Immunogenicity of subcutaneous TNF inhibitors and its clinical significance in real-life setting in patients with spondyloarthritis

Key messages

Considerable proportion of patients with SpA have been immunized to the subcutaneous anti-TNF drug they are using. Concomitant use of MTX protects from immunization, whereas SASP does not. Patients with SpA using subcutaneous anti-TNF drugs can benefit from monitoring of the drug trough levels.

Abstract

Immunization to biological drugs can lead to decreased efficacy and increased risk of adverse effects. The objective of this cross-sectional study was to assess the extent and significance of immunization to subcutaneous tumor necrosis factor (TNF) inhibitors in axial spondyloarthritis (axSpA) patients in real-life setting. A serum sample was taken 1–2 days before the next drug injection. Drug trough concentrations, anti-drug antibodies (ADAb) and TNF-blocking capacity were measured in 273 patients with axSpA using subcutaneous anti-TNF drugs. The clinical activity of SpA was assessed using the Bath AS Disease Activity Index (BASDAI) and the Maastricht AS Entheses Score (MASES). ADAb were found in 11% of the 273 patients: in 21/99 (21%) of patients who used adalimumab, in 0/83 (0%) of those who used etanercept, in 2/79 (3%) of those who used golimumab and in 6/12 (50%) of those who used certolizumab pegol. Use of methotrexate reduced the risk of formation of ADAb, whereas sulfasalazine did not. Presence of ADAb resulted in decreased drug concentration and reduced TNF-blocking capacity. However, low levels of ADAb had no effect on TNF-blocking capacity and did not correlate with disease activity. The drug trough levels were below the consensus target level in 36% of the patients. High BMI correlated with low drug trough concentration. Patients with low drug trough levels had higher disease activity. The presence of anti-drug antibodies was associated with reduced drug trough levels, and the patients with low drug trough levels had higher disease activity. The drug trough levels were below target level in significant proportion of patients and, thus, measuring the drug concentration and ADAb could help to optimize the treatment in SpA patients.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00296-021-04955-8.

Arginase activity in peripheral blood of patients with intestinal schistosomiasis, Wonji, Central Ethiopia

Morbidity and mortality caused by schistosomiasis usually results from immunopathology. But the underlying mechanisms are not yet clearly understood. Th2-type immune response is thought to be dominant during chronic schistosomiasis, and upregulation of arginase-I is one component of this milieu. A cohort study was conducted to assess arginase activity in peripheral blood of humans with intestinal schistosomiasis in Wonji-Shoa Sugar Estate, Central Ethiopia. Laboratory-confirmed 30 Schistosoma mansoni-infected patients and 18 apparently healthy controls were recruited. Faecal egg count was carried out by Kato-Katz technique. Plasma and peripheral blood mononuclear cells (PBMCs) were isolated from whole blood. Activity of arginase in plasma and PBMC lysates was measured, and results were compared with that of controls. Twenty-one of 30 patients had light infection, whereas moderate and heavy intensity infections were observed in eight and only one patient(s), respectively. A significant increase in both PBMC (patients: 59.96 + 82.99, controls: 25.44 + 24.6 mU/mg protein, P < 0.0001) and plasma (patients: 1.61 + 2.19, controls: 0.31 + 0.73 mU/mL plasma, P < 0.0001) arginase activity was observed during human S. mansoni infection. Arginase activity increases in peripheral blood of patients with intestinal schistosomiasis.

Efficacy and side effects of praziquantel in the treatment of Schistosomiasis mansoni in schoolchildren in Shesha Kekele Elementary School, Wondo Genet, Southern Ethiopia

OBJECTIVE

To evaluate the efficacy and side effects of praziquantel (PZQ) in the treatment of schistosomiasis in Ethiopia.

METHODS

In a cross-sectional study, stool specimens were collected from randomly selected 299 school children in Shesha Kekele Elementary School, Wondo Genet, Southern Ethiopia, in April 2010. Stool specimens were examined using a single Kato-Katz thick smear for Schistosoma mansoni (S. mansoni) ova. Children who were found positive for S. mansoni were treated with a single oral dose of PZQ at 40 mg/kg bw and interviewed for treatment-related symptoms 24 hours after drug administration. Four weeks post-treatment, stool specimens were collected from the same children and examined following the same procedure as in the pre-treatment. Drug efficacy was determined based on cure and egg reduction rates.

RESULTS

Pre-treatment prevalence of S. mansoni infection was 74.9% with geometric mean egg count of 268. The evaluated generic PZQ produced an overall cure rate of 73.6% (P<0.000 1, OR: 8.33, CI: 5.3-13.1) and egg reduction rate of 68.2% (P=0.03, F=0.64). The cure rate showed significant association with age (χ(2)=11, P=0.004), the highest rate being observed in the 15-22 age group. 83% of S. mansoni infected children showed various treatment-related symptoms, the most frequent being headache, nausea, and abdominal pain. These symptoms were associated with age (P<0.001) and pre-treatment intensity of infection (P<0.05).

