Refractory Rheumatoid Arthritis Patients Research Articles

OA27 Molecular divergences in CD4+ T Cells between early and refractory rheumatoid arthritis

Abstract Background/Aims Up to 21% of rheumatoid arthritis (RA) patients remain refractory to available treatments. This represents a clinical challenge due to the lack of efficacious alternatives for refractory RA (rRA) patients. Although CD4+ T cells are paramount in RA pathogenesis, a comprehensive understanding of their roles in rRA versus non-refractory RA has not been characterised. The aim of this study is to dissect the molecular differences in CD4+ T cells across these patient sub-groups and identify novel mechanisms driving rRA, which may inform tailored therapeutic strategies, using single cell multiomic analysis. Methods Primary CD4+ T-cells were isolated from PBMCs obtained from 3 rRA patients (defined as per EULAR definition of difficult-to-treat RA) and 3 treatment-naïve, early RA (ERA) patients, all seropositive with active disease (DAS28-ESR > 3.2), collected as part of the PRECISE-RA programme. Following nuclei extraction, the 10x Genomics Multiome ATAC + Gene Expression assay was used to simultaneously determine the transcriptional and chromatin landscapes from individual cells. Results Patient characteristics are reported in Table 1. 8,215 T-cells cells were clustered into 11 distinct cell states, which showed a trend towards diminished Tregs and modulated effector memory (TEM)/Th17 phenotype expressions in rRA compared to ERA patients. In ERA, expression of INPP4B, pivotal for cell growth and survival, was upregulated within naïve CD4+ T-cell subsets. ITGA4, crucial in leukocyte migration and adhesion, was elevated within a subset of naïve CD4+ T cells in early RA. ZEB2 exhibited increased expression within CD4 TEM/Th17 phenotype cells, potentially implicating divergent cellular differentiation, and migratory pathways within early RA contexts. Next, we utilised the multiomic nature of the data to functionally annotate GWAS variants, by creating peak-gene maps and overlaying RA risk SNPs. For example, an RA susceptibility SNP mapping to an intron of ANKRD55, rs7731626, was linked to the novel RA causal gene IL6ST. Furthermore, the RA SNP rs71508903, previously assigned to the ARID5B gene, was linked to the RTKN2 promoter, elucidating potential avenues for further exploration into RA pathogenesis. Conclusion These findings, to be validated in a larger cohort, suggest distinct biological mechanisms driving rRA and may help identify novel biomarkers and therapeutic avenues. Disclosure S.L. Smith: None. S. Rossi: None. R. Shukla: None. Y. Tan: None. A. Ariff: None. I. Lazar: None. K. Patel: None. C.F. Yap: None. N. Nair: None. S. Eyre: None. M.H. Buch: None. M.H. Buch: None. P. Martin: None. G. Orozco: None.

Expression of SALL4 in the synovial tissue of refractory rheumatoid arthritis patients

Expression of SALL4 in the synovial tissue of refractory rheumatoid arthritis patients

The effective threshold dose of etanercept in patients with methotrexate-resistant rheumatoid arthritis.

The therapy of rheumatoid arthritis (RA) was advanced by biological agents, yet costly. This study aims to identify the effective threshold dose of etanercept (ENT) and cost-effectiveness in methotrexate (MTX)-resistant RA in real world. Eligible patients had an inadequate response (DAS28-ESR > 3.2) to initial MTX monotherapy, and subsequently received etanercept. The effective cut-off value of cumulative dose was identified to maintain remission response (DAS28-ESR < 2.6) at month 24 by using restricted cubic splines. Remission rate, low disease activity (LDA) rate, glucocorticoid exposure, safety, and cost-effectiveness were compared between the saturated and non-saturated dose groups divided by the cut-off dose. Seventy-eight (14.2%) of 549 enrolled patients were eligible, and 72 patients completed follow-up. The 2-year cumulative cut-off dose that maintained remission response at 24months was 1975mg. And the recommended threshold dosing strategy of etanercept was twice weekly (BIW) for the first 6months, every week (QW) for the next 6months, and every 2weeks (Q2W) and every month (QM) for the second year. Greater net changes in DAS28-ESR score were observed in the ENT saturated dose group than in the non-saturated dose group (average change 0.569, 95%CI 0.236-0.901, p = 0.001). The proportion of patients achieving remission (27.8% vs 72.2%, p < 0.001) and LDA (58.3% vs 83.3%, p = 0.020) in the non-saturated group was both significantly lower than that in the saturated group at 24months. The incremental cost-effectiveness ratio of the saturated group referred to the non-saturated group was 5791.2 $/QALY. In refractory RA patients, the effective cumulative cut-off dose of etanercept for sustained remission at 24months was calculated as 1975mg, and receiving saturated dose was more effective and cost-effective than with non-saturated dose. Key Points • The effective cumulative cut-off dose of etanercept for sustained remission at 24months in RA patients is calculated as 1975mg. • Receiving saturated dose of etanercept is more effective and cost-effective than with non-saturated dose in refractory RA patients.

