A multicenter, double-blind, randomized, controlled phase III clinical trial of chicken type II collagen in rheumatoid arthritis

Valorizing sardine scales: a circular approach to sustainable collagen for cosmetics and nutrition applications

Background and Objective

In recent years, the consumption of fish products has led to a worrying trend where approximately two-thirds of the total amount of fish is discarded as waste. At the same time, scientific interest in exploring natural collagen sources for cosmetics and dietary supplements has increased. This study explores the potential of valorizing sardine scales (Sardina pilchardus), a by-product of the canning industry, through the extraction of collagen for potential use in dermocosmetic formulations and food supplements.

Methods

Collagen from sardine scales was obtained though acid and enzymatic extraction. The collagen extracts were characterized by UV-Vis, FTIR spectroscopy, SDS-PAGE, powder X-ray diffraction (PXRD) and scanning electron microscopy (SEM). The collagen was hydrolysed with papain to small peptides. Subsequently, the biological activities of acid-soluble collagen as well as the collagen peptides in terms of antioxidant and antimicrobial activity were evaluated. Furthermore, the capacity of collagen peptides to permeate the intestinal barrier, simulated with caco-2 cells, was evaluated.

Results

Purified collagen extracts were obtained from sardine scales, with enzymatic extraction method having a yield three times higher than the acid method. The SDS-PAGE analysis confirmed the extraction of type I collagen as well as its hydrolysis into small fragments (25-12 kDa). In terms of biological activities, collagen and collagen peptides have not demonstrated antimicrobial activity. However, regarding antioxidant activity, collagen peptides showed three times more capacity compared to non-hydrolyzed collagen. Meanwhile, in 6 h, about 6.37% of collagen peptides could permeate the intestinal barrier.

Conclusion

This work represents a continuous effort to advance our understanding and utilization of Portuguese marine waste resources, with focus on the valorization of sardine co-products for the development of food supplement or cosmetic formulations, contributing to the sustainable evolution of the circular blue economy.

Collagen type II solution extracted from supercritical carbon dioxide decellularized porcine cartilage: regenerative efficacy on post-traumatic osteoarthritis model

Osteoarthritis (OA) of the knee is a common degenerative articular disorder and is one of the main causes of pain and functional disability. Cartilage damage is frequently linked to elevated osteoarthritis incidence. Supercritical carbon dioxide (scCO2) decellularized cartilage graft produced from the porcine cartilage is an ideal candidate for cartilage tissue engineering. In the present study, we derived collagen type II (Col II) solution from the scCO2 decellularized porcine cartilage graft (dPCG) and compared its efficacy with hyaluronic acid (HA) in the surgical medial meniscectomy (MNX) induced post-traumatic osteoarthritis (PTOA) model. Dose-dependent attenuation of the OA (12.3 ± 0.8) progression was observed in the intra-articular administration of Col II solution (7.3 ± 1.2) which significantly decreased the MNX-induced OA symptoms similar to HA. The pain of the OA group (37.4 ± 2.7) was attenuated dose-dependently by Col II solution (45.9 ± 4.1) similar to HA (43.1 ± 3.5) as evaluated by a capacitance meter. Micro-CT depicted a dose-dependent attenuation of articular cartilage damage by the Col II solution similar to HA treatment. A significant (p < 0.001) dose-dependent elevation in the bone volume was also observed in Col II solution-treated OA animals. The protective competence of Col II solution on articular cartilage damage is due to its significant (p < 0.001) increase in the expression of type II collagen, aggrecan and SOX-9 similar to HA. To conclude, intra-articular administration of type II collagen solution and HA reestablished the injured cartilage and decreased osteoarthritis progression in the experimental PTOA model.

Selection of collagen IV fragments forming the outer sphere of the native protein: Assessment of biological activity for regenerative medicine

The aim of this research was to select the fragments that make up the outer layer of the collagen IV (COL4A6) protein and to assess their potential usefulness for regenerative medicine. It was expected that because protein-protein interactions take place via contact between external domains, the set of peptides forming the outer sphere of collagen IV will determine its interaction with other proteins. Cellulose-immobilized protein fragment libraries treated with polyclonal anti-collagen IV antibodies were used to select the peptides forming the outer sphere of collagen IV. In the first test, 33 peptides that strongly interacted with the polyclonal anti-collagen IV antibodies were selected from a library of non-overlapping fragments of collagen IV. The selected fragments of collagen IV (cleaved from the cellulose matrix) were tested for their cytotoxicity, their effects on cell viability and proliferation, and their impact on the formation of reactive oxygen species (ROS). The studies used RAW 264.7 mouse macrophage cells and Hs 680.Tr human fibroblasts. PrestoBlue, ToxiLight™, and ToxiLight 100% Lysis Control assays were conducted. The viability of fibroblasts cultured with the addition of increasing concentrations of the peptide mix did not show statistically significant differences from the control. Fragments 161-170, 221-230, 721-730, 1331-1340, 1521-1530, and 1661-1670 of COL4A6 were examined for cytotoxicity against BJ normal human foreskin fibroblasts. None of the collagen fragments were found to be cytotoxic. Further research is underway on the potential uses of collagen IV fragments in regenerative medicine.

Undenatured type II collagen and its role in improving osteoarthritis

Osteoarthritis (OA) is a degenerative joint disease, affecting 32.5 million US adults or 242 million people worldwide. There is no cure for OA. Many animal and clinical trials showed that oral administration of undenatured type II collagen could significantly reduce the incidence of OA or alleviate the symptoms of articular cartilage. Type II collagen is an important component of cartilage matrix. This article reviewed research progress of undenatured type II collagen including its methods of extraction and preparation, structure and characterization, solubility, thermal stability, gastrointestinal digestive stability, its role in improving OA, and the mechanism of its action in improving OA. Type II collagen has been extensively explored for its potential in improving arthritis. Methods of extraction of type II collagen are inefficient and tedious. The method of limited enzymatic hydrolysis is mainly used to prepare soluble undenatured type II collagen (SC II). The solubility, thermal and gastrointestinal digestive stability of SC II are affected by the sources of raw material, pH, salt ions, and temperature. Oral administration of undenatured type II collagen improves OA, whereas its activity is affected by the sources, degree of denaturalization, intervention methods and doses. However, the influence of the structure of undenatured type II collagen on its activity and the mechanism are unclear. The findings in this review support that undenatured type II collagen can be used in the intervention or auxiliary intervention of patients with OA.

