David E. Trentham

Efficacy of Low-Dose Methotrexate in Rheumatoid Arthritis

Twenty-eight patients with refractory rheumatoid arthritis completed a randomized 24-week double-blind crossover trial comparing oral methotrexate (2.5 to 5 mg every 12 hours for three doses weekly) with placebo. The methotrexate group had significant reductions (P less than 0.01 as compared with the placebo group) in the number of tender or painful joints, the duration of morning stiffness, and disease activity according to physician and patient assessments at the 12-week crossover visit; reductions in the number of swollen joints (P less than 0.05) and 15-m walking time (P less than 0.03) also occurred. These variables, as well as the grip strength and erythrocyte sedimentation rate, showed significant (P less than 0.01) improvement at 24 weeks in the population crossed over to methotrexate. A significantly increased frequency (P less than 0.03) of the HLA-DR2 haplotype occurred in the eight patients with the most substantial response to methotrexate. Adverse reactions during methotrexate therapy included transaminase elevation (21 per cent), nausea (18 per cent), and diarrhea (12 per cent); one patient was withdrawn from the trial because of diarrhea. One patient died while receiving the placebo. Methotrexate did not affect measures of humoral or cellular immunity. We conclude that this trial provides evidence of the short-term efficacy of methotrexate in rheumatoid arthritis, but the mechanism of action is unknown. Longer trials will be required to determine the ultimate safety and effectiveness of this drug.

Humoral and Cellular Sensitivity to Collagen in Type II Collagen-Induced Arthritis in Rats

We have recently described a new animal model of arthritis induced by intradermal injection of a distinct type of collagen found in cartilage (type II collagen). Since immunologic sensitivity to collagen could play a role in the pathogenesis of this type II collagen-induced arthritis in rats, the ability of purified types of native collagens to induce cellular and humoral responses was quantified by antigeninduced tritiated thymidine incorporation into lymphocytes by collagen and passive hemagglutination, respectively. Rats injected intradermally with native heterologous or homologous type II collagens in adjuvant developed type-specific cellular as well as humoral reactivity. Types I and III collagens were less immunogenic than was type II. The latter collagen induced brisk cellular and humoral responses that were equivalent whether complete Freunds adjuvant or incomplete Freunds adjuvant were employed. Both responses could be induced by native type II collagens modified by limited pepsin digestion, indicating that they are not attributable to determinants in the telopeptide regions of the molecule. Thus, these studies demonstrate the unique immunogenic as well as arthritogenic properties of the type II collagen molecule and indicate that both result from a helical conformation of its structurally distinct alpha-chains. Further, they suggest that type II collagen may, by humoral or cellular mechanisms, provoke or perpetuate inflammation in other arthritic diseases.

Treatment of rheumatoid arthritis with oral type II collagen: Results of a multicenter, double‐blind, placebo‐controlled trial

OBJECTIVE Oral administration of cartilage-derived type II collagen (CII) has been shown to ameliorate arthritis in animal models of joint inflammation, and preliminary studies have suggested that this novel therapy is clinically beneficial and safe in patients with rheumatoid arthritis (RA). The present study was undertaken to test the safety and efficacy of 4 different dosages of orally administered CII in patients with RA. METHODS Two hundred seventy-four patients with active RA were enrolled at 6 different sites and randomized to receive placebo or 1 of 4 dosages (20, 100, 500, or 2,500 microg/day) of oral CII for 24 weeks. Efficacy parameters were assessed monthly. Cumulative response rates (percentage of patients meeting the criteria for response at any time during the study) were analyzed utilizing 3 sets of composite criteria: the Paulus criteria, the American College of Rheumatology criteria for improvement in RA, and a requirement for > or = 30% reduction in both swollen and tender joint counts. RESULTS Eighty-three percent of patients completed 24 weeks of treatment. Numeric trends in favor of the 20 microg/day treatment group were seen with all 3 cumulative composite measures. However, a statistically significant increase (P = 0.035) in response rate for the 20 microg/day group versus placebo was detected using only the Paulus criteria. The presence of serum antibodies to CII at baseline was significantly associated with an increased likelihood of responding to treatment. No treatment-related adverse events were detected. The efficacy seen with the lowest dosage is consistent with the findings of animal studies and with known mechanisms of oral tolerance in which lower doses of orally administered autoantigens preferentially induce disease-suppressing regulatory cells. CONCLUSION Positive effects were observed with CII at the lowest dosage tested, and the presence of serum antibodies to CII at baseline may predict response to therapy. No side effects were associated with this novel therapeutic agent. Further controlled studies are required to assess the efficacy of this treatment approach.

