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ObjectiveIn MOBILITY (NCT01061736), sarilumab significantly reduced disease activity, improved physical function and inhibited radiographic progression at week 52 versus placebo in patients with rheumatoid arthritis (RA) and an inadequate response to methotrexate. We report 5-year safety, efficacy and radiographic outcomes of sarilumab from NCT01061736 and the open-label extension (EXTEND; NCT01146652), in which patients received sarilumab 200 mg every 2 weeks (q2w) + methotrexate.MethodsPatients (n=1197) with moderately to severely active RA were initially randomised to placebo, sarilumab 150 mg or sarilumab 200 mg subcutaneously q2w plus weekly methotrexate for 52 weeks. Completers were eligible to enrol in the open-label extension and receive sarilumab 200 mg q2w + methotrexate.ResultsOverall, 901 patients entered the open-label extension. The safety profile remained stable over 5-year follow-up and consistent with interleukin-6 receptor blockade. Absolute neutrophil count 3 was observed but not associated with increased infection rate. Initial treatment with sarilumab 200 mg + methotrexate was associated with reduced radiographic progression over 5 years versus sarilumab 150 mg + methotrexate or placebo + methotrexate (mean±SE change from baseline in van der Heijde-modified Total Sharp Score: 1.46±0.27, 2.35±0.28 and 3.68±0.27, respectively (pConclusionClinical efficacy, including inhibition of radiographic progression, reduction in disease activity and improvement in physical function, was sustained with sarilumab + methotrexate over 5 years. Safety appeared stable over the 5-year period.

Background Sarilumab, a human IL-6R blocker approved for the treatment of RA, has shown efficacy as monotherapy and in combination with csDMARDs in Phase 3 trials. Objectives We assessed long-term safety from the sarilumab clinical development program in adult patients with RA who received subcutaneous (SC) sarilumab in eight clinical trials and their open-label extensions: MOBILITY (NCT01061736), TARGET (NCT01709578), ASCERTAIN (NCT01768572), EASY (NCT02057250), COMPARE (NCT01764997), ACT11575 (NCT01217814), MONARCH (NCT02332590), ONE (NCT02121210), and the open-label extension EXTEND (NCT01146652). Methods Data (cut-off Jan 15, 2018) were pooled from patients on sarilumab+csDMARD (N=2887) or sarilumab monotherapy (N=471). Patients had received sarilumab 200 mg or 150 mg q2w SC, except for 151 patients from MOBILITY Part A who received 100 mg qw, 150 mg qw, or 100 mg q2w. Treatment-emergent (TE) adverse events (AEs), AEs of special interest (AESIs), and discontinuations were assessed. Results Demographics were similar between combination and monotherapy pools (mean age 52 years; 81–83% female), and 38.7% and 8.5% of patients had received prior bDMARDs. Cumulative drug exposure was 7,985.5 and 798.7 patient-years (PY), with maximum duration 7.3 and 3.5 years. Exposure-adjusted rates of TEAEs, serious AEs, and TEAEs leading to discontinuations were similar (Table). Infections were the most common AESI. Rates of serious infection were 3.7 and 1.0/100 PY for combination and monotherapy, respectively, and were not associated with decreased absolute neutrophil counts (ANCs). Incidences of ALT >3× upper limit of normal and ANC Conclusion The long-term safety profile of sarilumab, either as monotherapy (observed for >3.5 years) or with csDMARD (observed for >7 years), remains stable and consistent with the anticipated profile of an IL-6R blocker. Acknowledgement Study funding and editorial support (Helen Johns, Adelphi) were provided by Sanofi and Regeneron Pharmaceuticals, Inc. These data were previously presented at the 2018 American College of Rheumatology annual meeting. Disclosure of Interests Roy Fleischmann Grant/research support from: AbbVie, Amgen, AstraZeneca, Bristol-Myers Squibb, Celtrion, Genentech, GSK, Janssen, Lilly, Novartis, Pfizer Inc, Sanofi-Aventis, UCB, Consultant for: AbbVie, Amgen, AstraZeneca, Bristol-Myers Squibb, Celtrion, Genentech, GSK, Janssen, Lilly, Novartis, Pfizer Inc, Sanofi-Aventis, UCB, Yong Lin Shareholder of: Sanofi Genzyme, Employee of: Sanofi Genzyme, Gregory St John Shareholder of: Regeneron Pharmaceuticals Inc, Employee of: Regeneron Pharmaceuticals Inc, Desiree van der Heijde Consultant for: AbbVie, Amgen, Astellas, AstraZeneca, Bristol-Myers Squibb, Boehringer Ingelheim, Celgene, Daiichi, Eli-Lilly, Galapagos, Gilead, GlaxoSmithKline, Janssen, Merck, Novartis, Pfizer, Regeneron, Roche, Sanofi, Takeda, Union Chimique Belge, Chunfu Qiu Shareholder of: Sanofi Genzyme, Employee of: Sanofi Genzyme, Juan Jose Gomez-Reino Grant/research support from: Biogen, Gilead, Eli Lilly, Merck Sharp & Dohme, Pfizer, Roche, Consultant for: Biogen, Gilead, Eli Lilly, Merck Sharp & Dohme, Pfizer, Roche, Jose Antonio Maldonado-Cocco Consultant for: Pfizer, Merck Sharp Dohme, Sanofi – Aventis, Novartis, Bristol Myers Squibb, Roche, Boehringer Ingelheim, Schering – Plough, Abbott, UCB, Eli Lilly, Gilead, Speakers bureau: Pfizer, Merck Sharp Dohme, Sanofi – Aventis, Novartis, Bristol Myers Squibb, Roche, Boehringer Ingelheim, Schering – Plough, Abbott, UCB, Eli Lilly., Marina Stanislav Consultant for: R-Pharm, Bruno Seriolo: None declared, Gerd Rudiger Burmester Consultant for: Roche, Sanofi-Genzyme, Speakers bureau: Roche, Sanofi-Genzyme