The Effects of Mesenchymal Stem Cells on the Gene Expression of TGF-beta and IFN-gamma in Patients with Rheumatoid Arthritis.

The therapeutic and immunomodulatory potential of mesenchymal stem cells (MSCs) in rheumatoid arthritis (RA) has attracted considerable scientific attention in recent decades. This study aimed to evaluate the expression of genes encoding interleukin (IL)4 and IL10, as well as interferon-gamma (IFNG) and transforming growth factor beta (TGFB1) in refractory RA patients following intravenous injection of autologous bone marrow-derived MSCs (BM-MSCs). This study was registered in Iranian Registry of Clinical Trials (IRCT) (2015102824760N1) and ClinicalTrials.gov (identifier: NCT03333681). Blood samples were taken from 13 patients before and 1 and 6 months after the MSC injection to evaluate the clinical manifestations, paraclinical factors, and expression of IL4, IL10, IFNG, and TGFB1 genes employing the SYBR Green real-time reverse-transcriptase polymerase chain reaction (RT-PCR) technique. There was a significant increase in the expression of TGFB1 at 1 and 6 months after the MSC injection compared to that in the baseline, while the expression of IL4 and IL10 did not change significantly. On the other hand, the expression of IFNG increased significantly after 1 month but decreased significantly at 6 months compared to 1 month after the intervention. Nevertheless, it showed no significant decrease compared to the baseline. A significant decrease was observed for the expression of IFNG 6 months after the injection compared to that after 1 month, which was in concordance with the rise in the expression of the TGFB1 gene. A significant change in the gene expression of TGFB1 and IFNG in our study wasconsistent with the amelioration of clinical manifestations, suggesting a mechanism of action for MSCs in the treatment of RA.

Photodynamic therapy for synovial hyperplasia in patients with refractory rheumatoid arthritis: a study protocol for a randomized, double-blind, blank-controlled prospective trial

BackgroundPersistent synovial hyperplasia with inflammation in rheumatoid arthritis is one of the main pathogeneses of refractory rheumatoid arthritis (RRA). Photodynamic therapy (PDT) causes less trauma than steroid injections or arthroscopic synovectomy while providing stronger targeting and more durable curative effects. The aim of this trial was to evaluate the short-, medium-, and long-term clinical efficacy of PDT when applied as a treatment for RRA synovial hyperplasia and synovitis.Methods and analysisThis protocol is for a single-center, randomized, double-blind, blank-controlled prospective trial. A sample of 126 RRA patients will be randomly divided into 3 groups: the control group, the “PDT once” group, and the “PDT twice” group, with 42 participants per group. The trial will be conducted by the Rheumatology and Immunology Department of the Integrated Hospital of Traditional Chinese Medicine, Southern Medical University. The Ultrasound Compound Score of Synovitis (UCSS) has been selected as the primary outcome measure. The secondary outcome measures include knee joint clinical assessments, ratio of relapse, duration of remission, Disease Activity Score in 28 joints (DAS28), inflammation indexes, serum concentrations of specific antibodies, and changes in articular structures as detected by X-ray scans in the 48th week. The improvement ratios of the UCSS at the 8th, 24th, and 48th weeks (compared with baseline) reflect short-, medium-, and long-term time frames, respectively.Ethics and disseminationThe protocol was approved by the Medical Ethics Committee of the Integrated Hospital of Traditional Chinese Medicine, Southern Medical University, China (Approval No. granted by the ethics committee: NFZXYEC-2017-005) and then entered in the Chinese Clinical Trials Registry under registration number ChiCTR1800014918 (approval date: February 21, 2018). All procedures are in accordance with Chinese laws and regulations and with the Declaration of Helsinki by the World Medical Association (WMA). Any modifications of this protocol during execution will need additional approval from the Ethics Committee of our hospital.Trial registration numberChiCTR1800014918.