Cellular Sensitivity to Collagen in Rheumatoid Arthritis

We examined patients with rheumatoid arthritis for cellular sansitivity to native human Types I, II and III collagens. Mononuclear cells from 50 patients with rheumatoid arthritis, 21 with other inflammatory arthritides, 20 with osteoarthritis and 20 normal subjects were evaluated for the in vitro production of leukocyte inhibitory factor in response to collagen and a control antigen, streptokinase-streptodornase. By this assay, cells from 37 (74 per cent) and 39 (78 per cent) of the patients with rheumatoid arthritis responded to Types II and III collagens, respectively. In contrast, cells from the 41 patients with other kinds of arthritis and the normal group did not produce this lymphokine to collagens. There was no response to Type I collagen or to denatured alpha chains of these collagens. All four groups responded equivalently to streptokinase-streptodornase. These data demonstrate that most patients with rheumatoid arthritis exhibit cellular sensitivity to Types II and III collagens.

Passive Transfer by Cells of Type II Collagen-Induced Arthritis in Rats

To investigate the role of immunologic hypersensitivity to collagen in the causation of type II collagen-induced arthritis in rats, passive transfer experiments were performed. Wistar/Lewis rats used in these experiments were demonstrated to be histocompatible by prolonged skin graft survival and mixed lymphocyte cultures. Popliteal lymph node weight assays excluded a potential for graft-vs.-host reactivity in this strain. 9 of 32 naive rats developed arthritis after intravenous receipt of pooled spleen and lymph node cells from donors that had been injected intradermally with type II collagen emulsified in incomplete Freunds adjuvant. This passively transferred synovitis was evident clinically as well as histologically. In control cell transfer experiments involving a total of 97 recipients, transfer of arthritis was shown to require viable cells sensitized to type II collagen. These controls included 17 rats receiving cells from unimmunized donors, 20 recipients of cells from donors injected with incomplete Freunds adjuvant alone, and 24 recipients of cells from rats injected with type I collagen in adjuvant. Deliberate addition of solubilized type II collagen to unsensitized cells at the time of transfer or injection of heat-killed sensitized cells also did not cause arthritis in a total of 36 recipients. These latter two control groups indicate that disease transfer was not the result of antigen carry-over. Intravenous injection of sera from arthritic donors was incapable of passively transferring clinical or histologic synovitis in 30 recipients. Thus, these studies directly implicate immunologic sensitivity to the cartilage type of collagen in the etiology of this autoimmune disease.

Clinical and Immunologic Effects of Fractionated Total Lymphoid Irradiation in Refractory Rheumatoid Arthritis

Ten patients with refractory rheumatoid arthritis were given 3000 rad of fractionated total lymphoid irradiation in an uncontrolled therapeutic trial. Total lymphoid irradiation was associated with objective evidence of considerable clinical improvement in eight patients and with reduced blood lymphocyte counts in all 10. On completion of irradiation, there was an abrogation of lymphocyte reactivity in vitro in the patients with clinical responses, but abnormal antibody activities characteristic of rheumatoid arthritis and normal components of humoral immunity were not suppressed. Partial recrudescence of arthritis occurred shortly after a year after the completion of irradiation and was paralleled by a restitution of lymphocyte concentrations and responsiveness to mitogens to levels similar to those observed before irradiation. These data provide further evidence of T-cell involvement in the pathogenesis of rheumatoid arthritis and demonstrate that total lymphoid irradiation can induce temporary relief, but they do not ascertain whether the natural history of this disease was altered.

Autoimmunity to collagen in adjuvant arthritis of rats.

