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Kulkarni S, Durham H, Glover L, Ather O, Phillips V, Nemes S, Cousens L, Blomgran P, Ambery P. Metabolic adverse events associated with systemic corticosteroid therapy-a systematic review and meta-analysis. BMJ Open 2022; 12:e061476. [PMID: 36549729 PMCID: PMC9772659 DOI: 10.1136/bmjopen-2022-061476] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVES To assess the risk of new-onset or worsening hyperglycaemia, hypertension, weight gain and hyperlipidaemia with systemic corticosteroid therapy (CST) as reported in published randomised control trial (RCT) studies. DATA SOURCES Literature search using MEDLINE, EMBASE, Cochrane library, Web of Science and Scopus STUDY ELIGIBILITY CRITERIA: Published articles on results of RCT with a systemic CST arm with numerical data presented on adverse effect (AE). PARTICIPANTS AND INTERVENTIONS Reports of hyperglycaemia, hypertension, weight gain and hyperlipidaemia associated with systemic CST in patients or healthy volunteer's ≥17 years of age. STUDY APPRAISAL METHODS Risk of bias tool, assessment at the level of AE and key study characteristics. RESULTS A total of 5446 articles were screened to include 118 studies with 152 systemic CST arms (total participants=17 113 among which 8569 participants treated with CST). Pooled prevalence of hyperglycaemia in the CST arms within the studies was 10% (95% CI 7% to 14%), with the highest prevalence in respiratory illnesses at 22% (95% CI 9% to 35%). Pooled prevalence of severe hyperglycaemia, hypertension, weight gain and hyperlipidaemia within the corticosteroid arms was 5% (95% CI 2% to 9%), 6% (95% CI 4% to 8%), 13% (95% CI 8% to 18%), 8% (95% CI 4% to 17%), respectively. CST was significantly associated hyperglycaemia, hypertension and weight gain as noted in double-blinded placebo-controlled parallel-arms studies: OR of 2.13 (95% CI 1.66 to 2.72), 1.68 (95% CI 0.96 to 2.95) and 5.20 (95% CI 2.10 to 12.90), respectively. Intravenous therapy posed higher risk than oral therapy: OR of 2.39 (95% CI 1.16 to 4.91). LIMITATIONS There was significant heterogeneity in the AE definitions and quality of AE reporting in the primary studies and patient populations in the studies. The impact of cumulative dose effect on incidental AE could not be calculated. CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS Systemic CST use is associated with increased risk of metabolic AEs, which differs for each disease group and route of administration. PROSPERO REGISTRATION NUMBER CRD42020161270.
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Affiliation(s)
- Spoorthy Kulkarni
- Clinical Pharmacology and Therapeutics, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Hannah Durham
- Department of Urology, Imperial College Healthcare NHS Trust, London, UK
| | - Luke Glover
- Department of Medicine, Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK
| | - Osaid Ather
- Structural & Chemical Biology, The Francis Crick Institute, London, UK
| | - Veronica Phillips
- Medical Library, School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Szilard Nemes
- Data Science & AI, R&D BioPharmaceuticals, AstraZeneca, Gothenburg, Sweden
| | - Leslie Cousens
- Respiratory & Immunology, AstraZeneca R&D Boston, Waltham, Massachusetts, USA
| | - Parmis Blomgran
- Early Respiratory & Immunology, AstraZeneca R&D Gothenburg, Mölndal, Sweden
| | - Philip Ambery
- Late CVRM Research, AstraZeneca R&D Gothenburg, Mölndal, Sweden
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Nilsson M, Rhedin M, Hendrickx R, Berglund S, Piras A, Blomgran P, Cavallin A, Collins M, Dahl G, Dekkak B, Ericsson T, Hagberg N, Holmberg AA, Leffler A, Lundqvist AJ, Markou T, Pinkerton J, Rönnblom L, Siu S, Taylor V, Wennberg T, Zervas D, Laurence ADJ, Mitra S, Belvisi MG, Birrell M, Borde A. Characterization of Selective and Potent JAK1 Inhibitors Intended for the Inhaled Treatment of Asthma. Drug Des Devel Ther 2022; 16:2901-2917. [PMID: 36068788 PMCID: PMC9441147 DOI: 10.2147/dddt.s354291] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [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: 12/22/2021] [Accepted: 08/11/2022] [Indexed: 11/23/2022] Open
Abstract
Purpose Janus kinase 1 (JAK1) is implicated in multiple inflammatory pathways that are critical for the pathogenesis of asthma, including the interleukin (IL)-4, IL-5, IL-13, and thymic stromal lymphopoietin cytokine signaling pathways, which have previously been targeted to treat allergic asthma. Here, we describe the development of AZD0449 and AZD4604, two novel and highly selective JAK1 inhibitors with promising properties for inhalation. Methods The effects of AZD0449 and AZD4604 in JAK1 signaling pathways were assessed by measuring phosphorylation of signal transducer and activator of transcription (STAT) proteins and chemokine release using immunoassays of whole blood from healthy human volunteers and rats. Pharmacokinetic studies performed on rats evaluated AZD0449 at a lung deposited dose of 52 μg/kg and AZD4604 at 30 µg/kg. The efficacy of AZD0449 and AZD4604 was assessed by evaluating lung inflammation (cell count and cytokine levels) and the late asthmatic response (average enhanced pause [Penh]). Results Both