Background Systemic sclerosis (SSc) as well as rheumatoid artrhritis (RA) patients present an increased risk of osteoporosis (OP) as a result of the chronic inflammatory state, low vitamin D, immobilisation and other causes. The Wnt/β-catenin pathway is signalling identified like a key promoters of the osteoblastogenesis hence of the new bone formation in inflammatory conditions. Dickkopf-1 (DKK1) is a natural inhibitor of Wnt signalling pathway that could be involved in promoting osteoclastogenesis through suppression of osteoprotegerin.1Trabecular Bone Score (TBS) is an index of bone quality extracted from dual-energy X-ray absorptiometry (DXA) analysis.2 Objectives In this study, bone mineral density (BMD) and Dkk-1 levels were evaluated in SSc patients, in order to investigate possible associations between systemic OP and/or osteopenia and Dkk-1 concentrations, according to their different nailfold videocapillaroscopic (NVC) patterns of microangiopathy (NVC patterns ‘Early’, ‘Active’, and ‘Late’)3 in SSc patients and to compare the results regarding bone quality with RA patients and healthy subjects (CNT). Methods Eighty-four SSc patients,98 rheumatoid arthritis (RA) and 60 CNT were studied. Dkk-1 serum levels were measured by ELISA methods (Quantikine Human DKK-1 Immunoassay R and D System, Minneapolis, USA). Bone Mineral Density (BMD, g/cm2) of the lumbar spine (L1-L4) was analysed by dual-energy X-ray absorptiometry (DXA) scan. Lumbar spine bone quality was derived from each spine DXA examination using the TBS analysis. Nailfold videocapillaroscopic (NVC) patterns were analysed as previous reported.3 25 hydroxyvitamin D (25(OH)D ng/ml) serum concentration was evaluated in all subjects. Results Serum DKK-1 levels were significantly higher in patients with SSc than in CNT (2892±1121 pg/ml vs 2044±692 pg/ml, p Conclusions The data obtained showed a significantly Increased of Dkk-1 serum concentrations together and a decreased bone mass (lower TBS and BMD) in SSc patients compared to CNT. The bone quality seems lower in SSc patients with more altered microvasculature (‘Late’ NVC pattern). References [1] Krishnan V, et al. J Clin Invest2006;116:1202–9. [2] Roux JP, et al. Osteoporosis Int2013;24:2455–60. [3] Cutolo M, et al. J Rheumatol2000;27:155–60. Disclosure of Interest None declared

Background Systemic sclerosis (SSc) is associated with an increased risk of altered bone and fractures as a result of multiple factors, including treatment-related side effects, low vitamin D serum concentrations and reduced physical activity.1 Trabecular Bone Score (TBS) is an index extracted from dual-energy X-ray absorptiometry (DXA) analysis, that provides an indirect measurement of axial bone microarchitecture and bone quality(.2 Objectives The aim of this study was to evaluate possible correlation between bone quality, by TBS, and different levels of microvascular damage, as evaluated by nailfold videocapillaroscopy (NVC) patterns3 in SSc patients and to compare the results regarding bone quality with RA patients and healthy subjects (CNT). Methods Eighty-eight SSc patients, 98 rheumatoid arthritis (RA) patients and 60 CNT were studied. Bone Mineral Density (BMD, g/cm2) of the lumbar spine (L1-L4) was analysed by dual-energy X-ray absorptiometry (DXA) scan. Lumbar spine bone quality was derived from each spine DXA examination using the TBS analysis. NVC patterns were analysed as previous reported.3 All patients were subjected to 25 hydroxyvitamin D (25(OH)D ng/ml) serum dosage. Results TBS values were found statistically higher in SSc with a “Early” NVC pattern, compared to the “Active” or “Late” pattern (1.182±0.1, 1.101±0.8, 1.074±0.1 respectively, p Conclusions The bone quality seems lower in SSc patients with more altered microvasculature (“Late” NVC pattern). The data obtained showed also a significantly lower bone quality (lower TBS and BMD) in SSc and RA patients compared to CNT. The association between bone damage and the ”Late” advanced NVC pattern of microvascular damage, may suggest that tissue hypoxia/ischemia related to the diffuse microangiopathy might be a further promoting factor for osteoclastogenesis and bone loss. Our results support the development of a combined approach using both TBS and BMD for the assessment of bone microarchitecture/quality in SSc patients during their disease progression. References [1] Cutolo M, et al. Autoimmun Rev2011;12:84–7. [2] Roux JP, et al. Osteoporosis Int2013; 24:2455–60. [3] Cutolo M,et al. J Rheumatol. 2000;27:155–60. Disclosure of Interest None declared

Background Patients affected by Rheumatoid Arthritis (RA) show an increased risk of low bone mass, as a result of multi-systemic disorders including toxic drug, low vitamin D levels, use of glucocorticoids and physical inactivity. Trabecular Bone Score (TBS), is an index extracted from the dual-energy X-ray absorptiometry (DXA) images, that provides an indirect measurement (Score) of bone axial microarchitecture and allows to get information about bone quality.1,2 Objectives The aim of this investigation was to evaluate by TBS the bone quality in AR patients (high risk population) receiving vitamin D supplementation from at least 3 months (1000 IU/die). Methods 108 female patients (mean age 61±8 years) affected by RA and 60 age- matched controls (CNT) (mean age 64±11 years) were analysed in winter time. Bone Mineral Density (BMD, g/cm2) of the lumbar spine (L1-L4) was analysed using a DXA scan (GE, Lunar Prodigy). Lumbar spine TBS (TBS iNsight Medimaps) was derived for each spine DXA examination. All patients were evaluated for serum 25 hydroxyvitamin D (25(OH)D) serum concentrations. Results RA patients showed lower 25(OH)D concentrations (18.4±1.3 ng/ml) than CNT (26.2±0.9 ng/ml; p Conclusions This study shows in RA patients a reduction of TBS values that seem placed side by side with reduced BMD values and in presence of serum 25(OH)D insufficiency. A more carefull analysis of the clinical status/treatments should let to better identify RA patients at higher risk of bone loss. Reference [1] . Cutolo M et al. Autoimmun Rev 2011:12;84–7,2. Avouac J, et al. Arthritis Care Res 2012;64:1871–8 Disclosure of Interest None declared

The endogenous serum metabolite of vitamin D (calcitriol, 1,25(OH)2 D3 ) is considered a true steroid hormone (D hormone), and like glucocorticoids (GCs) and gonadal hormones, may exert several immunomodulatory activities. Serum vitamin D deficiency (25(OH) D), and therefore reduced 1,25(OH)2 D3 availability, is considered a risk factor for several chronic/inflammatory or autoimmune conditions, including infectious diseases, type 1 diabetes, multiple sclerosis, and especially autoimmune rheumatic diseases (ARD). In ARD in particular, 1,25(OH)2 D3 regulates both innate and adaptive immunity, potentiating the innate response (antimicrobial activity) but reducing adaptive immunity (antigen presentation, T and B cell activities). Regarding a possible synergism between vitamin D and GCs, several studies show that 1,25(OH)2 D3 has significant additive effects on dexamethasone-mediated inhibition of human lymphocyte and monocyte proliferation. Conversely, vitamin D deficiency seems to play a role in increasing autoantibody production by B cells, and seasonal vitamin D declines may trigger flares in ARD, as recently shown. Finally, 1,25(OH)2 D3 seems to reduce aromatase activity and limit the negative effects related to increased peripheral estrogen metabolism (cell proliferation, B cell overactivity).

