Effects of interferon-alpha2a treatment on serum levels of tumor necrosis factor-alpha, tumor necrosis factor-alpha2 receptor, interleukin-2, interleukin-2 receptor, and E-selectin in Behçet's disease

Elevated Monocyte to High-Density Lipoprotein Cholesterol Ratio and Endothelial Dysfunction in Behçet Disease

Behçet disease (BD) is a multisystemic disorder characterized by endothelial dysfunction and inflammation. Monocyte to high-density lipoprotein cholesterol ratio (MHR) is a recently emerged indicator of inflammation and oxidative stress. Sixty patients with BD and 50 control individuals were included to investigate the relationship between MHR and endothelial dysfunction. Endothelial function was assessed by flow- and nitroglycerin-mediated dilatation technique (FMD and NMD, respectively). Serum high-sensitivity C-reactive protein (hsCRP) levels were measured in all study participants. The MHR and hsCRP levels were significantly higher in patients with active BD than in controls. Brachial artery FMD was significantly lower in patients with active BD than in controls. Brachial artery NMD was similar between groups. There was a strong inverse correlation between MHR and FMD and a strong positive correlation between MHR and serum hsCRP levels. Thus, elevated MHR may be a useful marker reflecting impaired endothelial function and systemic inflammation in patients with BD.

Neutrophil–Lymphocyte Ratio and Carotid–Intima Media Thickness in Patients With Behçet Disease Without Cardiovascular Involvement

Behçet disease (BD) is associated with endothelial dysfunction and chronic inflammation. The neutrophil–lymphocyte (N/L) ratio and carotid intima–media thickness (cIMT) are markers of inflammation and vascular risk, respectively. We assessed the relationship between cIMT values and N/L ratio in BD (65 patients and 62 control participants). There were statistically significant differences in N/L ratios and cIMT values between the patients with BD and control group ( P < .001). There were moderate positive correlations between cIMT value, C-reactive protein, and N/L ratio in patients with BD. Receiver–operating characteristic curve analysis suggested that the optimum N/L ratio cutoff point for patients with BD was 1.29, with a sensitivity, specificity, negative predictive value, and positive predictive value of 97, 77, 96, and 75%, respectively (area under curve: 0.691, 95% confidence interval = 0.600-0.782, P < .001). The N/L ratio may be a useful index of BD activity.

Evidence-based practice in Behçet's disease: identifying areas of unmet need for 2014

BACKGROUND

Behçet's Disease (BD) is characterized by a relapsing-remitting course, with symptoms of varying severity across almost all organ systems. There is a diverse array of therapeutic options with no universally accepted treatment regime, and it is thus important that clinical practice is evidence-based. We reviewed all currently available literature describing management of BD, and investigated whether evidence-based practice is possible for all disease manifestations, and assessed the range of therapeutic options tested.

METHODS

We conducted an internet search of all literature describing management of BD up to August 2013, including pharmacological and non-pharmacological interventions. We recorded treatment options investigated and disease manifestations reported as primary and secondary study outcomes. Quality of data was assessed according to the Scottish Intercollegiate Guideline Network (SIGN) hierarchy of evidence.

RESULTS

Whilst there is much literature describing treatment of ocular and mucocutaneous disease, there is little to guide management of rheumatoid, cardiovascular and neurological disease. This broadly reflects the prevalence of disease manifestations of BD, but not the severity. Biologic therapies are the most commonly investigated intervention. The proportion of SIGN-1 graded studies is declining, and there are no SIGN-1 graded studies investigating neurological or gastrointestinal manifestations of BD.

CONCLUSIONS

This is the first study to investigate trends in published literature for management of BD over time. It identifies neurological, cardiovascular and gastro-intestinal disease as particular areas of unmet need and suggests that overall quality of evidence is declining. Future research should be designed to address these areas of insufficiency to facilitate evidence-based practice in BD.

Mean platelet volume is associated with aortic arterial stiffness in patients with Behçet's disease without significant cardiovascular involvement

BACKGROUND

Behçet's disease (BD), is a chronic, systemic vasculitis, which may affect all types and sizes of blood vessels. BD is associated with endothelial dysfunction and chronic inflammation. Endothelial dysfunction is the critical early step in the process of atherogenesis, and it is commonly investigated by measuring arterial stiffness. Mean platelet volume (MPV) has been investigated in relation with both thrombosis and inflammation. We aimed to investigate the relationship between an increased arterial stiffness and MPV in patients with Behçet's disease without significant cardiovascular involvement.