Arthritis can be induced in rats by intradermal injection of oil containing bacterial derivatives (adjuvant-induced arthritis) or cartilage collagen (type II collagen-induced arthritis). It was of interest, therefore, to determine whether collagen functions as an autoantigen in rats with adjuvant arthritis. Blood mononuclear cells from the majority of rats with adjuvant arthritis exhibited enhanced thymidine incorporation to homologous types I and II collagens, as well as to purified protein derivative of tuberculin. In contrast, cells from rats remaining nonarthritic after injection of adjuvant did not respond to collagen, although they did react to tuberculin. Similar results were obtained with a radiometric ear assay used to quantify intradermal delayed-type hypersensitivity in vivo. Using passive hemagglutination, autoantibodies to these collagens and their denatured alpha-chains were frequently detected in the sera of rats late in the course of adjuvant arthritis. Rats with inflammation of a hindlimb induced by turpentine did not acquire sensitivity to collagen. These data indicate that autoimmunity to collagen is a common feature of adjuvant- and collagen-induced arthritis, both of which are considered to be mediated by immunologic mechanisms.

Relapsing Polychondritis and Airway Involvement

OBJECTIVE To assess the prevalence and characteristics of airway involvement in relapsing polychondritis (RP). METHODS Retrospective chart review and data analysis of RP patients seen in the Rheumatology Clinic and the Complex Airway Center at Beth Israel Deaconess Medical Center from January 2004 through February 2008. RESULTS RP was diagnosed in 145 patients. Thirty-one patients had airway involvement, a prevalence of 21%. Twenty-two patients were women (70%), and they were between 11 and 61 years of age (median age, 42 years) at the time of first symptoms. Airway symptoms were the first manifestation of disease in 17 patients (54%). Dyspnea was the most common symptom in 20 patients (64%), followed by cough, stridor, and hoarseness. Airway problems included the following: subglottic stenosis (n = 8; 26%); focal and diffuse malacia (n = 15; 48%); and focal stenosis in different areas of the bronchial tree in the rest of the patients. Twelve patients (40%) required and underwent intervention including balloon dilatation, stent placement, tracheotomy, or a combination of the above with good success. The majority of patients experienced improvement in airway symptoms after intervention. One patient died during the follow-up period from the progression of airway disease. The rest of the patients continue to undergo periodic evaluation and intervention. CONCLUSION In this largest cohort described in the English language literature, we found symptomatic airway involvement in RP to be common and at times severe. The nature of airway problems is diverse, with tracheomalacia being the most common. Airway intervention is frequently required and in experienced hands results in symptom improvement.

Association between Bovine Collagen Dermal Implants and a Dermatomyositis or a Polymyositis-like Syndrome