Patients initially diagnosed as having primary Raynaud’s phenomenon (PRP) may shift to secondary (SRP) during the follow-up. Nailfold videocapillaroscopy (NVC) is a tool that allows to distinguish between PRP and SRP through the identification of the “early” scleroderma-pattern of microangiopathy. The aim of this study was to evaluate the transition from PRP to SRP in an Italian cohort of patients during their follow-up. 129 patients with PRP were identified and followed-up for 2721 months. The diagnosis of PRP was achieved as suggested by LeRoy. The NVC diagnosis of scleroderma-pattern was based on the presence of specific “early” capillary abnormalities (i.e. giant capillaries, microhaemorrhages, and/or slight reduction of capillary density). Based on the identification of the “early” scleroderma-pattern by NVC, 14% of patients changed from PRP to SRP during the follow-up. Interestingly, 4.6% of these patients showed at baseline a fully normal NVC pattern (transition from normal to scleroderma NVC pattern in 3427 months), and 10% showed slight and not-specific nailfold capillary abnormalities (i.e. dystrophic capillaries and/or enlarged capillaries) at baseline (transition to scleroderma NVC pattern in 2515 months). Following a careful NVC analysis, we showed the progression from PRP to SRP in 14% of the analyzed patients. We suggest the capillaroscopic analysis twice a year in presence of PRP, in order to early detect the transition to SRP in patients showing at the beginning a normal pattern or not-specific nailfold capillary abnormalities, as assessed by NVC.

The effects of low dose prednisone (PD) alone or in combination with leflunomide (LEF) were tested on inflammatory gene expression in early rheumatoid arthritis (RA). Ten RA patients were assigned as group A (untreated)and group B (pretreated with PD 5 mg/day for 3 months -T0). Therefore, both groups were treated with LFN (20mg/day). Expression ratio of 34 inflammatory genes was detected by microarray analysis in early RA patients and CNT (5), before (T0), and after 3 months (T1) of combined therapy (PN+LFN). At T0, 17 genes linked with arthritis were found altered in early RA, (A and B groups), compared to CNT. At T1 in the group A, 41% of genes were found unchanged, 12% upregulated, and 47% downregulated, whereas in the group B, 65% of genes were found unchanged, 6% upregulated, and 29% downregulated. The results suggest that the combination of PN and LEF seems to play a synergistic effect by modulating some inflammatory genes in early RA.

Rheumatoid arthritis (RA) prevalence is greater in females than in males, supporting estrogens as modulators of immune response. Leflunomide (LEF) is employed in the RA treatment. We studied the combinatory effects of LEF active metabolite A77 1726 (LEF-M) and 17beta-estradiol (E2) on inflammatory cytokine production by cultured macrophages obtained from activated human monocytes (THP-1 cells). Macrophages were cultured with LEF-M alone and in combination with E2. IL-6, TNF-alpha, and TGF-beta were evaluated by immunocytochemistry (ICC), Western blot (WB), and reverse transcriptase-polymerase chain reaction (RT-PCR). ICC, as well as WB and RT-PCR, showed that LEF-M, in respect to untreated cells, significantly downregulated the cytokine production (IL-6 P < 0.01, TNF-alphaP < 0.001, TGF-betaP < 0.01). On the contrary, E2 increased the cytokine production, a result that was significantly reversed when LEF-M was subsequently added (IL-6, TNF-alpha, TGF-betaP < 0.001 vs. E2). E2 seems to contrast the LEF-M activity. These results might support a more efficient therapeutical effect of LEF in male with respect to female RA patients.

To investigate the effects of 17beta-estradiol (E2) on extracellular matrix (ECM) protein synthesis (collagen type I, fibronectin, and laminin) using cultures of normal and scleroderma (SSc) skin fibroblasts. Primary fibroblasts cultures, obtained from skin biopsies of six female voluntary subjects and three female SSc patients, were treated for 24 h with E2 (10 -10 M) alone or in combination with tamoxifene (TAM, 10 -7 M) as an estrogen receptor (ER) antagonist. ECM protein synthesis was analyzed by immunocytochemistry and Western blotting. E2 induced a significant increase of fibronectin, collagen type I, and laminin synthesis both in normal (P < 0.01, P < 0.05, P < 0.01, respectively) and SSc fibroblasts (P < 0.001, P < 0.05, P < 0.001, respectively) when compared to untreated fibroblasts. TAM induced a significant decrease of ECM protein synthesis when compared to E2-treated TAM-untreated fibroblasts. This study seems to support important modulatory effects of E2 in the fibrotic progression of the SSc process via ER interactions.

Vitamin D is a steroid hormone that influences glucocorticoids and gonadal hormones, interfering with the immune system and estrogen-modulated cells. Therefore vitamin D deficiency is thought as a risk factor for several chronic inflammatory and autoimmune conditions.

Introduction: After thyroidectomy and radioiodine therapy, patients with differentiated thyroid cancer (DTC) are indefinitely treated with levothyroxine (L-T4). Osteoporosis is a debated consequence of hypothyroxinaemia. The aim of this study was to evaluate bone mineral density (BMD) and fracture risk assessed by FRAX in a cohort of DTC women. Material and methods: Seventy-four women with DTC (aged 56.5 ± 9.9 years) treated at the mean age of 51.9 ± 12.0 years were studied. Baseline BMD and FRAX were evaluated after 3.0 years (median). BMD and FRAX were further evaluated 5.5 years (median) after the baseline evaluation. A cohort of 120 euthyroid women, matched for age, BMI, and menopausal status, were evaluated as controls. Results: L-T4 dosages were 813.6 ± 208.8 μg/week and 782.1 ± 184.4 μg/week at the baseline and second evaluation, respectively. The risks of major osteoporotic fracture (MOF) and hip fracture (HF) were similar in DTC patients and in controls. In DTC women, significant changes in FRAX were found, with a higher increase in the probability of HF than of MOF. A similar change was found in controls. A significant inverse correlation (P < 0.001) between L-T4 dosage and HF/MOF probability on both first and second evaluations was found. A significant inverse correlation (P = 0.05) was found between fT4, TSH and duration of therapy and HF/MOF probability only on the second evaluation. Conclusions: FRAX increase is a multi-factorial, age-related phenomenon. The absence of correlations between L-T4 dosage, length of therapy or fT4 levels and FRAX does not enable us to attribute an increased fracture risk to DTC women with well-controlled disease on therapy. (Endokrynol Pol 2016; 67 (4): 350–358)

Objective.To evaluate the efficacy and safety of secukinumab, a fully human antiinterleukin-17A monoclonal antibody, administered with an intravenous (IV) or subcutaneous (SC) loading regimen versus placebo, in patients with active rheumatoid arthritis (RA).Methods.In this phase II, double-blind, double-dummy, 52-week study (ClinicalTrials.govNCT01359943), 221 patients with inadequate response to methotrexate were randomized (2:2:1) to secukinumab, IV loading 10 mg/kg at baseline, Weeks 2 and 4, then SC 150 mg every 4 weeks (n = 88); secukinumab SC loading 150 mg once weekly for 5 weeks, then every 4 weeks (n = 89); or a matching placebo (followed by secukinumab 150 mg every 4 weeks starting Week 16; n = 44). The primary endpoint was superior efficacy of pooled secukinumab versus placebo using American College of Rheumatology 20% response (ACR20) at Week 12.Results.The primary efficacy endpoint was not met: ACR20 response at Week 12 was 49.2% for pooled secukinumab versus 40.9% for placebo (p = 0.3559). These variables improved significantly with pooled secukinumab versus placebo at Week 12 (all p < 0.05): the 28-joint Disease Activity Score (DAS28), patient’s and physician’s global assessment of disease activity, patient’s assessment of RA pain, and high-sensitivity C-reactive protein levels. Results of continuous efficacy outcomes were similar between the IV and SC loading regimens. The most frequent adverse events were infections, with similar rates across secukinumab and placebo.Conclusion.Although the primary endpoint (ACR20) was not met, secukinumab demonstrated improved efficacy in reducing disease activity over placebo as measured by DAS28 and other secondary endpoints.

