Alberto Sulli

Anti-inflammatory mechanisms of methotrexate in rheumatoid arthritis

Methotrexate (MTX) is a folate analogue originally synthesised in the 1940s and designed to inhibit dihydrofolate reductase.1 Reduced folate (tetrahydrofolate) is the proximal single carbon donor in several reactions involved in the de novo synthetic pathways for purine and pyrimidine precursors of DNA and RNA required for cell proliferation. Furthermore, tetrahydrofolate plays a part in a second important biochemical step: the methionine-homocysteine cycle, which is necessary to provide a methyl group for several downstream reactions such as methylation of DNA, RNA proteins, and others. Therefore, MTX has been used extensively for treatment of neoplastic diseases. In 1951 the rationale for the introduction of MTX for the treatment of rheumatoid arthritis (RA) was that it inhibited proliferation of the lymphocytes and other cells responsible for inflammation in the joint.2 No further studies on clinical experience with MTX in RA were published until the early 1980s, when several uncontrolled trials were reported.3-8 Finally, four well designed, blinded, placebo controlled studies published in 1984 and 1985 introduced the use of MTX in the treatment of RA.9-12 The early indications for MTX use in the rheumatic diseases were first reported in a large review in 1984.13 From the considerable experience obtained over the past 15 years, several lines of evidence clearly suggest that MTX does not act simply as a cytotoxic (antiproliferative) agent for the cells responsible for the joint inflammation in RA.14 As a matter of fact, it would be difficult to understand how a drug that diminishes inflammation by preventing proliferation of immune cells might work at effective concentrations for only a very short time and once a week. In addition, the rapid clinical remission and the short term effect on the acute phase reactants, as seen with low dose MTX administration in most patients with …

Estrogens and autoimmune diseases

Abstract:  Sex hormones are implicated in the immune response, with estrogens as enhancers at least of the humoral immunity and androgens and progesterone (and glucocorticoids) as natural immune‐suppressors . Several physiological, pathological, and therapeutic conditions may change the serum estrogen milieu and/or peripheral conversion rate, including the menstrual cycle, pregnancy, postpartum period, menopause, being elderly, chronic stress, altered circadian rhythms, inflammatory cytokines, and use of corticosteroids, oral contraceptives, and steroid hormonal replacements, inducing altered androgen/estrogen ratios and related effects. In particular, cortisol and melatonin circadian rhythms are altered, at least in rheumatoid arthritis (RA), and partially involve sex hormone circadian synthesis and levels as well. Abnormal regulation of aromatase activity (i.e., increased activity) by inflammatory cytokine production (i.e., TNF‐alpha, IL‐1, and IL‐6) may partially explain the abnormalities of peripheral estrogen synthesis in RA (i.e., increased availability of 17‐beta estradiol and possible metabolites in synovial fluids) and in systemic lupus erythematosus, as well as the altered serum sex‐hormone levels and ratio (i.e., decreased androgens and DHEAS). In the synovial fluids of RA patients, the increased estrogen concentration is observed in both sexes and is more specifically characterized by the hydroxylated forms, in particular 16alpha‐hydroxyestrone, which is a mitogenic and cell proliferative endogenous hormone. Local effects of sex hormones in autoimmune rheumatic diseases seems to consist mainly in modulation of cell proliferation and cytokine production (i.e., TNF‐alpha, Il‐1, IL‐12). In this respect, it is interesting that male patients with RA seem to profit more from anti‐TNFalpha strategies than do female patients.

Androgens and estrogens modulate the immune and inflammatory responses in rheumatoid arthritis.

Abstract: Generally, androgens exert suppressive effects on both humoral and cellular immune responses and seem to represent natural anti‐inflammatory hormones; in contrast, estrogens exert immunoenhancing activities, at least on humoral immune response. Low levels of gonadal androgens (testosterone/dihydrotestosterone) and adrenal androgens (dehydroepiandrosterone and its sulfate), as well as lower androgen/estrogen ratios, have been detected in body fluids (that is, blood, synovial fluid, smears, salivary) of both male and female rheumatoid arthritis patients, supporting the possibility of a pathogenic role for the decreased levels of the immune‐suppressive androgens. Several physiological, pathological, and therapeutic conditions may change the sex hormone milieu and/or peripheral conversion, including the menstrual cycle, pregnancy, the postpartum period, menopause, chronic stress, and inflammatory cytokines, as well as use of corticosteroids, oral contraceptives, and steroid hormonal replacements, inducing altered androgen/estrogen ratios and related effects. Therefore, sex hormone balance is still a crucial factor in the regulation of immune and inflammatory responses, and the therapeutical modulation of this balance should represent part of advanced biological treatments for rheumatoid arthritis and other autoimmune rheumatic diseases.