CONCLUSIONS

The present observations revealed relatively lower cure and egg reduction rates of the PZQ evaluated as compared to previous reports for other PZQ brands in Ethiopia. Hence, in depth studies are recommended to clarify whether the present relatively lower cure rate is the actual cure rate of the praziquantel evaluated, treatment failure, or reduced susceptibility of the parasite. Treatment-related side effects observed were transient and tolerable.

Community awareness of intestinal parasites and the prevalence of infection among community members of rural Abaye Deneba area, Ethiopia

OBJECTIVE

To assess the knowledge of Abaye Deneba community members regarding intestinal parasites and prevalence of intestinal parasitic infections.

METHODS

Knowledge about intestinal parasites was assessed by administering a questionnaire to 345 randomly selected household heads. Parasitological stool examination of 491 randomly selected individuals was done using the formol ether concentration technique.

RESULTS

Knowledge of the Abaye Deneba community about parasitic diseases such as schistosomiasis, amoebiasis, ascariasis and taeniasis was very low. However, 204 (59.3%) members correctly responded that the cause of giardiasis is related to contaminated water and 176 (51.2%) knew how to prevent it. In some cases, respondents did correctly identify causes, symptoms of intestinal parasite infection and ways to prevent it, but they did not accurately link it to the appropriate disease caused by the different intestinal parasite species. Among the 491 stool samples examined, 50.2% of study participants showed infection with at least one intestinal parasite. Schistosoma mansoni was the most prevalent (41.3%) followed by Trichuris trichiura(9.4%), Ascaris lumbricoides (8.4%), Taenia saginata (2.4%), Enterobius vermicularis (2.0%) and hookworm (0.4%). Prevalence of schistosomiasis was highest in men aged 15-24 years.

CONCLUSIONS

Intestinal parasitic infection is highly prevalent in communities of the Abaye Deneba area. Nevertheless, the knowledge of the community members about the parasite is less. Implementation of preventive chemotherapy, supplemented with health education, provision and use of sanitary facilities would be recommended to reduce morbidity and control transmission of intestinal parasites in this area.

Transmission of Mycobacterium tuberculosis between farmers and cattle in central Ethiopia

Background

Transmission of Mycobacterium tuberculosis (M. tuberculosis) complex could be possible between farmers and their cattle in Ethiopia.

Methodology/Principal Findings

A study was conducted in mixed type multi-purposes cattle raising region of Ethiopia on 287 households (146 households with case of pulmonary tuberculosis (TB) and 141 free of TB) and 287 herds consisting of 2,033 cattle belonging to these households to evaluate transmission of TB between cattle and farmers. Interview, bacteriological examinations and molecular typing were used for human subjects while comparative intradermal tuberculin (CIDT) test, post mortem and bacteriological examinations, and molecular typing were used for animal studies. Herd prevalence of CIDT reactors was 9.4% and was higher (p<0.01) in herds owned by households with TB than in herds owned by TB free households. Animal prevalence was 1.8% and also higher (p<0.01) in cattle owned by households with TB case than in those owned by TB free households. All mycobacteria (141) isolated from farmers were M. tuberculosis, while only five of the 16 isolates from cattle were members of the M. tuberculosis complex (MTC) while the remaining 11 were members of non-tuberculosis mycobacteria (NTM). Further speciation of the five MTC isolates showed that three of the isolates were M. bovis (strain SB1176), while the remaining two were M. tuberculosis strains (SIT149 and SIT53). Pathology scoring method described by “Vordermeier et al. (2002)” was applied and the average severity of pathology in two cattle infected with M. bovis, in 11 infected with NTM and two infected with M. tuberculosis were 5.5, 2.1 and 0.5, respectively.

Conclusions/Significance

The results showed that transmission of TB from farmers to cattle by the airborne route sensitizes the cows but rarely leads to TB. Similarly, low transmission of M. bovis between farmers and their cattle was found, suggesting requirement of ingestion of contaminated milk from cows with tuberculous mastitis.

Efficacy of Praziquantel against Schistosoma haematobium in Dulshatalo village, western Ethiopia

Background

Praziquantel (PZQ) is the drug of choice for treatment of all human schistosomes. It is used in population based targeted or mass deworming strategies in several countries. The effect of PZQ on S. hematobium has not been studied in Ethiopia. The objective of this study was to determine the efficacy of PZQ against S. haematobium in Dulshatalo village, western Ethiopia.

Methods

A prospective study was conducted from October to December, 2007. Urine samples from 341 residents were collected and screened for haematuria and proteinuria using urinalysis dipstick. S. haematobium eggs were detected and quantified using filtration techniques. The participants who were positive for haematuria were treated with a standard dose of PZQ (40 mg/kg). Data on pre and 24 hours post treatment symptoms were collected via questionnaire. Urine samples were also collected 7 weeks after treatment and examined to assess the cure and the egg reduction rates.

