Effects of sulfasalazine and its metabolites on steady state messenger RNA concentrations for inflammatory cytokines, matrix metalloproteinases, and tissue inhibitors of metalloproteinase in rheumatoid synovial fibroblasts.

OBJECTIVE: To determine the effects of sulfasalazine (SASP) and its metabolites sulfapyridine (SP) and 5-amino salicylic acid (5ASA) on steady state mRNA levels of inflammatory cytokines [interleukin 1beta (IL-1beta), tumor necrosis factor alpha (TNF-alpha)], matrix metalloproteinases [collagenase (MMP1), stromelysin (MMP3), gelatinase 72 kDa (MMP2)], tissue inhibitors of metalloproteinase (TIMP 1 and TIMP 2), and the TNF-alpha receptor in rheumatoid synovial fibroblasts. METHODS: Cells were dosed with each compound for 24 h in the presence or absence of PMA inducer and messenger RNA (mRNA) extracted and subjected to Northern blot analysis. Messenger RNA levels were quantitated by densitometry and normalized to GAPDH or 18S rRNA. RESULTS: We observed some modest effects of sulfasalazine and its metabolites on steady state mRNA levels including: (1) repressed mRNA levels for TNF-alpha [approximately 40% with 3x (drug median serum concentration) all 3 drugs], stromelysin (approximately 24% with 3x all 3 drugs and approximately 31% with 3x 5ASA), and collagenase (approximately 27% with 3x 5ASA); (2) elevated mRNA levels for TIMP 2 (3.5 kb transcript) (51% with 3x SP and 44% with 3x 5ASA), gelatinase (approximately 20% with 3x SP and 3x 5ASA), stromelysin (approximately 40% with 3x and 1x SASP), IL-1beta (approximately 31% with 0.1x 5ASA); and (3) no effect on mRNA levels for TNF-alpha receptor and TIMP 1. CONCLUSION: (1) SASP and its metabolites showed varied effects on steady state mRNA concentrations for gene transcripts that fell into 3 categories: (a) repressed, (b) elevated, (c) no effect on mRNA levels. (2) No apparent linear dose response effect was observed for SASP or its metabolites, although a generalized suppression of mRNA levels at all doses was seen in some cases. (3) No predominant suppressive effect (> or = 50%) of mRNA levels by any of the drugs was observed for any of the genes studied; however, TIMP 2 mRNA levels increased 51% with 3x SP and 44% with 3x 5ASA.

Is there immune dysregulation in symptomatic Gulf War veterans?

Many Gulf War veterans complain of a variety of symptoms including skin rashes and joint pain which may have a common immunological basis. Other Gulf War veterans have post-traumatic stress disorder (PTSD), an anxiety disorder associated with chronic stress. Whether or not chronic stress may affect the capacity to resist disease has not been fully delineated, but recent work suggests that a dysregulated balance of cytokines produced by T helper cells of the immune system may play a role in stress-related illnesses. It is known that a balanced immune response (cell-mediated and humoral immunity) is an important defense mechanism. Although the mechanism(s) by which a change in immune system balance occurs is not clear, it may be secondary to stress-induced changes in hormones such as cortisol and catecholamines, both of which have been implicated in altering levels of cellular or humoral immunity. For these reasons, we are investigating the function of both the cellular and humoral arms of the immune system as well as the cytokine patterns associated with these different functions in symptomatic Gulf War veterans and control groups consisting of asymptomatic Gulf War veterans and symptomatic non-Gulf War veterans.

Stress and immune dysfunction in Gulf War veterans.

The role of stress and immunological abnormalities, as well as the neuroendocrine regulation of these two variables, in illnesses in Gulf War veterans (GWVs) is unknown. Many GWV patients complain of skin and joint problems, that is, disorders that may have a common immunological basis. Post-traumatic stress disorder (PTSD), an anxiety disorder associated with chronic stress, is diagnosed in approximately 10% of the Alabama GWVs. Chronic stress can lead to a reduced capacity to resist disease. Recent work suggests that a dysregulated balance of cytokines produced by T helper cells of the immune system can play a significant role in stress-related illnesses. Indeed, a balanced immune response (cell-mediated and humoral immunity) is an important defense mechanism, and cytokines can regulate this balance. It is therefore plausible that stress-induced changes in hormones (such as cortisol and catecholamines) and cytokines, both of which have been implicated in altering levels of cellular or humoral immunity, may play a role in GWV illnesses.

