A double-blind placebo-controlled study of auranofin in patients with psoriatic arthritis

Non-biologic disease-modifying antirheumatic drugs (DMARDs) improve pain in inflammatory arthritis (IA): a systematic literature review of randomized controlled trials

Evidence supports early use of non-biologic DMARDs to prevent irreversible damage in inflammatory arthritides, including rheumatoid arthritis (RA), psoriatic arthritis (PsA), and possibly ankylosing spondylitis (AS). However, there is a paucity of data exploring their effects on pain as a primary outcome in these conditions. This systematic literature review investigated the effect of non-biologic DMARDs on pain levels in IA and examined whether disease duration impacted efficacy. We searched Medline, Embase, Cochrane Central, and Cochrane Database of Systematic Reviews, abstracts from the 2008 to 2010 American College of Rheumatology annual congresses, and citation lists of retrieved publications. Only randomized, double-blind controlled trials were analyzed. Quality was assessed with the Risk of Bias tool. Descriptive statistics were used in meta-analysis. 9,860 articles were identified, with 33 eligible for inclusion: 8 in AS, 6 in PsA, 9 in early RA (ERA), and 10 in established RA. In ERA and established RA, all studies of DMARDs (monotherapy and combination therapies) consistently revealed statistically significant reductions in pain except three oral gold studies. In AS, sulfasalazine studies showed significant pain reduction, whereas use of other DMARDs did not. In PsA, 5 of 6 studies reported VAS-pain improvement. From the studies included, we were unable to assess the influence of disease duration on pain outcomes in these rheumatic conditions. DMARDs improve pain in early and established RA. Sulfasalazine may improve pain in AS and PsA. Further study is needed to assess the relationship between disease duration and DMARD efficacy in reducing pain in these conditions.

A randomized placebo-controlled trial of methotrexate in psoriatic arthritis

Objective. MTX is widely used to treat synovitis in PsA without supporting trial evidence. The aim of our study was to test the value of MTX in the first large randomized placebo-controlled trial (RCT) in PsA.

Methods. A 6-month double-blind RCT compared MTX (15 mg/week) with placebo in active PsA. The primary outcome was PsA response criteria (PsARC). Other outcomes included ACR20, DAS-28 and their individual components. Missing data were imputed using multiple imputation methods. Treatments were compared using logistic regression analysis (adjusted for age, sex, disease duration and, where appropriate, individual baseline scores).

Results. Four hundred and sixty-two patients were screened and 221 recruited. One hundred and nine patients received MTX and 112 received placebo. Forty-four patients were lost to follow-up (21 MTX, 23 placebo). Twenty-six patients discontinued treatment (14 MTX, 12 placebo). Comparing MTX with placebo in all randomized patients at 6 months showed no significant effect on PsARC [odds ratio (OR) 1.77, 95% CI 0.97, 3.23], ACR20 (OR 2.00, 95% CI 0.65, 6.22) or DAS-28 (OR 1.70, 95% CI 0.90, 3.17). There were also no significant treatment effects on tender and swollen joint counts, ESR, CRP, HAQ and pain. The only benefits of MTX were reductions in patient and assessor global scores and skin scores at 6 months (P = 0.03, P < 0.001 and P = 0.02, respectively). There were no unexpected adverse events.

Conclusions. This trial of active PsA found no evidence for MTX improving synovitis and consequently raises questions about its classification as a disease-modifying drug in PsA.

Trial registration. Current Controlled Trials, www.controlled-trials.com, ISRCTN:54376151.

Psoriatic arthritis

Although there is still some controversy about the existence of psoriatic arthritis (PsA) as a specific form of inflammatory arthritis associated with psoriasis, epidemiological and clinical studies support the unique features of PsA. Because of lack of diagnostic or classification criteria, the disease has been thought of as uncommon. New classification criteria should facilitate case definition of PsA. Over the past several decades, it has become clear that the disease leads to serious disability and even increased mortality. Traditional medications have not been effective in preventing the progression of joint damage. New medications, including biologics, have emerged with potential to controlling the inflammation and arresting the progression of joint damage.