The Evaluation of Some Biomarkers According to Rheumatoid Factor in Early Diagnosis of Rheumatoid Arthritis from Iraqi Patients

Rheumatoid arthritis (RA) was a chronic inflammatory autoimmune disease for long-term that primarily affects small joints and leads to chronic inflammation in synovial. The aimed of the study to identify the relationships among some serological markers (antibodies to citrullinated protein/peptide antigens (ACPAs), anti-mutated citrullinated vimentin (anti-MCV), anti-carbamylated protein (Anti-Carp), anti- heterogeneous nuclear ribonucleoproteins (anti-hnRNP) and Glucose-6-phosphate isomerase (GPI)) and early diagnosis of RA. The study involved (60) Patients of newly diagnosis with RA that divided in to two subgroups (30 RF positive and 30 RF negative) groups and 30 subjects as healthy control group. The serological data from serum concentration of (ACPAs, Anti-MCV, Anti-Carp, Anti-hnRNP, G6PI) estimated by ELISA methods, RF estimated by latex agglutination kits. The results revealed that ACPAs, Anti-MCV, Anti-Carp, Anti-hnRNP, G6PI having a statistical significants at the mean±SD titer different between the two RF groups, a higher value among the refractory RA patients in comparison with the control group. Also effectively distinguishing RA patients groups for RF+ve and RF-ve with showed the sensitivity and specificity of, ACPAs (90.8% , 94.1%, and 88.2%, 86.6%); anti-MCV (66.7% , 33.0% and 70.0%, 70.2%); anti-CarP (76.7% , 90.0% and 93.3%, 78.5%); anti-hnRNP (74.9% , 61.9% and 71.4%, 70.9%) and GPI (77.3% , 76.7% and 84.4%, 80.1%) respectively. This study confirm the importance of measuring multiple serum biomarkers and their com­binations with high diagnostic value for RA and provide sup­port for the early diagnosis of RA.

Cost-Effectiveness of a JAK1/JAK2 Inhibitor vs a Biologic Disease-Modifying Antirheumatic Drug (bDMARD) in a Treat-to-Target Strategy for Rheumatoid Arthritis.

BackgroundBaricitinib is a janus kinase (JAK1/JAK2) inhibitor developed for the treatment of patients suffering from rheumatoid arthritis (RA). Treating RA to the target of remission is current common practice. Cost-effectiveness of different treat-to-target (T2T) strategies, especially ones including new treatments is important for development and preference policy for treatment centers. European League Against Rheumatism (EULAR) and American College of Rheumatology (ACR) guidelines are currently unclear about preference between a JAK1/JAK2 versus a biological disease-modifying antirheumatic drug (bDMARD).ObjectiveThe main goal of this paper was to evaluate the cost-effectiveness of baricitinib versus first biological for methotrexate inadequate responders in a T2T strategy using a Markov model that incorporates hospital costs as well as societal costs. Costs and utilities over five years were compared between the two strategies.MethodsA Monte Carlo simulation model was developed to conduct cost–utility analysis from the societal perspective over 5 years. Health states were based on the DAS28-erythrocyte sedimentation rate (ESR) categories. Effectiveness of baricitinib was retrieved from randomized controlled trials. Effectiveness of all other treatments, health state utilities, medical costs, and productivity loss were retrieved from the Dutch RhEumatoid Arthritis Monitoring (DREAM) cohorts. Annual discount rates of 1.5% for utility and 4% for costs were used. Probabilistic sensitivity analysis was employed to incorporate uncertainty and assess robustness of the results.ResultsProbabilistic sensitivity analysis results showed the baricitinib strategy yielded lower costs and higher utility over a 5-year period. Scenario analyses showed the baricitinib strategy to be cost-effective in both the moderate and severe RA populations.ConclusionResults suggest that the use of a JAK1/JAK2 inhibitor instead of a bDMARD in a T2T approach is cost-effective in csDMARD refractory RA patients.