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-alpha 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-alpha 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-alpha 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-alpha 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-alpha-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-alpha therapy. However, BMD variations were not significant. In RA patients treated with TNF-alpha 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-alpha therapy, that is, the marked decrease of the proinflammatory (i.e., TNF-alpha) cytokine effects on bone metabolism.

The circadian changes in the metabolism or nocturnal secretion of endogenous corticosteroids (reduction) observed in rheumatoid arthritis (RA) patients are responsible, in part, for the time-dependent changes that are observed in the inflammatory response and related early morning clinical symptoms of the disease. Melatonin (MLT), another circadian nocturnal hormone that is the secretory product of the pineal gland, has been implicated in the time-dependent RA inflammatory reaction with effects that are opposite to those of corticosteroids. As a consequence, altered functioning of the HPA axis (early morning reduced corticosteroid production) and of the pineal gland (night increased MLT production) found in RA patients, seem to be important factors in the appearance and perpetuation of the clinical circadian symptoms of the disease. Consistently, human proinflammatory Th1-type cytokine production (related to MLT stimulation) exhibits a diurnal rhythmicity with peak levels during the night and early morning, at a time when plasma cortisol (inducing the Th2-type cytokine production) is lowest and MLT is highest. Reduced daily light exposure as observed in northern Europe (Estonia), at least during the winter, might explain the higher and more prolonged serum MLT concentrations that were observed in northern RA patients, as well as some epidemiological features versus southern Europe patients.

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, …

Summary Background : A triggering infectious agent has long been postulated in rheumatoid arthritis. Data on the possible role of Helicobacter pylori infection are lacking. Aim : To assess the effect of H. pylori eradication in patients with rheumatoid arthritis. Methods : Fifty-eight adult patients with established rheumatoid arthritis and dyspeptic symptoms were recruited — 28 were H. pylori-positive and 30 were H. pylori-negative on the basis of invasive tests. All infected patients were treated successfully. We evaluated the disease activity using clinical and laboratory parameters at baseline and every 4 months during 2 years, and compared the variations in the two subgroups. Results : H. pylori-eradicated rheumatoid arthritis patients showed progressive improvement over time (P

Methotrexate (MTX) is believed to exert both antiproliferative and antiinflammatory effects in a dose-related manner in a majority of rheumatoid arthritis (RA) patients along with an abrupt flare of the disease after drug discontinuation. To investigate the antiproliferative and antiinflammatory actions of MTX and the combined action of sex hormones, we evaluated these effects in differentiated monocytic myeloid cells (THP-1) prestimulated with testosterone (T) or 17-beta estradiol (E2). The effects of MTX and T combined treatment (T/MTX) on THP-1 cells showed a significant inhibition of cell proliferation when compared with E2/MTX- treated cells or controls: 53% at 72 h versus E2-treated cells; 58% at 96 h versus E2-treated cells; and 41% versus controls, respectively. Bax and Fas CD95 expression was found increased in T-treated cells: 14% T at 48 h vs. E(2)-treated cells and controls; 45% T at 72 h versus E2-treated cells and controls; 97% at 96 h versus E2-treated cells and 37% versus controls for Bax: 33%, 41%, and 42% T versus E2-treated cells for Fas. Moreover, a significant decrease of IL-12 levels in T/MTX treated cells was found at any time when compared to E2-treated cells. In summary, the association of testosterone and MTX compared to MTX alone suggests possible synergistic actions. Therefore, the enhancing antiinflammatory effects exerted by androgens might represent a further explanation for the reduced frequency of inflammatory diseases in male subjects.

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.

Several authors have reported the regulation of apoptotic phenomena by sex hormones in different cell lines, including T lymphocytes and mononuclear cells. Since androgens can modulate the programmed cell death in responsive cell lines, we decided to investigate the induction of apoptosis in THP-1 cells following their differentiation into macrophage-like cells and exposure to sex hormones. In addition, we decided to evaluate the proto-oncogene Bax and Fas (CD 95) and cleaved PARP (poly-adp-ribose-polymerase) expression in the same cultured cells. The results showed for the first time the dose-/time-dependent regulation of the apoptotic event in human monocytic THP-1 cells treated with different concentrations of androgens. No significant changes were observed for estrogen-treated and unstimulated control cells. In particular, the cells, after stimulation with androgens but not with estrogens, were found to be positive for the proto-oncogene Bax, Fas, and for cleaved subunits of PARP expression as demonstrated with different assays including immunocytochemical assay and Western blot analysis. In conclusion, these results support the possibility of sex hormone modulation of apoptosis in macrophage-like cells, with interesting therapeutic perspectives in rheumatoid arthritis.

The objective of this study was to assess the occurrence of generalized bone loss in rheumatoid arthritis (RA) patients and to evaluate the factors influencing bone loss, in particular, the usefulness of bone turnover markers. Twenty-five premenopausal patients (mean age, 40 x 5 years) with active RA were compared with 27 age-matched premenopausal patients with RA but without active disease and 30 age-matched healthy premenopausal controls. Serum concentrations of osteocalcin, intact parathyroid hormone (PTH), spot urine concentrations of crosslinked N-telopeptidases of type 1 collagen (NTX), and deoxypyridinoline (DPD) were detected by ELISA and radioimmunoassay. Serum osteocalcin levels were found to be significantly lower (p < 0.001) in patients with active RA compared with patients without active RA and controls. Similarly, serum intact PTH was significantly lower (p < 0.01) in patients with active RA than in patients with RA without active disease and controls. Spot urine concentrations of NTX and DPD were significantly higher (p < 0.01) in active RA patients than in patients with nonactive RA and controls. Positive correlations between osteocalcin and marker of disease activity were found to be significant (p < 0.01). There were no significant correlations between serum intact PTH, urine concentrations of NTX and DPD, and markers of inflammation. This study suggests that generalized bone loss occurs in active RA and is characterized by an evident bone resorption correlated with the high levels of inflammation.