compounds inhibited JAK1-dependent cytokine signaling pathways in a dose-dependent manner in human and rat leukocytes. After intratracheal administration in rats, both compounds exhibited low systemic exposures and medium-to-long terminal lung half-lives (AZD0449, 34 hours; AZD4604, 5 hours). Both compounds inhibited STAT3 and STAT5 phosphorylation in lung tissue from ovalbumin (OVA)-challenged rats. AZD0449 and AZD4604 also inhibited eosinophilia in the lung and reduced the late asthmatic response, measured as Penh in the OVA rat model. Conclusion AZD0449 and AZD4604 show potential as inhibitors of signaling pathways involved in asthmatic immune responses, with target engagement demonstrated locally in the lung. These findings support the clinical development of AZD0449 and AZD4604 for the treatment of patients with asthma.
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Affiliation(s)
- Magnus Nilsson
- Medicinal Chemistry, Research and Early Development, Respiratory & Immunology, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
- Correspondence: Magnus Nilsson, Medicinal Chemistry, Research and Early Development, Respiratory & Immunology, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, SE-431 83, Sweden, Tel +46722237222, Email
| | - Magdalena Rhedin
- Bioscience, Research and Early Development, Respiratory & Immunology, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Ramon Hendrickx
- DMPK, Research and Early Development, Respiratory & Immunology, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Susanne Berglund
- Medicinal Chemistry, Research and Early Development, Respiratory & Immunology, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Antonio Piras
- Bioscience, Research and Early Development, Respiratory & Immunology, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Parmis Blomgran
- Bioscience, Research and Early Development, Respiratory & Immunology, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Anders Cavallin
- Bioscience, Research and Early Development, Respiratory & Immunology, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Mia Collins
- Bioscience, Research and Early Development, Respiratory & Immunology, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Göran Dahl
- Discovery Science, R&D, AstraZeneca, Gothenburg, Sweden
| | - Bilel Dekkak
- Respiratory Pharmacology Group, Division of Airway Disease, National Heart and Lung Institute, Imperial College London, London, UK
| | - Therese Ericsson
- DMPK, Research and Early Development, Respiratory & Immunology, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Niklas Hagberg
- Rheumatology and Science for Life Laboratories, Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Ann Aurell Holmberg
- DMPK, Research and Early Development, Respiratory & Immunology, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Agnes Leffler
- Bioscience, Research and Early Development, Respiratory & Immunology, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Anders J Lundqvist
- DMPK, Research and Early Development, Respiratory & Immunology, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Thomais Markou
- Respiratory Pharmacology Group, Division of Airway Disease, National Heart and Lung Institute, Imperial College London, London, UK
- Research and Early Development, Respiratory & Immunology, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - James Pinkerton
- Respiratory Pharmacology Group, Division of Airway Disease, National Heart and Lung Institute, Imperial College London, London, UK
- Research and Early Development, Respiratory & Immunology, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Lars Rönnblom
- Rheumatology and Science for Life Laboratories, Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Stacey Siu
- Rigel Pharmaceuticals, South San Francisco, CA, USA
| | | | - Tiiu Wennberg
- Bioscience, Research and Early Development, Respiratory & Immunology, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Dimitrios Zervas
- Respiratory Pharmacology Group, Division of Airway Disease, National Heart and Lung Institute, Imperial College London, London, UK
- Research and Early Development, Respiratory & Immunology, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Arian D J Laurence
- Department of Haematology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Suman Mitra
- Bioscience, Research and Early Development, Respiratory & Immunology, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Maria G Belvisi
- Respiratory Pharmacology Group, Division of Airway Disease, National Heart and Lung Institute, Imperial College London, London, UK
- Research and Early Development, Respiratory & Immunology, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Mark Birrell
- Respiratory Pharmacology Group, Division of Airway Disease, National Heart and Lung Institute, Imperial College London, London, UK
- Research and Early Development, Respiratory & Immunology, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Annika Borde
- Bioscience, Research and Early Development, Respiratory & Immunology, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