METHODS

We studied 36 patients (20 males, mean age: 37.6 ± 11.7 years) who were diagnosed by the international diagnostic criteria of BD and 35 healthy controls (15 males, mean age: 35.0 ± 10.6 years), and the two groups were matched by age and gender. MPV levels and arterial stiffness measurements were compared in these groups.

RESULTS

Arterial stiffness was higher in patients with BD compared to control group. (BD and controls; 7.28 m/s, 6.64 m/s; respectively) (p: 0.02). MPV levels were also significantly higher in patients with BD compared to control group. (BD and controls; 8.86 ± 0.81 fl, 8.39 ± 0.96 fl, respectively) (p: 0.02). Additionally, arterial stiffness correlated positively with age, the duration of disease and MPV levels in patients with BD (p: 0.002, 0.03, 0.02 respectively).

CONCLUSIONS

In our study, increased MPV is associated with arterial stiffness in patients with BD without significant cardiovascular involvement. It shows that there is a relationship between thrombosis and chronic inflammation in BD. Furthermore, MPV is also a moderate predictor of cardiovascular disease and represents an increase in platelet activation. These findings provide further evidence of a link between inflammation and thrombosis in patients with BD.

AAV2-mediated combined subretinal delivery of IFN-α and IL-4 reduces the severity of experimental autoimmune uveoretinitis

We previously showed that adeno-associated virus 2 (AAV2) mediated subretinal delivery of human interferon-alpha (IFN-α) could effectively inhibit experimental autoimmune uveoretinitis (EAU). In this study we investigated whether subretinal injection of both AVV2.IFN-α and AAV2.IL-4 had a stronger inhibition on EAU activity. B10RIII mice were subretinally injected with AAV2.IFN-α alone (1.5×10⁷ vg), AAV2.IL-4 alone (3.55×10⁷ vg), and AAV2.IFN-α combined with AAV2.IL-4. PBS, AAV2 vector encoding green fluorescent protein (AAV2.GFP) (5×10⁷ vg) was subretinally injected as a control. IFN-α and IL-4 were effectively expressed in the eyes from three weeks to three months following subretinal injection of AAV2 vectors either alone or following combined administration and significantly attenuated EAU activity clinically and histopathologically. AAV2.IL-4 showed a better therapeutic effect as compared to AAV2.IFN-α. The combination of AAV2.IL-4 and AAV2.IFN-α was not significantly different as compared to AAV2.IL-4 alone. There was no difference concerning DTH (delayed-type hypersensitivity) reaction, lymphocyte proliferation and IL-17 production among the investigated treatment groups, suggesting that local retinal gene delivery did not affect the systemic immune response.

Expression of a soluble triggering receptor expressed on myeloid cells-1 (sTREM-1) correlates with clinical disease activity in intestinal Behcet's disease

BACKGROUND

No serological marker currently exists to assess disease activity in patients with intestinal Behcet's disease (BD). We conducted this study to determine if the expression level of serum soluble triggering receptor expressed on myeloid cells-1 (sTREM-1) can be used as a biological marker to assess disease activity in intestinal BD.

METHODS

A total of 88 patients with intestinal BD were enrolled prospectively. We assessed their clinical disease activities using the disease activity index for intestinal BD (DAIBD). At the time that the DAIBD was assessed, serum erythrocyte sedimentation rate (ESR) as well as levels of TREM-1, C-reactive protein (CRP), and tumor necrosis factor-α (TNF-α) were measured.

RESULTS

The mean ESR and mean levels of sTREM-1, CRP, and TNF-α in patients with intestinal BD were significantly higher than those in healthy controls. Levels of sTREM-1 were the most highly correlated with disease activity (r = 0.762 for the DAIBD score), followed by CRP levels (r = 0.383 for the DAIBD score) and ESR (r = 0.236 for the DAIBD score). However, serum levels of TNF-α level were not correlated with disease activity (r = -0.017 for the DAIBD score).