Efficacy of undenatured collagen in knee osteoarthritis: review of the literature with limited meta-analysis

BACKGROUND

Early knee osteoarthritis (OA) treatment is multimodal, with physical therapy and pharmacotherapy commonly used. Although popular, oral supplements like glucosamine and diacerein have not been reported to have high efficacy. Undenatured collagen type II (UC-II) has been introduced for therapy in early OA; it helps in cartilage repair and preservation. The present review was done to ascertain its efficacy in pain relief and knee function.

MATERIALS AND METHODS

A systematic literature search was performed on MEDLINE (PubMed), Embase, Scopus, and Cochrane Library for published literature; studies comparing the outcome of UC-II supplementation with placebo/control in adult humans with early knee OA were included. The outcomes evaluated were VAS Score, quality of life - Western Ontario and McMaster Universities (WOMAC-score), Knee function, Knee range of motion, and any complications during the course of treatment.

RESULTS

A total of 293 results were obtained after a primary search; 8 randomized control trials (RCT) were finally included. A total of 243 patients received UC-II supplementation (91 men and 152 women). The overall mean age range for the intervention group was 53.5±0.99 to 68.7±5.3 years across all included studies, and the mean follow-up duration was 3 to 6 months. Outcome measures like WOMAC and VAS scores showed better outcomes with UC-II in comparison to placebo. Walking measurements improved significantly from the baseline, reflected in improved timed up-and-go and 6-minute walk tests (6MWT). The overall complications were similar to other supplements.

CONCLUSION

With limited literature, UC-II has shown promise as a potent supplement in early knee OA with good pain relief and improved function. However, further large-scale studies are needed to substantiate these findings.

Significance of Type II Collagen Posttranslational Modifications: From Autoantigenesis to Improved Diagnosis and Treatment of Rheumatoid Arthritis

Collagen type II (COL2), the main structural protein of hyaline cartilage, is considerably affected by autoimmune responses associated with the pathogenesis of rheumatoid arthritis (RA). Posttranslational modifications (PTMs) play a significant role in the formation of the COL2 molecule and supramolecular fibril organization, and thus, support COL2 function, which is crucial for normal cartilage structure and physiology. Conversely, the specific PTMs of the protein (carbamylation, glycosylation, citrullination, oxidative modifications and others) have been implicated in RA autoimmunity. The discovery of the anti-citrullinated protein response in RA, which includes anti-citrullinated COL2 reactivity, has led to the development of improved diagnostic assays and classification criteria for the disease. The induction of immunological tolerance using modified COL2 peptides has been highlighted as a potentially effective strategy for RA therapy. Therefore, the aim of this review is to summarize the recent knowledge on COL2 posttranslational modifications with relevance to RA pathophysiology, diagnosis and treatment. The significance of COL2 PTMs as a source of neo-antigens that activate immunity leading to or sustaining RA autoimmunity is discussed.

Delivery route considerations for designing antigen-specific biomaterial strategies to combat autoimmunity

Disease modifying drugs and biologics used to treat autoimmune diseases, although promising, are non-curative. As the field moves towards development of new approaches to treat autoimmune disease, antigen-specific therapies immunotherapies (ASITs) have emerged. Despite clinical approval of ASITs for allergies, clinical trials using soluble ASITs for autoimmunity have been largely unsuccessful. A major effort to address this shortcoming is the use of biomaterials to harness the features unique to specific delivery routes. This review focuses on biomaterials being developed for delivery route-specific strategies to induce antigen-specific responses in autoimmune diseases such as multiple sclerosis, type 1 diabetes, rheumatoid arthritis, and celiac disease. We first discuss the delivery strategies used in ongoing and completed clinical trials in autoimmune ASITs. Next, we highlight pre-clinical biomaterial approaches from the most recent 3 years in the context of these same delivery route considerations. Lastly, we provide discussion on the gaps remaining in biomaterials development and comment on the need to consider delivery routes in the process of designing biomaterials for ASITs.

Collagen supplementation in skin and orthopedic diseases: A review of the literature

Collagen is one of the main components of the extracellular matrix of the dermis and articular cartilage and influences the body's mechanical, organizational, and tissue formation properties. Produced from food industry by-products, it is considered a nutraceutical product widely used as an ingredient or supplement in food, pharmaceutical, and cosmetic industries. This study aimed to conduct a literature review on the scientific evidence regarding the beneficial effects of collagen consumption in the treatment of skin and orthopedic diseases. Literature data have shown that hydrolyzed collagen supplementation promotes skin changes, such as decreased wrinkle formation; increased skin elasticity; increased hydration; increased collagen content, density, and synthesis, which are factors closely associated with aging-related skin damage. Regarding orthopedic changes, collagen supplementation increases bone strength, density, and mass; improves joint stiffness/mobility, and functionality; and reduces pain. These aspects are associated with bone loss due to aging and damage caused by strenuous physical activity. Thus, this review addresses the economic and health potential of this source of amino acids and bioactive peptides extracted from food industry by-products.