Psoriatic Arthritis: A Review

Psoriatic arthritis (PsA) is a seronegative inflammatory spondyloarthropathy occurring in individuals with psoriasis. Psoriasis precedes joint disease in approximately 80% of PsA cases. The clinical course of PsA varies from mild arthritis to a severe, debilitating erosive arthropathy that affects functional capacity and quality of life of patients. The incidence of PsA is gender neutral, but a significant genetic component exists. Hallmark clinical features include dystrophic nail changes in the fingers or toes, dactylitis, and enthesitis. Many drugs indicated for use in rheumatoid arthritis have been found useful in the treatment of PsA, suggesting a similar immune-mediated etiology. Nonsteroidal anti-inflammatory drugs and intraarticular corticosteroids are often sufficient to manage mild PsA. Moderate to severe forms of the disease require the initiation of disease modifying anti-rheumatic drugs. Failure of two disease modifying antirheumatic drugs justifies the initiation of biologic therapy with tumor necrosis factor-α inhibitors.

The treatment of psoriatic arthritis

Psoriatic arthritis (PsA) is a chronic, autoimmune, seronegative inflammatory arthritis characterized by varying degrees of axial and peripheral arthritis. Here, we review the literature on the pharmacological management of PsA and present a simple treatment algorithm based on the available information. Although PsA management must be individualized to the degree and type of joint pain and inflammation, in general, nonsteroidal antiinflammatory drugs (NSAIDs) still represent first-line treatment of mild PsA. Second-line therapy includes older agents such as gold salts, methotrexate, sulfasalazine, and cyclosporine. The tumor necrosis factor alpha (TNF-alpha) antagonists represent the most recent major advance in the clinical management of PsA.

Psoriatic arthritis therapy: NSAIDs and traditional DMARDs

Non-steroidal anti-inflammatory drugs (NSAIDs) and traditional disease modifying antirheumatic drugs (DMARDs) are widely used in the treatment of psoriatic arthritis (PsA), but this is based more upon clinical experience than adequate evidence from clinical trials. This report summarises the results from available trials highlighting evidence of efficacy and deficiencies with respect to effect on joints and to a lesser degree cutaneous disease. The available published data on efficacy of NSAIDs, glucocorticoids, antimalarials, sulfasalazine, gold, methotrexate, azathioprine, and ciclosporin are detailed, as well as new data on leflunomide and other novel agents. The conclusions of this review are that evidence supports marginal efficacy of sulfasalazine and perhaps gold in the treatment of peripheral psoriatic arthropathy, and methotrexate and ciclosporin are effective for treating the skin disease although evidence for improvement of the arthropathy is empirical at best. New trials with standardised and validated outcome measures are required to better assess efficacy. Evaluating newer agents, against and in combination with traditional DMARDS, may further clarify the latter's role in the future management of this condition.

Current and investigational treatment of psoriatic arthritis

Psoriatic arthritis (PsA) is now recognised as a progressively destructive inflammatory arthritis that can lead to joint deformity and functional disability. Early diagnosis and treatment with disease-modifying antirheumatic drugs (DMARDs) are necessary to control disease, particularly in patients with clinical factors and human leukocyte antigen markers predictive of progressive disease. However, there are few randomised controlled trials of the traditional DMARDs in PsA and none have demonstrated efficacy on axial manifestations or delay in radiological progression. The demonstration of raised levels of TNF-alpha in psoriatic skin and synovial tissue has provided a rationale for the application of biological agents in PsA. Furthermore, the recognition of the role of T-cell activation in both psoriasis and PsA has led to the therapeutic targeting of T lymphocytes, the results of which at this early stage are encouraging. This article reviews the studies of the most widely used traditional DMARDs in PsA followed by studies with leflunomide and the biological response modifiers, including TNF-alpha antagonists and T-cell-targeted therapies.

Psoriatic arthritis

Although there is still some controversy about the existence of psoriatic arthritis as a specific form of inflammatory arthritis associated with psoriasis, epidemiological, and clinical studies support the unique features of psoriatic arthritis. Because of lack of diagnostic or classification criteria, the disease has been thought of as uncommon. Over the past several decades, it has become clear that the disease leads to serious disability and even increased mortality. Traditional medications have not been effective in preventing the progression of joint damage. New medications, including biologics, have emerged with the potential to control the inflammation and arrest the progression of joint damage.