CONCLUSIONS

Serum sTREM-1 levels were more highly correlated with disease activity than were CRP levels or ESR in patients with intestinal BD, suggesting that serum sTREM-1 level could be a potential marker for the assessment of disease activity of intestinal BD.

Behçet's Disease as a Model of Venous Thrombosis

Behçet's disease (BD) is a chronic inflammatory disease of unknown aetiology characterized by recurrent oral, genital aphthous ulcerations, uveitis, skin lesions and other multisystem affections associated with vasculitis. Different types of vessels, predominantly veins, can be affected in BD. The frequency of vascular lesions in BD, such as superficial and deep venous thromboses, arterial aneurysms and occlusions, ranges between 7-29%. In this review, various factors of thrombogenesis in BD, particularly pro- and antithrombotic endothelial and non-endothelial factors, factors of coagulation, platelet activation and rheological changes are presented and discussed from positions of Virchow's triad of venous thrombosis. Despite advances in understanding of thrombogenesis in BD, still many issues of diagnosis and targeted preventive and therapeutic measures remain unresolved. Further studies are needed to clarify the pathobiology of BD-related thrombosis and to provide the clinicians with recommendations over the utility, safety and effectiveness of the antithrombotic therapy in BD.

Behçet’s Disease as a Model of Venous Thrombosis

Behçet’s disease (BD) is a chronic inflammatory disease of unknown aetiology characterized by recurrent oral, genital aphthous ulcerations, uveitis, skin lesions and other multisystem affections associated with vasculitis. Different types of vessels, predominantly veins, can be affected in BD. The frequency of vascular lesions in BD, such as superficial and deep venous thromboses, arterial aneurysms and occlusions, ranges between 7-29%.

In this review, various factors of thrombogenesis in BD, particularly pro- and antithrombotic endothelial and non-endothelial factors, factors of coagulation, platelet activation and rheological changes are presented and discussed from positions of Virchow’s triad of venous thrombosis.

Despite advances in understanding of thrombogenesis in BD, still many issues of diagnosis and targeted preventive and therapeutic measures remain unresolved. Further studies are needed to clarify the pathobiology of BD-related thrombosis and to provide the clinicians with recommendations over the utility, safety and effectiveness of the antithrombotic therapy in BD.

Treatment with levamisole and colchicine can result in a significant reduction of IL-6, IL-8 or TNF-alpha level in patients with mucocutaneous type of Behcet's disease

BACKGROUND

Mucocutaneous type of Behcet's disease (MCBD) is a multisystemic inflammatory disease with oral and genital ulcers with or without skin lesions.

METHODS

A solid phase, two-site sequential chemiluminescent immunometric assay was used to measure serum levels of interleukin (IL)-6, IL-8 and tumour necrosis factor (TNF)-alpha in 54 normal control subjects and in 64 MCBD patients before and after treatment with levamisole plus colchicine.

RESULTS

We found that 67%, 83% or 67% of MCBD patients had a serum IL-6, IL-8 or TNF-alpha level greater than the upper normal limit of 4.7, 8.7 or 7.4 pg/ml, respectively. The mean serum level of IL-6 (9.9 +/- 2.4 pg/ml, P < 0.005), IL-8 (107.5 +/- 21.4 pg/ml, P < 0.001) or TNF-alpha (22.5 +/- 4.1 pg/ml, P < 0.001) in 64 MCBD patients was significantly higher than that (2.1 +/- 0.2, 5.7 +/- 0.2 or 3.8 +/- 0.2 pg/ml for IL-6, IL-8 or TNF-alpha level, respectively) in normal control subjects. In 43 MCBD patients with all the serum IL-6, IL-8 and TNF-alpha levels higher than their upper normal limits, treatment with levamisole plus colchicine for a period of 0.5-11.5 (mean, 3.2 +/- 2.4) months could significantly reduce the mean serum IL-6, IL-8 and TNF-alpha levels from 9.0 +/- 1.7 to 1.6 +/- 0.2 pg/ml (P < 0.001), 134.6 +/-28.2-6.0 +/- 0.4 pg/ml (P < 0.001) and 25.7 +/- 5.6-3.5 +/- 0.4 pg/ml (P < 0.001), respectively.

CONCLUSIONS

Treatment with levamisole and colchicine can result in a significant reduction of serum IL-6, IL-8 or TNF-alpha level in MCBD patients.