Phosphatidylserine-mediated oral tolerance

Phosphatidylserine (PS) is an anionic phospholipid exposed on the surface of apoptotic cells. The exposure of PS typically recruits and signals phagocytes to engulf and silently clear these dying cells to maintain tolerance via immunological ignorance. However, recent and emerging evidence has demonstrated that PS converts an "immunogen" into a "tolerogen", and PS exposure on the surface of cells or vesicles actively promotes a tolerogenic environment. This tolerogenic property depends on the biophysical characteristics of PS-containing vesicles, including PS density on the particle surface to effectively engage tolerogenic receptors, such as TIM-4, which is exclusively expressed on the surface of antigen-presenting cells. We harnessed the cellular and molecular mechanistic insight of PS-mediated immune regulation to design an effective oral tolerance approach. This immunotherapy has been shown to prevent/reduce immune response against life-saving protein-based therapies, food allergens, autoantigens, and the antigenic viral capsid peptide commonly used in gene therapy, suggesting a broad spectrum of potential clinical applications. Given the good safety profile of PS together with the ease of administration, oral tolerance achieved with PS-based nanoparticles has a very promising therapeutic impact.

Is collagen supplementation friend or foe in rheumatoid arthritis and osteoarthritis? A comprehensive systematic review

Rheumatoid arthritis (RA) and osteoarthritis (OA) both are chronic diseases affecting joints. Immune response against collagen in both diseases may have a role in the initiation and progression of the disease. There is a hypothesis that suppression of immune response vs collagen could be a therapeutic approach in RA and OA. Exposure of gut immune system to collagen is a way to suppress immune response against collagen in the joints. So, the current systematic review is aimed to evaluate the effects of collagen supplementation in OA and RA patients. In the current systematic review, online electronic databases including PubMed/MEDLINE, Web of Sciences and Scopus were searched and finally 19 articles were included. The enrolled articles evaluated the effects of collagen supplementation on treatment of OA (n = 9) and RA (n = 10). Intact (n = 4) and hydrolyzed (n = 5) collagen were used to treat OA. All of the studies on RA used intact and type II collagen in their intervention. The last trials on collagen supplementation in RA and OA patients were performed in 2011 and 2016, respectively. High adverse effects of collagen supplementation and its low efficiency compared to routine treatments were reported by several included studies. Also, risk of bias assessment showed that most of the studies had poor quality. Therefore, it is not possible to definitely decide on the beneficial or detrimental effects of collagen supplementation on OA and RA patients. Further studies are needed to reach a final decision.

Industrial application of fish cartilaginous tissues

Cartilage is primarily composed of proteoglycans and collagen. Bioactive compounds derived from animal cartilage, such as chondroitin sulfate and type II collagen, have multiple bioactivities and are incorporated in popular health products. The aging population and increases in degenerative and chronic diseases will stimulate the rapid growth of market demand for cartilage products. Commercial production of bioactive compounds primarily involves the cartilages of mammals and poultry. However, these traditional sources are associated zoonosis concerns; thus, cartilage products from the by-products of fish processing has gained increasing attention because of their high level of safety and other activities. In this review, we summarize the current state of research into fish-derived cartilage products and their application, and discuss future trends and tasks to encourage further expansion and exploitation. At present, shark cartilage is the primary source of marine cartilage. However, the number of shark catches is decreasing worldwide, owing to overfishing. This review considers the potential alternative fish cartilage sources for industrialization. Three keys, the sustainable production of fish, new fish-processing model, and market demand, have been discussed for the future realization of efficient fish cartilage use. The industrialization of fish-derived cartilage products is beneficial for achieving sustainable development of local economies and society.

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Bioactive compounds derived from fish cartilage are popular as health products.

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Type II collagen and chondroitin sulfate are the major cartilage bioactive compounds.

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Cartilaginous fishes, sturgeons, and salmonids are potential fish cartilage sources.

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Keys for industrialization are fish production, processing model, and market demands.

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Industrialization of fish cartilage products accords with sustainable development.

A Review of the Effects of Collagen Treatment in Clinical Studies

Collagen, an abundant extracellular matrix protein, has been found to have a lot of pharmaceuticals, medicine, food, and cosmetics applications. Increased knowledge of collagen sources, extraction techniques, structure, and properties in the last decades has helped develop more collagen-based products and tissue engineering biomaterials. Collagen products have been playing an important role in benefiting the health of the human body, especially for aging people. In this paper, the effects of collagen treatment in different clinical studies including skin regeneration, bone defects, sarcopenia, wound healing, dental therapy, gastroesophageal reflux, osteoarthritis, and rheumatoid arthritis have been reviewed. The collagen treatments were significant in these clinical studies. In addition, the associations between these diseases were discussed. The comorbidity of these diseases might be closely related to collagen deficiency, and collagen treatment might be a good choice when a patient has more than one of these diseases, including the coronavirus disease 2019 (COVID-19). It concludes that collagen-based medication is useful in treating comorbid diseases and preventing complications.

Preclinical models of arthritis for studying immunotherapy and immune tolerance

Increasingly earlier identification of individuals at high risk of rheumatoid arthritis (RA) (eg, with autoantibodies and mild symptoms) improves the feasibility of preventing or curing disease. The use of antigen-specific immunotherapies to reinstate immunological self-tolerance represent a highly attractive strategy due to their potential to induce disease resolution, in contrast to existing approaches that require long-term treatment of underlying symptoms.Preclinical animal models have been used to understand disease mechanisms and to evaluate novel immunotherapeutic approaches. However, models are required to understand critical processes supporting disease development such as the breach of self-tolerance that triggers autoimmunity and the progression from asymptomatic autoimmunity to joint pain and bone loss. These models would also be useful in evaluating the response to treatment in the pre-RA period.This review proposes that focusing on immune processes contributing to initial disease induction rather than end-stage pathological consequences is essential to allow development and evaluation of novel immunotherapies for early intervention. We will describe and critique existing models in arthritis and the broader field of autoimmunity that may fulfil these criteria. We will also identify key gaps in our ability to study these processes in animal models, to highlight where further research should be targeted.