Traditional and Newer Therapeutic Options for Psoriatic Arthritis

Psoriatic arthritis (PsA) is a destructive form of inflammatory arthritis that occurs in about one-third of patients with psoriasis. The pathogenesis of PsA includes genetic and immunological factors. A review of the currently available therapies reveals that traditional disease-modifying medications have provided only marginal relief from joint inflammation in patients with PsA, and have not been successful in controlling the disease and preventing joint damage. On the basis of current understanding of the pathogenesis of joint destruction in PsA, several new medications have been introduced, including anti-tumour necrosis factor (TNF) agents and agents that interfere with T-cell function. Most of these medications have been found to be effective in both psoriasis and PsA. Recent randomised controlled trials suggest that at least anti-TNF agents may help prevent progression of joint destruction.

Diagnosis and management of psoriatic arthritis

Psoriatic arthritis (PsA) is considered to be one of the spondyloarthritides, and as such has both spinal and peripheral joint involvement. In 80% of patients, psoriasis usually precedes the development of arthritis. Although there are no widely accepted diagnostic criteria, a number of distinct clinical features allow it to be distinguished from other forms of inflammatory arthritis. It affects both sexes equally, and the pattern of joint involvement is characteristic with distal interphalangeal joint involvement, asymmetry, dactylitis, flail or ankylotic deformities of digits, and the frequent presence of enthesitis and spinal involvement. It may have a pattern of joint involvement similar to rheumatoid arthritis (RA) but in these patients rheumatoid factor and the other systemic features of RA are usually absent. Radiographs frequently reveal evidence of asymmetric sacroiliitis and spinal disease, and peripheral joints, as well as showing erosions, may also demonstrate profuse new bone formation and ankylosis. Profound osteolysis producing the pencil-in-cup deformity can also occur in the same individual. It is now recognised that PsA can be a destructive arthritis with an increased morbidity and mortality. Studies of standard disease-modifying therapies have been small and frequently inconclusive because of a high placebo response rate. This may be as a result of heterogeneity in patient selection, poor assessment tools, or the difference in underlying pathogenesis and subsequent response to therapy. In meta-analyses, sulfasalazine and methotrexate have been shown to be effective. Treating the skin alone seems to have little impact on joint disease, and the relationship between skin and joints is still unclear. However, recent studies with anti-tumour necrosis factor agents, such as etanercept and infliximab, have shown considerable significant clinical benefit and provided the hope that we will at last have effective therapies for this disease.

The experience of living with fibromyalgia: confronting an invisible disability

Fibromyalgia (FM) is a complex, chronic, painful musculoskeletal syndrome which is characterized by extreme fatigue, disordered sleep, and other associated physical and cognitive problems. Because its etiology is unknown, and because no specific pathophysiological mechanisms have been found to underlie the syndrome, making a diagnosis is very difficult. FM adversely affects the quality of life, and the societal costs based on medical expenses, lost wages, lost tax revenue and compensation expenditures are very significant. The purpose of this phenomenological study was to describe and enhance the understanding of the experience of living with FM. The participants included nine women ranging in age from 30 years to 56 years who had been diagnosed with the condition for more than a year. Data were collected by means of unstructured interviews. Thematic analysis, using van Manen's (1990) methodology, identified eight themes: (a) pain-the constant presence, (b) fatigue-the invisible foe, (c) sleep-the impossible dream, (d) thinking of a frog (e) dealing with a flare-up, (f) longing for a normal life, (g) the power of naming-seeking a diagnosis, and (h) living within the boundaries. These themes were integral parts of the whole story, and through their interrelationships, the essence confronting an invisible disability was captured. The findings of this qualitative study have implications for nursing practice, education and research. It has become an increasing challenge for our health care system to adequately cope with the large numbers of persons diagnosed with chronic illnesses. Administrators of these systems can benefit from the information learned during this study.

