Effect of Anti-Rheumatic Treatment on the Periodontal Condition of Rheumatoid Arthritis Patients.

Periodontitis, a bacterial-induced infection of the supporting soft and hard tissues of the teeth (the periodontium), is common in patients with rheumatoid arthritis (RA). As RA and periodontitis underlie common inflammatory pathways, targeting the progression of RA might mediate both periodontitis and RA. On the other hand, patients with RA on immunosuppressive medication have an increased risk of infection. Therefore, the objective of this longitudinal observation study was to assess the effect of methotrexate (MTX) and anti-tumor necrosis factor-α (anti-TNF, etanercept) treatment on the periodontal condition of RA patients. Overall, 14 dentate treatment-naive RA patients starting with MTX and 12 dentate RA patients starting with anti-TNF therapy in addition to MTX were included. Follow-up was scheduled matching the routine protocol for the respective treatments. Prior to the anti-rheumatic treatment with MTX or the anti-TNF therapy in addition to MTX, and during follow-up, i.e., 2 months for MTX, and 3 and 6 months for the anti-TNF therapy in addition to MTX, the periodontal inflamed surface area (PISA) was measured. The efficacy of the anti-rheumatic treatment was assessed by determining the change in RA disease activity (DAS28-ESR). Furthermore, the erythrocyte sedimentation rates were determined and the levels of C-reactive protein, IgM-rheumatoid factor, anti-cyclic citrullinated protein antibodies, and antibodies to the periodontal pathogen Porphyromonas gingivalis, were measured. Subgingival sampling and microbiological characterization of the subgingival microflora was done at baseline. MTX or anti-TNF treatment did not result in an improvement of the periodontal condition, while both treatments significantly improved DAS28 scores (both p < 0.01), and reduced C-reactive protein levels and erythrocyte sedimentation rates (both p < 0.05). It is concluded that anti-rheumatic treatment (MTX and anti-TNF) has negligible influence on the periodontal condition of RA patients.

Adherence to a treat-to-target strategy in early rheumatoid arthritis: results of the DREAM remission induction cohort.

INTRODUCTION: Clinical trials have demonstrated that treatment-to-target (T2T) is effective in achieving remission in early rheumatoid arthritis (RA). However, the concept of T2T has not been fully implemented yet and the question is whether a T2T strategy is feasible in daily clinical practice. The objective of the study was to evaluate the adherence to a T2T strategy aiming at remission (Disease Activity Score in 28 joints (DAS28) < 2.6) in early RA in daily practice. The recommendations regarding T2T included regular assessment of the DAS28 and advice regarding DAS28-driven treatment adjustments. METHODS: A medical chart review was performed among a random sample of 100 RA patients of the DREAM remission induction cohort. At all scheduled visits, it was determined whether the clinical decisions were compliant to the T2T recommendations. RESULTS: The 100 patients contributed to a total of 1,115 visits. The DAS28 was available in 97.9% (1,092/1,115) of the visits, of which the DAS28 was assessed at a frequency of at least every three months in 88.3% (964/1,092). Adherence to the treatment advice was observed in 69.3% (757/1,092) of the visits. In case of non-adherence when remission was present (19.5%, 108/553), most frequently medication was tapered off or discontinued when it should have been continued (7.2%, 40/553) or treatment was continued when it should have been tapered off or discontinued (6.2%, 34/553). In case of non-adherence when remission was absent (42.1%, 227/539), most frequently medication was not intensified when an intensification step should have been taken (34.9%, 188/539). The main reason for non-adherence was discordance between disease activity status according to the rheumatologist and DAS28. CONCLUSIONS: The recommendations regarding T2T were successfully implemented and high adherence was observed. This demonstrates that a T2T strategy is feasible in RA in daily clinical practice.

Advanced glycation endproducts are increased in rheumatoid arthritis patients with controlled disease.