Serum-soluble selectin levels in patients with Behçet’s disease

Soluble forms of selectins may play a regulatory role in inflammatory responses. The aim of this study was to examine the levels of serum-soluble (s) selectins in Behçet's disease (BD) patients and to evaluate the associations of these molecules to disease activity, clinical findings, and drugs taken for BD, mainly colchicine. Serum sE-, sL-, and sP-selectins levels were measured by sandwich enzyme-linked immunosorbent assay in 28 BD patients and 22 healthy subjects. The BD patients were classified according to the disease activity, clinical findings, and therapy. Ten patients were newly diagnosed and were not taking any therapy. Remainder were on colchicine (n = 18) and immunosuppressive drugs (n = 5). In BD patients, the levels of sL- and sP-selectins were significantly lower than those of healthy controls, but sE-selectin level was similar to that of the controls. The patients on the therapy had significantly lower levels of sE- and sL-selectins and insignificantly lower level of sP-selectin than the patients not receiving therapy. The BD patients with active disease had significantly higher levels of sE-, sL-, and sP-selectins compared with the patients with inactive disease. There were no significant differences in the levels of selectins between the treated active patients and inactive patients. However, the untreated patients with active disease had significantly higher selectin levels than the inactive patients. There were no significant differences in all selectin levels between the patients with or without vascular involvement. Serum sL-selectin was found to be significantly higher in patients with erythema nodosum. In conclusion, our findings suggest that the levels of soluble selectin molecules in BD patients seem to be modified by the drugs taken for BD. The colchicine therapy is associated with lower selectin levels.

Off-label uses of biologics in dermatology: Interferon and intravenous immunoglobulin (Part 1 of 2)

The introduction of a number of biologic therapies into the market has revolutionized the practice of dermatology. These therapies include interferons, intravenous immunoglobulin, infliximab, adalimumab, etanercept, efalizumab, alefacept, and rituximab. Most dermatologists are familiar with the Food and Drug Administration-approved indications of these medications. However, numerous off-label uses have evolved. As part 1 of a 2-part series, this article will review the literature regarding the off-label uses of the interferons and intravenous immunoglobulin in dermatology.

Serum levels of soluble P-selectin are increased and associated with disease activity in patients with Behçet's syndrome

Behçet's syndrome (BS) is a relapsing, chronic, inflammatory disease characterized by endothelial dysfunction, atherothromboembogenesis, and leukocytoclastic vasculitis with complex immunologic molecular interactions. Generalized derangements of the lymphocyte and neutrophil populations, activated monocytes, and increased PMNLs motility with upregulated cell surface molecules such as ICAM-1, VCAM-1, and E-selectin, which are found on the endothelial cells, leukocytes, and platelets, have all been demonstrated during the course of BS. Our aim is to investigate the association of serum concentrations of soluble P-selectin in patients with BS, and to evaluate whether disease activity has an effect on their blood levels. This multicenter study included 31 patients with BS (15 men and 16 women) and 20 age- and sex-matched healthy control volunteers (11 men and nine women). Neutrophil count, erythrocyte sedimentation rate, and acute-phase reactants as well as soluble P-selectin levels were determined. The mean age and sex distributions were similar (P > .05) between BS patients (35 years) and control volunteers (36 years). Serum levels of soluble P-selectin in patients with BS (399 +/- 72 ng/mL) were significantly (P < .001) higher when compared with control subjects (164 +/- 40 ng/mL). In addition, active BS patients (453 +/- 37 ng/mL) had significantly (P < .001) elevated levels of soluble P-selectin than those in inactive period (341 +/- 52 ng/mL). This study clearly demonstrated that serum soluble P-selectin levels are increased in BS patients when compared with control subjects, suggesting a modulator role for soluble P-selectin during the course of platelet activation and therefore, atherothrombogenesis formation in BS, especially in active disease.