Immunomodulating drugs in the management of psoriatic arthritis

Psoriatic arthritis is a chronic inflammatory arthropathy which can be distinguished from rheumatoid arthritis on the basis of differing patient demographics, genetic predisposition, histopathologic change, radiographic appearance, and clinical course. The cause of psoriatic arthritis remains unknown but appears to be autoimmune in nature as its pathogenesis is characterized by persistent synovial inflammation resulting in damage to the articular cartilage and osteolysis. Compared with rheumatoid arthritis, distinct lymphocyte subpopulations and pro-inflammatory cytokine levels appear to be present within the joint but the importance and therapeutic implications of these differences is uncertain. The clinical presentation of psoriatic arthritis is variable and overlapping patterns of joint involvement affecting both the appendicular and axial skeleton are seen. For patients with mild synovial disease and a favorable prognosis, the use of a nonsteroidal anti-inflammatory drug for symptomatic relief is often sufficient. However, the destructive potential of psoriatic arthritis is increasingly recognized and patients with more synovial disease and radiographic change at presentation appear to be at risk for greater morbidity and increased mortality. Immunomodulating therapy has the potential to suppress joint inflammation and preserve functional capacity but true disease modification has yet to be shown. The toxicity associated with presently available immunomodulatory agents makes careful patient selection and conscientious monitoring essential. The efficacy of methotrexate and sulfasalazine in patients with psoriatic arthritis is well defined while more anecdotal reports of benefit exist for other agents including the antimalarials, azathioprine, colchicine, cyclosporine, and the retinoids. For all treatment regimens, the magnitude of clinical improvement demonstrated to date has been rather small and quite subjective in character with few controlled studies of adequate size and duration having been reported. Emerging biologic therapies, such as those which target tumor necrosis factor, will hopefully provide future treatment options with greater efficacy and improved safety for patients with psoriatic arthritis.

Use of disease-modifying antirheumatic drugs in patients with psoriatic arthritis

Few prospective placebo-controlled studies have evaluated disease-modifying antirheumatic drugs (DMARDs) in the treatment of peripheral psoriatic arthritis.

OBJECTIVE

To evaluate second-line treatments used in clinical practice in patients with psoriatic arthritis.

METHOD

We studied a cross-section of 100 consecutive patients seen by hospital-based or office-based rheumatologists for psoriatic arthritis.

PATIENTS

The 55 men and 45 women had a mean age of 48 years (range, 17-79 years) and a mean disease duration of 7 years (range, 1-24 years).

RESULTS

The most commonly used DMARDs were sulfasalazine, gold, methotrexate, and hydroxychloroquine (64, 43, 41 et 17 patients, respectively). These drugs had been stopped because of inefficacy in 31%, 31%, 12%, and 53% of patients, respectively, and because of adverse events in 23%, 44%, 22%, and 41% of patients, respectively. At the time of the study, mean treatment durations were 15, 21, 34, and 12 months, respectively, and the drugs were still being used in 45%, 21%, 66%, and 6% of patients.

CONCLUSION

Our data confirm the value of methotrexate and salazopyrine. Methotrexate had the best risk/benefit ratio. Gold was often responsible for side effects. Hydroxychloroquine was inadequately effective and poorly tolerated.

Interventions for psoriatic arthritis

OBJECTIVES

To assess the effects of salazopyrin, auranofin, etretinate, fumaric acid, IMI gold, azathioprine, and methotrexate, in psoriatic arthritis.

SEARCH STRATEGY

We searched Medline up to 1995, and Excerpta Medica (June 1974-95). Search terms were psoriasis, arthritis, therapy and/or controlled trial. This was supplemented by manually searching bibliographies of previously published reviews, conference proceedings and contacting drug companies. All languages were included in the initial search.

SELECTION CRITERIA

All randomized trials comparing salazopyrin, auranofin, etretinate, fumaric acid, IMI gold, azathioprine, and methotrexate, in psoriatic arthritis. The main outcome measures included individual component variables derived from Outcome Measures in Rheumatology Clinical Trials (OMERACT). These include Acute Phase Reactants, Disability, Pain, Patient Global Assessment, Physician Global Assessment, Swollen joint count, Tender joint count and radiographic changes of joints in any trial of 1 year or longer [Tugwell 1993], and the change in pooled disease index. Only English trials were included in the review.