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Blomgran P, Hammerman M, Blomgran R, Aspenberg P. Role of Macrophages During early Achilles Tendon Healing. Muscles Ligaments Tendons J 2021. [DOI: 10.32098/mltj.01.2021.02] [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: 11/05/2022]
Affiliation(s)
- P. Blomgran
- Department of Clinical and Experimental Medicine, Faculty of Medicine and Health Sciences, Linkoping University, Sweden
| | - M. Hammerman
- Department of Clinical and Experimental Medicine, Faculty of Medicine and Health Sciences, Linkoping University, Sweden
| | - R. Blomgran
- Department of Biomedical and Clinical Sciences, Faculty of Medicine and Health Sciences, Linkoping University, Sweden
| | - P. Aspenberg
- Department of Clinical and Experimental Medicine, Faculty of Medicine and Health Sciences, Linkoping University, Sweden
- Deceased
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4
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Khayyeri H, Hammerman M, Turunen MJ, Blomgran P, Notermans T, Guizar-Sicairos M, Eliasson P, Aspenberg P, Isaksson H. Diminishing effects of mechanical loading over time during rat Achilles tendon healing. PLoS One 2020; 15:e0236681. [PMID: 33315857 PMCID: PMC7735574 DOI: 10.1371/journal.pone.0236681] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [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: 06/30/2020] [Accepted: 11/23/2020] [Indexed: 01/07/2023] Open
Abstract
Mechanical loading affects tendon healing and recovery. However, our understanding about how physical loading affects recovery of viscoelastic functions, collagen production and tissue organisation is limited. The objective of this study was to investigate how different magnitudes of loading affects biomechanical and collagen properties of healing Achilles tendons over time. Achilles tendon from female Sprague Dawley rats were cut transversely and divided into two groups; normal loading (control) and reduced loading by Botox (unloading). The rats were sacrificed at 1, 2- and 4-weeks post-injury and mechanical testing (creep test and load to failure), small angle x-ray scattering (SAXS) and histological analysis were performed. The effect of unloading was primarily seen at the early time points, with inferior mechanical and collagen properties (SAXS), and reduced histological maturation of the tissue in unloaded compared to loaded tendons. However, by 4 weeks no differences remained. SAXS and histology revealed heterogeneous tissue maturation with more mature tissue at the peripheral region compared to the center of the callus. Thus, mechanical loading advances Achilles tendon biomechanical and collagen properties earlier compared to unloaded tendons, and the spatial variation in tissue maturation and collagen organization across the callus suggests important regional (mechano-) biological activities that require more investigation.
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Affiliation(s)
- Hanifeh Khayyeri
- Department of Biomedical Engineering, Lund University, Lund, Sweden
| | - Malin Hammerman
- Department of Biomedical Engineering, Lund University, Lund, Sweden
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Mikael J. Turunen
- Department of Applied Physics, University of Eastern Finland, Kuopio, Finland
| | - Parmis Blomgran
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Thomas Notermans
- Department of Biomedical Engineering, Lund University, Lund, Sweden
| | | | - Pernilla Eliasson
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Per Aspenberg
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Hanna Isaksson
- Department of Biomedical Engineering, Lund University, Lund, Sweden
- * E-mail:
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Alim MA, Grujic M, Ackermann PW, Kristiansson P, Blomgran P, Eliasson P, Peterson M, Pejler G. Correction to: Glutamate triggers the expression of functional ionotropic and metabotropic glutamate receptors in mast cells. Cell Mol Immunol 2020; 17:1117. [PMID: 32884140 PMCID: PMC7609263 DOI: 10.1038/s41423-020-00543-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Affiliation(s)
- Md Abdul Alim
- Department of Public Health and Caring Sciences, General Medicine and Preventive Medicine, Uppsala University, Uppsala, Sweden.,Department of Medical Biochemistry and Microbiology, Uppsala University, Uppsala, Sweden
| | - Mirjana Grujic
- Department of Medical Biochemistry and Microbiology, Uppsala University, Uppsala, Sweden
| | - Paul W Ackermann
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Per Kristiansson
- Department of Public Health and Caring Sciences, General Medicine and Preventive Medicine, Uppsala University, Uppsala, Sweden
| | - Parmis Blomgran
- Department of Orthopedics and Sports Medicine, Linköping University, Linkoping, Sweden
| | - Pernilla Eliasson
- Department of Orthopedics and Sports Medicine, Linköping University, Linkoping, Sweden
| | - Magnus Peterson
- Department of Public Health and Caring Sciences, General Medicine and Preventive Medicine, Uppsala University, Uppsala, Sweden. .,Academic Primary Health Care, Region Uppsala, Uppsala, Sweden.
| | - Gunnar Pejler
- Department of Medical Biochemistry and Microbiology, Uppsala University, Uppsala, Sweden. .,Department of Anatomy, Physiology and Biochemistry, Swedish University of Agricultural Sciences, Uppsala, Sweden.