Scoring the nailfold microvascular changes during the capillaroscopic analysis in systemic sclerosis patients

Background: Longitudinal study to define a scoring system to quantify the specific capillary abnormalities, as observed by capillary microscopy in systemic sclerosis (SSc). Methods: Ninety patients with SSc were evaluated by nailfold videocapillaroscopy for an average of 72 (SD 23) months. Enlarged and giant capillaries, haemorrhages, loss of capillaries, disorganisation of the microvascular array, and capillary ramifications were the evaluated parameters identifying the “scleroderma patterns”. A semiquantitative rating scale to score these altered microvascular parameters was adopted (score 0–3). A “microangiopathy evolution score” (sum of three scores: loss of capillaries, disorganisation of the microvascular array and capillary ramifications) was also selected to assess the progression of the vascular damage. Results: At the end of the follow-up, the score for each nailfold videocapillaroscopy parameter significantly changed. The microangiopathy evolution score significantly increased in 53 of 90 patients (59%) indicating a worsening of the microangiopathy. On the contrary, 22 patients (24%) showed a significant decrease of the evolution score suggesting an improvement of the microangiopathy and no changes were detected in 15 patients with SSc (17%). Conclusions: The capillaroscopic score was found to be a sensitive tool to quantify and monitor the SSc microvascular damage. Furthermore, the microangiopathy evolution score might be used to survey the evolution of the microvascular damage, as the relative scores increase during the progression of the SSc.

Bone Metabolism Changes During Anti-TNF-α Therapy in Patients with Active Rheumatoid Arthritis

Abstract:  Osteoporosis (OP) occurs more frequently in patients with rheumatoid arthritis (RA) than in healthy individuals. Specific treatments of RA may increase susceptibility to OP, but at the same time decrease inflammatory activity, which is associated with accelerated bone loss. Treatment with TNF‐α blockers might influence bone metabolism and prevent structural bone damage in RA, in particular at the periarticular level. Our aim was to assess the influence of anti‐TNF‐α therapy on bone metabolism in RA patients. To that end we evaluated a group of 30 RA patients [mean age 50.6 ± 6.8 years; median disease duration 82 ± 38 months; median disease activity score (DAS‐28) 5.8 ± 1.2: 70% of whom were positive for the rheumatoid factor IgM (>40 IU/mL)]. Patients were treated with stable therapy of prednisone (7.5 mg/day) and methotrexate (MTX = 10 mg/week). Eleven of these RA patients further received etanercept (25 mg, twice/weekly) and 10 infliximab (3 mg/kg on 0, 2, 6, and every 8 weeks thereafter). A control group included 10 RA patients with stable therapy (prednisone and MTX) and without anti‐TNF‐α therapy. All the patients fulfilled the ACR criteria for the diagnosis of adult RA and were treated for 6 months. Quantitative ultrasound (QUS) bone densitometry was performed at the metaphyses of the proximal phalanges of both hands with a DBM Sonic 1200 QUS device (IGEA, Carpi, Italy). Amplitude‐dependent speed of sound (AD‐SoS) was evaluated at base line and at 3 and 6 months. Bone mineral density (BMD) of the hip and lumbar spine (L1–L4) was determined by a densitometer (GE Lunar Prodigy, USA) at base line at after 6 months. Soluble bone turnover markers [osteocalcin (BGP) and deoxypyridinoline/creatinine (Dpd/Cr) ratio] were measured in all patients at the same times, using enzyme‐linked immunosorbent assay tests. All data were compared using Wilcoxon signed rank test. Results were as follows: AD‐SoS values were found increased by 1.3% after 6 months of treatment in the RA patients treated with anti‐TNF‐α therapy. On the contrary, the Ad‐SoS levels decreased by 4.6% during the same period in the untreated RA group. BMD increased by 0.2% at lumbar spine and 0.1% at the hip in TNF‐α‐blocker‐treated patients and decreased by 0.8% and 0.6% (at lumbar spine and at the hip, respectively) in RA patients without anti‐TNF‐α therapy. However, BMD variations were not significant. In RA patients treated with TNF‐α blockers, BGP levels were found significantly increased (14.8 ± 3.8 mg/mL vs. 22.4 ± 4.2 mg/mL; P < 0.01) and Dpd/Cr levels were found significantly decreased (8.2 ± 2.1 nM vs. 4.6 ± 1.8 nM; P < 0.01) at 6 months when compared to base line values. On the contrary, there were no significant differences in the untreated RA patients concerning these latter parameters (BGP = 12.2 ± 3.1 mg/mL vs. 10.8 ± 2.8 mg/mL and Dpd/Cr = 8.9 ± 2.4 nM vs. 10.2 ± 1.8 nM, respectively). In conclusion, during 6 months of treatment of RA patients with TNF blockers, bone formation seems increased while bone resorption seems decreased. The reduced rate of OP appears to be supported by the same mechanisms involved in the decreased bone joint resorption during anti‐TNF‐α therapy, that is, the marked decrease of the proinflammatory (i.e., TNF‐α) cytokine effects on bone metabolism.