The predictive value of serum soluble ICAM-1 and CXCL13 in the therapeutic response to TNF inhibitor in rheumatoid arthritis patients who are refractory to csDMARDs

Tumor necrosis factor-α (TNFα) inhibitors (TNFi) have greatly improved the prognosis of RA and become the first therapeutic option for patients who failed the conventional synthetic disease-modifying anti-rheumatic drugs (csDMARDs) therapy, but not all these patients respond well to TNFi. So far, there has been no definite biomarker to predict the response to TNFi yet. Sixty rheumatoid arthritis (RA) patients with disease duration more than 6months and at least low disease activity defined by DAS28-CRP > 3.2 although after csDMARDs (including MTX and/or leflunomide) treatment for more than 3months were included. They were further treated with TNFα receptor Fc fusion protein and MTX 10mg per week for 12weeks. Soluble ICAM-1 (sICAM-1) and CXCL13 concentrations in sera from 60 RA patients and 20 healthy controls were tested by ELISA right before and at the end of 12weeks of TNFi therapy. The correlation between sICAM-1 and CXCL13 with disease activity and their predictive values for TNFi response were analyzed. The mean age of the 60 patients was 54.8 ± 11.6years. Serum sICAM-1 and CXCL13 concentrations were higher in RA patients than heathy controls, higher in seropositive RA patients than in seronegative ones, and higher in RA patients with higher disease activity. Serum sICAM-1 and CXCL13 levels were decreased after TNFi therapy, especially in good responders. Baseline sICAM-1 concentration was independently associated with the EULAR response (p = 0.033, OR = 1.014, 95% CI = 1.003-1.026). The sICAM-1high/CXCL13high patients had the highest response rate, which was significantly higher than the sICAM-1low/CXCL13low group (OR = 8.143, 95% CI = 1.040-75.482, p = 0.045). sICAM-1 and CXCL13 are elevated in RA patients and correlated with disease activity. sICAM-1 is an independent predictor of TNFi response in csDMARDs refractory RA patients. Key Points • This study confirmed the predictive value of soluble ICAM-1 (sICAM-1) and CXCL13 on the response to TNFi in RA patient. • Baseline sICAM-1 concentration was independently associated with the EULAR response. • The sICAM-1high/CXCL13high patients had significantly higher response rate than the sICAM-1low/CXCL13low group.

Safety of rituximab on testicles, a double-blindedcontrolled trial in mice

Objectives: Rituximab (RTX) is a biologic agent used for rheumatic and autoimmune disorders. RTX is a drug indicated for the treatment of patients with refractory rheumatoid arthritis patients who have not responded to nonbiological therapy and one or more anti-tumor necrosis factor-α drugs. The purpose of this trial was to investigate the RTX effects on testes in BALB/c mice by histology. Materials and Methods: A total of 20 mice were divided into two groups. Ten mice were subjected to weekly subcutaneous (SC) injection of RTX (0.31 mg/25 g body weight, in a final volume of 0.03 ml normal saline [NS] solution) for only the first 4 weeks. For the control group, ten mice were subjected to weekly SC injection of 0.03 ml NS solution. At the 10th week after first SC injection, mice were sacrificed, and histological analysis of tests was performed. Results: One out of ten mice died in the RTX-tested group; meanwhile, the remaining mice and the NS-tested group mice showed no abnormal histological findings. Conclusion: This is the first experimental animal trial which demonstrated that RTX treatment may not elicit testicular toxicity.

Subcutaneous Tocilizumab Is Effective for Treatment of Elderly-Onset Rheumatoid Arthritis.