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Kulkarni S, Durham H, Glover L, Cousens L, Blomgran P, Ather O, Ambery P. Abstract P176: Metabolic Side Effects Of Systemic Corticosteroids - A Systematic Review. Hypertension 2020. [DOI: 10.1161/hyp.76.suppl_1.p176] [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: 11/16/2022]
Abstract
Introduction:
Metabolic adverse events associated with corticosteroid therapy (CT) are seen as a necessary evil in the management of a wide variety of inflammatory conditions. Evidence on the burden of dysglycaemia associated with CT strategies is mostly based on case- control studies. The aim of this study was to quantify metabolic side effects of systemic steroids as reported in randomised clinical trials (RCT).
Methods:
We searched Medline, Embase, Cochrane Library, Web of Science and Scopus for studies reporting adverse effects of CT in trials since database inception to 13/01/2020. We used a standardised data extraction form to collect information from eligible studies using predefined inclusion and exclusion criteria. Cochrane risk of bias tool 2 (ROB2) was used to assess risk of bias in the RCTs. The study was registered prospectively with PROSPERO (CRD42020161270).
Results:
The search identified 5446 studies. In total 120 blinded studies were identified for the mixed method review of AEs. There was significant heterogeneity with respect to steroid dose, treatment duration, condition treated, exclusion criteria in the studies, data collection methods for adverse events (AE) and definition for specific AEs. A significant increase in cases of new onset diabetes, hyperglycaemia, episodes of rise in blood pressure (BP) was noted. Average adverse event rate for new onset of diabetes in the studies (N=21, 27 CT arms) was 4.8% (72 events in 1477 participants, range: 0.85%-18.75%). Event rate of hyperglycaemia in the CT arms was 11.8% approximately (53 CT arms, 222 events in 1854 participants, range: 2.5%-69%). Rise in BP was reported in 53 CT arms in 42 studies, with average event rate of 12.8% (160 events in 1251 participants, range: 0.94%-30.4%). Other significant AEs associated with steroid use included weight gain, dyslipidaemia, insomnia, infections, osteoporosis and fractures.
Conclusions:
Risk of new onset diabetes and worsening of diabetes control is significant in patients treated with CT, although available evidence to estimate risk is heterogenous. Both, alternatives to corticosteroids which do not elevate blood glucose and accurate estimation of risk of dysglycaemia from well-designed prospective RCTs are urgently required.
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Affiliation(s)
| | - Hannah Durham
- Cambridge Univ Hosp NHS Foundation trust, Cambridge, United Kingdom
| | - Luke Glover
- Cambridge Univ Hosp NHS Foundation trust, Cambridge, United Kingdom
| | | | | | - Osaid Ather
- Cambridge Univ Hosp NHS Foundation trust, Cambridge, United Kingdom
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Blomgran P, Blomgran R, Ernerudh J, Aspenberg P. Cox-2 inhibition and the composition of inflammatory cell populations during early and mid-time tendon healing. Muscles Ligaments Tendons J 2019. [DOI: 10.32098/mltj.02.2017.04] [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: 11/05/2022]
Affiliation(s)
- P. Blomgran
- Department of Clinical and Experimental Medicine, Linkoping University, Sweden
| | - R. Blomgran
- Department of Medical Microbiology, Linkoping University, Sweden
| | - J. Ernerudh
- Department of Clinical Immunology and Transfusion Medicine, Linkoping University, Sweden
| | - P. Aspenberg
- Department of Clinical and Experimental Medicine, Linkoping University, Sweden
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Dietrich-Zagonel F, Hammerman M, Tätting L, Dietrich F, Kozak Ljunggren M, Blomgran P, Eliasson P, Aspenberg P. Stimulation of Tendon Healing With Delayed Dexamethasone Treatment Is Modified by the Microbiome. Am J Sports Med 2018; 46:3281-3287. [PMID: 30265844 DOI: 10.1177/0363546518799442] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The immune system reflects the microbiome (microbiota). Modulation of the immune system during early tendon remodeling by dexamethasone treatment can improve rat Achilles tendon healing. The authors tested whether changes in the microbiota could influence the effect of dexamethasone treatment. HYPOTHESIS A change in microbiome would influence the response to dexamethasone on regenerate remodeling, specifically tendon material properties (peak stress). STUDY DESIGN Controlled laboratory study. METHODS Specific opportunist and pathogen-free female rats were housed separately (n = 41) or together with specific pathogen-free rats carrying opportunistic microbes such as Staphylococcus aureus (n = 41). After 6 weeks, all co-housed rats appeared healthy but now carried S aureus. Changes in the gut bacterial flora were tested by API and RapID biochemical tests. All rats (clean and contaminated) underwent Achilles tendon transection under aseptic conditions. Flow cytometry was performed 8 days postoperatively on tendon tissue. Sixty rats received subcutaneous dexamethasone or saline injections on days 5 through 9 after transection. The tendons were tested mechanically on day 12. The predetermined primary outcome was the interaction between contamination and dexamethasone regarding peak stress, tested by 2-way analysis of variance. RESULTS Dexamethasone increased peak stress in all groups but more in contaminated rats (105%) than in clean rats (53%) (interaction, P = .018). A similar interaction was found for an estimate of elastic modulus ( P = .021). Furthermore, dexamethasone treatment reduced transverse area but had small effects on peak force and stiffness. In rats treated with saline only, contamination reduced peak stress by 16% ( P = .04) and elastic modulus by 35% ( P = .004). Contamination led to changes in the gut bacterial flora and higher levels of T cells (CD3+CD4+) in the healing tendon ( P < .05). CONCLUSION Changes in the microbiome influence tendon healing and enhance the positive effects of dexamethasone treatment during the early remodeling phase of tendon healing. CLINICAL RELEVANCE The positive effect of dexamethasone on early tendon remodeling in rats is strikingly strong. If similar effects could be shown in humans, immune modulation by a few days of systemic corticosteroids, or more specific compounds, could open new approaches to rehabilitation after tendon injury.
