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Blake T, Gullick NJ, Hutchinson CE, Bhalerao A, Wayte S, Weedall A, Barber TM. Correction: More than skin‑deep: visceral fat is strongly associated with disease activity, function and metabolic indices in psoriatic disease. Arthritis Res Ther 2023; 25:115. [PMID: 37403185 PMCID: PMC10318798 DOI: 10.1186/s13075-023-03102-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/06/2023] Open
Affiliation(s)
- Tim Blake
- Department of Rheumatology, University Hospitals Coventry and Warwickshire, Clifford Bridge Road, Coventry, CV2 2DX, UK.
- Warwick Medical School, University of Warwick, Coventry, CV4 7HL, UK.
| | - Nicola J Gullick
- Department of Rheumatology, University Hospitals Coventry and Warwickshire, Clifford Bridge Road, Coventry, CV2 2DX, UK
- Warwick Medical School, University of Warwick, Coventry, CV4 7HL, UK
| | - Charles E Hutchinson
- Warwick Medical School, University of Warwick, Coventry, CV4 7HL, UK
- Division of Biomedical Sciences, Warwick Medical School, Clinical Sciences Research Laboratories, University Hospitals Coventry and Warwickshire, Coventry, CV2 2DX, UK
| | - Abhir Bhalerao
- Department of Computer Science, University of Warwick, Coventry, CV4 7EZ, UK
| | - Sarah Wayte
- Department of Radiology, University Hospitals Coventry and Warwickshire, Coventry, CV2 2DX, UK
- Radiology Physics, Department of Clinical Physics and Bioengineering, University Hospitals Coventry and Warwickshire, Coventry, CV2 2DX, UK
| | - Andrew Weedall
- Department of Radiology, University Hospitals Coventry and Warwickshire, Coventry, CV2 2DX, UK
- Radiology Physics, Department of Clinical Physics and Bioengineering, University Hospitals Coventry and Warwickshire, Coventry, CV2 2DX, UK
| | - Thomas M Barber
- Division of Biomedical Sciences, Warwick Medical School, Clinical Sciences Research Laboratories, University Hospitals Coventry and Warwickshire, Coventry, CV2 2DX, UK
- Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism, University Hospitals Coventry and Warwickshire, Coventry, CV2 2DX, UK
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Blake T, Gullick NJ, Hutchinson CE, Bhalerao A, Wayte S, Weedall A, Barber TM. More than skin-deep: visceral fat is strongly associated with disease activity, function and metabolic indices in psoriatic disease. Arthritis Res Ther 2023; 25:108. [PMID: 37353811 PMCID: PMC10288730 DOI: 10.1186/s13075-023-03085-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 06/04/2023] [Indexed: 06/25/2023] Open
Abstract
OBJECTIVE To compare body composition between patients with psoriatic disease (PsD), including cutaneous psoriasis (PsO) and psoriatic arthritis (PsA), and controls, and to explore associations between disease activity and measures of function and metabolic derangement. METHODS Body composition was assessed by air displacement plethysmography (ADP) and MRI-derived fat segmentation using an automated pipeline (FatSegNet). Function was assessed by Health Assessment Questionnaire (HAQ) and metabolic status by fasting lipid profile, insulin and adiponectin. Active and inactive PsO and PsA were defined by body surface area (BSA) and Psoriasis Area Severity Index (PASI) and minimal disease activity (MDA), respectively. RESULTS Thirty patients (median disease duration 15 years; median age 52 years) and 30 BMI-matched controls were enrolled. Compared with controls, all MRI-derived body composition parameters-whole-body volume, subcutaneous adipose tissue (SAT), visceral adipose tissue (VAT), abdominal adipose tissue (AAT), VAT/AAT and VAT/SAT-were higher in the PsD group, specifically, those with active disease. Body mass, body fat, whole-body volume and whole-body VAT were correlated with higher triglycerides, cholesterol:HDL (high-density lipoprotein), insulin resistance and lower adiponectin as well as higher HAQ and lower MDA. CONCLUSIONS In this pilot study, patients with PsD revealed excessive total adipose tissue and a greater volume of metabolically unfavourable ectopic fat, including VAT, compared with BMI-matched controls, which also correlated with HAQ, disease activity and overall dysmetabolism. We also provide the first evidence in patients with PsD for the clinical application of FatSegNet: a novel, automated and rapid deep learning pipeline for providing accurate MRI-based measurement of fat segmentation. Our findings suggest the need for a more integrated approach to the management of PsD, which considers both the metabolic and inflammatory burden of disease. More specifically, visceral fat is a surrogate marker of uncontrolled PsD and may be an important future target for both pharmacological and lifestyle interventions.
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Affiliation(s)
- Tim Blake
- Department of Rheumatology, University Hospitals Coventry and Warwickshire, Clifford Bridge Road, Coventry, CV2 2DX, UK.
- Warwick Medical School, University of Warwick, Coventry, CV4 7HL, UK.
| | - Nicola J Gullick
- Department of Rheumatology, University Hospitals Coventry and Warwickshire, Clifford Bridge Road, Coventry, CV2 2DX, UK
- Warwick Medical School, University of Warwick, Coventry, CV4 7HL, UK
| | - Charles E Hutchinson
- Warwick Medical School, University of Warwick, Coventry, CV4 7HL, UK
- Division of Biomedical Sciences, Warwick Medical School, Clinical Sciences Research Laboratories, University Hospitals Coventry and Warwickshire, Coventry, CV2 2DX, UK
| | - Abhir Bhalerao
- Department of Computer Science, University of Warwick, Coventry, CV4 7EZ, UK
| | - Sarah Wayte
- Department of Radiology, University Hospitals Coventry and Warwickshire, Coventry, CV2 2DX, UK
- Radiology Physics, Department of Clinical Physics and Bioengineering, University Hospitals Coventry and Warwickshire, Coventry, CV2 2DX, UK
| | - Andrew Weedall
- Department of Radiology, University Hospitals Coventry and Warwickshire, Coventry, CV2 2DX, UK
- Radiology Physics, Department of Clinical Physics and Bioengineering, University Hospitals Coventry and Warwickshire, Coventry, CV2 2DX, UK
| | - Thomas M Barber
- Division of Biomedical Sciences, Warwick Medical School, Clinical Sciences Research Laboratories, University Hospitals Coventry and Warwickshire, Coventry, CV2 2DX, UK
- Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism, University Hospitals Coventry and Warwickshire, Coventry, CV2 2DX, UK
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Campanholo CB, Maharaj AB, Corp N, Bell S, Costa L, de Vlam K, Gullick NJ, Khraishi M, Kishimoto M, Palmou-Fontana N, Reddy S, Scarpa R, Vega L, Duarte GV, Zisman D, van der Windt DA, Duruoz MT, Ogdie A. Management of Psoriatic Arthritis in Patients With Comorbidities: An Updated Literature Review Informing the 2021 GRAPPA Treatment Recommendations. J Rheumatol 2023; 50:426-432. [PMID: 36319003 DOI: 10.3899/jrheum.220310] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/16/2022] [Indexed: 11/07/2022]
Abstract
OBJECTIVE The 2021 Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) treatment recommendations provide an evidence-based guide for selecting therapy based on the individual's disease features. Beyond the disease features and associated conditions (eg, uveitis and inflammatory bowel disease), comorbidities play an important role in selecting therapy for an individual patient. METHODS We performed a systematic literature review. We examined the available evidence to inform treatment selection based on the presence or absence of comorbidities in psoriatic arthritis (PsA). RESULTS Common comorbidities in PsA that may affect treatment selection include presence of baseline cardiovascular disease (CVD) or high risk for CVD, obesity and metabolic syndrome, liver disease, mood disorders, including depression in particular, chronic infections, malignancies, osteoporosis, and fibromyalgia and/or central sensitization. CONCLUSION Comorbidities may influence both the effectiveness of a given therapy but also the potential for adverse events. It is important to assess for the presence of comorbidities prior to therapy selection.