Effects of Anti‐TNF‐α Treatment on Lipid Profile in Patients with Active Rheumatoid Arthritis

Abstract:  Cardiovascular morbidity and mortality appear to be increased in rheumatoid arthritis (RA), which might be due to increased prevalence of risk factors for cardiovascular disease, such as an accelerated progression of atherosclerosis. Patients with active RA frequently show an atherogenic lipid profile, which has been linked with the inflammatory reaction. Tumor necrosis factor‐α (TNF‐α), a pivotal proinflammatory cytokine implicated in the pathogenesis of atherosclerosis in RA, may be involved in the development of the altered lipid profile observed in active RA. Our aim was to investigate the effects of anti‐TNF‐α treatment in combination with methotrexate (MTX) and corticosteroid therapy on lipid profile in patients with active RA. In this prospective study 34 consecutive RA patients were included (all women, mean age 51.6 ± 7.9 years, range 46–72 years) with active (defined as Disease Activity Index 28 joint score [DAS‐28], of at least 3.2) and refractory RA, in stable treatment with MTX (7.5–10 mg/week) and prednisone (7.5–10 mg/day) for 3 months. All patients received TNF‐α blockers (n= 16, etanercept 25 mg twice weekly; n= 14, infliximab 3 mg/kg on 0, 2, 6, and every 8 weeks thereafter; and finally, n= 4, adalimumab 40 mg every other week). Total cholesterol, high‐density lipoprotein cholesterol (HDL cholesterol), triglycerides (TG) and lipoprotein (a) [Lp(a)] levels and the atherogenic index (ratio cholesterol/HDL cholesterol) were measured at base line, and at 16 and 24 weeks. Results were as follows: The DAS‐28 was 6.9 ± 2.1 at base line and decreased to 4.6 ± 1.8 after 16 weeks, and further to 4.1 ± 1.3 after 24 weeks (both, P < 0.01). Following anti‐TNF‐α treatment, the mean levels of total cholesterol were 168 ± 24 mg/dL at base line and increased to 188 ± 28 mg/dL at 16 weeks (P < 0.01), and 197 ± 26 mg/dL at 24 weeks (P < 0.001). However, also the mean levels of HDL cholesterol were significantly higher than basal values after 16 and 24 weeks of treatment (34 ± 12 mg/dL versus 36 ± 18 mg/dL [P < 0.05] and 38 ± 14 mg/dL [P < 0.01], respectively). TG and Lp(a) levels, as well as the atherogenic index were not significantly changed. Interestingly, variations in disease activity were significantly and inversely correlated with HDL cholesterol levels. In conclusion: Short anti‐TNF‐α treatment was associated with a significant increase of both total cholesterol and HDL cholesterol levels, and correlated with decreased disease activity. The atherogenic index showed no changes during the study. Therefore, anti‐TNF‐α treatment might affect lipid profile in RA patients.

Circadian rhythms in RA

Possible roles of cortisol and melatonin It is well known that some clinical signs and symptoms of rheumatoid arthritis (RA) vary within a day and between days, and the morning stiffness seen in patients with RA has become one of the diagnostic criteria of the disease (fig 1).1 Figure 1 Clinical signs and symptoms of articular inflammation in patients with RA change consistently as a function of the hours of the day: pain and joint stiffness are greater after waking up in the morning than in the afternoon or evening. Among the clinical signs of joint inflammation in patients with RA, the intensity of pain changes consistently as a function of the hours of the day: pain is greater after waking up in the morning than in the afternoon or evening.2 In patients with RA circadian variations are also found in joint swelling and finger size and these symptoms are in phase with the circadian rhythm of pain. The RA rhythms differ in phase by about 12 hours from the circadian changes of left and right hand grip strength: a greater grip strength is seen when joint circumferences and the subjective ratings of stiffness and pain are least and vice versa.3 “Clinical signs and symptoms in RA depend on the time of day” Therefore, clinical signs and symptoms in RA show a rhythm that seems driven by a biological clock. Biological rhythms have been seen in different models of inflammation, and maximal inflammation occurred during the activity period of the animals—that is, between midnight and 8 00 am.4 Biological rhythms with a periodicity longer than 24 hours have also been detected, and a circaseptan rhythm (almost seven days) of paw oedema, over a period of 30 days, was observed, with peak of inflammation every 6–7 days.5 Furthermore, …

