Position of the Expert Panel of the National Consultant for Rheumatology concerning diagnosis and treatment of rheumatoid arthritis

Celem publikacji przygotowanej przez zespół powołany przez konsultanta krajowego ds. reumatologii jest usystematyzowanie wiedzy na temat diagnostyki i terapii reumatoidalnego zapalenia stawów. Oprócz rozpoznania reumatoidalnego zapalenia stawów na podstawie kryteriów ACR, zaproponowano kryteria diagnostyczne wczesnego reumatoidalnego i wczesnego niesklasyfikowanego zapalenia stawów. Określono w nich przydatność oznaczania przeciwciał antycytrulinowych, ultrasonografii stawów oraz rezonansu magnetycznego. Podstawowym celem we wczesnym postępowaniu jest ustalenie obecności i aktywności zapalenia na podstawie wywiadu, badania fizykalnego, badań laboratoryjnych, ewentualnie USG i rezonansu magnetycznego. Postępowanie różnicujące powinno być prowadzone w miarę postępu choroby, do czasu ustalenia ostatecznego rozpoznania. W każdym przypadku zapale nia stawów (poza infekcyjnym) należy wdrożyć leczenie glikokortykosteroidami w dawce je opanowującej. W zależności od ustalonego rozpoznania stosowanie glikokortykosteroidów powinno być połączone ze stosowaniem leku podstawowego, nie później jednak niż od 4. mies. Preferowanym lekiem jest metotreksat w dawce tygodniowej 15–25 mg. W przypadku jego nietolerancji sugerowane jest zastosowanie leflunomidu. Brak skuteczności monoterapii którymkolwiek z nich jest wskazaniem do leczenia skojarzonego kilkoma lekami modyfikującymi przebieg choroby. Leki antycytokinowe należy wdrożyć w przypadku nieskuteczności tego postępowania, powinno ono być połączone z podawaniem metotreksatu w pełnych dawkach, wyjątkowo innego leku podstawowego. Leczenie rytuksymabem i abataceptem stosuje się u chorych, u których powyższe postępowanie jest nieskuteczne. Niesteroidowe leki przeciwzapalne stanowią leczenie uzupełniające tylko w okresach zaostrzeń. Przez wszystkie lata powinna być stosowana fizjoterapia. Celem leczenia jest uzyskanie i podtrzymywanie małej aktywności choroby ocenianej wg kryteriów DAS 28.The aim of the publication prepared by the panel formed by the State Consultant for Rheumatology is to summarize knowledge on diagnosis and treatment of rheumatoid arthritis. Except diagnosing rheumatoid arthritis on the basis of ACR criteria, diagnostic criteria for early rheumatoid and early unclassified arthritis have been proposed. These criteria establish the usefulness of anticitruline antibody determinations, ultrasonography of joints and magnetic resonance. The most important procedure in early detection is to establish the presence and activity of inflammatory process, based on history, physical examination, laboratory tests and, possibly, ultrasonography and magnetic resonance. Differentiation should progress following the disease progress, until final diagnosis is established. In each case of arthritis (except infective arthritis) treatment with glucocorticoids should be employed, at the dose allowing suppression of symptoms. Depending on established diagnosis, this treatment should be accompanied by first-line medication, not later than from the 4th month. Preferred medication is methotrexate at a weekly dose of 15-25 mg. In the case of intolerance, it is suggested to use leflunomide. Lack of efficiency of monotherapy with either of the above mentioned medications is an indication for a combined treatment with several drugs modifying the course of the disease. Anticytokine drugs should be used in the case of inefficiency of such a procedure; this should be connected with full doses of methotrexate or, in exceptional cases, with another first-line drug. Treatment with rituximab and abatacept is reserved for patients in whom the above therapy is ineffective. Nonsteroid anti-inflammatory drugs offer an adjuvant therapy option only during exacerbations. During all these years, physiotherapy should be continued. Treatment should aim at achieving and maintaining low activity of the disease, evaluated according to DAS 28 criteria

Rottlerin, a PKC isozyme-selective inhibitor, affects signaling events and cytokine production in human monocytes

The implication of select protein kinase C (PKC) isoenzymes in cytokine production by human monocytes was investigated using an isozyme-selective inhibitor of PKC, rottlerin. We found that lipopolysaccharide (LPS) triggers cytosol-to-membrane translocation of PKCalpha and delta isoenzymes, whereas phorbol ester (PMA) induces translocation of several PKC isoforms. Moreover, we show that in LPS- and PMA-stimulated monocytes rottlerin affects several cellular responses. (1) At low (15 microM) concentration it blocks translocation of PKCdelta, diminishes DNA binding activity of AP-1 transcription factor, and attenuates cytokine production [tumor necrosis factor alpha (TNF-alpha) > interleukin-1beta (IL-1beta)]. (2) At high (50 microM) concentration it prevents translocation of PKCalpha, and subsequently inhibits ERK1/ERK2 phosphorylation, DNA binding activities of AP-1 and nuclear factor-KB transcription factors, and the production of both tested cytokines. Thus, we propose that cytosol-to-membrane translocation of PKCalpha and PKdelta isoenzymes may represent early steps in the signaling cascades that lead to TNF-alpha and IL-1beta production in human monocytes

Apoptosis induced by membrane damage in human lymphocytes; effects of arachidonic acid and its photoproducts.

