MRI assessment of early response to certolizumab pegol in rheumatoid arthritis: a randomised, double-blind, placebo-controlled phase IIIb study applying MRI at weeks 0, 1, 2, 4, 8 and 16.

OBJECTIVES: To identify the first time point of an MRI-verified response to certolizumab pegol (CZP) therapy in patients with rheumatoid arthritis (RA). METHODS: Forty-one patients with active RA despite disease-modifying antirheumatic drug therapy were randomised 2:1 to CZP (CZP loading dose 400 mg every 2 weeks at weeks 0-4; CZP 200 mg every 2 weeks at weeks 6-16) or placebo→CZP (placebo at weeks 0-2; CZP loading dose at weeks 2-6; CZP 200 mg every 2 weeks at weeks 8-16). Contrast-enhanced MRI of one hand and wrist was acquired at baseline (week 0) and weeks 1, 2, 4, 8 and 16. All six time points were read simultaneously, blinded to time, using the Outcome Measures in Rheumatology Clinical Trials RA MRI scoring system. Primary outcome was change in synovitis score in the CZP group; secondary outcomes were change in bone oedema (osteitis) and erosion scores and clinical outcome measures. RESULTS: Forty patients were treated (27 CZP, 13 placebo→CZP), and 36 (24 CZP, 12 placebo→CZP) completed week 16. In the CZP group, there were significant reductions from baseline synovitis (Hodges-Lehmann estimate of median change, -1.5, p=0.049) and osteitis scores (-2.5, p=0.031) at week 16. Numerical, but statistically insignificant, MRI inflammation reductions were observed at weeks 1-2 in the CZP group. No significant change was seen in bone erosion score. Improvements across all clinical outcomes were seen in the CZP group. CONCLUSIONS: CZP reduced MRI synovitis and osteitis scores at week 16, despite small sample size and the technical challenge of reading six time points simultaneously. This study provides essential information on optimal MRI timing for subsequent trials. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov, NCT01235598.

An uneven expression of T cell receptor V genes in the arterial wall and peripheral blood in giant cell arteritis.

The aim of the study was to investigate T cell receptor (TCR) usage at the time of diagnosis of giant cell arteritis (GCA) and to estimate the degree of clonality of T-cells infiltrating the lesion. Seven patients with biopsy-proven giant cell arteritis were included in the study. Immunocytochemistry in biopsies from the temporal arteries and flow cytometric analysis of peripheral blood lymphocytes (PBL) was performed using monoclonal antibodies specific for CD3, CD4 and CD8 and 13 TCR Valpha and Vbeta gene segment products. The CDR3 fragment length polymorphism was assessed by gel electrophoresis of PCR-amplified TCR segments. The T lymphocytes were found to be concentrated to the adventitia rather than the media or intima. Six of the seven patients with GCA had expansions of T lymphocytes, expressing selected TCR V genes in the arterial wall. None of these expansions was found in PBL. The infiltrating T-cells were poly- or oligoclonal. In conclusion, the dominating part of the inflammatory infiltrate in GCA emanates from the adventitial microvessels. There is an uneven expression of TCR V genes by T lymphocytes in the inflammatory infiltrates as compared to peripheral blood T lymphocytes at the time of diagnosis, consistent with an antigen-driven immunological reaction in the arterial wall.

Remission and response to early treatment of RA assessed by the Disease Activity Score. BARFOT study group. Better Anti-rheumatic Farmacotherapy.

OBJECTIVE: To assess criteria for individual response and remission based on the Disease Activity Score (DAS) in patients with RA participating in a long-term observational study. METHODS: The EULAR (European League against Rheumatism) criteria for individual response and a recently proposed remission criterion, DAS < 1.6, were applied to 90 patients with RA after treatment for 2 yr with disease-modifying anti-rheumatic drugs (DMARDs) and/or corticosteroids. RESULTS: Seventy-six per cent of the patients were classified as responders (46% good and 30% moderate responders). Good responders had significantly more improvement in pain and Health Assessment Questionnaire (HAQ) score than moderate responders and non-responders. Paired comparisons showed significant X-ray progression both for moderate responders and non-responders but not for good responders. Twenty-nine per cent of all responders had an end-point DAS > 2.4, indicating active disease. In this group of responders, X-ray changes progressed significantly, but this could not be demonstrated in the group of responders with DAS < or = 2.4. Thirty-six per cent of the patients included in the study were classified as being in remission after 2 yr of treatment. The group of patients in remission showed no evidence of X-ray progression after 2 yr. CONCLUSIONS: Response and remission criteria based on DAS were useful in a study of patients with RA who were managed essentially as in clinical practice. The criteria used showed construct and criterion validity, although discriminant validity could not be shown. The application of valid criteria for response and remission in clinical practice may be a useful aid in the evaluation of treatment effects and in making treatment decisions for individual patients.

The effect of glucocorticoids on fat and lean tissue masses in giant cell arteritis.

The aim of the present prospective study over a follow-up period of two years was to assess the influence of various doses of glucocorticosteroids on the total body fat and lean tissue masses and their regional distribution, using DXA technique, in twenty-four patients with giant cell arteritis (GCA). Treatment with glucocorticoids for two years, using high doses of prednisolone the first six months and lower doses thereafter, resulted in a significant increase in total body fat as well as in trunk fat expressed either as absolute values or as a proportion of body weight. The abnormal accumulation of fat mass remained also after switching to a low dose glucocorticoid schedule. There was no redistribution of fat from peripheral areas to central parts of the body and there was no depletion of lean tissue at peripheral sites.