INTRODUCTION: Advanced glycation end products (AGEs) are produced and can accumulate during chronic inflammation, as might be present in patients with rheumatoid arthritis (RA). AGEs are involved in the development of cardiovascular disease. The aim of this study is to evaluate whether AGEs are increased in patients with long-standing RA and whether AGE accumulation is related to disease activity, disease severity and measures of (premature) atherosclerosis, such as endothelial activation, endothelial dysfunction and intima media thickness (IMT). METHODS: In a cross-sectional study, 49 consecutive RA patients with longstanding disease (median disease duration of 12.3 years (range 9.3 to 15.1)), receiving standard of care, were included and compared with 49 age- and sex-matched healthy controls (HC). AGEs were determined by skin autofluorescence. Disease activity was evaluated by the Disease Activity Score of 28 joints (DAS-28) score and joint damage by modified Sharp-v.d. Heijde score. Endothelial activation (soluble vascular cellular adhesion molecule-1) sVCAM-1, von Willebrand factor (vWF), thrombomodulin), endothelial dysfunction (determined by small artery elasticity (SAE)) and IMT were measured and related to AGE accumulation. RESULTS: AGEs were increased in RA patients (median 2.4 arbitrary units (a.u.), range 1.6 to 4.2) compared to HC (2.2, 1.3 to 3.8). RA patients had a DAS-28 score of 2.9 (0.8 to 6.9) and a modified Sharp-v.d. Heijde score of 19 (0 to 103). sVCAM-1 and vWF levels were higher in RA patients. SAE was significantly decreased in RA (3.9 ml/mmHg (1.4 to 12.2) vs. 6.1 in HC (1.7 to 12.9). IMT did not differ between the two groups. Combining both groups' AGEs correlated with vWF, sVCAM-1 and IMT, and was inversely related to SAE. In RA, AGEs had an inverse relation with SAE, but did not relate to disease activity or radiological damage. In multivariate analysis for both groups, smoking, glucose levels, vWF, SAE and male gender were significantly related to the formation of AGEs. CONCLUSIONS: AGEs were increased in RA patients with long-standing disease and without signs of premature atherosclerosis. AGEs were related to endothelial activation and endothelial dysfunction. This supports the hypothesis that in RA AGEs may be an early marker of cardiovascular disease.

Is small artery elasticity decreased prior to intima-media thickening in patients with longstanding rheumatoid arthritis?

OBJECTIVE: To determine small artery elasticity (SAE) in patients with longstanding rheumatoid arthritis (RA) in comparison to healthy controls, and to investigate its relation to markers of endothelial cell activation, disease activity, joint damage, and the presence of atherosclerosis. METHODS: Forty-nine patients with RA and 50 age- and sex-matched healthy controls were studied. Traditional cardiovascular risk factors and disease-related factors were recorded. SAE was measured noninvasively by pulse-wave analysis (PWA). Endothelial activation was assessed by measuring levels of soluble vascular cell adhesion molecule-1 (sVCAM-1) and von Willebrand factor (vWF). Carotid intima-media thickness (IMT), as an indicator of subclinical atherosclerosis, was assessed using ultrasonography. RESULTS: Patients with RA had higher body mass index, blood pressure, and triglyceride levels and were more often cigarette smokers compared to controls. SAE was decreased in RA patients compared to controls and was inversely related with age, smoking, blood pressure, vWF, sVCAM-1, high sensitivity C-reactive protein, and IMT. Presence of RA was independently related to SAE in multivariate linear regression analysis. SAE was inversely related with the Health Assessment Questionnaire score. No correlation was found between SAE and other disease activity markers and damage. IMT in patients and controls was not different. CONCLUSION: Small artery elasticity was decreased in patients with longstanding RA. The presence of RA was independently associated with SAE. Whereas IMT in patients with RA was not increased, we hypothesize that endothelial dysfunction, reflected by decreased SAE, is present prior to IMT thickening in these patients.

Angiopoietin-2 is highly correlated with inflammation and disease activity in recent-onset rheumatoid arthritis and could be predictive for cardiovascular disease.