The altered cortisol and adrenal androgen (i.e., dehydroepiandrosterone sulfate = DHEAS) secretion, observed during testing in rheumatoid arthritis (RA) patients not treated with corticosteroids, should be clearly regarded as a "relative adrenal insufficiency" in the setting of a sustained inflammatory process, as shown by high serum IL-6 levels. Androgens seem implicated in the pathophysiology of autoimmune disorders, including RA, as natural immunosuppressors. Low plasma and synovial fluid testosterone concentrations are observed in male RA patients; low plasma DHEAS levels are mainly observed in female RA patients. The menopausal peak of RA suggests that estrogens and/or progesterone deficiency also play a role in the disease, and many data indicate that estrogens suppress cellular immunity, but stimulate humoral immunity (i.e., deficiency promotes cellular Th1-type immunity). Gene polymorphisms for enzymes involved in the steroidogenesis seem to further complicate the role of sex hormones in the susceptibility to autoimmunity. Acquired changes of sex steroid metabolism seem to also play a role in the peripheral sex hormone levels. In conclusion, a complex interaction between the hypothalamus-pituitary-adrenocortical and gonadal axis functions is evident in RA.

Glucocorticoids (GC) exert many complex quantitative and qualitative immunosuppressive effects that induce cellular immunodeficiency and consequently might increase host susceptibility to various viral, bacterial, fungal, and parasitic infections. In chronic immune/inflammatory conditions cortisol is secreted at inadequate levels and GC therapy today is devoted in substituting this hormone in adequate doses (low) to compensate just for this; therefore, the correct timing of GC administration, such as given during the turning-on phase of TNF secretion (night), can be of major importance. Consequently, the use of the lowest possible GC dose, at the night time and even for the shortest possible time, should decrease dramatically the risk of infections.

Rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE) are multifactorial autoimmune diseases that originate from the patient’s excessive immune and inflammatory response to a pathogenic agent (that is, an infective antigen).1 The pathophysiological mechanisms are activated after the combination of several predisposing factors, which include the relations between histocompatibility epitopes and epitopes of the pathogenic antigen, the altered status of the stress response system (hypothalamic-pituitary-adrenocortical axis = HPA) and the gonadal hormone pattern (hypothalamic-pituitary-gonadal axis = HPG), with oestrogens principally implicated as enhancers of the immune response, and androgens and progesterone as natural suppressors (fig1).2-8 Figure 1 Genetic, infectious, and dietary factors, as well as gonadal/adreanal steroid hormones, play a predisposing part in autoimmune diseases such as RA and SLE. Therefore, the involvement of the hypothalamus-pituitary-adrenal (HPA = adrenal steroids) and -gonadal (HPG = gonadal steroids) axis is crucial and interferes with the immune system response. An intricate balance with bidirectional interactions between soluble mediators, released by the neuroendocrine system (that is, steroid hormones and neuropeptides) and products of activated cells of the immune/inflammatory system (cytokines) maintains the homeostasis in presence of the immune/inflammatory stimulus.9-12 Cytokine secretion seems fundamental in determining the duration and intensity of an immune response, and how steroid hormones (gonadal and adrenal steroids) influence autoimmunity may entail a further balance between Th1 and Th2 lymphocyte responses.13-15 Th1 lymphocytes produce mainly interleukin 2 (IL2) and interferon γ (IFNγ) and are primarly responsible for cell mediated immunity, while Th2 lymphocytes produce mainly IL4, IL5, IL13, and IL10, and are responsible for humoral immunity, supporting the activation of immunoglobulin secreting cells (fig 2).16 17 Figure 2 Role of Th1/Th2 cytokines in the regulation of cellular and humoral immunity. IL6, probably secreted by activated macrophages (Mφ) is able to polarise naive CD4+ T cells (Th0) to …

OBJECTIVE: To ascertain whether a different regulation and sensitivity of the hypothalamic-pituitary-adrenal axis exists and whether a type of cortisol resistance is present in rheumatoid arthritis (RA) patients, a chronic disease in whose pathogenesis modifications of the steroid milieu are involved. DESIGN: We studied the basal and dynamic response of ACTH and adrenal steroids to various stimuli acting on the hypophysis or directly on the adrenal gland. METHODS: We studied ten RA patients (39.8 +/- 7.4 (S.D.) years), defined according to the American Rheumatism Association, and seven healthy control patients (34.1 +/- 9.6 (S.D.) years). All subjects underwent testing, in random order, with placebo, desmopressin (DDAVP) (10 microg i.v.), ovine corticotropin-releasing hormone (oCRH) (1 microg/kg body weight) and low-dose ACTH (5 microg i.v.), during the follicular phase of two different menstrual cycles. Blood samples were collected at different times for ACTH and adrenal steroids assay. Baseline estradiol (E2), testosterone and IGF-I levels were also evaluated. All subjects collected urine specimens for 24 h urine free cortisol (UFC). RESULTS: No difference in E2, testosterone or UFC was found between RA patients and controls. IGF-I levels were significantly (P < 0.01) lower in RA patients (110.6 +/- 6.4 microg/l) than in controls (207.0 +/- 37.9 microg/l). Mean baseline dehydroepiandrosterone (DHEA) and delta4-androstenedione levels of the four tests were significantly (P < 0.05) lower in RA patients than in controls. In RA, a negative correlation was found between mean DHEA levels, class of disease (r = -0.67, P < 0.05) and erythrocyte sedimentation rate (r = -0.63, P < 0.05). After placebo no difference in ACTH and cortisol area under curves (AUCs) was found between RA patients and controls. After DDAVP no cortisol or ACTH response was found in RA patients, while a significant (P < 0.05) ACTH release was found in controls. Only in RA patients was DDAVP able to induce a significant (P < 0.01) DHEA increase. After oCRH a similar significant response in ACTH (P < 0.05), cortisol (P < 0.01), and DHEA (P < 0.01) was found in both groups. After low-dose ACTH, a similar significant (P < 0.01) cortisol response was found in both RA patients and controls; indeed in RA patients DHEA AUC (2196.0 +/- 321.8 nmol/l per 90 min) was significantly lower (P < 0.01) than DHEA AUC (4280.8 +/- 749.0 nmol/l per 90 min) in controls. A similar significant (P < 0.01), though not abnormal, 17-hydroxyprogesterone response to ACTH was found in both groups. CONCLUSIONS: Our study underlines reduced adrenal steroid and IGF-I levels, but not the previously described cortisol resistance in RA patients; it shows that baseline and dynamic cortisol levels are 'normal' but inadequate in the setting of a sustained inflammatory disease like RA. The reduced basal and low-dose ACTH-induced DHEA levels could reflect both a reduced sensitivity of the adrenal gland to exogenous corticotropin and a decreased steroid synthesis due to a partial adrenal enzymatic defect (P450 17,20 lyase).

