Unique case of a GLI1 amplified biphasic mesenchymal tumor of the orbit

GLI1-altered mesenchymal tumors are an emerging entity in soft tissue pathology. In the head and neck region, they are most commonly in the tongue. Limited published data indicate a propensity for local recurrence, regional spread, and distant metastasis in both GLI1-rearranged and GLI1-amplified tumors. The purpose of this report is to present the rare case of a GLI1-amplified spindle cell tumor of the orbit and a focused review of the literature. A 54-year-old woman presented with proptosis, eye pain, and ocular motility restriction in the left eye. Imaging demonstrated a tumor occupying the superomedial intraconal orbit that was distinct from the extraocular muscles, optic nerve, and globe. The tumor was totally resected with a combined open transorbital and endoscopic, endonasal approach. Pathological analysis demonstrated a spindled and epithelioid mesenchymal tumor with diffuse nuclear GLI1 expression. PCR-based, next*-generation sarcoma fusion panel was negative for GLI1 fusions, including GLI1::ACTB fusions; however, DDIT3 breaks apart fluorescence in situ hybridization (FISH), which can be used as a surrogate for GLI1 alterations due to proximity to 12q13.3, showing amplification. Post-operatively, the patient had recovered visual acuity. She received adjuvant radiation therapy (60 Gy in 30 fractions). Surveillance for recurrence, regional spread, and distant metastasis has been negative at a 6-month follow-up. Ultimately, we report the first case of a GLI1-amplified mesenchymal neoplasm of the intraconal orbit managed with gross total resection via a combined approach followed by adjuvant radiation therapy.

POS0089 AZD9567 VERSUS PREDNISOLONE IN PATIENTS WITH ACTIVE RHEUMATOID ARTHRITIS: A PHASE 2A, RANDOMISED, DOUBLE-BLIND, PARALLEL-GROUP EFFICACY AND SAFETY STUDY

Background:

Oral corticosteroids such as prednisolone are potent anti-inflammatory drugs but their use is limited by side effects caused by unwanted actions on the glucocorticoid receptor (GR), such as increased insulin resistance, and off-target actions on the mineralocorticoid receptor (MR) that disrupt electrolyte balance and increase water retention. AZD9567 is an oral, selective, non-steroidal glucocorticoid receptor modulator being developed to treat inflammatory diseases. Pre-clinical and phase 1 clinical data indicate that AZD9567 is the first GR modulator with an improved efficacy–dysglycaemic side effect profile versus prednisolone.

Objectives:

To compare the efficacy, safety and tolerability of AZD9567 with prednisolone in patients with active rheumatoid arthritis (RA), at doses with predicted equivalent anti-inflammatory activity.

Methods:

In this phase 2a, randomised, double-blind, parallel-group, multicentre study in RA patients with DAS28-CRP ≥ 3.2 despite stable treatment with conventional disease-modifying anti-rheumatic therapies (NCT03368235), patients were randomised 1:1 to AZD9567 40 mg or prednisolone 20 mg orally once daily for 14 days. The primary endpoint was change from baseline in DAS28-CRP at day 15. Secondary outcomes included components of DAS28-CRP, TJC68, SJC66, ACR response (ACR20, ACR50, ACR70) and safety outcomes, including serum electrolytes.

Results:

All 21 randomised patients (AZD9567, n = 11; prednisolone, n = 10) completed the study. There was a slight imbalance between the treatment groups at baseline, with higher age (mean ± SD: 64.5 ± 8.4 vs 55.5 ± 13.6 years), more women (8 vs 5) and greater disease severity (DAS28-CRP, mean ± SD: 5.26 ± 0.98 vs 4.90 ± 0.74) in the AZD9567 group versus the prednisolone group. There was no statistically significant or clinically meaningful (i.e. > 1.2) difference in change from baseline to day 15 in DAS28-CRP between AZD9567 and prednisolone, although this was numerically lower with AZD9567 (Table 1). Similar results were observed for TJC68, SJC66, CRP and GH (Table 1). The proportions of patients achieving ACR20, 50 and 70 response criteria were similar in both groups, albeit numerically lower with AZD9567. Similar numbers of patients in each group reported treatment-emergent adverse events (AZD9567, n = 10, prednisolone, n = 9); most were mild in severity. One serious adverse event, suicidal depression, was reported after completing AZD9567 treatment. Morning fasting serum sodium/potassium ratio at day 15 was not altered with AZD9567 but was increased from baseline with prednisolone (Figure 1).

Conclusion:

AZD9567 40 mg had a similar efficacy profile to prednisolone 20 mg in patients with active RA. Both drugs were well tolerated, with no new safety signals. Unlike prednisolone, AZD9567 had no effect on serum sodium/potassium ratio, suggesting selectivity of AZD9567 for the GR over the MR. These results support further trials of AZD9567 in patients with inflammatory disease.

Table 1.

Change from baseline to day 15 in clinical disease activity measures.