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Affiliation(s)
| | - Ajesh B Maharaj
- A.B. Maharaj, PhD, MBBS, Life Westville Hospital, Life Healthcare, Westville, South Africa
| | - Nadia Corp
- N. Corp, PhD, Primary Care Centre Versus Arthritis, School of Medicine, Keele University, Staffordshire, UK
| | - Stacie Bell
- S. Bell, PhD, National Psoriasis Foundation, Portland, Oregon, USA
| | - Luisa Costa
- L. Costa, MD, PhD, Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Kurt de Vlam
- K. de Vlam, MD, PhD, Department of Rheumatology, University Hospitals Leuven, Leuven, Belgium
| | - Nicola J Gullick
- N.J. Gullick, PhD, BMBS, Department of Rheumatology, University Hospitals Coventry & Warwickshire, and Warwick Medical School, University of Warwick, UK
| | - Majed Khraishi
- M. Khraishi, MD, Memorial University of Newfoundland, St. John's, Newfoundland and Labrador, Canada
| | - Mitsumasa Kishimoto
- M. Kishimoto, MD, PhD, Department of Nephrology and Rheumatology, Kyorin University School of Medicine, Tokyo, Japan
| | - Natalia Palmou-Fontana
- N. Palmou-Fontana, MD, PhD, Rheumatology Deparment, Marqués de Valdecilla University Hospital, Cantabria, Spain
| | - Soumya Reddy
- S. Reddy, MD, New York University Grossman School of Medicine, New York City, New York, USA
| | - Raffaele Scarpa
- R. Scarpa, MD, Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Luis Vega
- L. Vega, MD, Section of Rheumatology, Central Hospital of Peruvian Air Force, Lima, Peru
| | - Gleison Vieira Duarte
- G.V. Duarte, MD, PhD, Dermatology Division at IBIS, Instituto Bahiano de Imunoterapia, Salvador, Brazil
| | - Devy Zisman
- D. Zisman, MD, Rheumatology Unit, Carmel Medical Center, and the Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Danielle A van der Windt
- D.A. van der Windt, PhD, Primary Care Centre Versus Arthritis, School of Medicine, Keele University, Staffordshire, UK
| | - Mehmet T Duruoz
- M.T. Duruoz, Rheumatology Division, PMR Department, Marmara University School of Medicine, Istanbul, Turkey
| | - Alexis Ogdie
- A. Ogdie, MD, MSCE, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
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Raaphorst J, Gullick NJ, Pipitone N, Shokraneh F, Brassington R, Ali SS, Gordon PA. Immunosuppressive and immunomodulatory therapies for idiopathic inflammatory myopathies. Cochrane Database Syst Rev 2023; 2023:CD014510. [PMCID: PMC9885519 DOI: 10.1002/14651858.cd014510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
This is a protocol for a Cochrane Review (intervention). The objectives are as follows: This protocol is for two separate reviews to assess the effects (benefits and harms) of immunosuppressant and immunomodulatory treatments for the idiopathic inflammatory myopathies.
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Affiliation(s)
| | - Joost Raaphorst
- Department of NeurologyAmsterdam UMC, University of Amsterdam, Amsterdam NeuroscienceAmsterdamNetherlands
| | - Nicola J Gullick
- Department of RheumatologyUniversity Hospitals Coventry and Warwickshire NHS TrustCoventryUK,Warwick Medical SchoolUniversity of WarwickCoventryUK
| | - Nicolo Pipitone
- Rheumatology Unit, Department of Internal MedicineAzienda USL-IRCCS di Reggio EmiliaReggio EmiliaItaly
| | - Farhad Shokraneh
- Cochrane Neuromuscular GroupUniversity College London Hospitals TrustLondonUK
| | - Ruth Brassington
- Queen Square Centre for Neuromuscular DiseasesNational Hospital for Neurology and NeurosurgeryLondonUK
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Koduri GM, Gullick NJ, Hayes F, Dubey S, Mukhtyar C. Patient perceptions of co-morbidities in inflammatory arthritis. Rheumatol Adv Pract 2021; 5:rkaa076. [PMID: 33615128 PMCID: PMC7884022 DOI: 10.1093/rap/rkaa076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Accepted: 11/19/2020] [Indexed: 11/21/2022] Open
Abstract
Objective Longer life expectancy has resulted in people living with an increasing number of co-morbidities. The average individual with inflammatory arthritis has two co-morbidities, which contribute to higher mortality, poorer functional outcomes and increased health-care utilization and cost. A number of studies have investigated the prevalence of co-morbidities, whereas this study was designed to look at patient perspectives. Methods The study comprised two parts: a patient questionnaire and an interview. Individuals with physician-verified inflammatory arthritis along with one or more Charlson co-morbidities were invited to participate. In-depth data were obtained by interviews with 12 willing participants. Results One hundred and forty-six individuals were recruited; 50 (35%) had one co-morbidity, 69 (48%) had two and 25 (17%) had more than four co-morbidities. Seventy-seven individuals (53%) reported that co-morbidities affected their health as much as their arthritis, and 82 (56%) reported dependence on others for activities of daily living. Lack of education was highlighted by 106 (73%) participants. Qualitative data provided further support for the challenges, with participants highlighting the lack of time to discuss complex or multiple problems, with no-one coordinating their care. This, in turn, led to polypharmacy and insufficient discussion around drug and disease interactions, complications and self-help measures. Conclusion This study highlights the challenges for individuals with inflammatory arthritis who suffer with multiple co-morbidities. The challenges result from limited resources or support within the current health-care environments. Individuals highlighted the poor quality of life, which is multifactorial, and the need for better educational strategies and coordination of care to improve outcomes.
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Affiliation(s)
- Gouri M Koduri
- Rheumatology Department, Southend University Hospital, Westcliff-on-Sea
| | - Nicola J Gullick
- Rheumatology Department, University Hospitals Coventry & Warwickshire NHS Trust, Coventry
| | - Fiona Hayes
- Rheumatology Department, Southend University Hospital, Westcliff-on-Sea
| | - Shirish Dubey
- Rheumatology Department, University Hospitals Coventry & Warwickshire NHS Trust, Coventry
| | - Chetan Mukhtyar
- Rheumatology Department, Norfolk and Norwich University Hospital, Norwich, UK
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Blake T, Gullick NJ, Hutchinson CE, Barber TM. Psoriatic disease and body composition: A systematic review and narrative synthesis. PLoS One 2020; 15:e0237598. [PMID: 32790787 PMCID: PMC7425946 DOI: 10.1371/journal.pone.0237598] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 07/29/2020] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Obesity is a leading comorbidity in psoriatic disease, including both psoriasis (PsO) and psoriatic arthritis (PsA), and is associated with adverse metabolic and cardiovascular (CV) outcomes. Anthropometric parameters, such as weight, body mass index (BMI) and waist-to-hip ratio, have been extensively reported in psoriatic disease. However, the associations of body composition and fat distribution with psoriasis have not yet been fully defined. OBJECTIVES To identify whether patients with psoriatic disease, including psoriatic arthritis, have altered body composition compared with the general population, and to review existing modalities for the assessment of body composition. METHODS Electronic searches of the literature were conducted in PubMed, Medline (Ovid®), Embase (Ovid®), Cochrane Central Register of Controlled Trials (CENTRAL) and Google Scholar. Titles and abstracts were reviewed by two authors independently against a set of prespecified inclusion/exclusion criteria. The research question was answered with a systematic literature review and results were summarized narratively. RESULTS Twenty-five full text articles met the inclusion criteria and were included in the final narrative analysis. The studies were of heterogeneous design and used a range of objective measures to assess body composition, including simple anthropometric measures, bioimpedance analysis (BIA), dual energy X-ray absorptiometry (DXA) and computed tomography (CT). Few studies met all the quality assessment criteria. Clinical heterogeneity prevented meta-analysis. CONCLUSIONS Patients with psoriatic disease reveal defined body composition changes that are independent of obesity and the customary metabolic syndrome, including higher overall body fat, visceral fat and sarcopenia. These findings emphasize that patients with psoriatic disease should be screened for abnormal adipose effects beyond their weight and body mass index (BMI). Our findings show that the last decade has seen an exciting expansion of research interest in the development and validation of new modalities for the assessment of body composition. There is no consensus on the optimal assessment method of body composition for this diverse group; hence there is a need for validation of existing modalities and standardization of assessment tools.