Genotypic and phenotypic analysis of Mycoplasma fermentans strains isolated from different host tissues.

A correlation was found between the expression of a specific Mycoplasma fermentans surface antigen (Pra, proteinase-resistant antigen) and the site of isolation of the organism from the infected host. Strains which expressed Pra were most frequently associated with cells of bone marrow origin, and strains which lacked expression of Pra were most commonly isolated from the respiratory tract, genital tract, and arthritic joints, i.e., epithelial cell surfaces. Pra was previously shown to be resistant to degradation by proteinases and was hypothesized to play a protective role at the organism surface and perhaps to influence which host tissue site was colonized by the organism. The methods used for this phenotyping scheme required isolation and growth of the mycoplasma in quantities sufficient for immunoblot analysis using monoclonal antibodies. We wanted to determine a more rapid and less cumbersome technique to supplement this method for determining the Pra phenotype directly in clinical specimens. Here we describe PCR studies to investigate the movement of a previously identified M. fermentans insertion sequence (IS)-like element. These data showed a correlation between a specific IS genotype and the Pra+ phenotype. Production of a 160-bp product using a single set of IS-based primers was associated with expression of Pra. The genomic IS location resulting in the 160-bp product was determined by using Southern blot analysis and was found to be a stable insertion site characteristic of genotype I strains. Additional analyses of sequences within and flanking the IS insertion sites revealed another pair of PCR primer sites which resulted in the consistent production of a 450-bp amplicon. The stability of this site was dependent on the absence of the IS-like element between the primer sites. The production of this 450-bp amplicon correlated with the Pra mutant phenotype and was characteristic of genotype II strains. The data showed that the sequence within the IS may be unstable and that reliable genotyping sequences are more easily found in the stable genomic sites which flank the IS element.

Eosinophilia myalgia syndrome.

The term eosinophilia myalgia syndrome (EMS) was coined in 1989 after a cluster of cases with symptoms of incapacitating myalgias and eosinophilia were reported. This syndrome has been only defined as varying degrees of myalgias and peripheral eosinophilia. Case reports of EMS are protean and do not show a consistent clinical picture, raising the question of whether this reflects a single disorder or is a conflation of various disorders. There have been only two studies evaluating the association of EMS with 1-tryptophan. These two included only 23 patients with EMS. Apart from the obvious statistical fragility inherent in such small studies, each is further weakened by differences in the mechanisms by which patients and controls were selected. Furthermore, the continued reports of EMS after 1-tryptophan was removed from the market raise additional questions about the association. Nonetheless, there has been an inordinate reliance on a history of 1-tryptophan ingestion in making the diagnosis of EMS. When presented case studies, clinicians were much more likely to make the diagnosis of EMS when a history of 1-tryptophan ingestion was included. These observations underscore the need for careful application of well-considered diagnostic criteria to the study of new syndromes and their potential associations.

Lack of evidence of systemic inflammatory rheumatic disorders in symptomatic women with breast implants.