OBJECTIVE: To investigate whether serum levels of endothelial cell activation markers in early RA patients can serve as biomarkers for inflammation and disease activity, and are associated with radiological progression and development of cardiovascular disease (CVD). METHODS: Serum levels of VEGF, soluble vascular cell adhesion molecule (sVCAM)-1 and angiopoietin-2 (Angpt-2) were measured by ELISA in 176 patients with recent-onset RA, at the time of diagnosis and after 2 years. Markers of inflammation and disease activity were assessed, as well as radiological damage of hands and feet, at diagnosis and after 2 years. Prevalence of CVD of all patients after 12.5 years disease duration was retrieved from medical records. RESULTS: Patients with RA had higher levels of VEGF and Angpt-2 at disease onset compared with healthy controls, which correlated with markers of inflammation, but were not predictive of radiological progression after 2 years. Angpt-2 levels, moreover, significantly correlated with measures of disease activity. Nearly 18% of RA patients developed CVD after an average of 12.5 years of disease, and these patients had a significantly higher level of Angpt-2 at the onset of RA compared with patients who did not develop CVD. CONCLUSIONS: In early RA, markers of endothelial activation are highly correlated with inflammation and disease activity, but not with radiological progression. Angpt-2 could be predictive for the development of CVD since Angpt-2 levels were significantly higher in CVD patients than in non-CVD patients.

Risk factors and early detection of atherosclerosis in rheumatoid arthritis.

BACKGROUND: Patients with rheumatoid arthritis (RA) have an increased morbidity and mortality due to cardiovascular disease (CVD). This cannot be explained alone by the increased prevalence of traditional cardiovascular risk factors like smoking and hypertension. Other factors therefore seem to be involved in the pathogenesis of atherosclerosis in RA. METHODS: Literature was searched for epidemiology and pathophysiology of atherosclerosis in RA, with special focus on the role of advanced glycation end products (AGE's), endothelial activation, endothelial dysfunction and premature atherosclerosis as measured by intima media thickness (IMT). Finally, a literature search was performed on therapeutic strategies to prevent atherosclerosis in RA. RESULTS: In RA increased AGE accumulation, endothelial activation, endothelial dysfunction and premature atherosclerosis can be identified. Treatment of RA activity by multiple disease modifying anti rheumatic drugs (DMARD's) has shown to be effective in reducing premature atherosclerosis in RA. CONCLUSION: Cardiovascular disease is increased in RA. Tight disease control and treatment of other risk factors is recommended to prevent morbidity and mortality due to CVD in RA.

Amyloid load in fat tissue reflects disease severity and predicts survival in amyloidosis.

OBJECTIVE: The severity of systemic amyloidosis is thought to be related to the extent of amyloid deposition. We studied whether amyloid load in fat tissue reflects disease severity and predicts survival. METHODS: We studied all consecutive patients with systemic amyloidosis seen between January 1994 and January 2007 in our tertiary referral center. Congo red-stained abdominal fat smears were graded by 2 observers using a validated semiquantitative scoring system. Disease severity was measured by the total number of major organs involved and the extravascular retention of the serum amyloid P component (EVR(24)). The association of amyloid load in fat tissue with disease severity and overall survival was studied using multiple regression analysis. RESULTS: Two hundred twenty patients were included in the study (120 with AL amyloidosis, 66 with AA amyloidosis, and 34 with ATTR amyloidosis). Amyloid grade in fat tissue was associated with the number of major organs involved and EVR(24). Female sex turned out to be associated with a higher grade of amyloid in fat tissue than male sex. Amyloid grade in fat tissue was an independent predictor of decreased survival, as were heart involvement, the number of organs involved, AA or AL type of amyloid, and age. CONCLUSION: The amount of amyloid in subcutaneous fat tissue in systemic amyloidosis reflects disease severity, as measured by the number of organs involved and EVR(24), and predicts decreased survival independent of other well-known factors.

Expression and regulation of HIF-1alpha in macrophages under inflammatory conditions; significant reduction of VEGF by CaMKII inhibitor.