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Affiliation(s)
- Tim Blake
- Rheumatology Department, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, United Kingdom
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - Nicola J. Gullick
- Rheumatology Department, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, United Kingdom
| | - Charles E. Hutchinson
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
- Department of Imaging, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, United Kingdom
| | - Thomas M. Barber
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
- Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, United Kingdom
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Blake T, Gullick NJ. EP40 Real world efficacy of secukinumab: a single centre experience. Rheumatology (Oxford) 2020. [DOI: 10.1093/rheumatology/keaa109.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
Secukinumab was approved by NICE for patients with active ankylosing spondylitis and psoriatic arthritis in 2017. Clinical trial data suggests secukinumab is a useful treatment option in both conditions, but often real world experience differs greatly from clinical trial results. In addition, patients with more refractory disease are often excluded from clinical trials.
Methods
Patients starting secukinumab at UHCW were identified from the Blueteq funding database. Medical notes were reviewed retrospectively to assess response rates using BASDAI responses in Ankylosing spondylitis and PsARC responses in PsA. Patients who had previously had inadequate response to TNF inhibitors (PsA only) and severe psoriasis received 300mg secukinumab monthly; the remainder were prescribed 150mg monthly.
Results
113 patients commenced secukinumab between June 2017 and April 2019 and had outcome data recorded. 59 patients (52%) had received previous biologic agents prior to secukinumab exposure. Patients with ankylosing spondylitis had high BASDAI (6.91.4) and spinal pain (7.71.4). 38 patients had an initial response to treatment. Secukinumab was effective in 39 patients (63%), and 37 (62%) continued treatment. In psoriatic arthritis, despite high levels of activity at baseline (mean tender joint count 10 8; swollen joint count 63, and 65% prior biologic exposure, high rates of response were seen. The majority of patients have continued treatment. Secukinumab was well tolerated in both patient groups with low rates of discontinuation due to adverse events (11 patients, 9%). Adverse events included recurrent infection (6), rash (1), mouth ulcers (1), vertigo (1), new onset cancer (1) and new onset Crohn’s (1) although rates were low overall. Patients with pre-existing uveitis did not develop exacerbations but low numbers of patients with prior uveitis were treated.
Conclusion
Secukinumab demonstrates high levels of efficacy even in a cohort of patients with longstanding PSA and AS with high rates of inadequate responses to other biologics. Secukinumab is well tolerated with low rates of discontinuation due to adverse events.
Disclosures: T. Blake: None. N.J. Gullick: Honoraria; NG has received Honoraria from Abbvie, Eli Lilly, Novartis, UCB. Grants/research support; NG has received funding for research from Abbvie and Novartis.
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Affiliation(s)
- Tim Blake
- University Hospital Coventry & Warwickshire, Rheumatology, Coventry, UNITED KINGDOM
| | - Nicola J Gullick
- University Hospital Coventry & Warwickshire, Rheumatology, Coventry, UNITED KINGDOM
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Gullick NJ, Ibrahim F, Scott IC, Vincent A, Cope AP, Garrood T, Panayi GS, Scott DL, Kirkham BW. Real world long-term impact of intensive treatment on disease activity, disability and health-related quality of life in rheumatoid arthritis. BMC Rheumatol 2019; 3:6. [PMID: 30886994 PMCID: PMC6390620 DOI: 10.1186/s41927-019-0054-y] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Accepted: 01/25/2019] [Indexed: 12/25/2022] Open
Abstract
Background The emphasis on treating rheumatoid arthritis (RA) intensively reduces disease activity but its impact in routine care is uncertain. We evaluated temporal changes in disease activities and outcomes in a 10-year prospective observational cohort study of patients in routine care at one unit. Methods The Guy’s and St Thomas’ RA cohort was established in 2005. It involved most RA patients managed in this hospital. Clinical diagnoses of RA were made by rheumatologists. Patients were seen regularly in routine care. Each visit included measurement of disease activity scores for 28 joints (DAS28), health assessment questionnaire scores (HAQ) and EuroQol scores. Patients received intensive treatments targeting DAS28 remission. Results In 1693 RA patients mean DAS28 scores fell from 2005 to 15 by 11% from 4.08 (95% CI: 3.91, 4.25) in 2005 to 3.64 (3.34, 3.78); these falls were highly significant (p < 0.001). DAS28 components: swollen joint counts fell by 32% and ESR by 24%; in contrast tender joint counts and patient global assessments showed minimal or no reductions. The reduction in DAS28 scores was predominantly between 2005 and 2010, with no falls from 2011 onwards. Associated with falls in mean DAS28s, patients achieving remission increased (18% in 2005; 27% in 2015) and the number with active disease (DAS28 > 5.1) decreased (25% in 2005; 16% in 2015). In 752 patients seen at least annually for 3 years, persisting remission (68 patients) and intermittent remission (376 patients) were associated with less disability and better health related quality of life. Over time biologic use increased, but they were used infrequently in patients in persistent remission. Conclusions Over 10 years an intensive management strategy in a routine practice setting increased combination DMARD and biologic use: disease activity levels declined; this association is in keeping with a causal relationship. Patients who achieved remission, even transiently, had better functional outcomes than patients never achieving remission. Electronic supplementary material The online version of this article (10.1186/s41927-019-0054-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Nicola J Gullick
- 1Department of Rheumatology, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Fowzia Ibrahim
- 2Department of Rheumatology, 3rd Floor, Weston Education Centre, King's College London, Cutcombe Road, London, UK
| | - Ian C Scott
- 3Research Institute for Primary Care & Health Sciences, Primary Care Sciences, Keele University, Keele, Staffordshire UK.,4Department of Rheumatology, Haywood Hospital, High Lane, Burslem, Staffordshire UK.,6Academic Department of Rheumatology, Centre for Molecular and Cellular Biology of Inflammation, 1st Floor, New Hunt's House, Guy's Campus, King's College London, Great Maze Pond, London, UK
| | - Alexandra Vincent
- 5Department of Rheumatology, Guy's and St Thomas' NHS Trust, 4th Floor, Tower Wing, Guy's Hospital, Great Maze Pond, London, UK
| | - Andrew P Cope