Results

The prevalence of S. haematobium among the study participants was 57.8% (197/341). Haematuria was detected in 234 (68.6%) of the study participants. For PZQ efficacy asessment, 152 of the treated participants were considered. The presence of S. haemetaobium eggs showed statistically significant association (p < 0.05) with haematuria and proteinuria. Seven weeks post treatment, the extent of haematuria and proteinuria decreased from 100% to 40.8% and 94.07% to 48.7%, respectively. The cure and the parasitological egg reduction rates seven weeks post treatment were 86% and 85%, respectively. Post treatment symptoms revealed a wide range of side effects including straining, abdominal pain, nausea and headache.

Conclusions

There were marked cure and egg reduction rates, together with mild and short lived side effects of PZQ for treatment of S. haematobium, in this study.

The status of lactose absorption in Hong Kong Chinese children

Lactose malabsorption was investigated in 169 Chinese children aged between two and 16 years using the breath hydrogen test. The challenge was either lactose solution (1 g/kg) or cow's milk (10 ml/kg). Overall, 68% of the children showed a significant increase in breath hydrogen following the lactose challenge while only 17% showed an increase after the cow's milk challenge and 13% after both challenges. The number of malabsorbers increased significantly (p less than 0.001) with age and no associated gastrointestinal symptoms or signs were found in any of the children following the challenges, suggesting a gradual and partial loss of intestinal lactase activity. We conclude that the prevalence of lactose malabsorption in Hong Kong children is very high using the standard lactose tolerance test but when a more realistic amount of lactose and a natural medium such as a glass of milk is used as the challenge, the number of malabsorbers becomes small and clinically insignificant.

Breath methane excretion in Hong Kong Chinese children

The factors which determine whether an individual is a methane excretor or a nonexcretor are not clearly understood. Genetic makeup, ethnic origin, diet, environment, or an interaction of all these factors have been implicated. In order to delineate the incidence, the age of onset, and environmental factors that may influence the excretion of methane in our community, we investigated a total of 425 Chinese children in Hong Kong (204 females, 221 males). End-expiratory breath samples were collected after an overnight fast and measured by gas-chromatography using a flame ionization detector. Thirty one children (7.3%) excreted at least 1 ppm methane above the ambient level (median = 6.4, range = 1.8-26.0 ppm). There was no difference in methane excretion status and pattern between the sexes or between children who lived at home and those who lived at an institution. There was a general increase in the number of methane excretors with age, but a statistically significant increase was reached only after 14 years of age. The amount of methane excreted was unrelated to age and there were no excretors detected under the age of 5 years. It is concluded that the methane excretion pattern of these children was generally similar to those previously reported from other regions, but the incidence is much lower and the age of onset appears to be more gradual.

Late-onset hypolactasia in Hong Kong school children

Three hundred and twenty Chinese school children aged between 6 and 19 years from six schools in Hong Kong were tested for their lactose digestion status. After an overnight fast, the children were challenged with cow's milk, 5 ml/kg bodyweight (i.e. lactose approximately 0.25 g/kg). Malabsorption was assessed by measuring hydrogen concentration from end-expiratory breath samples taken in duplicate before and at 90 and 180 minutes after the challenge. On average, 10% of the children showed an increase in breath hydrogen excretion within 3 h after the challenge, indicating malabsorption of lactose. None of the children complained of gastro-intestinal symptoms or showed any clinical sign of intolerance to the milk. The number of malabsorbers increased significantly (p less than 0.001) with age, starting at about 3% at the age of 8 and reaching about 27% at the age of 18 years. The sharpest rise occurred between 14 and 15 years. It is concluded that, despite the high prevalence of hypolactasia, Hong Kong Chinese children can consume normal amounts of milk without developing any untoward clinical symptom or sign.

The effect on intestinal disaccharidase activity of feeding galactose to growing rats

The effect of supplementation of the diet with galactose on the age-related decline of intestinal lactase activity was investigated in 108 growing rats. Starting from 14 days of age, the rats were divided into two groups and fed with chow, and with fluid either as tap water or 5% galactose solution. At 14 days the specific lactase activity was 112.8 +/- 3.2 mumol min-1 (g protein)-1, which decreased to less than 10% of this value at maturity. Galactose supplementation did not prevent the decline. The increase of maltase, sucrase and trehalase was also unaffected. The result suggests that galactose plays no significant role in the regulation of disaccharidase activities in the rat.

