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Efficacy of doxycycline as a combination therapy in the treatment of rheumatoid arthritis: a randomized controlled clinical trial. THE EGYPTIAN JOURNAL OF INTERNAL MEDICINE 2021. [DOI: 10.1186/s43162-021-00032-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
This single-center randomized open-label clinical trial evaluates the effectiveness of doxycycline as a combination therapy for active rheumatoid arthritis (RA) with methotrexate (MTX).
Materials and methods
One hundred and sixty RA patients were recruited who fulfilled the 2010 American College of Rheumatology/European League Against Rheumatism (ACR/EULAR) classification criteria. Subjects were randomly allocated in a 1:1 ratio into one of two treatment arms; one group was maintained on MTX alone and the other group on MTX together with doxycycline orally 200 mg daily. Follow-up clinical response, erythrocyte sedimentation rate (ESR), levels of C-reactive protein (CRP), and disease activity score 28 (DAS28-CRP) after 3 months were done.
Results
There was a significant difference regarding DAS28-CRP between the two groups (median (IQR) 4.26 (3.6–5) for those treated with MTX alone compared with 2.8 (2.37–3.5) for those treated with MTX together with doxycycline) (p = 0.005). A higher number of patients treated with doxycycline in combination with MTX achieved remission (40.5%) compared to patients who received MTX alone (13.5%). The levels of ESR and CRP were lower in patients treated with MTX and doxycycline and this was statistically significant (p = 0.005, p = 0.003 respectively).
Conclusion
Doxycycline as a cost-effective combination therapy with MTX can achieve higher rates of remission than MTX alone in RA patients without causing increase in the adverse events profile.
Trial registration
Clinical Trials.gov, NCT03194204. Registered on 21 June 2017
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Heydari-Kamjani M, Demory Beckler M, Kesselman MM. Reconsidering the Use of Minocycline in the Preliminary Treatment Regime of Rheumatoid Arthritis. Cureus 2019; 11:e5351. [PMID: 31608186 PMCID: PMC6783212 DOI: 10.7759/cureus.5351] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Strong epidemiologic, clinical, and basic science studies have identified a number of factors that may lead to rheumatoid arthritis (RA) onset and progression, particularly involving the complex interplay between genomics, environmental risk factors, the breakdown of immune self-tolerance, and microbiome dysbiosis. A chronic state of inflammation established by infectious agents has long been suspected to set the stage for the development of RA. The purpose of this article is to review the contribution of the gut, lung, and oral microbiomes to the pathogenesis of RA and consider the importance of supplementing the preliminary treatment regime of RA patients with antibiotics, in particular, minocycline. Minocycline has been used in the treatment of RA due to its bacteriostatic, as well as immunomodulatory and anti-inflammatory properties. Ultimately, a short course of antibiotic treatment with minocycline may eliminate pathogenic organisms contributing to the development and progression of RA.
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Affiliation(s)
- Milad Heydari-Kamjani
- Osteopathic Medicine, Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine, Fort Lauderdale, USA
| | - Michelle Demory Beckler
- Immunology, Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine, Fort Lauderdale, USA
| | - Marc M Kesselman
- Rheumatology, Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine, Fort Lauderdale, USA
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Patel MI, Moore D, Milstein A. Redesigning Advanced Cancer Care Delivery: Three Ways to Create Higher Value Cancer Care. J Oncol Pract 2015; 11:280-4. [PMID: 25991638 DOI: 10.1200/jop.2014.001065] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The authors believe their cancer care model constructed from quality-improving strategies has potential to help US clinicians respond effectively to an urgent policy imperative.