- 5Department of Rheumatology, Guy's and St Thomas' NHS Trust, 4th Floor, Tower Wing, Guy's Hospital, Great Maze Pond, London, UK.,6Academic Department of Rheumatology, Centre for Molecular and Cellular Biology of Inflammation, 1st Floor, New Hunt's House, Guy's Campus, King's College London, Great Maze Pond, London, UK
| | - Toby Garrood
- 5Department of Rheumatology, Guy's and St Thomas' NHS Trust, 4th Floor, Tower Wing, Guy's Hospital, Great Maze Pond, London, UK
| | - Gabriel S Panayi
- 5Department of Rheumatology, Guy's and St Thomas' NHS Trust, 4th Floor, Tower Wing, Guy's Hospital, Great Maze Pond, London, UK
| | - David L Scott
- 2Department of Rheumatology, 3rd Floor, Weston Education Centre, King's College London, Cutcombe Road, London, UK
| | - Bruce W Kirkham
- 5Department of Rheumatology, Guy's and St Thomas' NHS Trust, 4th Floor, Tower Wing, Guy's Hospital, Great Maze Pond, London, UK
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Tjärnlund A, Tang Q, Wick C, Dastmalchi M, Mann H, Tomasová Studýnková J, Chura R, Gullick NJ, Salerno R, Rönnelid J, Alexanderson H, Lindroos E, Aggarwal R, Gordon P, Vencovsky J, Lundberg IE. Abatacept in the treatment of adult dermatomyositis and polymyositis: a randomised, phase IIb treatment delayed-start trial. Ann Rheum Dis 2017; 77:55-62. [PMID: 28993346 DOI: 10.1136/annrheumdis-2017-211751] [Citation(s) in RCA: 73] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2017] [Revised: 07/14/2017] [Accepted: 08/05/2017] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To study the effects of abatacept on disease activity and on muscle biopsy features of adult patients with dermatomyositis (DM) or polymyositis (PM). METHODS Twenty patients with DM (n=9) or PM (n=11) with refractory disease were enrolled in a randomised treatment delayed-start trial to receive either immediate active treatment with intravenous abatacept or a 3 month delayed-start. The primary endpoint was number of responders, defined by the International Myositis Assessment and Clinical Studies Group definition of improvement (DOI), after 6 months of treatment. Secondary endpoints included number of responders in the early treatment arm compared with the delayed treatment arm at 3 months. Repeated muscle biopsies were investigated for cellular markers and cytokines. RESULTS 8/19 patients included in the analyses achieved the DOI at 6 months. At 3 months of study, five (50%) patients were responders after active treatment but only one (11%) patient in the delayed treatment arm. Eight adverse events (AEs) were regarded as related to the drug, four mild and four moderate, and three serious AEs, none related to the drug. There was a significant increase in regulatory T cells (Tregs), whereas other markers were unchanged in repeated muscle biopsies. CONCLUSIONS In this pilot study, treatment of patients with DM and PM with abatacept resulted in lower disease activity in nearly half of the patients. In patients with repeat muscle biopsies, an increased frequency of Foxp3+ Tregs suggests a positive effect of treatment in muscle tissue.
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Affiliation(s)
- Anna Tjärnlund
- Rheumatology Unit, Department of Medicine, Karolinska University Hospital Solna, Karolinska Institutet, Stockholm, Sweden
| | - Quan Tang
- Rheumatology Unit, Department of Medicine, Karolinska University Hospital Solna, Karolinska Institutet, Stockholm, Sweden
| | - Cecilia Wick
- Rheumatology Unit, Department of Medicine, Karolinska University Hospital Solna, Karolinska Institutet, Stockholm, Sweden
| | - Maryam Dastmalchi
- Rheumatology Unit, Department of Medicine, Karolinska University Hospital Solna, Karolinska Institutet, Stockholm, Sweden
| | - Herman Mann
- Department of Rheumatology, Institute of Rheumatology, Prague, Czech Republic
| | | | - Radka Chura
- Department of Rheumatology, King's College Hospital NHS Foundation Trust, London, UK
| | - Nicola J Gullick
- Department of Rheumatology, King's College Hospital NHS Foundation Trust, London, UK
| | - Rosaria Salerno
- Department of Rheumatology, King's College Hospital NHS Foundation Trust, London, UK
| | - Johan Rönnelid
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | - Helene Alexanderson
- Division of Physiotherapy, Department of Neurobiology, Karolinska Institutet and Physical Therapy Clinic, Karolinska University Hospital, Stockholm, Sweden
| | - Eva Lindroos
- Rheumatology Unit, Department of Medicine, Karolinska University Hospital Solna, Karolinska Institutet, Stockholm, Sweden
| | - Rohit Aggarwal
- Division of Rheumatology and Clinical Rheumatology, University of Pittsburgh School of Medicine, Pittsburgh, USA
| | - Patrick Gordon
- Department of Rheumatology, King's College Hospital NHS Foundation Trust, London, UK
| | - Jiri Vencovsky
- Department of Rheumatology, Institute of Rheumatology, Prague, Czech Republic
| | - Ingrid E Lundberg
- Rheumatology Unit, Department of Medicine, Karolinska University Hospital Solna, Karolinska Institutet, Stockholm, Sweden
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Gullick NJ, Mian AN, Ibrahim F, Walker D, Hassell A, Kiely PDW, Walsh DA, Young A, Scott DL. Predicting responses in patients with rheumatoid arthritis to disease-modifying agents using baseline clinical data. Clin Exp Rheumatol 2017; 35:810-815. [PMID: 28516868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Accepted: 02/06/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVES The optimal treatment for active rheumatoid arthritis (RA) is unresolved, particularly in early RA. We used data from an observational cohort to develop the simple predictor algorithm and evaluated its application in two completed clinical trials in early and established RA. We assessed whether using a simple algorithm can identify patients who have persisting active disease despite treatment with disease-modifying drugs (DMARDs). We also examined if patients who have lower likelihoods of persisting active RA are likely to benefit from intensive treatment. METHODS We developed a simple predictive score for persisting disease activity using conventional clinical assessments in an observational cohort of patients with early RA (ERAN). It was tested in two trials in early (CARDERA) and established (TACIT) RA. Persistent disease activity was defined as disease activity score for 28 joints (DAS28) >3.2 at both 6 and 12 months. RESULTS Regression modelling identified three main predictors of persisting active disease in ERAN; tender joint counts, health assessment questionnaire (HAQ) scores and ESR. We dichotomised these predictors (≥6 tender joint counts, ≥1.0 HAQ ≥20 mm/h ESR) in a four-point prediction score. This simple prediction score predicted persisting active disease in the ERAN cohort and both CARDERA and TACIT trials. Patients with high scores were more likely to have persistently active disease at 6 and 12 months. The relationship was weaker in TACIT because no patients were without any predictive factors. CONCLUSIONS Combining tender joint counts, ESR and HAQ in a simple predictive score prospectively identifies patients with higher risks of persistent disease activity over the next 12 months. More patients with all three risk factors had persistent active disease than those with none or one risk factor.