Breast implants containing silicone have been used for approximately 30 years for breast augmentation or reconstruction. In general, the implants have been well tolerated and reports have indicated a high degree of patient satisfaction. Nonetheless, there have been anecdotal reports of patients with musculoskeletal complaints that have been attributed to silicone breast implants. To investigate this further, we prospectively examined 70 women with silicone breast implants who had complaints that they or their referring physicians thought were related to their implants. On clinical examination, the majority of the patients had fibromyalgia, osteoarthritis, or soft-tissue rheumatism. One patient had rheumatoid arthritis, which predated her implants, and one had Sjõgren's syndrome. Because many of our patients had myalgic symptoms, we further evaluated these patients by measuring circulating levels of soluble factors including interleukin-6, interleukin-8, tumor necrosis factor-alpha, soluble intercellular adhesion molecule-1, and soluble interleukin-2 receptor, which have been previously found to be elevated in patients with inflammatory diseases. We found that the levels of these molecules in women with silicone breast implants were not different from those seen in normal subjects and were significantly less than those seen when examining chronic inflammatory disorders such as rheumatoid arthritis or systemic lupus erythematosus. In summary, our clinical and laboratory evaluation of symptomatic breast implant patients argues against an association of silicone breast implants with a distinctive rheumatic disease or a systemic inflammatory disorder. Given these findings and the clinical picture, it is our impression that most symptomatic women with silicone breast implants have well-delineated noninflammatory musculoskeletal syndromes. Moreover, these data fail to support the concept that their symptoms are due to a systemic inflammatory response related to their implants.

Silicone-associated rheumatic disease: an unsupported myth.

Anecdotal, reports have raised the issue of an association between silicone breast implants and the development of rheumatic diseases. Fortunately, this issue has now been extensively addressed by controlled studies, which demonstrate no association between breast implants and rheumatoid arthritis, systemic lupus erythematosus, and scleroderma. Moreover, several studies that now have addressed the issue of "atypical connective tissue disease" indicate no association between a number of rheumatic complaints and silicone breast implants. Additionally, several controlled studies show no evidence of chronic inflammation in patients with silicone breast implants. These observations should be reassuring to women with breast implants and the individuals who care for them.

Characterization of a SV40-transformed rheumatoid synovial fibroblast cell line which retains genotypic expression patterns: a model for evaluation of anti-arthritic agents.

A chimeric Adenovirus-Simian Virus 40 (AdSV40) containing the large T antigen was used to transform rheumatoid synovial fibroblasts. A rheumatoid synovial fibroblast cell line was established by infection of primary rheumatoid arthritis (RA) synovial fibroblasts at Passage 10 with AdSV40 recombinants followed by selection in semisoft agarose cultures. The transformed cells grew anchor independent, exhibited continuous proliferation (> 65 passages) in monolayer culture, and formed multiple visible foci. The transformed synovial fibroblasts showed expression of the simian virus 40 large T antigen in the nucleus as determined by immunofluorescence staining. In addition, indirect immunofluorescence staining demonstrated that the transformed cells stained specifically with a fibroblast-specific antibody 1B10. Studies involving expression of metalloproteinases showed that collagenase and stromelysin were induced by phorbal 12-myristate 13-acetate (PMA), and such an induction was repressed by dexamethasone typical of primary RA fibroblasts. Levels of mRNAs for IL-1 beta, TNF-alpha, and c-jun were increased by PMA, and the mRNA transcripts of these genes were also repressed by addition of dexamethasone to the culture media. Our results indicate that transformed RA synovial fibroblasts display a similar gene expression pattern in response to PMA and dexamethasone as observed for untransformed primary RA synovial fibroblasts. These transformed rheumatoid arthritis synovial fibroblast cells provide an ideal cell culture model in which to test the efficacy of novel arthritis gene therapy reagents.

Comparison of sulfasalazine and placebo in the treatment of ankylosing spondylitis. A Department of Veterans Affairs Cooperative Study.

OBJECTIVE: To determine whether sulfasalazine (SSZ) at a dosage of 2,000 mg/day is effective for the treatment of active ankylosing spondylitis (AS) that is not controlled with nonsteroidal antiinflammatory drug therapy. METHODS: Two hundred sixty-four patients with AS were recruited from 15 clinics, randomized (double-blind) to SSZ or placebo treatment, and followed up for 36 weeks. Treatment response was based on morning stiffness, back pain, and physician and patient global assessments. RESULTS: While longitudinal analysis revealed a trend favoring SSZ in the middle of treatment, no difference was seen at the end of treatment. Response rates were 38.2% for SSZ and 36.1% for placebo (P = 0.73). The Westergren erythrocyte sedimentation rate declined more with SSZ treatment than with placebo (P < 0.0001). AS patients with associated peripheral arthritis showed improvement that favored SSZ (P = 0.02). Adverse reactions were fewer than expected and were mainly due to nonspecific gastrointestinal complaints. CONCLUSION: SSZ at a dosage of 2,000 mg/day does not seem to be more effective than placebo in the treatment of AS patients with chronic, longstanding disease. SSZ is well tolerated and may be more effective than placebo in the treatment of AS patients with peripheral joint involvement. This effect is more pronounced in treatment of the peripheral arthritis in this subgroup of AS patients.