The endogenous serum metabolite of vitamin D (calcitriol, 1,25(OH)2 D3 ) is considered a true steroid hormone (D hormone), and like glucocorticoids (GCs) and gonadal hormones, may exert several immunomodulatory activities. Serum vitamin D deficiency (25(OH) D), and therefore reduced 1,25(OH)2 D3 availability, is considered a risk factor for several chronic/inflammatory or autoimmune conditions, including infectious diseases, type 1 diabetes, multiple sclerosis, and especially autoimmune rheumatic diseases (ARD). In ARD in particular, 1,25(OH)2 D3 regulates both innate and adaptive immunity, potentiating the innate response (antimicrobial activity) but reducing adaptive immunity (antigen presentation, T and B cell activities). Regarding a possible synergism between vitamin D and GCs, several studies show that 1,25(OH)2 D3 has significant additive effects on dexamethasone-mediated inhibition of human lymphocyte and monocyte proliferation. Conversely, vitamin D deficiency seems to play a role in increasing autoantibody production by B cells, and seasonal vitamin D declines may trigger flares in ARD, as recently shown. Finally, 1,25(OH)2 D3 seems to reduce aromatase activity and limit the negative effects related to increased peripheral estrogen metabolism (cell proliferation, B cell overactivity).

Objective.To evaluate the longterm effects of endothelin-1 (ET-1) antagonism on peripheral blood perfusion (PBP) in patients with systemic sclerosis (SSc).Methods.Twenty-six patients with SSc already receiving cyclic intravenous iloprost (ILO) for severe Raynaud phenomenon were enrolled. Thirteen patients continued the treatment for a further 3 years (ILO group) and 13 patients, because of the appearance of digital ulcers, received in addition bosentan (BOS; 125 mg twice/day) for 3 years (ILO + BOS group). Both PBP at fingertips and nailfold microangiopathy were evaluated yearly by laser Doppler flowmetry and nailfold videocapillaroscopy, respectively.Results.A progressive significant increase of PBP was observed in the ILO + BOS group during the 3 followup years (p = 0.0007, p = 0.0002, p = 0.01, respectively). In contrast, an insignificant progressive decrease of PBP was observed in the ILO group. Difference of perfusion between the PBP evaluations at basal temperature and at 36°C (to test capillary dilation capacity), was found progressively decreased during the 3-year followup only in the ILO group (p = 0.05, p = 0.26, p = 0.09, respectively). A progressive increase of nailfold capillary number was observed only in the ILO + BOS group after 2 and 3 years of followup (p = 0.05).Conclusion.Longterm treatment of SSc patients with ET-1 antagonism, in combination with ILO, seems to increase fingertip blood perfusion, as well as both capillary dilation capacity and number.

The efficacy and tolerability of aceclofenac and naproxen sodium in the treatment of ankylosing spondylitis (AS) were evaluated and compared in this double-blind, multicenter, controlled study. Of the 130 patients who entered the study, 126 patients met the inclusion criteria. Efficacy was evaluated at baseline, 15 days, and 1, 2, and 3 months using a visual analog scale for spontaneous pain, a zero to three-point scale for pain on movement and pain at rest, and measurements of chest expansion, hand-to-floor distance, Schober's test, and normal daily activities. No significant between-group differences were seen for any of the variables at baseline, except hand-to-floor distance. Both drugs provided effective analgesia and a corresponding improvement in functional activity. Overall efficacy assessment made by the physician and patients was not statistically significant between the two treatment groups. The overall incidence of adverse effects was higher in the naproxen group than the aceclofenac group, 22 versus 15 patients, respectively. All adverse effects resolved. However, the overall assessment of tolerability given by the physician and patients was significantly (P

Evidence continue to accumulate indicating that patients with rheumatoid arthritis (RA) present an increased risk of cardiovascular disease (and death). The risk factors for coronary artery disease (CAD) in RA are not fully understood. However, a number of possible factors have been described, but more than one may be efficient, such as homocysteine, presence of antiphospholipid antibodies, altered serum levels of selected lipoproteins, and all together may have implications for the atherogenesis observed in these patients. Other factors that may facilitate this process, include corticosteroid use, methotrexate therapy and hormonal factors. However, the relative importance of these specific risk factors for the atherogenesis in this diseases is poorly known. Recent findings indicate that cardiac death is increased in RA patients when compared with subjects without arthritis and that generally, the inflammatory process may contribute to atherosclerosis. In addition, other studies indicate that serum concentration of pro-inflammatory cytokines are found elevated at baseline, among patients at risk for future coronary occlusion.

Introduction: The aim of the present study was to demonstrate, by nailfold videocapillaroscopy (NVC), the existence of diagnostic and follow-up parameters of microvascular damage in systemic sclerosis (SS) (grouped in the “early”, “active” and “late” NVC patterns). The presence of the different subsets of skin involvement (limSS and difSS), as well as the role of some specific serum autoantibodies in the expression of the NVC parameters were investigated. Methods: 245 consecutive SS patients were recruited and clinical data assessed. Antinuclear (ANA), antitopoisomerase I (Scl70) and anticentromere (ACA) antibodies were investigated in all patients. Results: Giant capillaries and hemorrhages were confirmed to be the earliest NVC finding in SS (diagnostic parameters). The loss of capillaries, along with ramified capillaries and vascular architectural disorganization were validated as parameters of progression of SS microangiopathy. Really, both Raynaud’s phenomenon (RP) and SS duration were detected longer in patients with the “late” than in those with the “active” or the “early” NVC pattern. Patients affected by limSS were found to have shorter disease duration, as well as showed more frequently the “early” or the “active” NVC patterns. Conversely, patients affected by the difSS showed longer disease duration and mostly the presence of the “active” or “late” NVC pattern. The Scl70 positivity was lower in the patients showing the “early” than in those with the “active” and the “late” NVC patterns, whereas no significant correlation was found between the Scl70 presence and both RP and SS duration. The ACA positivity was higher in patients showing the “early” NVC pattern, as well as in patients with longer disease duration. Conclusions: This study confirms that the identification of distinct NVC patterns may be useful to evaluate the severity and the stage of the SS microvascular damage. The presence of the Scl70 antibodies seems related to a more rapid progression of the SS microangiopathy. On the contrary, the presence of the ACA seems to be related to a slower progression of the SS microvascular damage. The SS peripheral microangiopathy is similar as in patients with limSS, as in those affected by difSS.

Microvascular involvements represent one of the first step in many autoimmune diseases such as scleroderma (SSc) or antiphospholipid syndrome. Early in the disease, the peripheral microangiopathy may be well recognised and studied by nailfold videocapillaroscopy (NVC), a noninvasive and safe technique, that is reported to have both diagnostic and prognostic value, especially in the presence of Raynaud’s phenomenon (RP). The classification of defined major NVC patterns in SSc might be useful in assessing the appearance and progression of the sclerodermic microangiopathy. In addition, the NVC changes might represent a morphological reproduction of the evolution of the SSc. The early appearance of giant capillaries and haemorrhages (Early pattern) is of great relevance for the early diagnosis of the SSc. Therefore, these alterations are more evident in the active phase of the disease (Active pattern). Converserly, the NVC observation of loss of capillaries, vascular architectural disorganisation and the presence of ramified/ bushy capillaries (Late pattern) represents the clearest aspect of advanced SSc microvascular damages. Interesting, correlations between the NVC and clinical aspects of SSc, as well as the effects of therapeutical intervenctions have been observed.