Vitamin D endocrine system involvement in autoimmune rheumatic diseases

Vitamin D is synthesized from cholesterol in the skin (80-90%) under the sunlight and then metabolized into an active D hormone in liver, kidney and peripheral immune/inflammatory cells. These endocrine-immune effects include also the coordinated activities of the vitamin D-activating enzyme, 1alpha-hydroxylase (CYP27B1), and the vitamin D receptor (VDR) on cells of the immune system in mediating intracrine and paracrine actions. Vitamin D is implicated in prevention and protection from chronic infections (i.e. tubercolosis), cancer (i.e. breast cancer) and autoimmune rheumatic diseases since regulates both innate and adaptive immunity potentiating the innate response (monocytes/macrophages with antimicrobial activity and antigen presentation), but suppressing the adaptive immunity (T and B lymphocyte functions). Vitamin D has modulatory effects on B lymphocytes and Ig production and recent reports have demonstrated that 1,25(OH)2D3 does indeed exert direct effects on B cell homeostasis. A circannual rhythm of trough vitamin D levels in winter and peaks in summer time showed negative correlation with clinical status at least in rheumatoid arthritis and systemic lupus erythematosus. Recently, the onset of symptoms of early arthritis during winter or spring have been associated with greater radiographic evidence of disease progression at 12 months possibly are also related to seasonal lower vitamin D serum levels.

Do worsening scleroderma capillaroscopic patterns predict future severe organ involvement? a pilot study

Objective Assessment of associations of nailfold videocapillaroscopy (NVC) scleroderma patterns (‘early’, ‘active’ and ‘late’) with future severe clinical involvement in a systemic sclerosis (SSc) population. Methods Sixty-six consecutive patients with SSc according to the LeRoy and Medsger criteria underwent NVC assessment at baseline. Videocapillaroscopic images were classified into ‘normal’, ‘early’, ‘active’ or ‘late’ NVC pattern. Clinical evaluation was performed for nine organ systems (general, peripheral vascular, skin, joint, muscle, gastrointestinal tract, lung, heart and kidney) according to the disease severity scale of Medsger (DSS) at 18–24 months of follow-up. Severe clinical involvement was defined as category 2–4 per organ of the DSS. Results NVC patterns were significantly associated with future severe, peripheral vascular/lung involvement at 18–24 months. The OR rose steadily throughout the patterns. The OR for future severe peripheral disease based on simple/multiple (correcting for disease duration, subset and medication) logistic regression was 2.49/2.52 (95% CI 1.33 to 5.43, p=0.003/1.11 to 7.07, p=0.026) for early, 6.18/6.37 for active and 15.35/16.07 for late NVC scleroderma patterns versus the normal NVC pattern. The OR for future severe lung involvement based on simple/multiple regression was 2.54/2.33 (95% CI 1.40 to 5.22, p=0.001/1.13 to 5.52, p=0.021) for early, 6.43/5.44 for active and 16.30/12.68 for late NVC patterns. Conclusions This pilot study is the first demonstrating an association between baseline NVC patterns and future severe, peripheral vascular and lung involvement with stronger odds according to worsening scleroderma patterns. This may indicate a putative role of capillaroscopy as a biomarker.

Nailfold capillaroscopy for day-to-day clinical use: construction of a simple scoring modality as a clinical prognostic index for digital trophic lesions

Objective Construction of a simple nailfold videocapillaroscopic (NVC) scoring modality as a prognostic index for digital trophic lesions for day-to-day clinical use. Methods An association with a single simple (semi)-quantitatively scored NVC parameter, mean score of capillary loss, was explored in 71 consecutive patients with systemic sclerosis (SSc), and reliable reduction in the number of investigated fields (F32–F16–F8–F4). The cut-off value of the prognostic index (mean score of capillary loss calculated over a reduced number of fields) for present/future digital trophic lesions was selected by receiver operating curve (ROC) analysis. Results Reduction in the number of fields for mean score of capillary loss was reliable from F32 to F8 (intraclass correlation coefficient of F16/F32: 0.97; F8/F32: 0.90). Based on ROC analysis, a prognostic index (mean score of capillary loss as calculated over F8) with a cut-off value of 1.67 is proposed. This value has a sensitivity of 72.22/70.00, specificity of 70.59/69.77, positive likelihood ratio of 2.46/2.32 and a negative likelihood ratio of 0.39/0.43 for present/future digital trophic lesions. Conclusions A simple prognostic index for digital trophic lesions for daily use in SSc clinics is proposed, limited to the mean score of capillary loss as calculated over eight fields (8 fingers, 1 field per finger).