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Affiliation(s)
- Nicola J Gullick
- Department of Rheumatology, King's College London School of Medicine, Weston Education Centre, King's College London, UK
| | - Aneela N Mian
- Department of Rheumatology, King's College London School of Medicine, Weston Education Centre, King's College London, UK.
| | - Fowzia Ibrahim
- Department of Rheumatology, King's College London School of Medicine, Weston Education Centre, King's College London, UK
| | - David Walker
- Musculoskeletal Unit, Freeman Hospital, Newcastle, UK
| | - Andrew Hassell
- Department of Rheumatology, Haywood Hospital, Keele University, UK
| | | | - David A Walsh
- Arthritis Research UK Pain Centre, Academic Rheumatology, University of Nottingham, UK
| | - Adam Young
- Department of Rheumatology, St. Albans City Hospital, St. Albans, UK
| | - David L Scott
- Department of Rheumatology, King's College London School of Medicine, Weston Education Centre, King's College London, UK
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11
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Mian AN, Chaabo K, Wajed J, Subesinghe S, Gullick NJ, Kirkham B, Garrood T. Rheumatoid arthritis patients with fibromyalgic clinical features have significantly less synovitis as defined by power Doppler ultrasound. BMC Musculoskelet Disord 2016; 17:404. [PMID: 27659057 PMCID: PMC5034619 DOI: 10.1186/s12891-016-1258-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Accepted: 09/14/2016] [Indexed: 11/13/2022] Open
Abstract
Background In patients with rheumatoid arthritis (RA) clinical measures of disease activity may not reliably discriminate between patients with active inflammatory disease and those with concomitant fibromyalgia (FM). Recent work has shown RA patients with a 28 tender joint count (TJC) minus swollen joint count (SJC) of 7 or more (joint count criteria) are more likely to meet classification criteria for FM. This study aimed to determine whether RA patients meeting clinical criteria for FM had lower levels of joint inflammation as determined by ultrasound (US). Methods RA patients with DAS28 > 2.6 were recruited. Patients underwent clinical assessment including ultrasound examination of the hands and wrists with quantification of grey scale (GS) and power Doppler (PD) synovitis. Patients completed questionnaires to assess pain, fatigue, disability and psychological comorbidity. Results Patients meeting either of the FM criteria had higher scores for disease activity, depression, disability and fatigue. Those meeting both the joint count and classification FM criteria had significantly lower levels of GS and PD inflammation on US. Conclusions RA patients with concomitant FM, as determined by widespread soft tissue tenderness but fewer clinically inflamed joints, have higher disease activity scores but may have lower levels of synovial inflammation on US. This has implications for the identification and management of these patients who may not respond to conventional therapy and hence be more suitable for alternative approaches to treatment.
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Affiliation(s)
- Aneela N Mian
- Department of Rheumatology, Guys and St Thomas' NHS Trust, Great Maze Pond, London, SE1 9RT, UK. .,Department of Academic Rheumatology, King's College London, 10 Cutcombe Road, London, SE5 9RT, UK.
| | - Khaldoun Chaabo
- Department of Rheumatology, Guys and St Thomas' NHS Trust, Great Maze Pond, London, SE1 9RT, UK
| | - Julekha Wajed
- Department of Rheumatology, Guys and St Thomas' NHS Trust, Great Maze Pond, London, SE1 9RT, UK
| | - Sujith Subesinghe
- Department of Rheumatology, Guys and St Thomas' NHS Trust, Great Maze Pond, London, SE1 9RT, UK
| | - Nicola J Gullick
- Department of Rheumatology, King's College Hospital London, Denmark Hill, SE5 9RS, UK
| | - Bruce Kirkham
- Department of Rheumatology, Guys and St Thomas' NHS Trust, Great Maze Pond, London, SE1 9RT, UK
| | - Toby Garrood
- Department of Rheumatology, Guys and St Thomas' NHS Trust, Great Maze Pond, London, SE1 9RT, UK
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12
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de Souza S, Galloway J, Simpson C, Chura R, Dobson J, Gullick NJ, Steer S, Lempp H. Patient involvement in rheumatology outpatient service design and delivery: a case study. Health Expect 2016; 20:508-518. [PMID: 27345769 PMCID: PMC5433532 DOI: 10.1111/hex.12478] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/24/2016] [Indexed: 01/06/2023] Open
Abstract
Background Patient involvement is increasingly recognized as important within the UK National Health Service to ensure that services delivered are relevant to users’ needs. Organizations are encouraged to work with service users to achieve excellence in care. Patient education can improve health outcomes and reduce health‐care costs. Mobile technologies could play a vital role in this. Aim Patient‐centred development of innovative strategies to improve the experience of rheumatology outpatients. Case study The Group Rheumatology Initiative Involving Patients (GRIIP) project was set up in 2013 as a joint venture between patients, clinicians, academics and management at a London hospital. The project saw (i) the formation of an independent patient group which provided suggestions for service improvement – outcomes included clearer signs in the outpatient waiting area, extended phlebotomy opening hours and better access to podiatry; (ii) a rolling patient educational evening programme initiated in 2014 with topics chosen by patient experts – feedback has been positive and attendance continues to grow; and (iii) a mobile application (app) co‐designed with patients launched in 2015 which provides relevant information for outpatient clinic attendees and data capture for clinicians – downloads have steadily increased as users adopt this new technology. Conclusion Patients can effectively contribute to service improvement provided they are supported, respected as equals, and the organization is willing to undergo a cultural change.
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Affiliation(s)
- Savia de Souza
- Academic Rheumatology, King's College London, London, UK.,Rheumatology, King's College Hospital NHS Foundation Trust, London, UK
| | - James Galloway
- Academic Rheumatology, King's College London, London, UK.,Rheumatology, King's College Hospital NHS Foundation Trust, London, UK
| | - Carol Simpson
- Academic Rheumatology, King's College London, London, UK.,Rheumatology, King's College Hospital NHS Foundation Trust, London, UK
| | - Radka Chura
- Rheumatology, King's College Hospital NHS Foundation Trust, London, UK
| | - Joanne Dobson
- Rheumatology, King's College Hospital NHS Foundation Trust, London, UK
| | - Nicola J Gullick
- Rheumatology, King's College Hospital NHS Foundation Trust, London, UK
| | - Sophia Steer
- Rheumatology, King's College Hospital NHS Foundation Trust, London, UK
| | - Heidi Lempp
- Academic Rheumatology, King's College London, London, UK
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13
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Menon B, Gullick NJ, Walter GJ, Rajasekhar M, Garrood T, Evans HG, Taams LS, Kirkham BW. Interleukin-17+CD8+ T cells are enriched in the joints of patients with psoriatic arthritis and correlate with disease activity and joint damage progression. Arthritis Rheumatol 2014; 66:1272-81. [PMID: 24470327 PMCID: PMC4158887 DOI: 10.1002/art.38376] [Citation(s) in RCA: 197] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2013] [Accepted: 01/16/2014] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Psoriatic arthritis (PsA) is associated with HLA class I genes, in contrast to the association with HLA class II in rheumatoid arthritis (RA). Since IL-17+ cells are considered important mediators of synovial inflammation, we sought to determine whether IL-17-producing CD8+ T cells may be found in the joints of patients with PsA and whether these cells might contribute to the disease process. METHODS Mononuclear cells from paired samples of synovial fluid (SF) and peripheral blood (PB) from patients with PsA or patients with RA were stimulated ex vivo, and CD4- T cells were examined by flow cytometry for cytokine expression, cytotoxic markers, and frequencies of γ/δ or mucosal-associated invariant T cells. Clinical measures of arthritis activity (C-reactive protein [CRP] level, erythrocyte sedimentation rate [ESR], Disease Activity Score in 28 joints [DAS28]) and power Doppler ultrasound (PDUS) scores for the presence of active synovitis in the aspirated knee were recorded and assessed for correlations with immunologic markers. RESULTS Within the CD3+ T cell compartment, both IL-17+CD4- (predominantly CD8+) and IL-17+CD4+ T cells were significantly enhanced in the SF compared to the PB of patients with PsA (P = 0.0003 and P = 0.002, respectively; n = 21), whereas in patients with RA, only IL-17+CD4+ T cells were increased in the SF compared to the PB (P = 0.008; n = 14). The frequency of IL-17+CD4- T cells in PsA SF was positively correlated with the CRP level (r = 0.52, P = 0.01), ESR (r = 0.59, P = 0.004), and DAS28 (r = 0.52, P = 0.01), and was increased in patients with erosive disease (P < 0.05). In addition, the frequency of IL-17+CD4- T cells positively correlated with the PDUS score, a marker for active synovitis (r = 0.49, P = 0.04). CONCLUSION These results show, for the first time, that the PsA joint, but not the RA joint, is enriched for IL-17+CD8+ T cells. Moreover, the findings reveal that the levels of this T cell subset are correlated with disease activity measures and the radiographic erosion status after 2 years, suggesting a previously unrecognized contribution of these cells to the pathogenesis of PsA.