Comparison of sulfasalazine and placebo in the treatment of psoriatic arthritis. A Department of Veterans Affairs Cooperative Study.

OBJECTIVE: To determine whether sulfasalazine (SSZ) at a dosage of 2,000 mg/day is effective for the treatment of active psoriatic arthritis (PsA) resistant to nonsteroidal antiinflammatory drug therapy. METHODS: Two hundred twenty-one patients with PsA were recruited from 15 clinics, randomized (double-blind) to SSZ or placebo treatment, and followed up for 36 weeks. Treatment response was based on joint pain/ tenderness and swelling scores and physician and patient global assessments. RESULTS: Longitudinal analysis revealed a trend favoring SSZ treatment (P = 0.13). At the end of treatment, response rates were 57.8% for SSZ compared with 44.6% for placebo (P = 0.05). The Westergren erythrocyte sedimentation rate declined more in the PsA patients taking SSZ than in those taking placebo (P < 0.0001). Adverse reactions were fewer than expected and were mainly due to nonspecific gastrointestinal complaints, including dyspepsia, nausea, vomiting, and diarrhea. CONCLUSION: SSZ at a dosage of 2,000 mg/day is well tolerated and may be more effective than placebo in the treatment of patients with PsA.

Comparison of sulfasalazine and placebo in the treatment of reactive arthritis (Reiter's syndrome). A Department of Veterans Affairs Cooperative Study.

OBJECTIVE: To determine whether sulfasalazine (SSZ) at a dosage of 2,000 mg/day is effective in the treatment of reactive arthritis (ReA) that has been unresponsive to nonsteroidal antiinflammatory drug (NSAID) therapy. METHODS: One hundred thirty-four patients with ReA who had failed to respond to NSAIDs were recruited from 19 clinics, randomized (double-blind) to receive either SSZ or placebo, and followed up for 36 weeks. The definition of treatment response was based on joint pain/tenderness and swelling scores and physician and patient global assessments. RESULTS: Longitudinal analysis revealed improvement in the patients taking SSZ compared with those taking placebo, which appeared at 4 weeks and continued through the trial (P = 0.02). At the end of treatment, response rates were 62.3% for SSZ treatment compared with 47.7% for placebo treatment. The Westergren erythrocyte sedimentation rate declined more with SSZ treatment than with placebo (P < 0.0001). Adverse reactions were fewer than expected and were mainly due to nonspecific gastrointestinal complaints. CONCLUSION: SSZ at a dosage of 2,000 mg/day is well tolerated and effective in patients with chronically active ReA.

Cartilage imaging in osteoarthritis.

Osteoarthritis (OA) is the most common articular disorder encountered worldwide. Its successful evaluation (and eventual treatment) depends on establishing a set of criteria for measuring disease progression. An ideal measurement would evaluate changes in articular cartilage, where the primary pathology of the disease takes place. Plain radiographs are the simplest and most readily employable means of joint evaluation, and now microfocal radiographs have been developed, which magnify the radiograph and help portray the joint space more accurately. However, radiography, along with nuclear medicine scans, arthrography, and computed tomography (CT) scans, are limited in their use because they are unable to detect early cartilage abnormalities. Magnetic resonance imaging (MRI) has the advantages of multiplanar imaging, soft tissue contrast, and noninvasiveness. Like radiography, MRI can underestimate the extent of cartilage abnormality. The most sensitive technique for measuring superficial articular abnormalities is arthroscopy, and small-bore arthroscopes are being used to assess knee damage in conscious, nonsedated patients. However, it is not yet clear if arthroscopy can detect subtle changes over time, and vision can be blocked by cloudy synovial fluid. Finally, although it is usually well tolerated, arthroscopy is an invasive technique.