Serum interleukin 18 and tumour necrosis factor-alpha levels are increased in Behcet's disease

Inflammation in Behcet's disease is thought to be mediated by cytokines derived from T-helper type 1 (Th1) lymphocytes. In this study, we tried to determine serum interleukin (IL)-18 and tumour necrosis factor (TNF)-alpha levels of patients with Behcet's disease. Twenty-seven patients with active Behcet's disease, and 20 healthy control subjects were included in this study. Differences between mean serum IL-18 and TNF-alpha level of patients with Behcet's disease were significantly increased when compared with the control group. A significant correlation was found between serum IL-18 and TNF-alpha levels of Behcet patients (rs = 0.627, P < 0.0001). IL-18 and TNF-alpha levels may be related to disease pathogenesis. Increased levels of IL-18 also support Th1 predominance in Behcet's disease.

Levels of soluble E-selectin in patients with active Behcet's disease

Behcet's disease is a systemic vasculitis of unknown aetiology. Endothelial cell injury plays an important role in the pathogenesis and immunopathology of Behcet's disease. E-selectin is expressed by activated endothelial cells. Because the selectin adhesion molecules are shed from activated cells, soluble forms of these proteins can be used as activation markers of endothelium (E-selectin). The pathogenesis of Behcet's disease (BD) is closely related to endothelial cells, leucocyte functions and immunity. The aim of this study was to investigate circulating E-selectin adhesion molecules, which are known to play a significant part in the immune response especially by regulating interaction of the leucocytes with endothelium in BD. Plasma E-selectin concentrations were evaluated in 23 patients with BD and 20 healthy control subjects. The disease activity was evaluated by clinical manifestations (oral aphthous ulcer, genital ulceration, positive pathergy test, skin lesions, eye involvement, thrombophlebitis and arthritis) and by laboratory investigations [erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP)]. The patients were newly or previously diagnosed cases not taking any drug for BD. Levels of E-selectin were measured with commercially available sandwich enzyme-linked immunosorbent assay (ELISA) kits using human sE-selectin (cat. no: BMS 205). Plasma E-selectin concentrations of patients and controls were compared with the Mann-Whitney U test. Statistical significance was assigned to p values lower than 0.05. Serum levels (mean+/-SD) of soluble E-selectin (sE-selectin) were significantly higher in 23 patients with BD than in 20 healthy controls (53.2+/-18.2 ng/ml vs 33.8+/-7.5 ng/ml, p<0.0001). A statistically significant positive correlation was observed between sE-selectin levels and CRP and ESR in patients with BD (r=0.78, p<0.001 and r=0.56, p<0.01, respectively). Increases in the E-selectin in BD may be a direct consequence of the leucocyte and endothelium activations observed during the disease process. The noninvasive investigations can be used as biochemical markers for inflammation. This may provide additional information regarding disease activity along with the traditional indices such as ESR and CRP.

The significance of immunohistochemistry in the skin pathergy reaction of patients with Behcet's syndrome

BACKGROUND

Behçet's syndrome is a chronic systemic immuno-inflammatory disorder affecting multiple organs with generalized vasculitis of arteries and veins. Although the aetiology is still unknown, endothelial dysfunction is one of the most prominent features in Behçet's syndrome. The skin pathergy reaction (SPR) is a non-specific hyperreactive lesion formation that is one of the major features and diagnostic criteria of the disease. It develops after 24-48 h at the site of the needle-prick, especially in the exacerbation period, and it is very similar to the erythematous papules or pustules that appear spontaneously in patients with Behçet's syndrome. Therefore, an investigation into the formation of the SPR lesion may contribute to the pathophysiology of skin lesions of this unique disorder.

OBJECTIVE

To evaluate the immunological features of SPR formation by assessing the immunohistochemical staining of cell adhesion molecules and endothelial growth factor markers such as E-selectin, P-selectin and endoglin (CD 105).

METHODS

Patients with Behçet's syndrome showing positive (n = 15) or negative (n = 10) SPR and 15 age- and sex-matched hospital-based healthy control subjects from a similar ethnic background were included in this study. Patients were divided into active and inactive stage by clinical findings and acute-phase reactant parameters including erythrocyte sedimentation rate (ESR) and neutrophil count. Punch biopsy specimens were obtained both from the lesion site on the forearms at 48 h and from normal skin approximately 5 cm adjacent to the SPR site. A biopsy was also obtained from the test application site in Behçet's syndrome patients with negative SPR and healthy volunteers. Biopsy specimens were then evaluated by immunohistochemical staining.