Secondary osteoporosis (OP) is a well-recognized complication of rheumatoid arthritis (RA). Treatment with TNF-a blockers, might influence bone metabolism and prevent structural bone damage in RA, in particular at the periarticular regions. Objective: To assess the influence of anti-TNF-a therapy, on bone metabolism in RA patients. 36 RA patients were treated with stable therapy of prednisone (7.5 mg/day) and methotrexate (MTX=10 mg/week). Nine of these RA patients further received etanercept (25 mg, twice/weekly) and eleven infliximab (3mg/kg on 0, 2, 6, and every 8 weeks thereafter). A control group included 16 RA patients only with stable therapy (some dosage of prednisone and MTX). Quantitative Ultrasound (QUS) bone densitometry was obtained at the metaphyses of the proximal phalanges of both hands with a DBM Sonic 1200 QUS device (IGEA, Carpi, Italy). Bone mineral density (BMD) of the hip and lumbar spine were performed with a densitometer ( Lunar Prodigy, GE, USA) at baseline and after 12 months. Soluble bone turnover markers [osteocalcin (OC), bone alkaline phospatase (ALP) deoxypyridinoline/creatinine ratio (Dpd/Cr) and cross-linked N-telopeptide of type I collagen / creatinine ratio (NTx/Cr)] were measured using ELISA tests. Results: AD-SoS values were found increased by +4.55% after 12 months of treatment in the RA patients treated with anti-TNF-a therapy. On the contrary, the Ad-SoS levels decreased by -4.48% during the same period in the control RA group. BMD increased by +3.64% at lumbar spine and +2.90% at the hip (both p

Objective: CTLA4-Ig, a biologic agent employed in rheumatoid arthritis (RA) treatment, downregulates the immune response and exerts anti-inflammatory effects acting on different cells including dendritic/T cells interaction and directly on osteoclasts. We investigated the anti-inflammatory effects of CTLA4-Ig in primary monocultures of RA synovial macrophages (SM). Methods SM were obtained, from 8 RA patients (7 F, 1 M; DAS28>5.2) who underwent therapeutic arthroscopic synoviectomy and were cultured in the absence and in the presence of CTLA4-Ig at the concentration of [500 μg/ml], the most reliable dose related to the previous pharmacological clinical and experimental experiences. Inflammatory cytokine (IL-6, TNFalpha, IL-1beta) expression was evaluated by immunocytochemistry (ICC with relative image analysis), western blot (WB), and quantitative real-time polymerase chain reaction (qRT-PCR). Results: ICC analysis revealed that CTLA4-Ig treatment significantly downregulated cytokine expression (p

The aim of this 13-week, multicenter, randomized, double-blind, double-dummy, placebo- and positive-internal (celecoxib)-controlled, parallel-group study was to demonstrate the efficacy, safety, and tolerability of lumiracoxib in primary hip osteoarthritis (OA) patients. Eligible patients (n = 1,262; ACR criteria) were randomized (1:1:1) to receive lumiracoxib 100 mg once daily (o.d.) (n = 427), celecoxib 200 mg o.d. (n = 419), or matching placebo o.d. (n = 416) administered orally. The primary objective was to compare lumiracoxib 100 mg o.d. and placebo with respect to three co-primary efficacy variables: the pain subscale of the Western Ontario and McMaster Universities Osteoarthritis Index Likert version 3.1 (WOMAC™ LK 3.1) questionnaire, the function subscale of the WOMAC™ LK 3.1 questionnaire, and patient’s global assessment of disease activity (100-mm visual analog scale (VAS)) after 13 weeks of treatment. Of the 1,262 randomized patients, 951 completed the study. All randomized patients were included in the intention-to-treat and safety populations. Lumiracoxib was superior to the placebo (p

Changes in bone mineral density and bone strength following treatment with zoledronic acid (ZOL) were measured by quantitative computed analysis (QCT) or dual-energy X-ray absorptiometry (DXA). ZOL treatment increased spine and hip BMD vs placebo, assessed by QCT and DXA. Changes in trabecular bone resulted in increased bone strength.To investigate bone mineral density (BMD) changes in trabecular and cortical bone, estimated by quantitative computed analysis (QCT) or dual-energy X-ray absorptiometry (DXA), and whether zoledronic acid 5 mg (ZOL) affects bone strength.In 233 women from a randomized, controlled trial of once-yearly ZOL, lumbar spine, total hip, femoral neck, and trochanter were assessed by DXA and QCT (baseline, Month 36). Mean percentage changes from baseline and between-treatment differences (ZOL vs placebo, t-test) were evaluated.Mean between-treatment differences for lumbar spine BMD were significant by DXA (7.0%, p0.01) and QCT (5.7%, p0.0001). Between-treatment differences were significant for trabecular spine (p = 0.0017) [non-parametric test], trabecular trochanter (10.7%, p0.0001), total hip (10.8%, p0.0001), and compressive strength indices at femoral neck (8.6%, p = 0.0001), and trochanter (14.1%, p0.0001).Once-yearly ZOL increased hip and spine BMD vs placebo, assessed by QCT vs DXA. Changes in trabecular bone resulted in increased indices of compressive strength.

Objective.To investigate possible correlations between fingertip blood perfusion (FBP) status, assessed by laser Doppler flowmetry (LDF), and morphological microvascular abnormalities, detected by nailfold videocapillaroscopy (NVC), in patients with systemic sclerosis (SSc). The effects on FBP of intravenous (IV) treatment with the prostacyclin analog iloprost were also investigated.Methods.Thirty-four consecutive patients with SSc and 16 healthy subjects were evaluated. LDF was performed by analyzing blood perfusion at the fingertips in both hands. Patients with SSc were distributed into the appropriate NVC pattern of microangiopathy (early, active, and late). Iloprost was administered to inpatients with SSc by 24-hour IV infusion for 7 consecutive days (4 μg/h).Results.FBP was significantly lower in patients with SSc (p < 0.05) compared to controls. Heating of the LDF probe at 36°C induced a significant increase of FBP in all subjects (p < 0.001), but the slope of variation was significantly lower in patients with SSc compared to controls (p < 0.05). Patients with SSc showing the late NVC pattern of microangiopathy had significantly lower FBP than patients with the active and early NVC patterns (p < 0.05). A negative correlation was observed between FBP and NVC rating of the microvascular damage (p < 0.05). After iloprost treatment, a significant increase of FBP was observed in patients with SSc (p < 0.05).Conclusion.Patients with SSc show a decreased FBP partially reversible by local skin heating. The FBP correlated negatively with the extent of nailfold microvascular damage, and IV iloprost treatment increased the FBP.