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Affiliation(s)
- Franciele Dietrich-Zagonel
- Orthopedics, Department of Clinical and Experimental Medicine, Faculty of Medicine and Health Sciences, Linköping University, Linköping, Sweden
| | - Malin Hammerman
- Orthopedics, Department of Clinical and Experimental Medicine, Faculty of Medicine and Health Sciences, Linköping University, Linköping, Sweden
| | - Love Tätting
- Orthopedics, Department of Clinical and Experimental Medicine, Faculty of Medicine and Health Sciences, Linköping University, Linköping, Sweden
| | - Fabrícia Dietrich
- Division of Pediatrics, Department of Clinical and Experimental Medicine, Faculty of Medicine and Health Sciences, Linköping University, Linköping, Sweden
| | - Monika Kozak Ljunggren
- Department of Clinical and Experimental Medicine, Faculty of Medicine and Health Sciences, Linköping University, Linköping, Sweden
| | - Parmis Blomgran
- Orthopedics, Department of Clinical and Experimental Medicine, Faculty of Medicine and Health Sciences, Linköping University, Linköping, Sweden
| | - Pernilla Eliasson
- Orthopedics, Department of Clinical and Experimental Medicine, Faculty of Medicine and Health Sciences, Linköping University, Linköping, Sweden
| | - Per Aspenberg
- Orthopedics, Department of Clinical and Experimental Medicine, Faculty of Medicine and Health Sciences, Linköping University, Linköping, Sweden
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Hammerman M, Dietrich-Zagonel F, Blomgran P, Eliasson P, Aspenberg P. Different mechanisms activated by mild versus strong loading in rat Achilles tendon healing. PLoS One 2018; 13:e0201211. [PMID: 30044869 PMCID: PMC6059492 DOI: 10.1371/journal.pone.0201211] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [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: 05/09/2018] [Accepted: 07/10/2018] [Indexed: 11/19/2022] Open
Abstract
Background Mechanical loading stimulates Achilles tendon healing. However, various degrees of loading appear to have different effects on the mechanical properties of the healing tendon, and strong loading might create microdamage in the tissue. This suggests that different mechanisms might be activated depending on the magnitude of loading. The aim of this study was to investigate these mechanisms further. Methods Female rats had their right Achilles tendon cut transversely and divided into three groups: 1) unloading (calf muscle paralysis by Botox injections, combined with joint fixation by a steel-orthosis), 2) mild loading (Botox only), 3) strong loading (free cage activity). Gene expression was analyzed by PCR, 5 days post-injury, and mechanical testing 8 days post-injury. The occurrence of microdamage was analyzed 3, 5, or 14 days post-injury, by measuring leakage of injected fluorescence-labelled albumin in the healing tendon tissue. Results Peak force, peak stress, and elastic modulus of the healing tendons gradually improved with increased loading as well as the expression of extracellular matrix genes. In contrast, only strong loading increased transverse area and affected inflammation genes. Strong loading led to higher fluorescence (as a sign of microdamage) compared to mild loading at 3 and 5 days post-injury, but not at 14 days. Discussion Our results show that strong loading improves both the quality and quantity of the healing tendon, while mild loading only improves the quality. Strong loading also induces microdamage and alters the inflammatory response. This suggests that mild loading exert its effect via mechanotransduction mechanisms, while strong loading exert its effect both via mechanotransduction and the creation of microdamage. Conclusion In conclusion, mild loading is enough to increase the quality of the healing tendon without inducing microdamage and alter the inflammation in the tissue. This supports the general conception that early mobilization of a ruptured tendon in patients is advantageous.
