synovial fluid concentration of PGE2 was 319 +/- 89 pg/mL before treatment; it remained unaltered over 4 hours after the administration of nimesulide or diclofenac (235 +/- 72 pg/mL). In contrast, in six patients receiving long-term treatment with nimesulide or a non-selective NSAID, synovial PGE2 was 61 +/- 24 pg/ mL, suggesting that inhibition of synovial prostaglandin formation is delayed compared with that in plasma. Nimesulide caused partial inhibition of serum TxB2 (a decrease from a mean of 268 +/- 24 ng/mL to one of 164 +/- 27 ng/mL at 2 hours), whereas diclofenac had a greater effect (a decrease from 224 +/- 33 ng/mL, to 76 +/- 27 ng/mL at 3 hours). CONCLUSIONS: Nimesulide, a COX-2 selective inhibitor, has a rapid onset of action in the blood compartment, with early inhibition of PGE2 generation, an index of COX-2 activity. In contrast, it exhibits a delay in achieving therapeutic concentrations in the synovial fluid. Thus factors other than local inhibition of prostaglandins may explain the rapid onset of analgesia that is associated with nimesulide, including a possible central mechanism of pain relief.

Infection complications associated with the use of biologic agents.

Despite the considerable clinical, radiologic, and functional benefits of biologic inhibitors in inflammatory arthritides, some concern exists regarding the occurrence of infections in patients treated with these agents. Clearly, comorbidities such as diabetes mellitus, heart disease, disability, and concurrent immunosuppressive medication all contribute to the risk of infection. Increased and closer observation may be in part responsible for some of the reported increases in the rates of mild infections with these drugs. The development of serious infections, particularly TB, in patients taking infliximab seems to be greater than would be expected in this population. Furthermore, experimental data from in vitro investigations and animal models demonstrate a link between decreased TNF alpha activity and increased susceptibility to TB. Why some patients, but not others, succumb to rapidly disseminated infection is unknown but may be related to the extent of TNF inhibition in different individuals. This difference in inhibition may also explain why the incidence of TB seems to be increased with infliximab in comparison with the other TNF blockers. Attribution analysis is the method used to assess the likelihood of a connection between two occurrences and includes such factors as temporal association, few alternative explanations, analogy with similar cases, and biologic plausibility. The putative relationship between anti-TNF treatment and infection is further strengthened by the presence of these factors [101]. Continued vigilance is therefore required in the use of biologic agents in patients with RA, most of whom are already in some way immunocompromised. Everyone who is under consideration for such treatment should be carefully evaluated for the presence of infection, and prophylactic antituberculous therapy should be used if latent TB is discovered. Both patients and primary physicians need to be aware of the possibility that serious infection may develop; if such a problem is diagnosed, the biologic inhibitor should be discontinued until adequate treatment has been completed. Caution is advised in patients with recurring infections and in those with severe comorbidities, for example, poorly controlled diabetes mellitus or heart failure. Administration of live vaccines to patients taking these drugs is not recommended, but patients should be brought up-to-date with all immunizations relevant to their age group before commencement of therapy. Physicians prescribing biologic agents should be encouraged to report any suspected drug-related adverse event. Long-term observation will be required to determine the exact nature of the relationship between cytokine inhibition and infection.

Corticotropin-releasing hormone signaling in synovial tissue vascular endothelium is mediated through the cAMP/CREB pathway.

Modulation of locally produced corticotropin-releasing hormone (CRH) is a component of the cytokine network in human inflammatory arthritis. CRH signaling, through the CRH-receptor subtype R1alpha, may play a role in both vascular changes and pathologic mechanisms associated with joint inflammation. Furthermore, the peripheral actions of CRH may be mediated in part through the NURR subfamily of nuclear orphan receptors. The aim of this study was to establish the signaling mechanisms through which CRH receptor-mediated responses contribute to gene regulation in inflamed synovial vasculature. Immunohistochemical analysis of serial rheumatoid arthritis (RA) tissue sections demonstrates CRH and NURR1 expression in the synovial lining layer, subsynovial lining layer, and the vascular endothelium. The identical pattern of immunolocalization confirms that NURR1 is produced at the same synovial sites shown to produce CRH. The distribution of specific NURR1 staining on the synovial vasculature parallels that observed for CRH-R1 expression. Using primary synovial tissue endothelial cells, we demonstrate that CRH induces specific CREB-1 and ATF-2 binding to the NURR1 promoter. We further provide evidence that CRH signaling can be mimicked by activation of cAMP/PKA/CREB using forskolin in primary human microvascular endothelial cells. These data indicate that the CRH receptor-dependent inflammatory response in synovial tissue endothelium is mediated through the cAMP/CREB signaling pathway.

Infections and biological therapy in rheumatoid arthritis.

Infections are common in patients with rheumatic disorders. Reasons for such vulnerability include alterations of immunoregulation, disease severity, debility, co-morbid illnesses and the use of immunosuppressive medications. The advent of new biological agents has precipitated a further examination of the links between infection, the underlying disease and its treatment, resulting in several interesting observations. Interleukin-1 (IL-1) and tumour necrosis factor alpha (TNF-alpha), the major pro-inflammatory cytokines, play important roles in host defence against infection. Inhibition of their activity could therefore be anticipated to augment the risk of infection in patients with pre-existing abnormalities of immune regulation. Slight increases in the rates of infection were noted in the clinical trials of IL-1 receptor antagonist (IL-1Ra). In addition, a small number of opportunistic infections have been observed with the TNF inhibitor, etanercept. However, a marked increase in opportunistic infection, particularly tuberculosis, has occurred with the use of infliximab, an agent that also blocks TNF activity. The precise mechanisms by which these agents predispose to infection are currently being explored. The answers are likely to add significantly to our knowledge of how immune dysfunction contributes both to the pathophysiology of disease and the complications of therapy.