The effect of continued feeding of physiological amounts of lactose on the level of intestinal lactase and other disaccharidase enzyme activities in the rat

Intestinal lactase activity in mammals is high at birth but begins to decline around weaning and reaches very low levels in adult life. The triggering mechanism for this decline is not clear. Because of the association of the decline with weaning, lack of lactose in the diet has been implicated. In 110 growing rats, the effect of continued supplementation of the diet after weaning with physiological amounts of either cows' milk or a 5% lactose solution on intestinal lactase and other disaccharidase enzyme activities was investigated. In both control and test animals, the specific lactase activity decreased from a peak value of 115 +/- 4 mumol min-1 g-1 protein before weaning to about 10% at maturity. There was no significant difference in the level or the pattern of decline between the groups. Sucrase, maltase and trehalase showed the normal maturational changes without being affected by the test diets. The finding suggests that diet, particularly the presence or absence of physiological amounts of lactose, has no appreciable effect on the age related spontaneous decline of intestinal lactase activity or on the pattern of development of the other disaccharidases.

A new method of expired gas collection for the measurement of breath hydrogen (H2) in infants and small children

The measurement of hydrogen (H2) in breath is becoming increasingly useful as a diagnostic and research tool, but there is still no satisfactory method of sampling expired air in infants and small children. We tested a modified open-flow hood method where the child's head is put in a perspex box and expired air is collected by sucking air from the box by means of an air pump. Comparison of this method with end-expiratory sampling by a modified Haldane-Priestly and nasopharyngeal catheter gave a correlation coefficient of 0.83 and 0.65, respectively. We conclude that expired air sampling in children with this method is a more satisfactory and as reliable a method as any available at present, and has the added advantage of being quantitative.

The effect of dietary fibre isolates on gastric secretion, acidity and emptying

1. In six volunteers, the effect of intragastric administration of different water-soluble chemical isolates of dietary fibre on gastric secretion, acidity and emptying was studied. 2. At 30 min after administration of the test meals, the stomach contents were completely aspirated and the volume, pH, phenol red concentration, total titratable acidity and different electrolytes were measured. 3. Compared with the control meal, the pH and unionized (combined) hydrogen concentrations were significantly higher (P less than 0.05) following most of the fibre-containing meals, while the total titratable acid concentration was not significantly different. None of the fibre-containing meals appreciably altered the volume or type of gastric secretion but had a low-grade variable effect on gastric emptying. 4. It is concluded that most dietary fibre isolates, although having a definite and notable buffering effect on the acid in the stomach, have a minimal effect on gastric secretion and a variable and small effect on gastric emptying.

The effect of dietary fibre on bile acid metabolism in rats

1. Forty-eight male rats were fed sequentially for 14 d periods on diets containing different fibre contents. 2. One of the high-fibre diets was a commercial pelleted diet. The other was a low-fibre diet supplemented with 200 g wheat bran/kg. 3. At the end of each feeding period eight rats were killed. Liver microsomal cholesterol 7 alpha-hydroxylase (EC 1.14.1.-) activity and bile acid content of small intestine and colon were determined. 4. The different diets did not significantly alter the total intestinal bile acids, but affected the distribution and qualitative pattern in the colon and small intestine. 5. On the high-fibre diets deoxycholate, and hyodeoxycholate tended to be increased. 6. On the low-fibre diets the alpha, beta- and omega-muricholic acids tended to be increased. 7. Liver microsomal cholesterol 7 alpha-hydroxylase activity was lower in rats on the low-fibre and bran-supplemented low-fibre diets compared with that in rats fed on the commercial pelleted diet.

Breath hydrogen in pneumatosis cystoides intestinalis

Pneumatosis cystoides intestinalis (PCI) is an uncommon condition of unknown aetiology. Bacterial gas production may be an important aetiological factor, but experimental evidence in humans has been lacking. We have studied breath hydrogen excretion as an index of bacterial gas production in 12 patients with PCI and have shown that four out of five with demonstrable cysts produced unusually high levels of hydrogen while fasting. This abnormality has not been previously reported. One patient showed resolution of PCI after antibiotic treatment. These findings confirm the importance of bacterial gas production in the pathogenesis of PCI.

The effect of raw carrot on serum lipids and colon function

Two hundred grams of raw carrot eaten at breakfast each day for 3 weeks significantly reduced serum cholesterol by 11%, increased fecal bile acid and fat excretion by 50%, and modestly increased stool weight by 25%. This suggests an associated change in bacterial flora or metabolism. The changes in serum cholesterol, fecal bile acids, and fat persisted 3 weeks after stopping treatment.

Metabolism of dietary fibre components in man assessed by breath hydrogen and methane

1. Breath hydrogen and methane were measured in eight normal individuals after acute and separate administration of different chemical components of dietary fibre. 2. Hemicellulose, raffinose and lactulose increased H2 production, while cellulose pectin and lignin did not. Methane production was found to be individual and unaffected by any of the substances. Differences in physical properties of the same chemical appear to have no influences on H2 and CH4 production.