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Affiliation(s)
- Malin Hammerman
- Experimental orthopedics, Department of Clinical and Experimental Medicine, Faculty of Health Science, Linköping University, Linköping, Sweden
| | - Franciele Dietrich-Zagonel
- Experimental orthopedics, Department of Clinical and Experimental Medicine, Faculty of Health Science, Linköping University, Linköping, Sweden
| | - Parmis Blomgran
- Experimental orthopedics, Department of Clinical and Experimental Medicine, Faculty of Health Science, Linköping University, Linköping, Sweden
| | - Pernilla Eliasson
- Experimental orthopedics, Department of Clinical and Experimental Medicine, Faculty of Health Science, Linköping University, Linköping, Sweden
- * E-mail:
| | - Per Aspenberg
- Experimental orthopedics, Department of Clinical and Experimental Medicine, Faculty of Health Science, Linköping University, Linköping, Sweden
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Blomgran P, Hammerman M, Aspenberg P. Systemic corticosteroids improve tendon healing when given after the early inflammatory phase. Sci Rep 2017; 7:12468. [PMID: 28963482 PMCID: PMC5622078 DOI: 10.1038/s41598-017-12657-0] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Accepted: 09/19/2017] [Indexed: 12/26/2022] Open
Abstract
Inflammation initiates tendon healing and then normally resolves more or less completely. Unresolved inflammation might disturb the remodeling process. We hypothesized that suppression of inflammation during the early remodeling phase by systemic dexamethasone treatment can improve healing. 36 rats underwent Achilles tendon transection and were randomized to dexamethasone or saline on days 0–4 after surgery (early inflammatory phase), and euthanasia day 7. Another 54 rats received injections days 5–9 (early remodeling phase) and were euthanized day 12 for mechanical, histological and flow cytometric evaluation. Dexamethasone treatment days 0–4 reduced the cross-sectional area, peak force and stiffness by day 7 to less than half (p < 0.001 for all), while material properties (peak stress and elastic modulus) were not significantly affected. In contrast, dexamethasone treatment days 5–9 increased peak force by 39% (p = 0.002) and stiffness by 58% (p < 0.001). The cross-sectional area was reduced by 42% (p < 0.001). Peak stress and elastic modulus were more than doubled (p < 0.001 for both). Semi-quantitative histology at day 12 showed that late dexamethasone treatment improved collagen alignment, and flow cytometry revealed reduced numbers of CD8a+ cytotoxic T cells in the tendon callus. These results suggest that downregulation of lingering inflammation during the early remodeling phase can improve healing.
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Affiliation(s)
- Parmis Blomgran
- Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden.
| | - Malin Hammerman
- Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Per Aspenberg
- Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
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Blomgran P, Blomgran R, Ernerudh J, Aspenberg P. Cox-2 inhibition and the composition of inflammatory cell populations during early and mid-time tendon healing. Muscles Ligaments Tendons J 2017; 7:223-229. [PMID: 29264332 DOI: 10.11138/mltj/2017.7.2.223] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Background During early tendon healing, the cells within the regenerating tissue are, to a large part, inflammatory leukocytes (CD45+). In a rat Achilles tendon healing model, the inflammation resolves between 5 and 10 days. In the same model, Cox inhibitors (NSAIDs) impair healing when given during the first 5 days, but have a positive effect if given later. We tested the hypothesis that a Cox inhibitor would exert these effects by influencing inflammation, and thereby the composition of the inflammatory cell subpopulations. Methods Achilles tendon transection was performed in 44 animals. Animals were randomized to either parecoxib or saline injections. Healing was evaluated by mechanical testing day 7 after surgery and by flow cytometry day 3 and 10. Results Cross-sectional area, peak force and stiffness were reduced by parecoxib 31, 33, and 25% respectively (p=0.005, p=0.002, and p=0.005). By flow cytometry, there was a strong effect of time (p<0.001) on virtually all inflammatory cell subpopulations (CD45, CD11b, CD68, CCR7, CD163, CD206, CD3, CD4), but no significant effect of parecoxib at any time point. Conclusion The results suggest that the negative effects of Cox inhibitors on tendon healing might be exerted mainly via mechanisms not directly related to inflammatory cells.