Management of osteoarthritis and rheumatoid arthritis: prospects and possibilities.

Conventional drug therapy in rheumatoid arthritis (RA) has failed to control the longterm morbidity and mortality associated with RA. Similarly, drug therapy for osteoarthritis (OA) can relieve symptoms, but it is not clear that it alters progression of disease. Three classes of drugs are widely used for treatment of RA: nonsteroidal anti-inflammatory drugs (NSAIDs), corticosteroids, and the slow-acting agents. In most patients, pharmacologic therapy is initiated with NSAIDs. These drugs can relieve symptoms but do not alter the course of the disease. The gastrointestinal and other side effects attributed to these compounds are well known. Similarly, use of corticosteroids can provide rapid pain relief to patients with RA and, if used in low doses, pose limited risk of toxicity. Slow-acting agents, including gold, d-penicillamine, and methotrexate, appear to decrease radiographic progression and improve clinical and biochemical indicators of RA. Therefore, newer treatment philosophies encourage use of slow-acting agents earlier in the course of the disease in order to prevent or diminish bone and joint erosions and destruction and other manifestations of disease progression. Drugs under investigation for the treatment of arthritis appear to exhibit disease-modifying or immunomodulating properties. Tenidap is a novel agent that possesses a dual mechanism of action: cyclooxygenase inhibition and modulation of cytokine activity. In addition, several biologic agents, including antibodies to tumor necrosis factor-alpha (TNF-alpha) and to intercellular adhesion molecule-1, may prove useful. These immunotherapeutic strategies are based on knowledge of the role of cytokines in the inflammatory process in arthritis. Osteoarthritis may be managed using drug and nondrug modalities. Weight loss is especially important when OA is in the weight-bearing joints. Biopsies of synovium from patients with OA show evidence of inflammation, but whether this disease should be treated with analgesics alone or with anti-inflammatory drugs remains controversial. Other treatment modalities, including tissue transplants and cytokine-modulating drugs, are emerging for the potential therapy of OA. Surgery may also be appropriate if drug treatment fails to control symptoms.

Rheumatoid synovial fibroblast adhesion to human articular cartilage. Enhancement by neutrophil proteases.

OBJECTIVE: To determine if preexposure of human articular cartilage to activated neutrophils alters rheumatoid synovial fibroblast adhesion to human articular cartilage. METHODS: Human articular cartilage was exposed to either activated neutrophils, interleukin-1, or supernatants obtained from activated neutrophils that had been treated with different protease inhibitors. Radiolabeled rheumatoid synovial fibroblasts were then incubated with the cartilage and the number of counts associated with the cartilage was determined. RESULTS: Pretreatment of human articular cartilage with either activated neutrophils or supernatants obtained from activated neutrophils enhanced subsequent rheumatoid synovial fibroblast adhesion. In contrast, interleukin-1 treatment of cartilage did not alter the adhesion of synovial fibroblasts. The enhanced adhesion could be attenuated by pretreatment of the neutrophil supernatants with either diisopropylfluorophosphonate or EGTA and almost completely abolished by using both inhibitors. CONCLUSION: This study demonstrates that adhesion of rheumatoid synovial fibroblasts to human articular cartilage can be enhanced by exposing the cartilage to proteases released by neutrophils. These results suggest that neutrophil products may play a role in enhancing adhesion of rheumatoid synovium to cartilage in vivo.

Tenidap in rheumatoid arthritis. A 24-week double-blind comparison with hydroxychloroquine-plus-piroxicam, and piroxicam alone.