Rheumatoid arthritis (RA) is an autoimmune disease characterized by systemic articular and bone manifestations and its pathogenesis is driven by a complex network of proinflammatory cytokines, including tumor necrosis factor and interleukin (IL)-6. Treatment of rheumatoid arthritis (RA) has been standardized by the introduction of a treat-to-target approach. Subcutaneous tocilizumab (TCZ-SC) is a humanized anti-IL-6 receptor monoclonal antibody, and is widely used for refractory RA patients in the clinical settings. However, it remains unknown whether TCZ-SC shows effectiveness for elderly onset RA. The study was aimed to assess the effectiveness and safety of TCZ-SC in elderly-onset rheumatoid arthritis (EORA) patients in daily practice. Fifty-five RA patients were divided into two age groups upon TCZ-SC administration: young (Y) group (< 65 years old, n = 30) and elderly-onset (EO) group (> 65 years old, n = 25). Disease activity score-28 (DAS28) upon TCZ-SC administration (4.84 in EO group vs. 4.41 in Y group) was significantly decreased to 1.94 vs. 1.93 at 3 months and 1.61 vs. 1.75 at 12 months after administration. The clinical remission (DAS28 < 2.6) rate was 75% in EO group vs. 83% in Y group at 3 months and 90% vs. 85% at 12 months. The retention rate at 12 months was 88% in EO group and 92% in Y group without significant difference. The cessation cases of adverse events were two in each group. In conclusion, TCZ-SC showed good clinical effectiveness and safety in EORA patients. TCZ-SC is a useful agent for patients with EORA.

Targeting Granulocyte-Monocyte Colony-Stimulating Factor Signaling in Rheumatoid Arthritis: Future Prospects.

Rheumatoid arthritis (RA) is a systemic, autoimmune disease that affects joints and extra-articular structures. In the last decade, the management of this chronic disease has dramatically changed with the introduction of several targeted mechanisms of action, such as tumor necrosis factor-α inhibition, T-cell costimulation inhibition, B-cell depletion, interleukin-6 blockade, and Janus kinase inhibition. Beyond its well-known hematopoietic role on the proliferation and differentiation of myeloid cells, granulocyte-monocyte colony-stimulating factor (GM-CSF) is a proinflammatory mediator acting as a cytokine, with a proven pathogenetic role in autoimmune disorders such as RA. In vitro studies clearly demonstrated the effect of GM-CSF in the communication between resident tissue cells and activated macrophages at chronic inflammation sites, and confirmed the elevation of GM-CSF levels in inflamed synovial tissue of RA subjects compared with healthy controls. Moreover, a pivotal role of GM-CSF in the perception of pain has been clearly confirmed. Therefore, blockade of the GM-CSF pathway by monoclonal antibodies directed against the cytokine itself or its receptor has been investigated in refractory RA patients. Overall, the safety profile of GM-CSF inhibitors seems to be very favorable, with a particularly low incidence of infectious complications. The efficacy of this new mechanism of action is comparable with main competitors, even though the response rates reported in phase II randomized controlled trials (RCTs) appear to be numerically lower than the response rates observed with other biological disease-modifying antirheumatic drugs already licensed for RA. Mainly because of this reason, nowadays the development program of most GM-CSF blockers for RA has been discontinued, with the exception of otilimab, which is under evaluation in two phase III RCTs with a head-to head non-inferiority design against tofacitinib. These studies will likely be useful for better defining the potential role of GM-CSF inhibition in the therapeutic algorithm of RA. On the other hand, the potential role of GM-CSF blockade in the treatment of other rheumatic diseases is now under investigation. Phase II trials are ongoing with the aim of evaluating mavrilimumab for the treatment of giant cell arteritis, and namilumab for the treatment of spondyloarthritis. Moreover, GM-CSF inhibitors have been tested in osteoarthritis and diffuse subtype of systemic sclerosis. This review aims to describe in detail the available evidence on the GM-CSF blocking pathway in RA management, paving the way to a possible alternative treatment for RA patients. Novel insights regarding the potential use of GM-CSF blockers for alternative indications will be also addressed.