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Affiliation(s)
- Parmis Blomgran
- Department of Clinical and Experimental Medicine, Linkoping University, Sweden
| | - Robert Blomgran
- Department of Medical Microbiology, Linkoping University, Sweden
| | - Jan Ernerudh
- Department of Clinical Immunology and Transfusion Medicine, Linkoping University, Sweden
| | - Per Aspenberg
- Department of Clinical and Experimental Medicine, Linkoping University, Sweden
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Dietrich F, Hammerman M, Blomgran P, Tätting L, Bampi VF, Silva JB, Aspenberg P. Effect of platelet-rich plasma on rat Achilles tendon healing is related to microbiota. Acta Orthop 2017; 88:463. [PMID: 28657489 PMCID: PMC5499342 DOI: 10.1080/17453674.2017.1338417] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Affiliation(s)
- Franciele Dietrich
- Department of Clinical and Experimental Medicine, Orthopedics, Linköping University, Linköping, Sweden;,CAPES Foundation, Ministry of Education of Brazil, Brasília;,Laboratory of Medical Abilities and Surgical Research, Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, Rio Grande do Sul, Brazil
| | - Malin Hammerman
- Department of Clinical and Experimental Medicine, Orthopedics, Linköping University, Linköping, Sweden
| | - Parmis Blomgran
- Department of Clinical and Experimental Medicine, Orthopedics, Linköping University, Linköping, Sweden
| | - Love Tätting
- Department of Clinical and Experimental Medicine, Orthopedics, Linköping University, Linköping, Sweden
| | - Vinicius Faccin Bampi
- Laboratory of Medical Abilities and Surgical Research, Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, Rio Grande do Sul, Brazil
| | - Jefferson Braga Silva
- Laboratory of Medical Abilities and Surgical Research, Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, Rio Grande do Sul, Brazil
| | - Per Aspenberg
- Department of Clinical and Experimental Medicine, Orthopedics, Linköping University, Linköping, Sweden;,Correspondence:
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Abstract
Background and purpose - In 3 papers in Acta Orthopaedica 10 years ago, we described that platelet-rich plasma (PRP) improves tendon healing in a rat Achilles transection model. Later, we found that microtrauma has similar effects, probably acting via inflammation. This raised the suspicion that the effect ascribed to growth factors within PRP could instead be due to unspecific influences on inflammation. While testing this hypothesis, we noted that the effect seemed to be related to the microbiota. Material and methods - We tried to reproduce our old findings with local injection of PRP 6 h after tendon transection, followed by mechanical testing after 11 days. This failed. After fruitless variations in PRP production protocols, leukocyte concentration, and physical activity, we finally tried rats carrying potentially pathogenic bacteria. In all, 242 rats were used. Results - In 4 consecutive experiments on pathogen-free rats, no effect of PRP on healing was found. In contrast, apparently healthy rats carrying Staphylococcus aureus showed increased strength of the healing tendon after PRP treatment. These rats had lower [corrected] levels of cytotoxic T-cells in their spleens. Interpretation - The failure to reproduce older experiments in clean rats was striking, and the difference in response between these and Staphylococcus-carrying rats suggests that the PRP effect is dependent on the immune status. PRP functions may be more complex than just the release of growth factors. Extrapolation from our previous findings with PRP to the situation in humans therefore becomes even more uncertain.
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Affiliation(s)
- Franciele Dietrich
- Department of Clinical and Experimental Medicine, Orthopedics, Linköping University, Linköping, Sweden;,CAPES Foundation, Ministry of Education of Brazil, Brasília;,Laboratory of Medical Abilities and Surgical Research, Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, Rio Grande do Sul, Brazil
| | - Malin Hammerman
- Department of Clinical and Experimental Medicine, Orthopedics, Linköping University, Linköping, Sweden
| | - Parmis Blomgran
- Department of Clinical and Experimental Medicine, Orthopedics, Linköping University, Linköping, Sweden
| | - Love Tätting
- Department of Clinical and Experimental Medicine, Orthopedics, Linköping University, Linköping, Sweden
| | - Vinicius Faccin Bampi
- Laboratory of Medical Abilities and Surgical Research, Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, Rio Grande do Sul, Brazil
| | - Jefferson Braga Silva
- Laboratory of Medical Abilities and Surgical Research, Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, Rio Grande do Sul, Brazil
| | - Per Aspenberg
- Department of Clinical and Experimental Medicine, Orthopedics, Linköping University, Linköping, Sweden;,Correspondence:
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Hammerman M, Blomgran P, Dansac A, Eliasson P, Aspenberg P. Different gene response to mechanical loading during early and late phases of rat Achilles tendon healing. J Appl Physiol (1985) 2017; 123:800-815. [PMID: 28705996 DOI: 10.1152/japplphysiol.00323.2017] [Citation(s) in RCA: 14] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Revised: 07/06/2017] [Accepted: 07/06/2017] [Indexed: 11/22/2022] Open
Abstract