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Bykerk VP. Nonimmunosuppressive disease-modifying antirheumatic drugs. Rheumatology (Oxford) 2015. [DOI: 10.1016/b978-0-323-09138-1.00055-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Shehwaro N, Langlois AL, Gueutin V, Gauthier M, Casenave M, Izzedine H. [Doxycycline or how to create new with the old?]. Therapie 2014; 69:129-41. [PMID: 24926631 DOI: 10.2515/therapie/2013069] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2013] [Accepted: 09/26/2013] [Indexed: 11/20/2022]
Abstract
Tetracyclines are broad-spectrum antibiotics that interfere with protein synthesis. They were first widely prescribed by dermatologists in the early 1950s in the treatment of acne. More recently, their biological actions on inflammation, proteolysis, angiogenesis, apoptosis, metal chelation, ionophoresis, and bone metabolism were studied. Matrix metalloproteinases (MMPs) are a family of proteolytic enzymes that degrade components of the extracellular matrix (ECM). MMPs have direct or indirect effects on the vascular endothelium and the vascular relaxation/contraction system. The therapeutic effects of tetracyclines and analogues were studied in rosacea, bullous dermatoses, neutrophilic diseases, pyoderma gangrenosum, sarcoidosis, aortic aneurysms, cancer metastasis, periodontitis and autoimmune diseases autoimmune diseases such as rheumatoid arthritis and scleroderma. In addition, downregulation of MMP using doxycycline could be beneficial in reducing vascular dysfunction mediated by MMPs and progressive damage of the vascular wall. We review the nonantibiotic properties of doxycycline and its potential clinical applications.
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Smith CJ, Sayles H, Mikuls TR, Michaud K. Minocycline and doxycycline therapy in community patients with rheumatoid arthritis: prescribing patterns, patient-level determinants of use, and patient-reported side effects. Arthritis Res Ther 2011; 13:R168. [PMID: 22008667 PMCID: PMC3308103 DOI: 10.1186/ar3491] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2011] [Revised: 09/19/2011] [Accepted: 10/18/2011] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Minocycline and doxycycline are safe and moderately effective disease-modifying anti-rheumatic drugs (DMARDs) in the treatment of early, DMARD-naïve rheumatoid arthritis (RA), although little is known about their use outside clinical trials. We characterize the use of minocycline and doxycycline in community-dwelling RA patients by examining associated prescribing patterns, patient-level determinants of use, and side-effect profiles. METHODS We studied 15,716 patients with RA observed between 1998 and 2009 while participating in a long-term US observational study. RESULTS Minocycline or doxycycline was prescribed by 18% of rheumatologists (interquartile range one to two patients per physician) to 9% of RA patients. Significant differences between minocycline-treated and doxycycline-treated patients and nontreated patients included age (58.4 years vs. 59.8 years), RA duration (14.8 years vs. 13.7 years), Caucasian race (93.7% vs. 89.7%), lifetime DMARDs and biologics (3.3 vs. 2.5), prednisone use (40.1% vs. 35.3%), and Medical Outcomes Study 36-Item Short Form Survey physical component summary score (35.0 vs. 36.4). In multivariable Cox regression, patients initiating minocycline or doxycycline had increased disease activity, more comorbidities, and a greater number of prior nonbiologic DMARDs. Side effects were reported by 17.8% of minocycline users and 11.8% of doxycycline users. Skin complaints accounted for 54% of minocycline patient-reported side effects. The most commonly effected organ systems for doxycycline were gastrointestinal (35.4%) and skin (33.7%). Approximately 75% of side effects were of mild or moderate severity. CONCLUSIONS Rheumatologists have not embraced minocycline or doxycycline as primary treatment options for RA and reserve their use primarily in patients with long-standing, refractory disease. These drugs are generally well tolerated, with skin complaints, nausea, and dizziness being the most common patient-reported side effects.