The effect of arachidonic acid (AA) combined with UVA irradiation was studied in a model system mimicking phototherapy PUVA (psoralen+UVA) ex vivo in vitro. The contribution of damage to the plasma membrane by PUVA was tested on human lymphocytes derived from healthy donors. The effect of arachidonic acid (AA) combined with UVA irradiation was compared with that of a psoralen photoadduct to AA added to the culture. The adduct, obtained photochemically and purified, was characterized by NMR and MS spectrometry as a cycloadduct of psoralen to the vinylene bond of the acid (AAPSO). The reactions of cultured cells, manifested 20 h after treatment by changes in apoptosis and mitochondrial depolarization, were monitored by flow cytometry by tagging lymphocytes with appropriate fluorescent probes. Treatment of lymphocyte suspension within AA doses from 40 to 100 μM gradually induced a shift from Anx-V+ (single positive cells) to late apoptotic, Anx-V+PI+ (double positive cells) in a dose dependent manner. The adduct, AAPSO, induced apoptotic changes at a concentration 2-3 times higher than free AA. Combination of psoralen (1 μM ) or arachidonic acid (20-120 μM) with UVA irradiation (2-6 J/cm2) accelerated the plasma membrane changes in a synergic way. Preliminary studies indicated that changes in the transmembrane potential of mitochondria paralleled the apoptosis when cells were treated by AA alone. Our findings showed that UVA radiation of lymphocytes in the presence of arachidonic acid, as in the presence of psoralen, enhanced apoptosis of cells in a synergic manner. Thus, PUVA-induced apoptosis may proceed in part by a still undefined signaling pathway(s) triggered in lymphocyte membranes

Rottlerin, a PKC isozyme-selective inhibitor, affects signaling events and cytokine production in human monocytes

The implication of select protein kinase C (PKC) isoenzymes in cytokine production by human monocytes was investigated using an isozyme-selective inhibitor of PKC, rottlerin. We found that lipopolysaccharide (LPS) triggers cytosol-to-membrane translocation of PKCalpha and delta isoenzymes, whereas phorbol ester (PMA) induces translocation of several PKC isoforms. Moreover, we show that in LPS- and PMA-stimulated monocytes rottlerin affects several cellular responses. (1) At low (15 microM) concentration it blocks translocation of PKCdelta, diminishes DNA binding activity of AP-1 transcription factor, and attenuates cytokine production [tumor necrosis factor alpha (TNF-alpha) > interleukin-1beta (IL-1beta)]. (2) At high (50 microM) concentration it prevents translocation of PKCalpha, and subsequently inhibits ERK1/ERK2 phosphorylation, DNA binding activities of AP-1 and nuclear factor-KB transcription factors, and the production of both tested cytokines. Thus, we propose that cytosol-to-membrane translocation of PKCalpha and PKdelta isoenzymes may represent early steps in the signaling cascades that lead to TNF-alpha and IL-1beta production in human monocytes

Original paper HLA-B27 detection – comparison of genetic sequence-based method and flow cytometry assay

Objectives : The presence of human leukocyte antigen B27 (HLA-B27) is strongly associated with ankylosing spondylitis. HLA-B27 testing is routinely applied in the diagnosis of this disease. The aim of the present study was to compare two methods of HLA-B27 detection – a genetic sequence-based method and a flow cytometry assay. Material and methods : Peripheral blood was obtained from 300 individuals with suspected spondyloarthropathy. Expression of HLA-B27 on the T cell surface was analysed by flow cytometry assay using GS145.2 monoclonal antibody specific for HLA-B27. DNA was isolated from the whole blood. Genes coding for HLA-B27, -B40 and -B47:01 were detected by polymerase chain reaction using the MW02/MW09 primer pair. Then, positive samples were sequenced in order to discriminate allelic variations of the HLA-B27 gene. Results of sequencing were analysed using Chromas LITE 2.1.1 software, BLAST software and the IMGT/HLA database. Ambiguous samples were additionally analysed by polymerase chain reaction using E91 and E136 primers amplifying a 135-bp fragment of the human HLA-B27 gene. Results : Among 300 samples, 76 were HLA-B27-positive on the basis of flow cytometry analysis. Genetic sequence analysis confirmed positivity of 73 from among 76 samples. Two hundred twenty six samples were HLA-B27-negative, whereas the result of one sample analysis was ambiguous. Fifty-three samples were identified as allelic variation 27:05, 19 samples as allelic variation 27:02, and one sample as allelic variation 27:07. Conclusions : This study shows that the genetic sequence-based method and the flow cytometry assay give consistent results in 99% of cases. The performed genetic analysis proves that the majority of HLA-B27-positive samples belong to the 27:05 allelic variation, which is strongly associated with high risk of ankylosing spondylitis

Enthesopathies and enthesitis. Part 1. Etiopathogenesis

The pathologies of tendon and ligament attachments are called enthesopathies. One of its types is enthesitis which is a characteristic sign of peripheral spondyloarthropathy. Clinical diagnosis of enthesitis is based on rather non-specific clinical signs and results of laboratory tests. Imaging examinations are highly promising. Numerous publications prove that enthesitis can be differentiated from other enthesopathic processes in an ultrasound examination or magnetic resonance imaging. However, some reports indicate the lack of histological criteria, specific immunological changes and features in imaging examinations that would allow the clinical diagnosis of enthesitis to be confirmed. The first part of the publication presents theories on the etiopathogenesis of enthesopathies: inflammatory, mechanical, autoimmune, genetic and associated with the synovio-entheseal complex, as well as theories on the formation of enthesophytes: infl ammatory, molecular and mechanical. The second part of the paper is a review of the state-of-the-art on the ability of imaging examinations to diagnose enthesitis. It indicates that none of the criteria of inflammation used in imaging medicine is specific for this pathology. As enthesitis may be the only symptom of early spondyloarthropathy (particularly in patients with absent HLA-B27 receptor), the lack of its unambiguous picture in ultrasound and magnetic resonance scans prompts the search for other signs characteristic of this disease and more specific markers in imaging in order to establish diagnosis as early as possible