Amelioration of clinical symptoms of patients with refractory rheumatoid arthritis following treatment with autologous bone marrow-derived mesenchymal stem cells: A successful clinical trial in Iran

Rheumatoid arthritis (RA) is a chronic inflammatory autoimmune arthropathy characterized by synovial hyperplasia leading to functional impairment. Although the exact cause of RA is unknown, there is evidence suggesting the role of T cell subtypes in the pathogenesis of RA. Conventional therapy in some RA patients is associated with mild or severe side effects, and resistance of some patients has been reported to these types of therapy. The therapeutic potential of mesenchymal stem cells (MSCs) introduced them as a novel therapeutic choice for the treatment of rheumatic diseases. The aim of our study was to evaluate the effects of intravenous administration of autologous bone marrow-derived MSCs on the immunological, clinical and para-clinical factors such as regulatory T cells, Th17 cells, CD8+ T cells, CD4+ T cells, disease activity score 28-erythrocyte sedimentation rate (DAS28-ESR), visual analogue scale (VAS), ESR, C-reactive protein (CRP), rheumatoid factor (RF), and anti-cyclic citrullinated peptide (anti-CCP) antibodies in patients with refractory RA. Nine refractory RA patients with no other rheumatologic disorders were included in this study. All patients received a single intravenous dose of 1 × 106 autologous bone marrow-derived MSCs/kg, and were followed up at 1, 6 and 12 months after injection of MSCs. We found a significant decreasing trend in Th17 percentage and geometric mean fluorescence intensity for IL-17A following injection of MSCs at 12 months compared to the time point zero. Furthermore, a significant increase in regulatory T cells percentage was observed at the end of the first month after the intervention. DAS28-ESR decreased significantly at 1 and 12 months after MSC therapy. VAS score showed a significant decreasing trend during the follow-up periods. No significant difference was found for serum CRP and anti-CCP levels after the intervention. In conclusion, our data indicated that clinical symptoms were significantly ameliorated following the intravenous injection of autologous bone marrow-derived MSCs to the patients with refractory RA.

The Study on P-Glycoprotein Expression on Peripheral Lymphocytes of Refractory Rheumatoid Arthritis Patients

The Study on P-Glycoprotein Expression on Peripheral Lymphocytes of Refractory Rheumatoid Arthritis Patients

Long-term efficacy and safety of add-on tacrolimus for persistent, active rheumatoid arthritis despite treatment with methotrexate and tumor necrosis factor inhibitors.

To assess the long-term efficacy and safety of adding tacrolimus for patients with active rheumatoid arthritis (RA) despite anti-tumor necrosis factor (TNF) therapy with methotrexate. Consecutive patients who were treated with adding tacrolimus onto anti-TNF therapy with methotrexate for active RA despite anti-TNF therapy with methotrexate, were retrospectively analyzed in terms of treatment response, achieving remission, subsequent treatment tapering and adverse events. Fifteen patients could be analyzed. Median symptom duration was 2.9 years and prior duration of anti-TNF therapy was 40 weeks. Median value of Disease Activity Score in 28 joints was 4.6. Five, eight and two were on infliximab, etanercept and adalimumab at the onset of tacrolimus, respectively. At 2 years, the proportions of patients achieving responses of American College of Rheumatology 50, 70 and 90, were 80%, 73% and 40%, respectively, and those achieving remission as defined by Simplified Disease Activity Index ≤ 3.3 were 67%. All patients could discontinue oral glucocorticoids and 10 had been successfully withdrawn from anti-TNF therapy for more than 1 year at the final observation. Adding tacrolimus onto anti-TNF therapy is a promising therapeutic option with sustained benefit for refractory RA patients despite treatment with anti-TNF therapy combined with methotrexate.