Table. SI Units Dermatomyositis and polymyositis are uncommon, acquired inflammatory myopathologic abnormalities [1]. Regional studies of hospital-diagnosed cases in Memphis and Shelby County, Tennessee [2] and in Pittsburgh and Allegheny County, Pennsylvania [3] indicate that the annual incidence rate for these conditions is approximately 5.0 to 8.9 patients/million population. The overall female-to-male incidence ratio for these diseases is approximately 2:1, and the observed black-to-white incidence ratio is between 3:1 and 4:1 [2, 3]. Although dermatomyositis or polymyositis may occur at any age, a bimodal age distribution appears to exist with a small peak in children between the ages of 5 and 14 years and a much larger peak among adults 45 to 65 years old [2-5]. As in a number of autoimmune disorders, the inflammatory myopathologic abnormalities are associated with human leukocyte antigens (HLA), specifically an increased frequency of the HLA-DR3 and HLA-B8 phenotypes [6]. The diagnosis is generally made on the basis of the five Bohan and Peter criteria [7], which are as follows: 1) symmetric progressive proximal muscle weakness; 2) muscle-biopsy evidence of muscle fiber necrosis, phagocytosis, and regeneration; variation in fiber size; and inflammatory exudates, predominantly lymphocytes and often in a perivascular pattern; 3) increased serum levels of skeletal-muscle enzymes; 4) electromyographic changes characteristic of myositis, including short-duration, low-amplitude, polyphasic potentials; fibrillation potentials; and high-frequency, repetitive discharges; and 5) dermatologic involvement, which may include a scaly, erythematous rash on the face, neck, upper chest, and extensor surfaces of the elbows and knees; a periorbital, violaceous discoloration (heliotrope rash), often accompanied by edema; and scaly, erythematous plaques (Gottron papules) on the dorsa of the hands, primarily over the knuckles [4-7]. Using the Bohan and Peter system, polymyositis is classified as definite with the presence of all four of the nonrash criteria, probable with three of the nonrash criteria, and possible with two of the nonrash criteria. Dermatomyositis is classified as definite with the presence of the skin-rash criterion plus three or four other criteria, probable with the skin rash plus two other criteria, and possible with the skin rash plus one other criterion. Injectable bovine collagen is used to correct superficial facial defects, including wrinkles due to aging and depressed scars resulting from acne, surgery, or trauma [8-10]. Zyderm collagen implant was approved as a medical device by the Food and Drug Administration in July 1981 and Zyplast implant, a glutaraldehyde cross-linked collagen, was approved in June 1985. Both Zyderm and Zyplast implants (manufactured by Collagen Corporation, Palo Alto, California) are pepsin-solubilized suspensions derived from bovine skin and consist of approximately 95% type I and 5% type III collagen. Glutaraldehyde cross-linking has been used in the production of Zyplast collagen to make the material more resistant to proteolytic degradation and, therefore, more persistent as an implant [8-10]. The products contain 0.3% lidocaine and are injected using a fine needle into the dermal layer beneath depressed scars or wrinkles where correction is needed [10]. The suspensions remain fluid when refrigerated but, after injection and warming to body temperature, the collagen fibrils coalesce to form a matrix that remains in place after excess fluid is reabsorbed, thus filling the tissue defect [11, 12]. Although a patient or family history of autoimmune disease was originally listed as a contraindication for the use of bovine collagen implants [12, 13], the family history contraindication was eliminated in October 1982. More recently, a personal history of autoimmune disease was downgraded from a contraindication to a warning on the package insert. The possibility that bovine collagen injections might trigger autoimmune disease is controversial [12, 14-19]. Our article describes nine patients who developed a dermatomyositis or polymyositis-like syndrome diagnosed an average of 6.4 months after Zyderm or Zyplast exposure. Methods Case Finding A case was defined as any person with definite or probable dermatomyositis or polymyositis [7] who had a history of bovine collagen injection(s) before their diagnosis. Case finding was achieved through various methods, including patients (seen by coauthors JC and JS) at the Doctors Center and Arthritis Clinic of Houston (three cases), self-referred patients (one case), and patients found after review of adverse reaction reports received by the manufacturer (five cases). Because no reports after June 1988 were available for review, the study period was limited to July 1980 through June 1988. Determining Expected Dermatomyositis or Polymyositis Case Ratio Annual estimates of the number of new patients treated with collagen and their demographic characteristics were obtained from the manufacturer. These data were combined to produce age-, race-, and sex-specific monthly estimates of the collagen-treated population during the study period. The test and treatment dates for each case patient, together with the date of diagnosis, were used to derive an average latency period for that patient. As each of the nine case patients was added to the series, the period for that case patient was combined with those of all previous case patients to produce the mean latency period for the group up to that point in time. The cumulative number of patients who had received collagen injections to that point in time was determined from the projected 1-month treatment cohorts. These figures were combined to derive the effective total patient-years of observation for collagen recipients through the date of diagnosis for each case patient. Age-, race-, and sex-specific incidence rates of dermatomyositis or polymyositis were obtained from a 20-year, hospital-based study by Oddis and colleagues [3], in which the incidence during 1973 to 1982 more than tripled compared with 1963 to 1972. Because the second decade of this study is closer in time to our 1980 to 1988 study period, the incidence rates were adjusted upward to produce an overall rate of 8.6 instead of their reported 20-year rate of 5.5 case patients/million population per year. These adjusted rates were then applied to the patient-years of observation to arrive at the number of dermatomyositis or polymyositis cases expected at the point in time when each of the observed case patients was diagnosed. From these data, the standardized incidence ratio, the 95% confidence interval, and the Poisson probability were calculated for cumulative observed and expected pairs. Oddis and colleagues [3] reported that, of the 115 persons with adult dermatomyositis or polymyositis (not including patients who also had other types of connective tissue disease [overlap patients] or patients whose cases were associated with malignancy), 88 (77%) had polymyositis and 27 (23%) had dermatomyositis. In our series, only 1 case patient (11%) had polymyositis, whereas 8 case patients (89%) had dermatomyositis. To evaluate the importance of dermatomyositis alone in the series, the single patient who had polymyositis was excluded. The incidence rates from the Oddis and colleagues [3] study were modified to reflect the proportion of dermatomyositis case patients with respect to polymyositis and dermatomyositis combined. The number of dermatomyositis case patients, expected at the point in time when each of the eight observed case patients were diagnosed, was then calculated using the method described above. Monte Carlo Simulation The third phase of the analysis used a Monte Carlo simulation to further assess the apparent temporal association between bovine collagen dermal implants and the development of dermatomyositis or polymyositis. The term Monte Carlo simulation refers to any experiment in which random numbers are drawn (either using a table of random numbers or using computer generation) to simulate sampling from a population or probability distribution [20]. These techniques are often used to simulate experiments that either cannot be done in the laboratory, are mathematically intractable, or would require prohibitively expensive equipment [21-23]. Although the simulation results are only an approximation of the true value, any desired degree of accuracy may be obtained by selecting a large enough number of trials [24]. The first step of the analysis involved the calculation of the maximum number of patients who could have been observed at intervals from 1 to 96 months after collagen exposure. Because the collagen-treated patients were not under any form of systematic medical follow-up, these calculations were made only to determine the theoretical maximum number of dermatomyositis or polymyositis case patients expected for this select population. Using these assumptions, patients treated early in the study period contributed many patient-months of observation, whereas those treated in the last month were considered to have been observable for only a single month. These data were summed and converted to patient-years of observation within each of the 96 observation periods. The age-, race-, and sex-specific dermatomyositis or polymyositis incidence rates were applied to the patient-years of observation to arrive at the number of patients with dermatomyositis or polymyositis expected to occur in each age group and within each of the 96 periods. Expected case patients from each age group were summed within each postexposure observation period to produce a single total for each of the 96 periods. This distribution was then converted to a probability distribution by dividing each element by the sum for the entire distribution. The corresponding data for expected dermatomyositis case patients were calculated by adjusting the rates from