To investigate the effects of 17beta-estradiol (E2) on extracellular matrix (ECM) protein synthesis (collagen type I, fibronectin, and laminin) using cultures of normal and scleroderma (SSc) skin fibroblasts. Primary fibroblasts cultures, obtained from skin biopsies of six female voluntary subjects and three female SSc patients, were treated for 24 h with E2 (10(-10)M) alone or in combination with tamoxifene (TAM, 10(-7)M) as an estrogen receptor (ER) antagonist. ECM protein synthesis was analyzed by immunocytochemistry and Western blotting. E2 induced a significant increase of fibronectin, collagen type I, and laminin synthesis both in normal (P0.01, P0.05, P0.01, respectively) and SSc fibroblasts (P0.001, P0.05, P0.001, respectively) when compared to untreated fibroblasts. TAM induced a significant decrease of ECM protein synthesis when compared to E2-treated TAM-untreated fibroblasts. This study seems to support important modulatory effects of E2 in the fibrotic progression of the SSc process via ER interactions.

Objective.We evaluated endothelin (ET)-1 plasma levels and some clinical measures in patients with primary Raynaud’s phenomenon (PRP), and in patients with systemic sclerosis (SSc) and secondary RP (SRP), in the latter according to their different nailfold videocapillaroscopy (NVC) patterns of microangiopathy (early, active, and late).Methods.Ninety-nine patients with SSc, 49 with PRP, and 45 control subjects were studied. NVC was performed in all patients to distinguish the pattern of microvascular damage, and the morphological alterations were scored by a semiquantitative rating scale. ET-1 plasma levels were evaluated in all individuals by ELISA.Results.ET-1 plasma levels were significantly higher (p = 0.001) in patients with both PRP and SRP, compared to controls. A significant positive correlation (p = 0.03) was found between ET-1 plasma levels and SRP duration, but not between ET-1 plasma levels and PRP duration. Significant correlations were observed in patients with SSc between ET-1 plasma levels and clinical measures (e.g., digital ulcers), as well as the score value of single NVC measures, such as the number of capillaries, “ramified” capillaries, and enlarged capillaries (p < 0.05). Finally, the highest ET-1 plasma levels were found in patients with SSc showing the late pattern of microangiopathy when compared to the early pattern (p = 0.03) and to controls (p = 0.003).Conclusion.Highest ET-1 plasma levels were detected in the more advanced stage of the SSc microangiopathy, namely the late NVC pattern, characterized by capillary loss and increased tissue fibrosis; this might support the involvement of ET-1 in the progression of the microvascular/fibrotic SSc damage.

We read with interest the paper by Costenbader et al on vitamin D intake and risks of systemic lupus erythaematosus (SLE) and rheumatoid arthritis (RA) in women.1 The authors conclude that their prospective study does not lend evidence that to the hypothesis that increasing vitamin D intake can protect against SLE or RA. In this case, using semiquantitative questionnaires regarding the intake of food and the frequency of supplements to assess vitamin D status may not necessarily be a reliable way to indicate the actual absorption and serum levels. This is due to the fact that several other factors, including altered metabolic pathways and others, regulate the real availability. Therefore, the most reliable way to assess vitamin D …

Objective:To evaluate the influence of endothelin-1 (ET-1) and sex hormones on cell proliferation and extracellular matrix (ECM) synthesis (ie, fibronectin, laminin) by cultured normal and scleroderma (SSc) human skin fibroblasts (FBs).Methods:Primary cultures of FBs were treated with ET-1 and sex hormones (17β-oestradiol or testosterone) for 24 h. Cell growth was analysed by methiltetrazolium salt test, ECM synthesis was evaluated by immunocytochemistry and western blot, both at 24 h.Results:In normal FBs, ET-1 and 17β-oestradiol, as well as their combination, increased cell growth (pConclusions:ET-1 and 17β-oestradiol seem to exert a profibrotic effect in normal and SSc culture FBs and might suggest their synergistic effect in the pathogenesis of the fibrotic process in SSc.

Immune response is greater in females than in males and lymphocytes/monocytes from female subjects (or tested in vitro with estrogens) show higher immune/inflammatory reactivity. In order to test in vitro the interactions between 17beta-estradiol (E2--10(-9) M), testosterone (T--10(-8) M) and the antiproliferative/immune suppressive drug Leflunomide metabolite A77 1726 (LEF-M--30 microM) employed in rheumatoid arthritis (RA), their combined effects were evaluated on inflammatory cytokine (CK) expression/production in cultures of differentiated macrophages (M) (from activated THP-1 monocytes) and primary cultures of RA synovial macrophages (SM). TNFalpha, IL-6 and TGFbeta were detected by immunocytochemistry (ICC), Western blot analysis (WB) and reverse transcriptase-polymerase chain reaction (RT-PCR). The ICC, WB and RT-PCR showed a significant down-regulation induced by LEF-M on CK expression by cultured M when compared to untreated cells (IL-6 p < 0.01, TNFalpha p < 0.001, TGFbeta p < 0.01). At ICC analysis E2 increased CK expression, whereas T decreased the expression, confirmed by WB and RT-PCR (range between p < 0.05 and p < 0.001). LEF-M treatment significantly downregulated the CK expression in E2/T treated M: the effect was more significant in LEF-M plus T-treated cells versus controls (range between p < 0.01 and p < 0.001). Concerning the RA SM, the results were replicated (range between p < 0.05 and p < 0.001). E2 seems to contrast, but T seems to synergize the LEF-M activity. Results might support a stronger therapeutical efficacy, at least for LEF, in male RA patients, as already reported by clinical evidences.

The discovery of the vitamin D receptor (VDR) in the cells of the immune system and the fact that activated dendritic cells produce the vitamin D hormone suggested that vitamin D could have immunoregulatory properties. VDR, a member of the nuclear hormone receptor superfamily, was identified in mononuclear cells, dendritic cells, antigen-presenting cells, and activated T-B lymphocytes. In synthesis, the most evident effects of the D-hormone on the immune system seem to be in the downregulation of the Th1-driven autoimmunity. Low serum levels of vitamin D3 might be partially related, among other factors, to prolonged daily darkness (reduced activation of the pre vitamin D by the ultra violet B sunlight), different genetic background (i.e. vitamin D receptor polymorphism) and nutritional factors, and explain to the latitute-related prevalence of autoimmune diseases such as rheumatoid arthritis (RA), by considering the potential immunosuppressive roles of vitamin D. 25(OH)D3 plasma levels have been found inversely correlated at least with the RA disease activity showing a circannual rhythm (more severe in winter). Recently, greater intake of vitamin D was associated with a lower risk of RA, as well as a significant clinical improvement was strongly correlated with the immunomodulating potential in vitamin D-treated RA patients.