An Analysis on Pyrin E148Q Mutations in Patients with Refractory Rheumatoid Arthritis

Objective: Rheumatoid arthritis (RA) is an autoimmune disease with lifelong disability in adults. Given the high prevalence of Mediterranean fever and its overlapping and modulatory effects on autoimmune diseases, we analyzed molecular mutation in exon 2 of MEFV gene in patients with refractory RA and healthy subjects as a control group. Methods: Thirty four patients with refractory RA and fifty healthy controls were conducted in this study and their DNA samples were analyzed. We studied the most common exon 2 variation on MEFV gene which known as E148Q. At the end of this study, we compared the results of both groups. Results: The mean age of patients with refractory RA were 43.8 ± 7.7 years and disease duration was 49.8 ± 7.36 months. The mean of DAS 28 (Disease Activity score) of patients with refractory RA was 4.2 ± 0.51. The mean ages of healthy control cases were 45.4 ± 8.27 years. The mutation frequency of exon 2 MEFV variant was 6 (17.6%) of 34 and 5 (10%) of 50 in the refractory RA patients and healthy subjects, respectively. According to results no significant difference were observed between two groups (P=0.405). Conclusion: Overall mutation rate of E148Q gene has not increased in patients with refractory rheumatoid arthritis and this mutation possibly has no effect on disease severity.

Methotrexate Combined with 4-Hydroperoxycyclophosphamide Downregulates Multidrug-Resistance P-Glycoprotein Expression Induced by Methotrexate in Rheumatoid Arthritis Fibroblast-Like Synoviocytes via the JAK2/STAT3 Pathway.

Objective Rheumatoid arthritis (RA) multidrug resistance is associated with P-glycoprotein (P-gp) overexpression. We investigated the effects of methotrexate (MTX) alone and combined with 4-hydroperoxycyclophosphamide (4-HC) on P-gp expression in fibroblast-like synoviocytes (FLSs) from patients with RA and examined the signaling pathway involved. Methods RA-FLSs were treated with MTX, MTX + 4-HC, AG490 + MTX, or AG490 + MTX + 4-HC for 72 h. Proliferation inhibition rates were determined by MTT assay; P-gp expression was measured by flow cytometry and real-time polymerase chain reaction (RT-PCR); JAK2 and STAT3 were measured by RT-PCR and cell-based ELISA to assess STAT3 signaling. Results MTX alone significantly induced P-gp expression and mRNA production in RA-FLSs. P-gp expression and mRNA levels were lower in the MTX + 4-HC group than in the MTX-alone group. In contrast to MTX, MTX + 4-HC reduced the STAT3 phosphorylation and downregulated JAK2 and STAT3 mRNA production. Inhibition of constitutively active STAT3 accompanied by 4-HC suppressed P-gp levels in RA-FLSs. The MTT assays revealed no significant differences in proliferation inhibition rates among groups. Conclusions The increased anti-P-gp effect of MTX + 4-HC versus MTX alone in RA-FLSs was mediated via inhibition of the JAK2/STAT3 pathway and may have helped reverse MDR in refractory RA patients with high-P-gp levels.

Hearing status in patients with rheumatoid arthritis.

Rheumatoid arthritis is thought to induce conductive hearing loss and/or sensorineural hearing loss. This study evaluated the function of the middle ear and cochlea, and the related factors. Pure tone audiometry, speech reception thresholds, speech discrimination scores, tympanometry, acoustic reflexes, and distortion product otoacoustic emissions were assessed in rheumatoid arthritis patients and healthy volunteers. Pure tone audiometry results revealed a higher bone conduction threshold in the rheumatoid arthritis group, but there was no significant difference when evaluated according to the sensorineural hearing loss definition. Distortion product otoacoustic emissions related prevalence of conductive or mixed hearing loss, tympanometry values, acoustic reflexes, and speech discrimination scores were not significantly different between the two groups. Sensorineural hearing loss was significantly more prevalent in patients who used azathioprine, cyclosporine and etanercept. Higher bone conduction thresholds in some frequencies were detected in rheumatoid arthritis patients that were not clinically significant. Sensorineural hearing loss is significantly more prevalent in refractory rheumatoid arthritis patients.

Circulating Biomarkers for Predicting Infliximab Response in Rheumatoid Arthritis: A Systematic Bioinformatics Analysis.