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Affiliation(s)
- Bina Menon
- King's College London and Guy's and St. Thomas' Hospitals Foundation NHS Trust, London, UK
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14
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Evans HG, Roostalu U, Walter GJ, Gullick NJ, Frederiksen KS, Roberts CA, Sumner J, Baeten DL, Gerwien JG, Cope AP, Geissmann F, Kirkham BW, Taams LS. TNF-α blockade induces IL-10 expression in human CD4+ T cells. Nat Commun 2014; 5:3199. [PMID: 24492460 PMCID: PMC3918582 DOI: 10.1038/ncomms4199] [Citation(s) in RCA: 86] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2013] [Accepted: 01/03/2014] [Indexed: 12/20/2022] Open
Abstract
IL-17+ CD4+ T (Th17) cells contribute to the pathogenesis of several human inflammatory diseases. Here we demonstrate that TNF inhibitor (TNFi) drugs induce the anti-inflammatory cytokine IL-10 in CD4+ T cells including IL-17+ CD4+ T cells. TNFi-mediated induction of IL-10 in IL-17+ CD4+ T cells is Treg-/Foxp3-independent, requires IL-10 and is overcome by IL-1β. TNFi-exposed IL-17+ CD4+ T cells are molecularly and functionally distinct, with a unique gene signature characterized by expression of IL10 and IKZF3 (encoding Aiolos). We show that Aiolos binds conserved regions in the IL10 locus in IL-17+ CD4+ T cells. Furthermore, IKZF3 and IL10 expression levels correlate in primary CD4+ T cells and Aiolos overexpression is sufficient to drive IL10 in these cells. Our data demonstrate that TNF-α blockade induces IL-10 in CD4+ T cells including Th17 cells and suggest a role for the transcription factor Aiolos in the regulation of IL-10 in CD4+ T cells.
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Affiliation(s)
- Hayley G. Evans
- Centre for Molecular & Cellular Biology of Inflammation (CMCBI), Division of Immunology, Infection and Inflammatory Disease, King’s College London, SE1 1UL, UK
| | - Urmas Roostalu
- Centre for Molecular & Cellular Biology of Inflammation (CMCBI), Division of Immunology, Infection and Inflammatory Disease, King’s College London, SE1 1UL, UK
| | - Gina J. Walter
- Centre for Molecular & Cellular Biology of Inflammation (CMCBI), Division of Immunology, Infection and Inflammatory Disease, King’s College London, SE1 1UL, UK
| | - Nicola J. Gullick
- Centre for Molecular & Cellular Biology of Inflammation (CMCBI), Division of Immunology, Infection and Inflammatory Disease, King’s College London, SE1 1UL, UK
| | - Klaus S. Frederiksen
- Novo Nordisk A/S, Biopharmaceuticals Research Unit, Inflammation Biology, 2760 Måløv, Denmark
| | - Ceri A. Roberts
- Centre for Molecular & Cellular Biology of Inflammation (CMCBI), Division of Immunology, Infection and Inflammatory Disease, King’s College London, SE1 1UL, UK
| | - Jonathan Sumner
- Centre for Molecular & Cellular Biology of Inflammation (CMCBI), Division of Immunology, Infection and Inflammatory Disease, King’s College London, SE1 1UL, UK
| | - Dominique L. Baeten
- Division of Clinical Immunology and Rheumatology, Academic Medical Centre, Amsterdam, 1105 AZ, the Netherlands
| | - Jens G. Gerwien
- Novo Nordisk A/S, Biopharmaceuticals Research Unit, Inflammation Biology, 2760 Måløv, Denmark
| | - Andrew P. Cope
- Centre for Molecular & Cellular Biology of Inflammation (CMCBI), Division of Immunology, Infection and Inflammatory Disease, King’s College London, SE1 1UL, UK
- Academic Department of Rheumatology, SE1 1UL, King’s College London, UK
| | - Frederic Geissmann
- Centre for Molecular & Cellular Biology of Inflammation (CMCBI), Division of Immunology, Infection and Inflammatory Disease, King’s College London, SE1 1UL, UK
| | - Bruce W. Kirkham
- Department of Rheumatology, Guy’s & St Thomas’ NHS Trust, London, SE1 9RT, UK
| | - Leonie S. Taams
- Centre for Molecular & Cellular Biology of Inflammation (CMCBI), Division of Immunology, Infection and Inflammatory Disease, King’s College London, SE1 1UL, UK
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15
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Gullick NJ, Abozaid HS, Jayaraj DM, Evans HG, Scott DL, Choy EH, Taams LS. Enhanced and persistent levels of interleukin (IL)-17⁺ CD4⁺ T cells and serum IL-17 in patients with early inflammatory arthritis. Clin Exp Immunol 2013; 174:292-301. [PMID: 23815507 DOI: 10.1111/cei.12167] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/25/2013] [Indexed: 12/14/2022] Open
Abstract
Prognosis of patients with early inflammatory arthritis (EIA) is highly variable. The aim of this study was to compare, longitudinally and cross-sectionally, the levels of cytokine-expressing cells in peripheral blood (PB) from patients with EIA to those in established rheumatoid arthritis (RA) and healthy controls (HC). PB mononuclear cells from HC (n = 30), patients with EIA (n = 20) or RA (n = 38) were stimulated with phorbol myristate acetate (PMA)/ionomycin for 3 h, and stained for cell markers and cytokines. Serum cytokines and chemokines were measured by Luminex. Patients with EIA were reassessed at 6 and 12 months. The percentage of interleukin (IL)-17⁺ interferon (IFN)-γ⁻ CD4⁺ T cells [T helper type 17 (Th17)] was increased in RA and EIA versus HC. Serum IL-1β, IL-2, IL-4 IL-17 and macrophage inflammatory protein (MIP)-1α were increased in RA and EIA versus HC. IL-1Ra, IL-15 and IFN-α were increased in EIA versus HC. IL-6 and tumour necrosis factor (TNF)-α was increased in RA but not EIA versus HC. Disease activity scores in EIA patients improved over 12 months' treatment. Th17 percentage at baseline was correlated with both rheumatoid factor (RF) titre and functional deficit at 12 months. Baseline levels of serum granulocyte-macrophage colony-stimulating factor (GM-CSF), IL-6 and IL-8 were correlated with Larsen score at 12 months. There were no significant changes in cytokine-expressing CD4⁺ T cells over time, although the percentage of IL-6⁺monocytes increased. IL-17⁺ CD4⁺ T cells and serum IL-17 levels are increased in EIA. IL-6-expressing monocytes increase during the first year of disease, irrespective of disease-modifying anti-rheumatic drug (DMARD) therapy. We observed incomplete clinical responses, suggesting EIA patients need more intensive early therapy.