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Affiliation(s)
- Christopher J Smith
- Department of Internal Medicine, University of Nebraska Medical Center, 986270 Nebraska Medical Center, Omaha, NE 68198-6270, USA
| | - Harlan Sayles
- Department of Internal Medicine, University of Nebraska Medical Center, 986270 Nebraska Medical Center, Omaha, NE 68198-6270, USA
| | - Ted R Mikuls
- Department of Internal Medicine, University of Nebraska Medical Center, 986270 Nebraska Medical Center, Omaha, NE 68198-6270, USA
| | - Kaleb Michaud
- Department of Internal Medicine, University of Nebraska Medical Center, 986270 Nebraska Medical Center, Omaha, NE 68198-6270, USA
- National Data Bank for Rheumatic Diseases, 1035 North Emporia, Suite 288, Wichita, KS 67214, USA
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Abstract
The potential role of a collagenase inhibitor for treatment of arthritis was recognized almost immediately after the discovery of vertebrate collagenase. Yet despite vast efforts from the pharmaceutical industry, no such drug has been approved for such use by a regulatory agency. Although two semisynthetic antimicrobial tetracyclines, viz. minocycline and doxycycline, have been shown to have modest clinical benefits in over a dozen trials in rheumatoid arthritis, neither drug is in widespread use. The almost universal use of methotrexate and the rapid development of potent biologic agents have eclipsed the potential usage of TETs for RA. Ironically, it is in osteoarthritis, where there has only been one clinical trial which essentially failed, that the best potential exists for use of an MMP-inhibiting TET.
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Affiliation(s)
- Robert A Greenwald
- The Division of Rheumatology, Prohealthcare Associates, LLP, Lake Success, NY, United States.
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Thabet MM, Huizinga TW. Dapsone, penicillamine, thalidomide, bucillamine, and the tetracyclines. Rheumatology (Oxford) 2011. [DOI: 10.1016/b978-0-323-06551-1.00056-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
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Abstract
Tetracyclines are broad-spectrum antibiotics that act at the ribosomal level. They were first introduced in 1948 and were widely prescribed by dermatologists in the early 1950s for treatment of acne. More recently, biologic actions of tetracyclines affecting inflammation, angiogenesis, and bone metabolism have been researched. The therapeutic effects of tetracycline and its analogues in rheumatic diseases have also been investigated. This article will review the rheumatological use of tetracycline and its analogues.
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Affiliation(s)
- Suzan M Attar
- Department of Medicine, King Abdulaziz University Hospital, Jeddah, Saudi Arabia.
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O'Dell JR, Elliott JR, Mallek JA, Mikuls TR, Weaver CA, Glickstein S, Blakely KM, Hausch R, Leff RD. Treatment of early seropositive rheumatoid arthritis: doxycycline plus methotrexate versus methotrexate alone. ACTA ACUST UNITED AC 2006; 54:621-7. [PMID: 16447240 DOI: 10.1002/art.21620] [Citation(s) in RCA: 76] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
OBJECTIVE To compare the efficacy of doxycycline plus methotrexate (MTX) versus MTX alone in the treatment of early seropositive rheumatoid arthritis (RA), and to attempt to differentiate the antibacterial and antimetalloproteinase effects of doxycycline. METHODS Sixty-six patients with seropositive RA of <1 year's duration who had not been previously treated with disease-modifying antirheumatic drugs were randomized to receive 100 mg of doxycycline twice daily with MTX (high-dose doxycycline group), 20 mg of doxycycline twice daily with MTX (low-dose doxycycline group), or placebo with MTX (placebo group), in a 2-year double-blind study. Treatment was started with an MTX dosage of 7.5 mg/week, which was titrated every 3 months until remission was reached (maximum dosage of 17.5 mg/week). The primary end point was an American College of Rheumatology 50% improvement (ACR50) response at 2 years. RESULTS ACR50 responses were observed in 41.6% of patients in the high-dose doxycycline group, 38.9% of those in the low-dose doxycycline group, and 12.5% of patients in the placebo group. Results of chi-square analysis of the ACR50 response in the high-dose doxycycline group versus that in the placebo group were significantly different (P = 0.02). Trend analysis revealed that the ACR20 response and the ACR50 response were significantly different between groups (P = 0.04 and P = 0.03, respectively). MTX doses at 2 years were not different among groups. Four patients in the high-dose doxycycline group, 2 patients in the low-dose doxycycline group, and 2 patients in the placebo group were withdrawn because of toxic reactions. CONCLUSION In patients with early seropositive RA, initial therapy with MTX plus doxycycline was superior (based on an ACR50 response) to treatment with MTX alone. The therapeutic responses to low-dose and high-dose doxycycline were similar, suggesting that the antimetalloproteinase effects were more important than the antibacterial effects. Further studies to evaluate the mechanism of action of tetracyclines in RA are indicated.