BACKGROUND: Macrophages expressing the pro-angiogenic transcription factor hypoxia-inducible factor (HIF)-1alpha have been demonstrated in rheumatoid arthritis (RA) in the synovial tissue. Aim of the present study was to investigate intracellular signal transduction regulation of pro-inflammatory HIF-1 alpha expression in macrophages to identify possible new intervention strategies. We investigated the effects of CaMKII-inhibitors amongst other kinase inhibitors, on HIF-1 alpha expression and downstream production of pro-angiogenic factors in macrophages. METHODS: Differentiated THP-1 cells and synovial fluid (SF) macrophages were stimulated with 1 microg/ml LPS with or without pretreatment with specific inhibitors of the ERK pathway (PD98059), the PI3K pathway (LY294002), and the CaMKII pathway (KN93 and SMP-114). mRNA and protein expression of HIF-1 alpha, VEGF, MMP-9, and IL-8 was measured in cell lysates and cell supernatants. RESULTS: HIF-1 alpha protein expression in LPS-stimulated THP-1 macrophages could be blocked by ERK- and PI3K-inhibitors, but also by the CaMKII inhibitor KN93. THP-1 and SF macrophages produced high levels of VEGF, IL-8, and MMP-9, and VEGF protein production was significantly inhibited by PI3K-inhibitor, and by both CaMKII inhibitors. LPS stimulation in an hypoxic environment did not change VEGF levels, suggesting that LPS induced VEGF production in macrophages is more important than the hypoxic induction. CONCLUSIONS: Expression of HIF-1 alpha and downstream effects in macrophages are regulated by ERK-, PI3K, but also by CaMKII pathways. Inhibition of HIF-1alpha protein expression and significant inhibition of VEGF production in macrophages was found using CaMKII inhibitors. This is an unknown but very interesting effect of the CaMKII inhibitor SMP-114, which has been in clinical trial as DMARD for the treatment of RA. This effect may contribute to the anti-arthritic effects of SMP-114.

Humoral responses after influenza vaccination are severely reduced in patients with rheumatoid arthritis treated with rituximab.

OBJECTIVE: For patients with rheumatoid arthritis (RA), yearly influenza vaccination is recommended. However, its efficacy in patients treated with rituximab is unknown. The objectives of this study were to investigate the efficacy of influenza vaccination in RA patients treated with rituximab and to investigate the duration of the possible suppression of the humoral immune response following rituximab treatment. We also undertook to assess the safety of influenza vaccination and the effects of previous influenza vaccination. METHODS: Trivalent influenza subunit vaccine was administered to 23 RA patients who had received rituximab (4-8 weeks after rituximab for 11 patients [the early rituximab subgroup] and 6-10 months after rituximab for 12 patients [the late rituximab subgroup]), 20 RA patients receiving methotrexate (MTX), and 29 healthy controls. Levels of antibodies against the 3 vaccine strains were measured before and 28 days after vaccination using hemagglutination inhibition assay. The Disease Activity Score in 28 joints (DAS28) was used to assess RA activity. RESULTS: Following vaccination, geometric mean titers (GMTs) of antiinfluenza antibodies significantly increased for all influenza strains in the MTX-treated group and in healthy controls, but for no strains in the rituximab-treated group. However, in the late rituximab subgroup, a rise in GMT for the A/H3N2 and A/H1N1 strains was demonstrated, in the absence of a repopulation of CD19+ cells at the time of vaccination. Seroconversion and seroprotection occurred less often in the rituximab-treated group than in the MTX-treated group for the A/H3N2 and A/H1N1 strains, while seroprotection occurred less often in the rituximab-treated group than in the healthy controls for the A/H1N1 strain. Compared with unvaccinated patients in the rituximab-treated group, previously vaccinated patients in the rituximab-treated group had higher pre- and postvaccination GMTs for the A/H1N1 strain. The DAS28 did not change after vaccination. CONCLUSION: Rituximab reduces humoral responses following influenza vaccination in RA patients, with a modestly restored response 6-10 months after rituximab administration. Previous influenza vaccination in rituximab-treated patients increases pre- and postvaccination titers. RA activity was not influenced.

Role for CaMKII inhibition in rheumatoid arthritis: effects on HIF-1-induced VEGF production by rheumatoid synovial fibroblasts.