DATA COLLECTION AND ANALYSIS

Data were independently extracted from the published reports by two of the reviewers. An independent blinded quality assessment was also performed.

MAIN RESULTS

Nineteen randomized trials were identified of which eleven were included in the quantitative analysis with data from 777 subjects. Although all agents were better than placebo, parenteral high dose methotrexate (not included), salazopyrin, azathioprine and etretinate were the agents that achieved statistical significance in a global index of disease activity (although it should be noted that only one component variable was available for azathioprine and only one trial was available for etretinate suggesting some caution is necessary in interpreting these results). Analysis of response in individual disease activity markers was more variable with considerable differences between different medications and responses. In all trials the placebo group improved over baseline (pooled improvement 0.43 DI units, 95% CI 0. 28-0.59). There was insufficient data to examine toxicity.

REVIEWER'S CONCLUSIONS

Parenteral high dose methotrexate and salazopyrin are the only two agents with well demonstrated published efficacy in psoriatic arthritis. The magnitude of the effect seen with azathioprine, etretinate, oral low dose methotrexate and perhaps colchicine suggests that they may be effective but that further multicentre clinical trials are required to establish their efficacy. Furthermore, the magnitude of the improvement observed in the placebo group strongly suggests that uncontrolled trials should not be used to guide management decisions in this condition.

Dual effects of auranofin on prostaglandin E2 production by rat peritoneal macrophages

Incubation of rat peritoneal macrophages in medium containing various concentrations of auranofin (1, 3 and 10 microM) increased prostaglandin E2 production at 4 h in a concentration-dependent manner, in accordance with the increase in the release of [3H]arachidonic acid from membrane phospholipids. However, at 20 h, no stimulation of prostaglandin E2 production by auranofin was observed. When the peritoneal macrophages were incubated in the presence of 12-O-tetradecanoylphorbol 13-acetate (TPA), thapsigargin or A23187, prostaglandin E2 production at 4 and 20 h was enhanced. The stimulator-induced prostaglandin E2 production at 20 h was suppressed by 10 microM of auranofin. Western blot analysis demonstrated that auranofin inhibited the induction of cyclooxygenase 2 by TPA, thapsigargin or A23187 at 4 and 20 h. The level of cyclooxygenase 1 did not change by treatment with these stimulators in the presence or absence of auranofin. These findings suggest that auranofin has dual effects on prostaglandin E2 production: without stimulation, auranofin increases prostaglandin E2 production at 4 h due to the increased release of arachidonic acid which is converted to prostaglandin E2 mainly by cyclooxygenase 1, but inhibits the stimulator-induced late-phase prostaglandin E2 production by inhibiting the induction of cyclooxygenase 2.

Comparison of sulfasalazine and placebo in the treatment of psoriatic arthritis. A Department of Veterans Affairs Cooperative Study

OBJECTIVE

To determine whether sulfasalazine (SSZ) at a dosage of 2,000 mg/day is effective for the treatment of active psoriatic arthritis (PsA) resistant to nonsteroidal antiinflammatory drug therapy.

METHODS

Two hundred twenty-one patients with PsA were recruited from 15 clinics, randomized (double-blind) to SSZ or placebo treatment, and followed up for 36 weeks. Treatment response was based on joint pain/ tenderness and swelling scores and physician and patient global assessments.

RESULTS

Longitudinal analysis revealed a trend favoring SSZ treatment (P = 0.13). At the end of treatment, response rates were 57.8% for SSZ compared with 44.6% for placebo (P = 0.05). The Westergren erythrocyte sedimentation rate declined more in the PsA patients taking SSZ than in those taking placebo (P < 0.0001). Adverse reactions were fewer than expected and were mainly due to nonspecific gastrointestinal complaints, including dyspepsia, nausea, vomiting, and diarrhea.

CONCLUSION

SSZ at a dosage of 2,000 mg/day is well tolerated and may be more effective than placebo in the treatment of patients with PsA.