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Kirwan JR, Hällgren R, Mielants H, Wollheim F, Bjorck E, Persson T, Book C, Bowman S, Byron M, Cox N, Field M, Kanerud L, Leirisalo-Repo M, Malaise M, Mohammad A, Palmer R, Petersson IF, Ringertz B, Sheldon P, Simonsson M, Snowden N, Van den Bosch F. A randomised placebo controlled 12 week trial of budesonide and prednisolone in rheumatoid arthritis. Ann Rheum Dis 2004; 63:688-95. [PMID: 15140776 PMCID: PMC1755023 DOI: 10.1136/ard.2003.008573] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To compare budesonide, a locally acting glucocorticoid with minimal systemic exposure, with conventional glucocorticoid treatment and placebo in rheumatoid arthritis. METHODS A double blind, randomised, controlled trial over 12 weeks in 143 patients with active rheumatoid arthritis, comparing budesonide 3 mg daily, budesonide 9 mg daily, prednisolone 7.5 mg daily, and placebo. Particular attention was paid to the pattern of clinical response and to changes in the four week period following discontinuation of treatment. RESULTS There were improvements in tender joint count and swollen joint count on budesonide 9 mg compared with placebo (28% for tender and 34% for swollen joint counts, p<0.05). Prednisolone 7.5 mg gave similar results, while budesonide 3 mg was less effective. ACR20 response criteria were met by 25% of patients on placebo, 22% on budesonide 3 mg, 42% on budesonide 9 mg, and 56% on prednisolone 7.5 mg. A rapid and significant reduction in symptoms and signs in response to budesonide 9 mg and prednisolone 7.5 mg was evident by two weeks and maximal at eight weeks. There was no evidence that budesonide provided a different pattern of symptom control from prednisolone, or that symptoms became worse than placebo treatment levels after discontinuation of glucocorticoid treatment. Adverse effects attributable to glucocorticoids were equally common in all groups. CONCLUSIONS The symptomatic benefits of budesonide 9 mg and prednisolone 7.5 mg are achieved within a short time of initiating treatment, are maintained for three months, and are not associated with any rebound in symptoms after stopping treatment.
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Affiliation(s)
- J R Kirwan
- Academic Rheumatology Unit, University Division of Medicine, Bristol Royal Infirmary, Bristol BS2 8HW, UK.
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Criscione LG, Sugarman J, Sanders L, Pisetsky DS, St Clair EW. Informed consent in a clinical trial of a novel treatment for rheumatoid arthritis. ARTHRITIS AND RHEUMATISM 2003; 49:361-7. [PMID: 12794792 DOI: 10.1002/art.11057] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE To evaluate the informed consent process for a clinical trial of intravenous doxycycline for rheumatoid arthritis. METHODS Participants completed a self-administered questionnaire about the consent process at baseline and 16 weeks following enrollment in a clinical trial. RESULTS Respondents (n = 30) affirmed voluntary participation in the parent trial. Participants acknowledged hope and altruism as reasons for entering the trial more than expectation of personal benefit or outside influences. Many respondents did not understand randomization (14/30), placebos (15/30), or risks of study medications; 11/30 respondents believed that the study drug was completely safe. CONCLUSION Respondents generally understood the experimental nature of the trial and confirmed their participation was voluntary. However, gaps existed in participants understanding of trial design, raising the question of whether they were adequately informed about the research study prior to enrollment. Further education of potential participants in clinical trials may be required to achieve valid informed consent.