BACKGROUND AND AIMS: The present study was designed to investigate the effects of a novel CaMKII inhibitor SMP-114, which was effective in a collagen-induced arthritis model in rats, on rheumatoid synovial fibroblasts. METHODS: Rheumatoid synovial fibroblasts (RSF) were cultured under pro-inflammatory (IL-1beta stimulation) and hypoxic conditions. Protein and mRNA expression of HIF-1alpha and the effects of inhibitors of the CaMKII-, PI3K-, and ERK pathway on VEGF and IL-6 production were analyzed. RESULTS: Stimulation under hypoxic conditions induced higher expression of HIF-1alpha and VEGF mRNA than treatment with either IL-1beta or hypoxia alone. However, incubation with a specific CaMKII inhibitor did not result in reduced VEGF production in RSF. CONCLUSIONS: CaMKII activation has been reported to be involved in HIF-1alpha stabilization, but incubation with SMP-114, a specific CaMKII inhibitor, had no effect on HIF-1-induced VEGF production by rheumatoid synovial fibroblasts.

Laryngeal presentation of systemic apolipoprotein A-I-derived amyloidosis.

OBJECTIVE: To study the clinical and pathological characteristics of two patients with laryngeal apolipoprotein A-I (apoA-I)-derived (AApoAI) amyloidosis with the apolipoprotein A-I variants Leu174Ser and Leu178Pro, respectively. The latter variant has not been associated with amyloid before. STUDY DESIGN: Descriptive report of two patients who presented with laryngeal amyloid presumed to be of localized AL type, but in who further assessments demonstrated systemic amyloidosis. METHODS: The larynx was examined by videolaryngostroboscopy. The voice was analyzed with the GRBAS system, phonation times, and phonetography. Laryngeal biopsies were stained with Congo red and analyzed immunohistochemically. Organ function was assessed and tissue involvement by amyloid further determined by rectal biopsy, abdominal fat tissue aspirate, and serum amyloid P component scintigraphy. RESULTS: The appearance of the laryngeal amyloid was unusual in both patients, occurring as small, irregular floppy proliferations affecting the borders of both vocal folds. Amyloid was stained with antibodies to apoA-I and not with antibodies to immunoglobulin light chains. The 45-year-old woman with the previously described amyloidogenic apoA-I Leu174Ser variant had possible involvement by amyloid in joints, peripheral nerves, and heart. Whereas in the 67-year-old man with apoA-I Leu178Pro there was a clinical suggestion of autonomic and cardiac amyloid and histological corroboration of systemic amyloidosis in abdominal fat. CONCLUSIONS: Laryngeal symptoms may be the presenting feature of hereditary systemic AApoAI amyloidosis, and comprehensive investigations including apoA-I genotyping are warranted in patients who present with apparently localized laryngeal amyloidosis. The distinctive appearance of the amyloidotic vocal folds described here may further signal the possibility of hereditary AApoAI type.

Regulation of cytokine-induced HIF-1alpha expression in rheumatoid synovial fibroblasts.

The transcription factor hypoxia-inducible factor (HIF)-1 plays a central physiological role in oxygen and energy homeostasis, and is activated during hypoxia by stabilization of the subunit HIF-1alpha. Activation can also occur by proinflammatory cytokines during inflammation. Hypoxia, as well as proinflammatory cytokines, plays an important role in the synovia in rheumatoid arthritis (RA) patients. Expression of HIF-1alpha has been demonstrated in RA synovial lining layer. The aim of the study was to investigate the regulation of the intracellular signal transduction pathways, involved in the expression of HIF-1alpha, and in the expression of genes regulated by HIF-1alpha in rheumatoid synovial fibroblasts (RSF). RSF were cultured under proinflammatory conditions (IL-1beta and TNF-alpha stimulation) and under chemical hypoxia (CoCl2 treatment). Expression of HIF-1alpha was analyzed in nuclear extracts by Western blotting. The effect of inhibitors of the PI3K and the ERK pathway on HIF-1alpha protein expression was measured. mRNA expression of HIF-1alpha, COX-2, vascular endothelial growth factor (VEGF), and stromal cell-derived factor (SDF)-1 was determined by real-time RT-PCR, and protein production of VEGF and SDF-1 by ELISA. Treatment of the synovial fibroblasts with 150 mM CoCl2 as well as stimulation with 10 ng/mL IL-1beta or TNF-alpha resulted in strong protein expression of HIF-1alpha, measured with Western blotting. Pretreatment with the MEK1/2 inhibitor PD98059 as well as the PI3K inhibitor LY294002 resulted in inhibition of the cytokine-induced HIF-1alpha expression. Furthermore, it was shown that cytokine-induced mRNA expression of HIF-1alpha was inhibited by the PI3K inhibitor. We found that cytokine stimulation induced VEGF mRNA and protein production, but no significant effect of kinase inhibition was found on VEGF production in cytokine-stimulated RSF. Both the ERK pathway and the PI3K pathway are involved in the cytokine-induced HIF-1alpha expression in RSF and in the expression of proangiogenic factors.