The ineffectiveness of cyclical oral clodronate on bone mineral density in glucocorticoid-treated patients with giant-cell arteritis.

OBJECTIVES AND DESIGN: The aim of the present study was to determine whether cyclic oral administration of clodronate, a bisphosphonate, every second month prevents rapid bone loss during the first year of glucocorticoid treatment in patients with giant-cell arteritis (GCA). The trial was designed as a prospective double blind study, assessing total body mineral content (BMC) and bone mineral density (BMD) using DXA technique. Supplementation of calcium was given to both groups of patients. SETTING: The outpatient clinics of the rheumatic and infectious diseases of Sahlgren University Hospital of the city of Göteborg on the west coast of Sweden. SUBJECTS: Twenty-seven patients with confirmed GCA were consecutively included during a 15-month period. RESULTS: An early influence on bone turnover was found with a temporary decrease in BMC after six months of glucocorticoid treatment, which was normalized after 12 months in both study groups. No significant differences between the patients given clodronate and calcium and the controls, who got supplementation with calcium alone, was observed at any assessment point. However, there was a significant and prolonged depression of the osteocalcin levels in the clodronate-treated patients. CONCLUSIONS: Oral administration of clodronate in a moderately high dose given cyclically every other month had no additive effect on BMD compared with calcium supplementation alone during the first year of glucocorticoid treatment. A larger material might have revealed some differences between the categories. In most patients with GCA, however, the BMD seems to recover after one year of glucocorticoid treatment, provided there is good control of the inflammation and patients are kept physically active. It needs to be elucidated whether there are subsets of patients who might benefit from bone sparing agents: women near menopause with a high turnover rate of bone, individuals who have low BMD from the start of glucocorticoid treatment or patients requiring high doses of glucocorticoids during a long period of time.

Epidemiology and mortality in 220 patients with polymyalgia rheumatica.

Between 1985 and 1987 a total of 521 people underwent temporal artery biopsy with no histological evidence of arteritis in Göteborg, Sweden. Two-hundred-and-twenty people were diagnosed as having polymyalgia rheumatica (PMR). Among the patients without PMR 30% had rheumatic, 17% malignant and 14% infectious disorders. The annual incidence of PMR with negative biopsy was 17/100,000 and for the population over 50 yr it was 50/100,000. We found an increased mortality in vascular diseases among men with PMR in the first 2 yr after diagnosis with 13 observed deaths compared to the expected six (P < 0.01). There was also a tendency toward an increased mortality among the women with 16 observed deaths compared to the expected 11 (not statistically significant). The mortality in malignant diseases was not increased.

CD4+ and CD8+ T cell expansions using selected TCR V and J gene segments at the onset of giant cell arteritis.

OBJECTIVE: To investigate T cell receptor (TCR) V alpha/V beta (and in selected cases, J beta) usage in CD4+ and CD8+ peripheral blood lymphocytes of patients with giant cell arteritis (GCA), before and after treatment, as well as to analyze the HLA types of these patients. METHODS: Flow cytometry, with 10 anti-TCR V-specific monoclonal antibodies (MAb), was used. To analyze J beta usage by cell populations expressing certain V beta, we used the polymerase chain reaction (PCR) technique, with V beta- and C beta-specific primers, Southern blotting of PCR products, and subsequent hybridization with radiolabeled J beta-specific probes. HLA typing was performed using the microlymphocytotoxicity technique. RESULTS: Seven of the 9 GCA patients had increased anti-TCR V MAb reactivities (interpreted as T cell expansions), which in many cases, correlated with clinical signs of disease. A strict preference for particular J beta segments was found in 3 of 3 expanded CD4+ T cell populations. CONCLUSION: T lymphocytes expressing specific antigen receptors are implicated in the pathogenesis of GCA.

T lymphocytes in giant cell arteritic lesions are polyclonal cells expressing alpha beta type antigen receptors and VLA-1 integrin receptors.

Giant cell arteritis (GCA) is a common disease in the elderly. It is characterized by focal inflammatory lesions dominated by T lymphocytes and macrophages. The etiology of GCA is, however, still unknown. The aim of the present study was to determine whether lesional T cells represent clonal proliferations, and to characterize adhesion receptors that could be important for recruitment of T cells and antigen receptors involved in their activation. Temporal artery biopsies were obtained from 13 patients presenting with clinical signs of GCA. Immunohistochemistry was used to characterize cell surface receptors on CD3+ T cells in situ in the lesions of eight patients with biopsy-verified GCA. The overwhelming majority of T cells in GCA lesions expressed the TCR alpha beta receptors. In sections from three of eight patients, a small proportion of cells expressing TCR gamma delta was also seen. Almost all T cells expressed the integrin receptors, LFA-1 and VLA-1, as determined by double-staining. To characterize the clonal composition of the lesional T cell population, cells were isolated by collagenase digestion of two lesions and T cells cloned by limiting dilution in the presence of mitogenic antibodies, IL-2 and autologous feeder cells. Rearrangements of the T cell receptor (TCR) genes of the clones were analysed by Southern hybridization using probes for TCR gamma and beta genes. T cell clones established from GCA lesions exhibited heterogeneous rearrangement patterns, indicating a polyclonal origin of the cells. We conclude that GCA lesions contain T lymphocytes that are of polyclonal origin and express integrin-type adhesion receptors. This supports the hypothesis that GCA involves an inflammatory response during which polyclonal T cells adhere to arterial tissue components and accumulate in the developing lesions.