OBJECTIVE: To compare the clinical efficacy, effect on serum C-reactive protein (CRP), serum amyloid A (SAA), and plasma interleukin-6 (IL-6) levels, and safety of tenidap with a combination of hydroxychloroquine-plus-piroxicam, and piroxicam alone, in the treatment of rheumatoid arthritis (RA) patients. METHODS: A double-blind, randomized, multicenter study in which patients with active RA were treated with tenidap 120 mg/day, hydroxychloroquine 400 mg/day and piroxicam 20 mg/day, or piroxicam alone 20 mg/day, for 24 weeks. RESULTS: At weeks 12 and 24, tenidap produced greater improvements than piroxicam based on 5 primary efficacy parameters; this improvement showed statistical significance in 4 of the 5 measures at week 12, and in 3 of the 5 measures at week 24. Clinical improvements in the hydroxychloroquine-plus-piroxicam-treated with tenidap. Compared with piroxicam, tenidap was associated with significantly greater reductions in serum CRP concentrations at 4, 12, and 24 weeks, and significantly greater reductions in SAA concentrations at weeks 12 and 24. The decrease in SAA concentrations was also significantly greater at weeks 4 and 24 in the tenidap-treated group than in the hydroxychloroquine-plus-piroxicam-treated group. Significant reductions in plasma IL-6 levels were observed at weeks 4, 12, and 24 within the tenidap group, and at week 24 within the hydroxychloroquine-plus-piroxicam-treated group. The overall occurrence of side effects, including gastrointestinal side effects, was similar in all 3 treatment groups. A small proportion of tenidap-treated patients (6.4%) manifested mild, nonprogressive, reversible proteinuria of presumed renal proximal tubular origin, and 3-4% of patients had elevated transaminase levels. CONCLUSION: In the treatment of patients with RA, tenidap is as effective as the combination of hydroxychloroquine-plus-piroxicam, and is more effective than piroxicam alone; moreover, tenidap's safety profile is comparable to that observed with piroxicam alone, and with hydroxychloroquine-plus-piroxicam. The clinical response observed in this study, as well as the prompt decreases in acute-phase protein levels of CRP and SAA, and in plasma IL-6 levels, suggest that tenidap represents a new type of antiarthritic medication, with properties similar to, but not identical to, a therapeutic combination of a nonsteroidal antiinflammatory drug with disease-modifying antirheumatic drugs.

Effects of tenidap on superoxide-generating enzymes. Non-competitive inhibition of xanthine oxidase.

The anti-rheumatic drug tenidap has been shown previously to attenuate superoxide production by activated neutrophils. Given the importance of leukocyte as well as endothelial cell derived superoxide in mediating inflammatory responses, the effects of tenidap on mammalian enzymes capable of generating superoxide were determined. Tenidap had no effect on the generation of superoxide by NADPH oxidase reconstituted from fractionated neutrophil lysates. However, significant inhibition of superoxide production by mixtures of hypoxanthine and xanthine oxidase was observed in the presence of 3-30 micrograms/mL tenidap. The kientics of xanthine oxidase inhibition by tenidap were non-competitive; the Ki of tenidap for xanthine oxidase was 11 micrograms/mL (34 microM). No inhibition of xanthine oxidase was observed in the presence of other known inhibitors of cyclooxygenase. Inhibition of xanthine oxidase may be a heretofore unrecognized mechanism of the antirheumatic effects of tenidap.

Activation of human neutrophils by surface-associated IgA is associated with the release of activated collagenase.

Neutrophils contain on their surface a receptor for the Fc portion of IgA. Cross-linking of this receptor in the fluid phase induces superoxide production and release of granule constituents, but the response to surface associated IgA has not been previously studied. Neutrophils incubated with surface-associated IgA (SAIgA) release significant amounts of activated collagenase in addition to the granule proteins myeloperoxidase and lactoferrin. This activation is associated with release of superoxide as well as hydrogen peroxide and hypochlorous acid. Although neutrophils incubated with soluble aggregates of IgA also release granule proteins and produce superoxide, soluble aggregates of IgA do not trigger the release of activated collagenase and do not generate hydrogen peroxide or hypochlorous acid. In summary, neutrophils activated by surface associated IgA respond differently than when cells are activated by soluble aggregates of IgA. These differences may be important in understanding the mechanisms of tissue injury in patients with inflammatory disorders.