Familial amyloidotic polyneuropathy: long-term follow-up of abdominal fat tissue aspirate in patients with and without liver transplantation.

To estimate the evolution of amyloid in tissue, we studied abdominal fat aspirates of cases with familial amyloidotic polyneuropathy (FAP) longitudinally at regular intervals between 1994 and 2006. In 22 cases (13 carriers and nine patients) not yet transplanted median follow-up was 3.3 years (range 0.4-11.3). We found a significant increase in the amyloid grade of fat tissue from 2+ to 4+ and from 0 to 4+ in two of three subjects with follow-ups of >7 years, after 7 and 11 years, respectively. All other subjects remained negative or did not show a significant change. In 11 liver transplant patients, follow-up with fat aspirate was available with a median duration of 3.1 years (range 1.0-10.1). A comparison was made with cardiac amyloid as judged by the cardiac septum diameter and the serum NT-ProBNP (N-terminal pro-B-type natriuretic peptide) level. No stable increase of amyloid in fat was seen in any patient. A stable decrease of amyloid grade was seen in one patient 5 years after transplantation. In contrast, the cardiac septum diameter increased >or=4 mm in six of the 11 transplant patients. Our study shows the diagnostic utility of a regularly repeated fat aspirate in carriers at risk for the development of ATTR amyloidosis. Evolution of amyloid deposition in fat tissue is very gradual. After liver transplantation, amyloid deposition in fat tissue seems to stabilize and may even decrease in the long term, whereas amyloid deposition in cardiac tissue appears to be progressive.

Diagnostic performance and prognostic value of extravascular retention of 123I-labeled serum amyloid P component in systemic amyloidosis.

UNLABELLED: Serum amyloid P component (SAP) binds to amyloid. (123)I-SAP scintigraphy is used to evaluate the extent and distribution of amyloid in systemic amyloidosis and has great clinical value in the detection of systemic amyloidosis. The aim of the study was to assess during scintigraphy the diagnostic performance and prognostic value of a simple parameter describing extravascular (123)I-SAP retention in systemic amyloidosis. METHODS: Two hundred megabecquerels of (123)I-labeled human SAP was injected intravenously for scintigraphy in 20 controls and in 189 consecutive patients with systemic and localized amyloidosis. Extravascular retention of (123)I-SAP was quantified from serum and urine measurements after 24 h (EVR(24)) and 48 h. Sensitivity and specificity were assessed, and retention was correlated with kidney, heart, liver, and nerve involvement and with survival. RESULTS: The cutoff value representing a desired specificity of 90% of EVR(24) was 50%. The associated sensitivity of EVR(24) for detecting reactive systemic, immunocyte-derived (AL), and hereditary amyloidosis was 65%, 61%, and 22%, respectively, using a cutoff point of 50%. In AL amyloidosis, the EVR(24) increased with the number of organs involved (from a mean of 43% for 1 organ to a mean of 81% for 4 organs). The EVR(24) correlated with serum alkaline phosphatase (r = 0.63) and with creatinine clearance (r = -0.36). In AL amyloidosis, both cardiac involvement (hazard ratio, 3.9; 95% CI, 2.0-7.8) and EVR(24) (hazard ratio, 2.0; 95% CI, 1.1-3.9) were independent predictors of survival. CONCLUSION: In AL amyloidosis, the EVR(24) is strongly associated with organ involvement and with prognosis and might serve as an indicator of the body amyloid load. Quantification of SAP retention using the EVR(24) has no additional value over (123)I-SAP scintigraphy in the detection of systemic amyloidosis.