Niacinamide and undenatured type II collagen modulates the inflammatory response in rats with monoiodoacetate-induced osteoarthritis

The current work aimed to examine the properties of oral supplementation of niacinamide and undenatured type II collagen (UCII) on the inflammation and joint pain behavior of rats with osteoarthritis (OA). Forty-nine Wistar rats were allocated into seven groups; control (no MIA), MIA as a non-supplemental group with monosodium iodoacetate (MIA)-induced knee osteoarthritis, MIA + undenatured type II collagen (UCII) at 4 mg/kg BW, MIA + Niacinamide at 40 mg/kg BW (NA40), MIA + Niacinamide at 200 mg/kg BW (NA200), MIA + UCII + NA40 and MIA + UCII + NA200. Serum IL-1β, IL-6, TNF-α, COMP, and CRP increased in rats with OA and decreased in UCII and NA groups (p < 0.05). Rats with osteoarthritis had greater serum MDA and knee joint MMP-3, NF-κB, and TGβ protein levels and decreased in treated groups with UCII and NA (p < 0.05). The rats with OA also bore elevated joint diameters with joint pain behavior measured as decreased the stride lengths, the paw areas, and the paw widths, and increased the Kellgren-Lawrence and the Mankin scores (p < 0.05) and decreased in UCII treated groups. These results suggest the combinations with the UCII + NA supplementation as being most effective and reduce the inflammation responses for most OA symptoms in rats.

Antigen-specific tolerance approach for rheumatoid arthritis: Past, present and future

Rheumatoid arthritis is a chronic systemic autoimmune disease, affecting mainly the joints. It is caused by an adaptive immune reaction against self-antigens, leading to the over production of inflammatory cytokines and autoantibodies, mainly mediated by autoreactive CD4+ T cells and pathological B cell clones. The treatment options currently available rely on palliative global immunosuppression and do not restore tolerance to self-components. Here, we review antigen-specific tolerance approaches that have been developed to inhibit or delete autoreactive clones, while maintaining a potent immune system for rheumatoid arthritis. The first attempts relied on the oral ingestion of self-reactive peptides, with lukewarm results in human clinical trials. To enhance treatment efficacy, self-peptides have been engineered and combined with immunosuppressive molecules. In addition, several routes of delivery have been tested, in particular, nanoparticles carrying self-antigens and immunomodulatory molecules. More recently, transfer of immune cells, such as tolerogenic dendritic cells or regulatory T cells, has been considered to restore tolerance. Although promising results have been obtained in mouse models, the translation to humans remains highly challenging, mainly because the disease is already well developed when treatments start and because patient's specific self-antigens are often unknown. Nevertheless, these approaches hold great promises for long-term RA treatment.

Low-Dose Methotrexate and Mucocutaneous Adverse Events: Results of a Systematic Literature Review and Meta-Analysis of Randomized Controlled Trials

OBJECTIVE

Methotrexate (MTX) increases the risk of alopecia and stomatitis, but the prevalence of these adverse events among rheumatic patients taking MTX is poorly defined. We conducted a systematic literature review and meta-analysis to estimate the prevalence of alopecia and stomatitis with MTX in rheumatic diseases.

METHODS

We searched PubMed, The Cochrane Library, and CINAHL databases for double-blind randomized controlled trials (RCTs) with an MTX monotherapy arm. Alopecia, stomatitis, and oral/mouth ulcers data were extracted. The quality of trials was assessed by 2 authors. We included trials published since 1990 that used at least 10 mg of MTX weekly, coadministered with folic or folinic acid. We estimated the prevalence using random-effects models because heterogeneity was anticipated. Two estimates of prevalence were included; the lower bound estimate included all trials (assuming no alopecia and stomatitis if not mentioned), and the upper bound estimate included only those that specifically described prevalence estimates of alopecia or stomatitis.

RESULTS

Of 3,954 studies identified, 20 RCTs were included, with a total of 24 MTX monotherapy arms, of which 10 reported the prevalence of alopecia (n = 1,113), and 21 reported stomatitis or mouth/oral ulcers (n = 2,056). The prevalence of alopecia was between 1.0% and 4.9%. The prevalence of stomatitis was between 5.7% and 8.0%.

CONCLUSION

This meta-analysis gives more precise estimates of mucocutaneous adverse events that occur in rheumatic disease patients taking MTX. These estimates will help inform patient decision-making regarding MTX.

Efficacy of high-intensity laser therapy on arthropathy of the hands in patients with systemic lupus erythematosus: a double-blinded, randomized controlled trial

OBJECTIVE

To determine the efficacy of high-intensity laser therapy (HILT) on arthropathy of the hands in patients with systemic lupus erythematosus.

DESIGN

A double-blinded randomized, controlled study.

SETTING

Outpatient setting.

PARTICIPANTS

Fifty patients, 30-50-years-old, suffering from arthropathy of the hands were randomly assigned either into the experimental group, received HILT plus the routine physical therapy program or the control group, received sham HILT plus the same routine physical therapy program.

INTERVENTION

All treatment interventions were applied at a frequency of three sessions per week for eight weeks.

OUTCOME MEASURES

Handgrip strength, joints swelling counts, joints tenderness counts, visual analog scale (VAS) were measured before and after eight-weeks of interventions.

RESULTS

There were statistically significant differences in handgrip strength, joint swelling count, joint tenderness count and VAS in favor of the study group (P < 0.05). After eight-weeks of intervention, the mean (SD) for handgrip strength, joint swelling counts, joint tenderness count, and pain score was 28.34 ± 8.3 kg, 4.4 ± 2.18, 5 ± 2.1, and 35.6 ± 13.87 mm in the study group, and 22.96 ± 8.76 kg, 7.36 ± 2.14, 9.08 ± 1.63, and 58.8 ± 10.54 mm in the control group, respectively. The MD (95%CI) for handgrip strength, joint swelling counts, joint tenderness count, and pain score was 5.38(0.53,10.23) kg, -2.96(-4.19, -1.73), -4.08(-5.15, -3.01), and -23.2(-30.2, -16.2) mm between groups, respectively.