Mechanical loading stimulates tendon healing both when applied in the inflammatory phase and in the early remodeling phase of the process, although not necessarily via the same mechanisms. We investigated the gene response to mechanical loading in these two phases of tendon healing. The right Achilles tendon in rats was transected, and the hindlimbs were unloaded by tail suspension. The rats were exposed to 5 min of treadmill running 3 or 14 days after tendon transection. Thereafter, they were resuspended for 15 min or 3 h until euthanasia. The controls were suspended continuously. Gene analysis was first performed by microarray analysis followed by quantitative RT-PCR on selected genes, focusing on inflammation. Fifteen minutes after loading, the most important genes seemed to be the transcription factors EGR1 and C-FOS, regardless of healing phase. These transcription factors might promote tendon cell proliferation and differentiation, stimulate collagen production, and regulate inflammation. Three hours after loading on day 3, inflammation was strongly affected. Seven inflammation-related genes were upregulated according to PCR: CCL20, CCL7, IL-6, NFIL3, PTX3, SOCS1, and TLR2. These genes can be connected to macrophages, T cells, and recruitment of leukocytes. According to Ingenuity Pathway Analysis, the recruitment of leukocytes was increased by loading on day 3, which also was confirmed by histology. This inflammation-related gene response was not seen on day 14 Our results suggest that the immediate gene response after mechanical loading is similar in the early and late phases of healing but the late gene response is different.NEW & NOTEWORTHY This study investigates the direct effect of mechanical loading on gene expression during different healing phases in tendon healing. One isolated episode of mechanical loading was studied in otherwise unloaded healing tendons. This enabled us to study a time sequence, i.e., which genes were the first ones to be regulated after the loading episode.
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Affiliation(s)
- Malin Hammerman
- Orthopedics, Department of Clinical and Experimental Medicine, Faculty of Health Science, Linkoping University, Linköping, Sweden
| | - Parmis Blomgran
- Orthopedics, Department of Clinical and Experimental Medicine, Faculty of Health Science, Linkoping University, Linköping, Sweden
| | - Arie Dansac
- Orthopedics, Department of Clinical and Experimental Medicine, Faculty of Health Science, Linkoping University, Linköping, Sweden
| | - Pernilla Eliasson
- Orthopedics, Department of Clinical and Experimental Medicine, Faculty of Health Science, Linkoping University, Linköping, Sweden
| | - Per Aspenberg
- Orthopedics, Department of Clinical and Experimental Medicine, Faculty of Health Science, Linkoping University, Linköping, Sweden
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Hammerman M, Blomgran P, Ramstedt S, Aspenberg P. COX-2 inhibition impairs mechanical stimulation of early tendon healing in rats by reducing the response to microdamage. J Appl Physiol (1985) 2015; 119:534-40. [PMID: 26159755 DOI: 10.1152/japplphysiol.00239.2015] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2015] [Accepted: 07/06/2015] [Indexed: 11/22/2022] Open
Abstract
Early tendon healing can be stimulated by mechanical loading and inhibited by cyclooxygenase (COX) inhibitors (nonsteroidal anti-inflammatory drugs). Therefore, we investigated if impairment of tendon healing by a COX-2 inhibitor (parecoxib) is related to loading. Because loading might infer microdamage, which also stimulates healing, we also investigated if this effect is inhibited by parecoxib. The Achilles tendon was transected in 114 rats. Three degrees of loading were used: full loading, partial unloading, and unloading (no unloading, Botox injections in the plantar flexor muscles, or Botox in combination with tail suspension). For each loading condition, the rats received either parecoxib or saline. In a second experiment, rats were unloaded with Botox, and the tendon was subjected to microdamage by needling combined with either saline or parecoxib. Mechanical testing day 7 showed that there was a significant interaction between loading and parecoxib for peak force at failure (P < 0.01). However, logarithmic values showed no significant interaction, meaning that we could not exclude that the inhibitory effect of parecoxib was proportionate to the degree of loading. Microbleeding was common in the healing tissue, suggesting that loading caused microdamage. Needling increased peak force at failure (P < 0.01), and this effect of microdamage was almost abolished by parecoxib (P < 0.01). Taken together, this suggests that COX-2 inhibition impairs the positive effects of mechanical loading during tendon healing, mainly by reducing the response to microdamage.
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Affiliation(s)
- Malin Hammerman
- Orthopaedics, Department of Clinical and Experimental Medicine, Faculty of Health Science, Linköping University, Linköping, Sweden
| | - Parmis Blomgran
- Orthopaedics, Department of Clinical and Experimental Medicine, Faculty of Health Science, Linköping University, Linköping, Sweden
| | - Sandra Ramstedt
- Orthopaedics, Department of Clinical and Experimental Medicine, Faculty of Health Science, Linköping University, Linköping, Sweden
| | - Per Aspenberg
- Orthopaedics, Department of Clinical and Experimental Medicine, Faculty of Health Science, Linköping University, Linköping, Sweden
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