RESULTS

Immunohistochemical examination demonstrated a mixed inflammatory cell infiltrate around the vessels and skin appendages that extended somewhat into the deep dermis. A positive segmental staining of E-selectin and P-selectin was noted in the endothelial cells of biopsies obtained from the patients with positive SPR. A positive segmental staining of CD 105 in the endothelial cells was also observed in the same group of patients. However, the immunostaining of the same markers was found to be negative in the biopsies obtained from normal skin of SPR-positive patients, SPR-negative patients and healthy control subjects. Both acute-phase reactant levels were significantly higher in the active stage than in inactive patients or healthy controls.

CONCLUSION

Interaction of cellular adhesion molecules together with endothelial proliferation may play an important role in the formation of SPR lesions in patients with Behçet's syndrome. The involvement of the vascular endothelium in a large number of diseases including Behçet's syndrome supports the importance of vascular-specific adhesion molecules for their aetiopathogenesis.

Vgamma9/Vdelta2 T lymphocytes in Italian patients with Behçet's disease: evidence for expansion, and tumour necrosis factor receptor II and interleukin-12 receptor beta1 expression in active disease

Behçet's disease is a multisystem disease in which there is evidence of immunological dysregulation. It has been proposed that gamma/delta T cells are involved in its pathogenesis. The aim of the present study was to assess the capacity of gamma/delta T cells with phenotype Vgamma9/Vdelta2, from a group of Italian patients with Behçet's disease, to proliferate in the presence of various phosphoantigens and to express tumour necrosis factor (TNF) and IL-12 receptors. Twenty-five patients and 45 healthy individuals were studied. Vgamma9/Vdelta2 T cells were analyzed by fluorescence activated cell sorting, utilizing specific monoclonal antibodies. For the expansion of Vgamma9/Vdelta2 T cells, lymphocytes were cultured in the presence of various phosphoantigens. The expression of TNF receptor II and IL-12 receptor beta1 was evaluated with the simultaneous use of anti-TNF receptor II phycoerythrin-labelled (PE) or anti-IL-12 receptor beta1 PE and anti-Vdelta2 T-cell receptor fluorescein isothiocyanate. There was a certain hierarchy in the response of Vgamma9/Vdelta2 T cells toward the different phosphoantigens, with the highest expansion factor obtained with dimethylallyl pyrophosphate and the lowest with xylose 1P. The expansion factor was fivefold greater in patients with active disease than in those with inactive disease or in control individuals. TNF receptor II and IL-12 receptor beta1 expressions were increased in both patients and control individuals. The proportion of Vgamma9/Vdelta2 T cells bearing these receptors was raised in active disease when Vgamma9/Vdelta2 T cells were cultured in the presence of dimethylallyl pyrophosphate. These results indicate that Vgamma9/Vdelta2 T cell activation is correlated with disease progression and probably involved in the pathogenesis.

[Interferons and Behçet's disease]

BACKGROUND

Behçet's disease is a vasculitis of unknown origin. Various therapeutic agents have been proposed. Interferon alpha 2a or 2b appear to be the most promising.

CURRENT KNOWLEDGE AND KEY POINTS

Numerous anecdotal reports and some short series have shown the efficacy of interferon in some cases previously resistant to conventional therapy, particularly to immunosuppressors. Posology, depending on the author, may vary from three million three times a week to 18 million three times a week. Interferon alpha is useful in cases of ocular, muco-cutaneous and articular involvement. Data is lacking for digestive, vascular and neurological manifestations.

FUTURE PROSPECTS AND PROJECTS

Multicenter trials will nevertheless be required to determine the duration of therapy, risk of relapses, associated therapy and the optimal time to commence interferon treatment.

Current therapy for Behçet's disease

Classified among the vasculitides, the clinical spectrum of Behçet's disease (BD) ranges from a mild mucocutaneous disease to a life-threatening systemic vasculitis, characterized by remissions and recurrences. The major morbidity is recurrent eye inflammation that may lead to blindness, but severe central nervous system, gastrointestinal, or vascular involvement may occur and might be fatal. In contradistinction to most other vasculitides, the venous system is commonly affected in BD. The treatment of BD is usually symptomatic and palliative. This includes topical steroids for orogenital ulcers, nonsteroidal antiinflammatory agents for joint involvement, and colchicine as prophylaxis against disease flares (although evidence that colchicine prevents recurrences of oral and genital ulcers is restricted to female patients). Immunosuppressives and cytotoxic agents are used for more severe involvement, and thalidomide and interferon have attracted attention in recent years.