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Affiliation(s)
- N J Gullick
- Academic Department of Rheumatology, King's College London, London, UK; NIHR Comprehensive Biomedical Research Centre, Guy's and St Thomas' Hospital and King's College London, London, UK
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16
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Walter GJ, Evans HG, Menon B, Gullick NJ, Kirkham BW, Cope AP, Geissmann F, Taams LS. Interaction with activated monocytes enhances cytokine expression and suppressive activity of human CD4+CD45ro+CD25+CD127(low) regulatory T cells. ACTA ACUST UNITED AC 2013; 65:627-38. [PMID: 23280063 DOI: 10.1002/art.37832] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2012] [Accepted: 12/11/2012] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Despite the high frequency of CD4+ T cells with a regulatory phenotype (CD25+CD127(low) FoxP3+) in the joints of patients with rheumatoid arthritis (RA), inflammation persists. One possible explanation is that human Treg cells are converted into proinflammatory interleukin-17 (IL-17)-producing cells by inflammatory mediators and thereby lose their suppressive function. The aim of this study was to investigate whether activated monocytes, which are potent producers of inflammatory cytokines and are abundantly present in the rheumatic joint, induce proinflammatory cytokine expression in human Treg cells and impair their regulatory function. METHODS The presence and phenotype of CD4+CD45RO+CD25+CD127(low) T cells (memory Treg cells) and CD14+ monocytes in the peripheral blood (PB) and synovial fluid (SF) of patients with RA were investigated by flow cytometry. Memory Treg cells obtained from healthy control subjects underwent fluorescence-activated cell sorting and then were cocultured with autologous activated monocytes and stimulated with anti-CD3 monoclonal antibodies. Intracellular cytokine expression, phenotype, and function of cells were determined by flow cytometry, enzyme-linked immunosorbent assay, and proliferation assays. RESULTS In patients with RA, the frequencies of CD4+CD45RO+CD25+CD127(low) Treg cells and activated CD14+ monocytes were higher in SF compared with PB. In vitro-activated monocytes induced an increase in the percentage of IL-17-positive, interferon-γ (IFNγ)-positive, and tumor necrosis factor α (TNFα)-positive Treg cells as well as IL-10-positive Treg cells. The observed increase in IL-17-positive and IFNγ-positive Treg cells was driven by monocyte-derived IL-1β, IL-6, and TNFα and was mediated by both CD14+CD16- and CD14+CD16+ monocyte subsets. Despite enhanced cytokine expression, cells maintained their CD25+FoxP3+CD39+ Treg cell phenotype and showed an enhanced capacity to suppress T cell proliferation and IL-17 production. CONCLUSION Treg cells exposed to a proinflammatory environment show increased cytokine expression as well as enhanced suppressive activity.
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Abstract
Rheumatoid arthritis (RA) remains a major clinical problem with many patients having continuing systemic inflammatory disease resulting in progressive erosive damage and high levels of disability. A range of pro-inflammatory cytokines including tumor necrosis factor (TNF), interleukin (IL)-1 and IL-6 are involved in RA pathogenesis; these cytokines can be specifically inhibited by biological agents. Tocilizumab (TCZ) is a recombinant humanized anti-IL-6 receptor monoclonal antibody, administered monthly by intravenous infusion that prevents IL-6 signal transduction. There is strong evidence that it is both clinically efficacious and cost-effective. There have been several key clinical trials evaluating the safety and efficacy of TCZ in RA patients. We review five Phase II trials and seven Phase III trials enrolling a total of 626 and 5268 RA patients respectively. The American College of Rheumatology (ACR) response criteria were used as the primary or secondary outcome measure in all trials. Overall these trials demonstrated that TCZ was effective in the treatment of RA in a number of patient groups, including those with an inadequate response to methotrexate (MTX) or TNF inhibition. TCZ use, both as monotherapy and in combination with MTX, improved the signs and symptoms of RA within several weeks of commencing treatment. Additionally, TCZ was shown to reduce radiological disease progression and improve physical function, both as monotherapy and in combination with MTX. A 5-year extension study demonstrated that TCZ sustained good long-term efficacy and safety profiles. TCZ was generally well tolerated. Although its use increased the risk of an adverse event, these were usually mild to moderate in severity and treatment did not increase the risk of a serious adverse event in comparison to controls. Due to moderate increases in serum levels of total cholesterol, triglycerides, high-density lipoproteins and serum transaminases seen in those patients treated with TCZ, as well as severe neutropenia in some, regular blood monitoring of full blood count, liver function and lipids is recommended. Given its clinical efficacy in the treatment of RA, TCZ may be beneficial in the treatment of other autoimmune diseases where IL-6 plays a role in the inflammatory cascade.
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Affiliation(s)
- Israa Al-Shakarchi
- Department of Rheumatology, Kings College Hospital, London, UK
- Correspondence: Israa Al-Shakarchi, Department of Rheumatology, Kings College Hospital, Denmark Hill, London, United Kingdom, SE5 9RS, Tel +44 0203 299 1731, Fax +44 0203 299 1734, Email
| | | | - David L Scott
- Department of Rheumatology, Kings College Hospital, London, UK
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Evans HG, Gullick NJ, Walter GJ, Roostalu U, Frederiksen KS, Gerwien JG, Cope AP, Geissmann F, Kirkham BW, Taams LS. TNF-inhibitor drugs regulate human pathogenic Th17 cells through induction of IL-10. Lab Invest 2012. [PMCID: PMC3508830 DOI: 10.1186/1479-5876-10-s3-p49] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
Inflammatory arthritis involves a diverse range of conditions in which an uncontrolled immune response occurs. A number of advances in assessment, diagnosis and treatment have been made in recent years. Drug therapies used in inflammatory arthritis aim to reduce symptoms and suppress inflammation, joint damage and disability. In rheumatoid arthritis (RA), immunosuppression is used in almost all patients, with an emphasis on early aggressive treatment to achieve clinical remission. This approach is less successful in spondylarthropathies, for which non-steroidal anti-inflammatory drugs remain first-line therapy. The use of biologic therapies has increased dramatically across a range of indications and has resulted in improved outcomes for patients. These agents are associated with an increased risk of infection, particularly tuberculosis in patients receiving tumour necrosis factor inhibitors. Alternative biologics have entered clinical practice for RA in recent years, and clinical trials using these agents, as well as novel non-biologic therapies, are in progress for RA and other conditions.
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Affiliation(s)
- Nicola J Gullick
- Academic Department of Rheumatology, King's College London School of Medicine, Weston Education Centre, London.
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20
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Abstract
Co-morbid conditions are common in patients with rheumatoid arthritis (RA). Although the presence of co-morbid conditions can be assessed using standardised indexes such as the Charlson index, most clinicians prefer to simply record their presence. Some co-morbidities are causally associated with RA and many others are related to its treatment. Irrespective of their underlying pathogenesis, co-morbidities increase disability and shorten life expectancy, thereby increasing both the impact and mortality of RA. Cardiac co-morbidities are the most crucial, because of their frequency and their negative impacts on health. Treatment of cardiac risk factors and reducing RA inflammation are both critical in reducing cardiac co-morbidities. Gastrointestinal and chest co-morbidities are both also common. They are often associated with drug treatment, including non-steroidal anti-inflammatory drug and disease-modifying drugs. Osteoporosis and its associated fracture risk are equally important and are often linked to long-term glucocorticoid treatment. The range of co-morbidities associated with RA is increasing with the recognition of new problems such as periodontal disease. Optimal medical care for RA should include an assessment of associated co-morbidities and their appropriate management. This includes risk factor modification where possible. This approach is essential to improve quality of life and reduce RA mortality. An area of genuine concern is the impact of treatment on co-morbidities. A substantial proportion is iatrogenic. As immunosuppression with conventional disease-modifying drugs and biologics has many associated risks, ranging from liver disease to chest and other infections, it is essential to balance the risks of co-morbidities against the anticipated benefits of treatment.