CONCLUSIONS

Adding HILT to the routine physical therapy program might be more effective than routine physical therapy program alone in improving handgrip strength, decreasing joint swelling counts, joint tenderness counts, and pain in patients with arthropathy of the hands.

Structural characterization and in vitro immunogenicity evaluation of amphibian-derived collagen type II from the cartilage of Chinese Giant Salamander (Andrias davidianus)

Collagen type II (CT-II) has unique biological activities and functions, yet the knowledge on amphibian-derived CT-II is rare. Herein, acid-soluble collagen (ASC) and pepsin-soluble collagen (PSC) were successfully isolated and characterized from the cartilage of Chinese Giant Salamander (CGS). The in vitro immunogenicity of collagen was then evaluated and compared with that of the standard bovine CT-II (SCT-II) by T-lymphocyte cell proliferation activity. Results demonstrated that ASC and PSC were predominantly CT-II along with minor collagen type I and maintained intact triple-helical structure of nature collagen. Compared with SCT-II, higher glycine content (337.80 and 339.93 residues/1000 residues) and lower degree of proline hydroxylation (51.81% and 52.52%) were observed in ASC and PSC. Additionally, PSC showed comparable T _d (63 °C) and higher T _m (109 °C) than SCT-II (64 °C and 103 °C, respectively), indicating its high thermal and structural stability. SEM revealed that the lyophilized ASC and PSC had interconnected porous network structures of collagen-based materials. Moreover, different from SCT-II, both ASC and PSC presented no immunogenicity because they did not cause obvious proliferation of murine T-lymphocyte regardless of the induced concentration of collagen increased from 8 to 417 μg/mL. These data suggested that the amphibian-derived CGS cartilage collagens avoid the immunogenic risk of terrestrial animal collagen, and show high thermal stability and potential advantage in biomedical application.

Dynamic profiles, biodistribution and integration evaluation after intramuscular/intravenous delivery of a novel therapeutic DNA vaccine encoding chicken type II collagen for rheumatoid arthritis in vaccinated normal rodent

BACKGROUND

The persistence, biodistribution, and risk of integration into the host genome of any new therapeutic DNA vaccine must be established in preclinical studies. We previously developed the DNA vaccine pcDNA-CCOL2A1 encoding chicken type II collagen (CCII) for the treatment of rheumatoid arthritis (RA). In the present study, we characterized its dynamic profile, biodistribution, and potential for genomic DNA integration in normal vaccinated rodent.

RESULTS

A real-time quantitative PCR analysis (RT-qPCR) of animals administered a single dose of pcDNA-CCOL2A1 (300 μg/kg by intramuscular injection) showed that CCOL2A1 mRNA level in the blood peaked between 2 and 6 h post-immunization and then rapidly declined, and was undetectable between day 1-42. CCOL2A1 transcript was detected at the muscle injection site on days 3-14 post-immunization. Starting from day 14, the transcript was detected in the heart, liver, lung, and kidney but not in the spleen or thymus, and was expressed only in the lung on day 28. There was no CCOL2A1 mRNA present in the testes or ovaries at any time point. Non-invasive in vivo fluorescence imaging revealed CCII protein expression from 2 h up to day 10 and from 2 h up to day 35 after administration of pcDNA-CCOL2A1 via the intravenous and intramuscular routes, respectively; the protein had disappeared by day 42. Importantly, CCOL2A1 was not integrated into the host genome.

CONCLUSIONS

These results indicate that pcDNA-CCOL2A1 vaccine is rapidly cleared within a short period of time and is therefore safe, and merits further development as a therapeutic vaccine for RA treatment.

Molecular assembly of recombinant chicken type II collagen in the yeast Pichia pastoris

Effective treatment of rheumatoid arthritis can be mediated by native chicken type II collagen (nCCII), recombinant peptide containing nCCII tolerogenic epitopes (CTEs), or a therapeutic DNA vaccine encoding the full-length CCOL2A1 cDNA. As recombinant CCII (rCCII) might avoid potential pathogenic virus contamination during nCCII preparation or chromosomal integration and oncogene activation associated with DNA vaccines, here we evaluated the importance of propeptide and telopeptide domains on rCCII triple helix molecular assembly. We constructed pC- and pN-procollagen (without N- or C-propeptides, respectively) as well as CTEs located in the triple helical domain lacking both propeptides and telopeptides, and expressed these in yeast Pichia pastoris host strain GS115 (his4, Mut⁺) simultaneously with recombinant chicken prolyl-4-hydroxylase α and β subunits. Both pC- and pN-procollagen monomers accumulated inside P. pastoris cells, whereas CTE was assembled into homotrimers with stable conformation and secreted into the supernatants, suggesting that the large molecular weight pC-or pN-procollagens were retained within the endoplasmic reticulum whereas the smaller CTEs proceeded through the secretory pathway. Furthermore, resulting recombinant chicken type II collagen pCα1(II) can induced collagen-induced arthritis (CIA) rat model, which seems to be as effective as the current standard nCCII. Notably, protease digestion assays showed that rCCII could assemble in the absence of C- and N-propeptides or telopeptides. These findings provide new insights into the minimal structural requirements for rCCII expression and folding.