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Affiliation(s)
- Lisa G Criscione
- Duke University Medical Center, Durham, North Carolina 27710, USA
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Perez N, Plence P, Millet V, Greuet D, Minot C, Noel D, Danos O, Jorgensen C, Apparailly F. Tetracycline transcriptional silencer tightly controls transgene expression after in vivo intramuscular electrotransfer: application to interleukin 10 therapy in experimental arthritis. Hum Gene Ther 2002; 13:2161-72. [PMID: 12542847 DOI: 10.1089/104303402320987851] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The doxycycline (Dox)-inducible reverse tetracycline transactivator (rtTA) is often used to control gene expression. However, the Tet-on system displays a high background activity. To overcome this unregulated expression we used the tetracycline-dependent transcriptional silencer (tTS), which binds the tetO inducible promoter in the absence of Dox. Controlled gene expression was analyzed in vivo by delivering combinations of Dox-regulated luciferase reporter construct, rtTA, and tTS expression plasmids into mouse muscle, using electrotransfer. Elevated luciferase expression levels were observed in the absence of doxycycline, and a 10-fold induction was obtained after drug administration. In contrast, when tTS was added, background expression was dramatically lowered by three to four orders of magnitude, and induction was maintained. The tTS system was then used to control expression of a therapeutic gene in experimental arthritis. DBA/1 mice were coinjected with plasmids encoding the antiinflammatory interleukin-10 cytokine under the control of the tetO promoter, the rtTA, and the tTS. Electrotransfer resulted in a dose-dependent increase in IL-10 expression, maintained over a 3-month period, and significant inhibitory effects on collagen-induced arthritis. We conclude that the use of tTS significantly improves the utility of the rtTA system for somatic gene transfer by reducing background activity.
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Affiliation(s)
- Norma Perez
- Genethon, CNRS URA 1923, 91000 Evry, France.
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Martel-Pelletier J, Welsch DJ, Pelletier JP. Metalloproteases and inhibitors in arthritic diseases. Best Pract Res Clin Rheumatol 2001; 15:805-29. [PMID: 11812023 DOI: 10.1053/berh.2001.0195] [Citation(s) in RCA: 190] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Controlling degradation of the extracellular matrix is crucial in arthritic diseases such as osteoarthritis (OA) and rheumatoid arthritis (RA), as conventional treatments do not positively affect the structural properties of the articular tissues. Metalloproteases, a family of zinc-dependent enzymes, and more specifically the matrix metalloproteases (MMPs), play a premier role in joint articular tissue degeneration. Additional enzymes of the metalloprotease family, such as the membrane-type metalloproteases (MT-MMPs) and the adamalysins that include the ADAMs and the ADAMTS families, have also been found to be involved in these disease processes. At present, therapeutic intervention based on the inhibition of metalloproteases, and more particularly of the MMPs, is under intensive investigation, and several MMP inhibitors are in clinical development. Currently, MMP inhibitors are exemplified by several chemical classes: hydroxamic acids, carboxylic acids and thiols. One key issue in the clinical development of MMP inhibitors relates to whether broad-spectrum inhibitors active against a range of different enzymes or selective inhibitors targeted against a single enzyme or particular subset of the MMPs represents the optimal strategy. In this chapter, we address the different metalloprotease enzymes and sub-families and their implication in arthritic diseases. Furthermore, we assess physiological and chemical metalloprotease inhibitors, and for the latter, the current inhibitory classes of compounds being studied.
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Affiliation(s)
- J Martel-Pelletier
- Osteoarthritis Research Unit, Hôpital Notre-Dame, Centre Hospitalier de l'Université de Montréal, 1560 rue Sherbrooke Est, Montréal, Quebec, Canada
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