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Affiliation(s)
- Nicola J Gullick
- Department of Rheumatology, King's College London School of Medicine, Weston Education Centre, United Kingdom.
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Gullick NJ, Oakley SP, Zain A, Gibson T, Jones T, Mistlin A, Rees JD, Panayi GS, Kirkham BW. Goal-directed therapy for RA in routine practice is associated with improved function in patients with disease duration up to 15 years. Rheumatology (Oxford) 2012; 51:759-61. [PMID: 22223707 PMCID: PMC3306167 DOI: 10.1093/rheumatology/ker399] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
| | | | - Amir Zain
- RA Centre, Guy's and St Thomas’ NHS Foundation Trust, London, UK
| | - Terence Gibson
- RA Centre, Guy's and St Thomas’ NHS Foundation Trust, London, UK
| | - Tim Jones
- RA Centre, Guy's and St Thomas’ NHS Foundation Trust, London, UK
| | - Alan Mistlin
- RA Centre, Guy's and St Thomas’ NHS Foundation Trust, London, UK
| | - Jonathan D. Rees
- RA Centre, Guy's and St Thomas’ NHS Foundation Trust, London, UK
| | | | - Bruce W. Kirkham
- RA Centre, Guy's and St Thomas’ NHS Foundation Trust, London, UK
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22
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Jagger AL, Evans HG, Walter GJ, Gullick NJ, Menon B, Ballantine LE, Gracie A, Magerus-Chatinet A, Tiemessen MM, Geissmann F, Rieux-Laucat F, Taams LS. FAS/FAS-L dependent killing of activated human monocytes and macrophages by CD4+CD25- responder T cells, but not CD4+CD25+ regulatory T cells. J Autoimmun 2011; 38:29-38. [PMID: 22197557 DOI: 10.1016/j.jaut.2011.11.015] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2011] [Revised: 11/07/2011] [Accepted: 11/28/2011] [Indexed: 12/24/2022]
Abstract
Conclusive resolution of an immune response is critical for the prevention of autoimmunity and chronic inflammation. We report that following co-culture with autologous CD4+CD25- responder T cells, human CD14+ monocytes and monocyte-derived macrophages become activated but also significantly more prone to apoptosis than monocytes/macrophages cultured alone. In contrast, in the presence of CD4+CD25+ regulatory T cells (Tregs), monocytes and macrophages survive whilst adopting an anti-inflammatory phenotype. The induction of monocyte death requires responder T cell activation and cell-contact between responder T cells and monocytes. We demonstrate a critical role for FAS/FAS-L ligation in responder T cell-induced monocyte killing since responder T cells, but not Tregs, upregulate FAS-ligand (FAS-L) mRNA, and induce FAS expression on monocytes. Furthermore, responder T cell-induced monocyte apoptosis is blocked by neutralising FAS/FAS-L interaction, and is not observed when monocytes from an autoimmune lymphoproliferative syndrome (ALPS) patient with complete FAS-deficiency are used as target cells. Finally, we show that responder T cell-induced killing of monocytes is impaired in patients with active rheumatoid arthritis (RA). Our data suggest that resolution of inflammation in the course of a healthy immune response is aided by the unperturbed killing of monocytes with inflammatory potential by responder T cells and the induction of longer-lived, Treg-induced, anti-inflammatory monocytes.
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Affiliation(s)
- Ann L Jagger
- Centre for Molecular and Cellular Biology of Inflammation, Division of Immunology, Infection and Inflammatory Disease, King's College London, London SE1 1UL, UK
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Gullick NJ, Evans HG, Jayaraj D, Kirkham BW, Taams LS. Interleukin 17-producing cells are increased in the peripheral blood of patients with rheumatoid arthritis and are enriched at the site of inflammation. Ann Rheum Dis 2010. [DOI: 10.1136/ard.2010.129668s] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Evans HG, Gullick NJ, Kelly S, Pitzalis C, Lord GM, Kirkham BW, Taams LS. In vivo activated monocytes from the site of inflammation in humans specifically promote Th17 responses. Proc Natl Acad Sci U S A 2009; 106:6232-7. [PMID: 19325128 PMCID: PMC2669354 DOI: 10.1073/pnas.0808144106] [Citation(s) in RCA: 157] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2008] [Indexed: 12/23/2022] Open
Abstract
Th17 cells are a recently defined subset of proinflammatory T cells that contribute to pathogen clearance and tissue inflammation by means of the production of their signature cytokine IL-17A (henceforth termed IL-17). Although the in vitro requirements for human Th17 development are reasonably well established, it is less clear what their in vivo requirements are. Here, we show that the production of IL-17 by human Th17 cells critically depends on both the activation status and the anatomical location of accessory cells. In vivo activated CD14+ monocytes were derived from the inflamed joints of patients with active rheumatoid arthritis (RA). These cells were found to spontaneously and specifically promote Th17, but not Th1 or Th2 responses, compared with resting CD14+ monocytes from the blood. Surprisingly, unlike Th17 stimulation by monocytes that were in vitro activated with lipopolysaccharide, intracellular IL-17 expression was induced by in vivo activated monocytes in a TNF-alpha- and IL-1beta-independent fashion. No role for IL-6 or IL-23 production by either in vitro or in vivo activated monocytes was found. Instead, in vivo activated monocytes promoted Th17 responses in a cell-contact dependent manner. We propose that, in humans, newly recruited memory CD4(+) T cells can be induced to produce IL-17 in nonlymphoid inflamed tissue after cell-cell interactions with activated monocytes. Our data also suggest that different pathways may be utilized for the generation of Th17 responses in situ depending on the site or route of accessory cell activation.
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Affiliation(s)
- Hayley G. Evans
- Departments of Immunobiology
- National Institute for Health Research Biomedical Research Centre at Guy's and St. Thomas' National Health Service Foundation Trust and King's College London, London SE1 9RT, United Kingdom
| | - Nicola J. Gullick
- Rheumatology, and
- National Institute for Health Research Biomedical Research Centre at Guy's and St. Thomas' National Health Service Foundation Trust and King's College London, London SE1 9RT, United Kingdom
| | - Stephen Kelly
- Centre for Experimental Medicine and Rheumatology, William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, London E1 2AD, United Kingdom; and
| | - Costantino Pitzalis
- Centre for Experimental Medicine and Rheumatology, William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, London E1 2AD, United Kingdom; and
| | - Graham M. Lord
- Nephrology and Transplantation, Division of Immunology, Infection and Inflammatory Diseases, King's College London School of Medicine at Guy's, King's College and St. Thomas' Hospitals, London SE1 1UL, United Kingdom
- National Institute for Health Research Biomedical Research Centre at Guy's and St. Thomas' National Health Service Foundation Trust and King's College London, London SE1 9RT, United Kingdom
| | - Bruce W. Kirkham
- Rheumatology, and
- National Institute for Health Research Biomedical Research Centre at Guy's and St. Thomas' National Health Service Foundation Trust and King's College London, London SE1 9RT, United Kingdom
| | - Leonie S. Taams
- Departments of Immunobiology
- National Institute for Health Research Biomedical Research Centre at Guy's and St. Thomas' National Health Service Foundation Trust and King's College London, London SE1 9RT, United Kingdom
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