BackgroundInfliximab shows good efficacy in treating refractory rheumatoid arthritis (RA). However, many patients responded poorly and related studies were inconsistent in predictive biomarkers. This study aimed to identify circulating biomarkers for predicting infliximab response in RA.Material/MethodsPublic databases of Gene Expression Omnibus (GEO) and ArrayExpress were searched for related microarray datasets, focused on the response to infliximab in RA. All peripheral blood samples were collected before infliximab treatment and gene expression profiles were measured using microarray. Differential genes associated with infliximab efficacy were analyzed. The genes recognized by half of the datasets were regarded as candidate biomarkers and validated by prospective datasets.ResultsEight microarray datasets were identified with 374 blood samples of RA patients, among which 191 (51.1%) were diagnosed as non-responders in the subsequent infliximab treatment. Five genes (FKBP1A, FGF12, ANO1, LRRC31, and AKR1D1) were associated with the efficacy and recognized by half of the datasets. The 5-gene model showed a good predictive power in random- and prospective-designed studies, with AUC (area under receiver operating characteristic [ROC] curve)=0.963 and 1.000, and it was also applicable at the early phase of treatment (at week 2) for predicting the response at week 14 (AUC=1.000). In the placebo group, the model failed to predict the response (AUC=0.697), indicating the model’s specificity in infliximab treatment.ConclusionsThe model of FKBP1A, FGF12, ANO1, LRRC31, and AKR1D1 in peripheral blood is useful for efficiently predicting the response to infliximab treatment in rheumatoid arthritis.

Overexpression of P-glycoprotein on fibroblast-like synoviocytes in refractory rheumatoid arthritis patients: a potential mechanism for multidrug resistance in rheumatoid arthritis treatment.

This study aims to investigate the role of P-glycoprotein (P-gp) expression level in drug resistance to disease-modifying anti-rheumatic drugs in refractory rheumatoid arthritis (RRA). We evaluated and compared the expression levels of P-gp in fibroblast-like synoviocyte (FLS) cells in patients with rheumatoid arthritis (RA) and osteoarthritis (OA), and investigated the potential mechanism of P-gp-induced multidrug resistance in RRA. Ten patients were enrolled and divided into two groups: six in the RA group and four in the OA group. The expression level of P-gp in FLS cells was detected by western blotting following cell culture. A linear correlation algorithm was used to assess the association between the level of P-gp and disease activity (using DAS28 scoring), as well as the duration of methotrexate (MTX) treatment in the RRA patients. The level of P-gp in the RRA patients was markedly higher than that in the OA patients (P < 0.05, t = -4.179). There was a positive linear correlation between the P-gp level in FLS cells and the duration of MTX treatment in the RRA group (Г = 0.733, P < 0.05), whereas there was no significant correlation between the P-gp level and DAS28 scoring (Г = 0.206, P > 0.05). P-gp might be upregulated during the progression of RRA, which possibly correlates with the development of resistance to MTX.

Low pre-treatment B-cell counts are not a risk factor of infection in patients treated with rituximab for autoimmune diseases: An observational study

ObjectivesRituximab (RTX) is increasingly used in patients with refractory rheumatoid arthritis (RA) and other severe autoimmune diseases (AID). In practice, many clinicians are reluctant to prescribe RTX in patients with low B-cell counts because of the presumed risk of infection. The aim of this study was therefore to investigate whether B-cell counts before treatment or retreatment with RTX predict the occurrence of infections. MethodsObservational, single-centre study of 161 patients treated with RTX for RA and other AID at a tertiary hospital. CD19+ B-cell counts were assessed by flow cytometry and multivariate statistical analysis adjusted for various potential predictors was performed. ResultsThe rate of severe infection was 5.9/100 patient-years in RA patients and 24.9 in non-RA AID (P<0.001). Low B-cell counts at the time of RTX infusion were not associated with subsequent severe (HR=0.55, P=0.60) or overall infection (HR=0.85, P=0.58). Significant pre-treatment predictors of severe infection were a diagnosis other than RA (HR=4.68, P<0.001), immunoglobulin (Ig) G levels <7g/L (HR=2.36, P=0.01), age (HR=1.03, P=0.01), and diabetes (HR=3.61, P=0.01). ConclusionsLow B-cell counts before RTX infusion did not predict subsequent infections in this population treated with RTX for RA and other AID, therefore not supporting the practice of pre-treatment assessment of B-cells. Nevertheless, a higher risk of severe infection was confirmed for low pre-treatment IgG levels, older age, diabetes, and AID other than RA.