Perspectives for TNF-alpha-targeting therapies

Rheumatoid arthritis (RA) is the most common chronic autoimmunopathy, clinically leading to joint destruction as a consequence of the chronic inflammatory processes. The pathogenesis of this disabling disease is not well understood, but molecular events leading to tissue inflammation with cartilage and bone destruction are now better defined. Therapy with slow-acting, disease-modifying antirheumatic drugs (DMARDs), such as low-dose methotrexate, which is generally accepted as a standard, leads to a significant amelioration of symptoms but does not stop joint destruction. Due to these disappointing treatment options and the identification of certain inflammatory mediators as therapeutic targets, novel therapeutic agents such as monoclonal antibodies, cytokine-receptor/human-immunoglobulin constructs or recombinant human proteins have been tested in RA with some success. Clinical trials testing anti-TNF-alpha agents, alone or in combination with methotrexate, have convincingly shown the feasibility and efficacy of these novel approaches to the therapy of RA. A clinical trial testing combination therapy with chimeric (mouse/human) anti-TNF-alpha monoclonal antibody infliximab and methotrexate showed, for the first time in any RA trial, that there was no median radiological progression in the groups given infliximab plus methotrexate over a 12-month observation period. Similar encouraging results might arise from trials employing other TNF-alpha-directed agents, such as the fully human monoclonal antibody D2E7, the p75 TNF-alpha-receptor/Ig construct, etanercept, or others, as discussed in this review. Combination partners other than methotrexate will be established as suitable cotreatment along with anti-TNF-alpha biologicals. Forthcoming new indications for TNF-alpha-targeted therapies are discussed.

New approaches to treatment in systemic vasculitis: biological therapies

Although the effectiveness of biological agents in systemic vasculitis is unproven, their introduction heralds a new era of vasculitis treatment. These agents offer the promise of targeted immunotherapies; the possibility of greater efficacy (and fewer side-effects) than conventional vasculitis treatments; and the potential to provide novel insights into the pathophysiology of these diseases-insights that may be gained only by using these agents in humans. Challenges to the investigation of these therapies in the systemic vasculitides exist, but important basic and clinical investigations are already in progress. We review the major issues facing the investigation of biological agents in vasculitis; examine the rationale for believing that biological strategies in vasculitis will be efficacious; identify several candidate targets for biological approaches; and discuss the results to date of early studies. The potential biological targets discussed include cytokines such as tumour necrosis factor; interleukins-1, -6, and -12; interferon-gamma; the co-stimulatory molecules B7-1 and B7-2; and others.

Efficacy of interferon alfa-2a in severe and refractory uveitis associated with Behçet's disease

PURPOSE

To evaluate the efficacy of interferon alfa-2a (IFN alfa) in severe uveitis associated with Behçet's disease, that is refractory to steroids and conventional immunosuppressive agents.

PATIENTS AND METHODS

Patients with Behçet's disease (according to the International Study Group criteria), who relapsed despite steroids and immunosuppressive agents, were included in this retrospective study. Ophthalmological examination, laser flare photometry, and fluorescein angiography associated with laboratory tests were performed at regular intervals. IFN alfa (3 millions units thrice a week) was injected subcutaneously.

RESULTS

Eight patients (sex ratio: 1) were included between May 1995 and January 1999. The mean age was 29.1 years (14-54 years) and the disease was present between 11 and 167 months before the administration of IFN alfa. IFN alfa was efficient in all cases with a mean follow-up of 22 months (10-55 months). Steroids were tapered from a mean dosage of 47 mg/d to a mean dosage of 8.5 mg/d. Ocular inflammation was controlled and visual acuity improved in all cases. Treatment was generally well tolerated despite a constant but transient flu-like syndrome. IFN alfa was tapered in three patients and stopped in one case without any relapse after five months.

CONCLUSIONS

Within the limitations of this retrospective study, low-dose IFN alfa seems to be well tolerated, promising in the management of refractory forms of uveitis due to Behçet's disease, and effective in allowing a reduction of steroid dosage. A prospective controlled study is necessary to confirm these preliminary results.