Safety and immunogenicity of a novel therapeutic DNA vaccine encoding chicken type II collagen for rheumatoid arthritis in normal rats

Current clinically available treatments for rheumatoid arthritis (RA) fail to cure the disease or unsatisfactorily halt disease progression. To overcome these limitations, the development of therapeutic DNA vaccines and boosters may offer new promising strategies. Because type II collagen (CII) as a critical autoantigen in RA and native chicken type II collagen (nCCII) has been used to effectively treat RA, we previously developed a novel therapeutic DNA vaccine encoding CCII (pcDNA-CCOL2A1) with efficacy comparable to that of the current "gold standard", methotrexate(MTX). Here, we systemically evaluated the safety and immunogenicity of the pcDNA-CCOL2A1 vaccine in normal Wistar rats. Group 1 received only a single intramuscular injection into the hind leg with pcDNA-CCOL2A1 at the maximum dosage of 3 mg/kg on day 0; Group 2 was injected with normal saline (NS) as a negative control. All rats were monitored daily for any systemic adverse events, reactions at the injection site, and changes in body weights. Plasma and tissues from all experimental rats were collected on day 14 for routine examinations of hematology and biochemistry parameters, anti-CII IgG antibody reactivity, and histopathology. Our results indicated clearly that at the maximum dosage of 3 mg/kg, the pcDNA-CCOL2A1 vaccine was safe and well-tolerated. No abnormal clinical signs or deaths occurred in the pcDNA-CCOL2A1 group compared with the NS group. Furthermore, no major alterations were observed in hematology, biochemistry, and histopathology, even at the maximum dose. In particularly, no anti-CII IgG antibodies were detected in vaccinated normal rats at 14 d after vaccination; this was relevant because we previously demonstrated that the pcDNA-CCOL2A1 vaccine, when administered at the therapeutic dosage of 300 μg/kg alone, did not induce anti-CII IgG antibody production and significantly reduced levels of anti-CII IgG antibodies in the plasma of rats with established collagen-induced arthritis (CIA). This is the first study demonstrating the safety and immunogenicity of a DNA vaccine encoding CCII for treating RA in normal rats. These results may support the use of this novel therapeutic DNA vaccine for the treatment of RA in the future.

Effects of Native Type II Collagen Treatment on Knee Osteoarthritis: A Randomized Controlled Trial

OBJECTIVE

The aim of this randomized controlled study was to evaluate the efficacy of oral native type II collagen treatment on the symptoms and biological markers of cartilage degradation, when given concomitantly with acetaminophen in patients with knee osteoarthritis.

MATERIALS AND METHODS

Thirty-nine patients diagnosed with knee osteoarthritis were included and randomly distributed into two groups: one treated with 1500 mg/day of acetaminophen (group AC; n=19) and the other treated with 1500 mg/day of acetaminophen plus 10 mg/day of native type II collagen (group AC+CII; n=20) for 3 months. Visual Analogue Scale (VAS) at rest and during walking, Western Ontario McMaster (WOMAC) pain, WOMAC function, and Short Form-36 (SF-36) scores, were recorded. Coll2-1, Coll2-1NO2 and Fibulin-3 levels were quantified in urine as biomarkers of disease progression. ClinicalTrials.gov: NCT02237989.

RESULTS

After 3 months of treatment, significant improvements compared to baseline were reported in joint pain (VAS walking), function (WOMAC) and quality of life (SF-36) in the AC+CII group, while only improvements in some subscales of the SF-36 survey and VAS walking were detected in the AC group. Comparisons between the groups revealed a significant difference in VAS walking score in favour of the AC+CII group as compared to AC group. Biochemical markers of cartilage degradation in urine did not significantly improve in any of the groups.

CONCLUSION

All in all, these results suggest that native type II collagen treatment combined with acetaminophen is superior to only acetaminophen for symptomatic treatment of patients with knee osteoarthritis.

Evaluation of humoral and cellular immune responses to a DNA vaccine encoding chicken type II collagen for rheumatoid arthritis in normal rats

A major challenge in the development of effective therapies for rheumatoid arthritis (RA) is finding a method for the specific inhibition of the inflammatory disease processes without the induction of generalized immunosuppression. Of note, the development of therapeutic DNA vaccines and boosters that may restore immunological tolerance remains a high priority. pcDNA-CCOL2A1 is a therapeutic DNA vaccine encoding chicken type II collagen(CCII). This vaccine was developed by our laboratory and has been shown to exhibit efficacy comparable to that of the current "gold standard" treatment, methotrexate (MTX). Here, we used enzyme-linked immunosorbent assays with anti-CII IgG antibodies, quantified the expression levels of Th1, Th2, and Th3 cytokines, and performed flow cytometric analyses of different T-cell subsets, including Th1, Th2, Th17, Tc, Ts, Treg, and CD4(+)CD29(+)T cells to systemically evaluate humoral and cellular immune responses to pcDNA-CCOL2A1 vaccine in normal rats. Similar to our observations at maximum dosage of 3 mg/kg, vaccination of normal rats with 300 μg/kg pcDNA-CCOL2A1 vaccine did not induce the production of anti-CII IgG. Furthermore, no significant changes were observed in the expression levels of pro-inflammatory cytokines interleukin (IL)-1α, IL-5, IL-6, IL-12(IL-23p40), monocyte chemotactic protein (MCP)-1, macrophage inflammatory protein (MIP)-1α, regulated on activation in normal T-cell expressed and secreted (RANTES), receptor activator for nuclear factor-κB ligand (RANKL), and granulocyte colony-stimulating factor (G-CSF) or anti-inflammatory cytokines IL-4 and IL-10 in vaccinated normal rats relative to that in controls(P > 0.05). However, transforming growth factor (TGF)-β levels were significantly increased on days 10 and 14, while interferon (IFN)-γ and tumor necrosis factor (TNF)-α levels were significantly decreased on days 28 and 35 after vaccination(P < 0.05). Similarly, there were no significant differences in the percentages of Tc, Ts, Th1/Th2, and Th17 cells between the 2 groups(P > 0.05), with the exception of Treg cells, which were significantly reduced on days 14 and 21 after vaccination (P < 0.05), and CD4(+)CD29(+)T cells, which were significantly increased on days 7 and 14 after vaccination(P < 0.05).Taken together, these results suggested that pcDNA-CCOL2A1 vaccine did not markedly affect the balance of immune system components in vaccinated normal rats, indicating that this DNA vaccine may have clinical applications in the treatment of RA.

