Expression of 5-lipoxygenase and 15-lipoxygenase in rheumatoid arthritis synovium and effects of intraarticular glucocorticoids

The past years have witnessed tremendous progress in the treatment of rheumatoid arthritis, a chronic debilitating autoimmune disease mainly characterized by joint inflammation with progressive tissue destruction and loss of function. This condition affects 0.5-1% of the population, is associated with important co-morbidities and represents a heavy economical burden. New strategies, employing early and aggressive therapies with classical drugs or new agents, have resulted in impressive improvements in controlling disease activity. In some cases they even lead to clinical remission. Despite potent and efficient biological agents that specifically modulate distinct pathological pathways a large proportion of patients remain unresponsive to these therapies; drug-free remission is also difficult to achieve since attempting discontinuation of treatment usually results in disease flare. In rheumatoid arthritis joints there is a constant activation of complex networks of cytokines and factors mediating immune interactions and inflammation, in which prostaglandin E2 (PGE2) and leukotriene B4 (LTB4) are important players and contributors to pathogenesis. Our research aimed to investigate the synovial expression of enzymes controlling prostaglandin E2 synthesis and degradation – cyclooxygenase (COX) 1 and 2, microsomal prostaglandin E2 synthase 1 (MPGES1) and 15-prostaglandin dihydrogenase (15-PGDH) as well as enzymes involved in leukotriene synthesis, such as 5-lipoxygenase (LO) and 15-LO. In addition, we evaluated how traditional and new therapies influence these pathways, by analyzing enzyme expression before and after systemic treatment with tumor necrosis factor (TNF) antagonists, rituximab or methotrexate, as well as before and after intra-articular treatment with glucocorticoids. We also evaluated the in vitro effects of TNF antagonists and glucocorticoids on synovial fluid cells and that of methotrexate on synovial fibroblasts. We demonstrated that synovial tissue from RA patients displayed an important expression of enzymes involved in the metabolism of PGE2, as well as 5-LO and 15-LO. MPGES1 and COX-2, the inflammation-inducible enzymes co-localized mainly in fibroblasts and macrophage-like cells and accounted for the local PGE2 production. Intra-articular glucocorticoids significantly reduced all enzymes involved in the PGE2 cascade – COX-1 and COX-2, MPGES1 and 15-PGDH, but also 5-LO, responsible for leukotriene formation. However, they did not influence the expression of 15-LO, an enzyme involved in the formation of both pro-and anti-inflammatory lipid mediators. Regarding the effects of TNF blockers, rituximab or methotrexate, they did not alter the expression profile of enzymes involved in PGE2 metabolism despite showing clinical efficiency in improving disease activity. Although anti-TNF agents reduced the in vitro expression of MPGES1 and COX-2 in synovial fluid cells, the lack of effect ex vivo in biopsies emphasized once again the differences between synovial compartments and possibly the difficulty in mimicking the micro-environment at the site of inflammation in vitro. In conclusion, this thesis demonstrates that potent anti-rheumatic drugs currently used in the clinic with good efficiency also leave inflammatory pathways un-affected, which may account for subclinical ongoing disease activity. Blocking the PGE2 pathway by using MPGES1 inhibitors as combination therapy may show benefit in dampening ongoing local inflammation

Studies of molecular mechanisms of action of TNF antagonists in rheumatoid arthritis