Minocycline in early diffuse scleroderma

Based on its efficacy in rheumatoid arthritis and anecdotal evidence, we did an open trial of minocycline in early diffuse scleroderma. Patients satisfied criteria for the diagnosis of scleroderma and did not have additional rheumatic disease. Inclusion criteria were clinical systemic sclerosis on the extremities proximal to the elbow and knee and on the trunk below the clavicles, and disease duration of 3 years or less from the onset of the first symptoms, including Raynaud’s phenomenon, as determined by the patient’s rheumatologist. Exclusion criteria included internal-organ damage. Patients were evaluated at 3-month intervals for 1 year. Medications for Raynaud’s and gastrointestinal-tract disturbances were continued. Patients on treatments that might modify scleroderma had a 1-month washout period. Minocycline was started at 50 mg twice daily, taken with water on an empty stomach; the dose was increased to 100 mg twice daily after 1 month. At each visit, a previously validated total skin score (TSS) was determined by palpation of the skin at 17 surface areas and was graded: 0=normal, 1=thickened skin, 2=thickened, unable to move, and 3=thickened, unable to pinch; maximum possible TSS was 51. Response in TSS was defined as a more than 35% decrease at 12 months. To measure overall well being, a patient and physician 10 cm visual analogue scale (VAS) was used: 0 cm=could not be better, 10 cm=could not be worse. Response in VAS was arbitrarily defined as more than 35% decreased at 12 months. Eleven patients, all diagnosed by at least one independent rheumatologist, were enrolled. Patients number 1, 4, and 11 washed off penicillamine and 2, methotrexate (table). A single observer (CHL) did the evaluations except for the final two visits of patient 11. At the end of 1 year, four patients had complete resolution of their skin disease and their final TSS was 0 (table). In three of these four patients, patient and physician VAS scores improved to 0. In two of the 11 patients, there was no improvement in TSS. In one of these two patients, there was a significant improvement in VAS scores. Five patients did not complete the study; two with renal crisis, one died of adenocarcinoma, and two were noncompliant. Adverse reactions included oral yeast infection in one patient and two episodes of vaginal yeast infection in another. One patient developed nausea and dizziness for the first two weeks. On initial testing, serum concentrations of the adhesion molecules, ICAM-1, VCAM-1, and E-selectin were elevated in patients 11, 10, and nine. Changes did not occur during the trial. No accepted reversal treatment for scleroderma exists. Although the mechanism of action is unknown, minocycline should undergo larger-scale study in scleroderma.