Risk of liver injury among methotrexate users: A meta-analysis of randomised controlled trials

OBJECTIVE

Methotrexate is an effective treatment for a variety of inflammatory diseases. Robust evidence on the risk of serious liver injury is lacking. The aim of this study was to evaluate the relative risk and severity of liver disease among patients treated with methotrexate.

METHODS

We searched PubMed and the Cochrane Central Register of Controlled Trials from 1 January 1990 to 24 April 2014 for double-blind randomised controlled trials of methotrexate versus comparator agents in adults with rheumatoid arthritis, psoriasis, psoriatic arthritis or inflammatory bowel disease. Studies with less than 100 subjects or of less than 24 weeks' duration were excluded. Two investigators independently searched both the databases. All authors reviewed the selected studies. We compared relative risk (RR) differences using the Mantel-Haenszel random effects method to assess total liver adverse events, minor liver enzyme abnormalities (≤ 3 ULN), major liver enzyme abnormalities (>3 ULN or treatment withdrawal) and a composite outcome of liver failure, fibrosis, cirrhosis or death.

RESULTS

A total of 32 studies with 13,177 participants met our inclusion criteria. Methotrexate was associated with an increased risk of total adverse liver events, RR = 2.19 (95% CI: 1.73-2.77, I(2) = 68%), as well as minor and major liver enzyme abnormalities, RR = 2.16 (95% CI: 1.67-2.79, I(2) = 68%) and RR = 2.63 (95% CI: 1.90-3.64, I(2) = 10%), respectively. Patients treated with methotrexate were not at increased risk of liver failure, cirrhosis or death, RR = 0.12 (95% CI: 0.01-1.09, I(2) = 0%).

CONCLUSION

Our study found an increased risk of elevated transaminases but not liver failure, cirrhosis or death with methotrexate compared to other agents. We were unable to assess long-term liver toxicity due to the short duration of included clinical trials.

Trials in type 1 diabetes: Antigen-specific therapies

Type 1 diabetes (T1D) results from an aberrant immunological response against the insulin-producing beta cells in the islets of the pancreas. The ideal therapy would restore immune balance in a safe and lasting fashion, stopping the process of beta cell decay. The efficacy of immune suppressive agents such as cyclosporin underscores the notion that T1D can in principle be prevented, albeit at an unacceptable long-term safety risk. Immune modulatory drugs such as monoclonal anti-CD3 antibody, on the other hand, have recently had rather disappointing results in phase 3 trials, possibly due to inadequate dosing or choice of inappropriate endpoints. Therefore, it is argued that striking the right balance between safety and efficacy, together with careful trial design, will be paramount in preventing T1D. Here we outline the concept of antigen-specific tolerization as a strategy to safely induce long-term protection against T1D, focusing on available clinical trial data, key knowledge gaps and potential future directions.

Antigen-specific gene therapy after immunisation reduces the severity of collagen-induced arthritis

Reestablishment of tolerance induction in rheumatoid arthritis (RA) would be an optimal treatment with few, if any, side effects. However, to develop such a treatment further insights in the immunological mechanisms governing tolerance are needed. We have developed a model of antigen-specific tolerance in collagen type II (CII) induced arthritis (CIA) using lentivirus-based gene therapy. The immunodominant epitope of CII was inserted into a lentivirus vector to achieve expression on the MHC class II molecule and the lentiviral particles were subsequently intravenously injected at different time points during CIA. Injection of lentiviral particles in early phases of CIA, that is, at day 7 or day 26 after CII immunisation, partially prevented development of arthritis, decreased the serum levels of CII-specific IgG antibodies, and enhanced the suppressive function of CII-specific T regulatory cells. When lentiviral particles were injected during manifest arthritis, that is, at day 31 after CII immunisation, the severity of arthritis progression was ameliorated, the levels of CII-specific IgG antibodies decreased and the proportion of T regulatory cells increased. Thus, antigen-specific gene therapy is effective when administered throughout the inflammatory course of arthritis and offers a good model for investigation of the basic mechanisms during tolerance in CIA.

Low dose native type II collagen prevents pain in a rat osteoarthritis model

Background

Osteoarthritis is the most widespread joint-affecting disease. Patients with osteoarthritis experience pain and impaired mobility resulting in marked reduction of quality of life. A progressive cartilage loss is responsible of an evolving disease difficult to treat. The characteristic of chronicity determines the need of new active disease modifying drugs. Aim of the present research is to evaluate the role of low doses of native type II collagen in the rat model of osteoarthritis induced by sodium monoiodoacetate (MIA).

Methods

1, 3 and 10 mg kg^-1 porcine native type II collagen were daily per os administered for 13 days starting from the day of MIA intra-articular injection.

Results

On day 14, collagen-treated rats showed a significant prevention of pain threshold alterations induced by MIA. Evaluation were performed on paws using mechanical noxious (Paw pressure test) or non-noxious (Electronic Von Frey test) stimuli, and a decrease of articular pain was directly measured on the damaged joint (PAM test). The efficacy of collagen in reducing pain was as higher as the dose was lowered. Moreover, a reduced postural unbalance, measured as hind limb weight bearing alterations (Incapacitance test), and a general improvement of motor activity (Animex test) were observed. Finally, the decrease of plasma and urine levels of CTX-II (Cross Linked C-Telopeptide of Type II Collagen), a biomarker of cartilage degradation, suggests a collagen-dependent decrease of structural joint damage.