Rheumatoid Arthritis (RA) is a common chronic inflammatory disease characterized by progressive bone destruction that leads to joint deformity and physical disability. Even though several therapeutic drugs are available, none have emerged as an ideal RA treatment that delays joint destruction and halts disease progression. A new class of drugs, tumor necrosis factor (TNF) antagonists, has recently been introduced in clinical practice: infliximab (chimeric anti-TNF antibody), etanercept (soluble TNF receptor) and adalimumab (fully human anti-TNF antibody). The exact mechanisms of action of these drugs are still poorly understood, even though the important role played by cytokines in RA pathogenesis is the main rationale behind using them for treatment. This thesis investigates the molecular mechanisms of action for TNF antagonists in RA with a focus on synovial inflammation and bone destruction. A major feature of RA is synovial inflammation with local accumulation of immune cells through increased cell influx and decreased clearance of resident cells. We demonstrated that early RA, which is characterized by important macrophage infiltration, is associated with low levels of synovial apoptosis. We also identified macrophage infiltration and synovial expression of the anti-apoptotic molecule FLIP (FLICE inhibitory protein) as determinant factors of synovial apoptosis. As apoptosis is a potential relevant mechanism for RA, we investigated if treatment with TNF antagonists modulates this process. We demonstrated that therapy with both infliximab and etanercept induces apoptosis of macrophages but not of lymphocytes in RA joints. Blood-derived macrophages were less susceptible to anti-TNF induced apoptosis, suggesting that induction of apoptosis through TNF blockade is specific for an inflammatory milieu such as the rheumatoid joint. Synovial inflammation leads to bone destruction that is mediated through either an indirect mechanism induced through cytokine-mediated release of pro-destructive factors such as the matrix metalloproteinases (MMP)-tissue inhibitors of MMPs (TIMPs) system or a direct mechanism mediated through receptor activator of the nuclear factor-?B ligand (RANKL)-osteoprotegerin (OPG) system. We demonstrated that etanercept is able to decrease serum levels of MMPs and the ratio between MMPs and TIMP, which represents a potential mechanism involved in prevention of future development of joint damage. Moreover, baseline MMP-3 serum levels could predict the changes in disease activity during therapy. The RANKL/OPG system is considered to be the final denominator of bone remodeling. We demonstrated that treatment with both etanercept and infliximab increased synovial OPG expression without changes in RANKL expression. The synovial RANKL/OPG ratio thus decreased following therapy, the effect being more pronounced in the responders compared to non-responders to therapy. In conclusion, we have demonstrated that TNF antagonists modulate important mechanisms implicated in synovial inflammation and bone destruction. We propose that therapies which target synovial TNF independent mechanisms, such as RANKL expression and lymphocyte apoptosis, are also valuable candidates for adjuvant therapy in RA

Impact of Temporomandibular Joint Pain in Rheumatoid Arthritis

To investigate the impact of temporomandibular joint (TMJ) pain on daily activities and quality of life in relation to systemic inflammatory activity in patients with rheumatoid arthritis (RA), thirty-three consecutive outpatients with RA were included. TMJ pain intensity at rest, on maximum mouth opening, and on chewing was assessed on a 0–10 numerical rating scale. TMJ palpatory tenderness, degree of anterior open bite, the impact of TMJ pain on daily activities and quality of life were also assessed. The systemic inflammatory activity was estimated by the disease activity score 28 (DAS28), blood levels of inflammatory markers and number of painful musculoskeletal regions. TMJ pain at rest, on maximum mouth opening, and on chewing as well as DAS28 was correlated with the impact of the TMJ pain on daily activities and quality of life. Partial correlations showed a significant interaction between TMJ pain on movement and DAS28 that explained the TMJ pain impact on daily activities and quality of life to a significant degree. This study indicates that both current TMJ pain intensity and systemic inflammatory activity play roles in the impact of TMJ pain on daily living and quality of life in RA

Impact of Temporomandibular Joint Pain in Rheumatoid Arthritis

To investigate the impact of temporomandibular joint (TMJ) pain on daily activities and quality of life in relation to systemic inflammatory activity in patients with rheumatoid arthritis (RA), thirty-three consecutive outpatients with RA were included. TMJ pain intensity at rest, on maximum mouth opening, and on chewing was assessed on a 0–10 numerical rating scale. TMJ palpatory tenderness, degree of anterior open bite, the impact of TMJ pain on daily activities and quality of life were also assessed. The systemic inflammatory activity was estimated by the disease activity score 28 (DAS28), blood levels of inflammatory markers and number of painful musculoskeletal regions. TMJ pain at rest, on maximum mouth opening, and on chewing as well as DAS28 was correlated with the impact of the TMJ pain on daily activities and quality of life. Partial correlations showed a significant interaction between TMJ pain on movement and DAS28 that explained the TMJ pain impact on daily activities and quality of life to a significant degree. This study indicates that both current TMJ pain intensity and systemic inflammatory activity play roles in the impact of TMJ pain on daily living and quality of life in RA