Auranofin and its combination with LTB4 influences ATP level and migration of human polymorphonuclear cells in vitro

Auranofin (AF), an orally administered antirheumatic drug, reduces the ATP level of PMN cells in vitro in a dose-dependent manner and provokes various effects on PMN migration. Under the experimental conditions, AF in concentrations between 10(-8) M and 10(-3) M produced a statistically significant (P < 0.05) dose-related reduction in ATP level, which ranged from 89% of the control value with 10(-8) M AF to 46.8% of the control with 10(-3) M AF. On the other hand, the combination of AF and the chemoattractant LTB4 (1 ng/ml) shows agonistic effects on the intracellular ATP level. AF at 10(-5) M significantly increases the ATP (33%; P < 0.03). In general migration of PMN cells is stimulated by 10(-7) M AF [chemotactic index (CI) = 1.26], but inhibited by 10(-5) M (CI = 0.65), 10(-4) M (CI = 0.09) and 10(-3) M AF (CI = 0.01). These effects were statistically significant at P < 0.05. In the presence of LTB4 (1 ng/ml), which resulted in an average CI of 2.9, AF also inhibits the chemotactic effect of the chemoattractant, with the CI being significantly reduced at 10(-6) M AF (CI = 2.3) and 10(-4) M AF (CI = 0.05). In the latter case the effect was also confirmed by the leading-front technique. AF at 10(-6) M is a level that could be reached in the blood after continuous therapy regimens, and these results are therefore of practical interest. They expand our knowledge of the effects of AF on PMN cells, whereby reducing effects on intracellular ATP were observed with AF alone and stimulating effects in combination with LTB4. With low AF concentrations, the reduction of the ATP level is only a part of its action that seems to be independent of its effect on cell migration and chemotaxis.

Treatment of psoriatic arthritis with auranofin and gold sodium thiomalate

Forty-two patients with psoriatic arthritis were included in a multicenter, double-blind trial comparing auranofin and gold sodium thiomalate (GST) for 6 months, followed by a 6-month open treatment. Fifty-two percent of the patients on auranofin and 33% on GST were able to complete the 1-year course of therapy. As a result of the study we conclude that both gold compounds are effective agents in the treatment of psoriatic arthritis. Degree of improvement of arthritis was better in the GST group, but the number of improved patients was greater in the auranofin group. Two patients on auranofin were withdrawn for side effects (one diarrhoea, one worsening of psoriasis) and 5 on GST (rash 2, total loss of appetite 1, exacerbation of psoriasis 2). Comparing the side effects of both compounds, auranofin is less likely to aggravate the psoriatic condition or result in withdrawal of patients for adverse reactions.

Treatment of psoriatic arthritis

The treatment of psoriatic arthritis has acquired relevance in the past few years because of advances and better understanding of the pathogenetic mechanisms implicated in the disease, and also because of recognition that this disorder is not a benign disease as was previously thought. The general principles of management for any inflammatory arthritis, including pharmacological, surgical and rehabilitative treatment, are to be used, with concomitant therapeutic management of skin involvement. Non-steroidal anti-inflammatory drugs constitute the mainstay of pharmacological therapy for most patients, with a good clinical response observed in 75-85%. Early use of remittive agents, especially methotrexate, is indicated in patients with a poor response to NSAIDs or those with polyarticular and progressive joint involvement. Patients who are refractory to conventional therapy should be considered for newer and potentially more toxic therapeutic modalities such as cyclosporin A and retinoids.

Treatment of psoriatic arthropathy

Psoriatic arthritis develops in 5% of patients with cutaneous psoriasis. Management is similar to that of other chronic inflammatory joint diseases, and the characteristic features of psoriatic arthritis should be considered: the disease is usually mild, with unpredictable flares and remissions, and skin disease is a concomitant feature. Nonsteroidal antiinflammatory agents are the mainstay of therapy and usually provide adequate control. Among long-term treatments, parenteral gold salts, methotrexate, and azathioprine have been shown to be effective. Retinoids are often used in patients with extensive skin lesions. Other treatments are currently being evaluated (auranofin, colchicine, D-penicillamine, sulfasalazine, cyclosporine, and gamma-interferon). Antimalarials are difficult to handle and may cause progression of skin lesions. Topical treatments are indicated in every case. Indications depend on the specific features of psoriatic arthritis, the clinical pattern, and the severity of the condition.