Conclusions

These results describe the preclinical efficacy of low dosages of native type II collagen as pain reliever by a mechanism that involves a protective effect on cartilage.

Exosome removal as a therapeutic adjuvant in cancer

Exosome secretion is a notable feature of malignancy owing to the roles of these nanoparticles in cancer growth, immune suppression, tumor angiogenesis and therapeutic resistance. Exosomes are 30-100 nm membrane vesicles released by many cells types during normal physiological processes. Tumors aberrantly secrete large quantities of exosomes that transport oncoproteins and immune suppressive molecules to support tumor growth and metastasis. The role of exosomes in intercellular signaling is exemplified by human epidermal growth factor receptor type 2 (HER2) over-expressing breast cancer, where exosomes with the HER2 oncoprotein stimulate tumor growth and interfere with the activity of the therapeutic antibody Herceptin®. Since numerous observations from experimental model systems point toward an important clinical impact of exosomes in cancer, several pharmacological strategies have been proposed for targeting their malignant activities. We also propose a novel device strategy involving extracorporeal hemofiltration of exosomes from the entire circulatory system using an affinity plasmapheresis platform known as the Aethlon ADAPT™ (adaptive dialysis-like affinity platform technology) system, which would overcome the risks of toxicity and drug interactions posed by pharmacological approaches. This technology allows affinity agents, including exosome-binding lectins and antibodies, to be immobilized in the outer-capillary space of plasma filtration membranes that integrate into existing kidney dialysis systems. Device therapies that evolve from this platform allow rapid extracorporeal capture and selective retention of target particles < 200 nm from the entire circulatory system. This strategy is supported by clinical experience in hepatitis C virus-infected patients using an ADAPT™ device, the Hemopurifier®, to reduce the systemic load of virions having similar sizes and glycosylated surfaces as cancer exosomes. This review discusses the possible therapeutic approaches for targeting immune suppressive exosomes in cancer patients, and the anticipated significance of these strategies for reversing immune dysfunction and improving responses to standard of care treatments.

Evidence for the efficacy of complementary and alternative medicines in the management of rheumatoid arthritis: a systematic review

OBJECTIVE

To critically evaluate the evidence regarding complementary and alternative medicine (CAM) taken orally or applied topically (excluding fish oil) in the treatment of RA.

METHODS

Randomized controlled trials (RCTs) of RA using CAMs, in comparison with other treatments or placebo, published in English up to August 2010, were eligible for inclusion. They were identified using systematic searches of bibliographic databases and manual searching of reference lists. Information was extracted on outcomes and statistical significance, in comparison with alternative treatments, and reported side effects. The methodological quality of the primary studies was determined using the Jadad scoring system.

RESULTS

Reported RCTs were available for 18 CAMs in the management of RA. There was no consistent evidence available for any of the reviewed substances to suggest that they were efficacious as complementary medicines to standard treatment. Nevertheless, the studies conducted on borage seed oil (n = 2) and thunder god vine (n = 3) have been positive and may warrant further investigation. Not all CAM compounds studied were free of major adverse effects.

CONCLUSION

The major limitation in reviewing the evidence for CAMs is the paucity of RCTs in the area. The available evidence does not support their current use in the management of RA.

How should morning function in rheumatoid arthritis be assessed? Bibliographic study of current assessment

In patients with rheumatoid arthritis (RA), symptoms of joint stiffness and pain may be most severe in the morning, resulting in impaired ability to carry out normal morning functions. Although morning stiffness was included in the criteria for classification and remission of RA, defined by the American College of Rheumatology (ACR) in 1987, the approach to assessment of this circadian symptom has not been standardized, and other circadian aspects of the disease (i.e. pain, functional ability) were not included. A bibliographic study of papers published in English in the period January 2007 to January 2010 and reporting morning stiffness, pain or function was undertaken to investigate methods of assessing circadian aspects of RA. A total of 73 studies were identified using Medline, including 62 clinical trials. Full papers were obtained for 52 reports of clinical studies (84%), most of which (44/52, 85%) assessed duration of morning stiffness. Only two studies (4%) specified that severity of morning stiffness was assessed, only three (6%) assessed pain in the morning, and none assessed morning functional ability. These findings suggest the need for consistent reporting of a measure to reflect the impaired morning function, arising from joint stiffness and pain that is commonly experienced by patients.

Serological investigation of IgG levels and subclasses in rheumatoid arthritis patients following ingestion of bovine type II collagen: results of a double blind, randomised controlled trial

The purpose of this study was to investigate whether clinical improvement in patient with rheumatoid arthritis (RA) taking oral Bovine type II collagen (bCII) is associated with changes in levels of anti-bCII total IgG antibody and its subclasses. Four groups were given either 5, 0.5 or 0.05 mg of bCII or a placebo in a double-blind randomised control trial. The sera IgG anti-collagen type II and antibodies of the IgG subclasses, IgG1-4, were measured at the start and end of the trial by ELISA. Total IgG anti-collagen II antibodies in the pooled active treatment groups were statistically significantly reduced compared with the placebo group (p = 0.021). Decreasing total IgG titres were observed in the 0.5-mg group (p = 0.008), 0.05-mg group (p = 0.004) and 5-mg group (p = 0.078) before and after treatment. For IgG1, IgG2, IgG3 and IgG4 subclasses, in the 0.5-mg group in which the best clinical response was observed, there was statistically significant decreases observed in the IgG2 and IgG3 subclasses (p = 0.047, p = 0.046). Treatment with bCII in patients with RA led to a reduction in anti-collagen II antibody titre indicating an active biological effect as observed previously in animal model of RA. The largest decrease in total and subclasses of anti-collagen antibody titres occurred in the groups of patients with the best therapeutic response to bCII, supporting the conclusion of the clinical trial and suggests that immune regulation explains the therapeutic effect.