AZD9567 (n = 11)Prednisolone (n = 10)Comparison(AZD9567 – prednisolone)LSM CFB (SE)95% CILSM CFB (SE)95% CILSMD (SE)95% CIp valueDAS28−CRP score−1.93 (0.35)−2.66, −1.21−2.40 (0.34)−3.11, −1.700.47 (0.46)−0.49, 1.430.315TJC28 score−6.12 (1.25)−8.76, −3.49−6.07 (1.21)−8.61, −3.52−0.05 (1.60)−3.43, 3.320.973SJC28 score−5.14 (0.65)−6.51, −3.76−5.40 (0.63)−6.73, −4.080.26 (0.84)−1.50, 2.030.757GH score−27.7 (7.3)−42.8, −12.5−37.4 (7.1)−52.3, −22.69.8 (9.7)−10.5, 30.10.325CRP, mg/L−10.8 (2.4)−15.9, −5.8−15.6 (2.5)−20.9, −10.34.8 (3.5)−2.5, 12.00.187TJC68 score−9.02 (2.46)−14.21, −3.82−7.90 (2.36)−12.88, −2.91−1.12 (3.12)−7.69, 5.460.724SJC66 score−6.24 (0.89)−8.13, −4.36−6.66 (0.86)−8.48, −4.850.42 (1.14)−1.98, 2.810.717

CFB, change from baseline; CRP, C-reactive protein; DAS28, 28-joint disease activity score; GH, global health; LSM(D), least-squares mean (difference); SJC, swollen joint count; TJC, tender joint count.

Acknowledgements:

Medical writing support was provided by Richard Claes PhD of PharmaGenesis London, London, UK, funded by AstraZeneca, Gothenburg, Sweden in accordance with Good Publication Practice 3 (GPP3) guidelines (http://www.ismpp.org/gpp3).

This study was funded by AstraZeneca. AZD9567 is an investigational medical product with no approved indication.

Disclosure of Interests:

Jacob M. van Laar Consultant of: Honoraria from - Abbvie, Arxx Tx, Galapagos, Gesyntha, Leadiant, Magenta, Roche, Sanofi Genzyme, Grant/research support from: AstraZeneca, Pfizer, Roche, Alejhandra Lei Shareholder of: AstraZeneca., Grant/research support from: Boehringer Ingelheim in 1998, Bristol-Myers Squibb in 1999, Employee of: AstraZeneca. Past employee of Almirall, Grünenthal, Boehringer Ingelheim, CESIF Pharma, Mary Safy-Khan Grant/research support from: Student grant from AstraZeneca 2015-2018., Joachim Almquist Shareholder of: AstraZeneca, Consultant of: AstraZeneca., Employee of: AstraZeneca., Carol Astbury Shareholder of: AstraZeneca., Employee of: AstraZeneca., Maria Belvisi Shareholder of: AstraZeneca., Grant/research support from: AstraZeneca and Chiesi, Employee of: AstraZeneca., Adam Platt Shareholder of: AstraZeneca., Employee of: AstraZeneca., Susanne Prothon Shareholder of: AstraZeneca., Employee of: AstaZeneca., Sara Samuelsson Shareholder of: AstraZeneca, Employee of: AstraZeneca, Petter Svanberg Employee of: AstraZeneca, Christina Keen Shareholder of: AstraZeneca., Employee of: AstraZeneca.

POS1432 SHORT-TERM RISK OF OSTEOPOROSIS IN ADULTS TREATED WITH CORTICOSTEROIDS: AN OBSERVATIONAL STUDY

Background:

Exposure to corticosteroids is recognised to increase the risk of osteoporosis.

Objectives:

Our aim was to evaluate patients’ short-term absolute risk of osteoporosis over the course of their first continuous exposure to corticosteroids.

Methods:

This was an observational study using UK data from the Clinical Practice Research Datalink. Adult patients were selected if exposed to systemic corticosteroids for any condition and had no prior osteoporosis. Non-exposed adults matched on age, sex, and disease burden were selected from the general population. Patients were followed from their first exposure to corticosteroid to the earlier of 90 days following the end of continuous prescribing or for a maximum of three years. Cohorts were categorised by age (18-42 years, 43-67 and 68-92 years), BMI (underweight, normal overweight, obese and obese+) and gender. Absolute risk rates were calculated for each of these categories.

Results:

In total, 573,056 exposed patients were matched 1:1 to non-exposed controls. Mean age was 52 years; 57% were female. The mean and median days’ supply were 50.9 and 13 days, respectively. Underweight females aged 68-92 years exposed to corticosteroids had the highest absolute risk of osteoporosis (70.9 per 1000 patient years (PKPY)); in matched non-exposed controls this was 26.6 PKPY. Generally, following their first continuous exposure to corticosteroids, patients taking steroids had greater risk of osteoporosis compared with those in the same age, sex and BMI category never exposed to corticosteroids.

Conclusion:

Whilst it is understood that exposure to corticosteroids increases the risk of osteoporosis, there are large differences in risk in accordance with age, sex and BMI. Alternatives to corticosteroids are urgently needed.

MaleFemaleSteroid-exposedNever exposedSteroid-exposedNever exposedAge groupBMI groupPatientsAbsolute rate (per 1,000 patient years)PatientsAbsolute rate (per 1,000 patient years)p-valuePatientsAbsolute rate (per 1,000 patient years)PatientsAbsolute rate (per 1,000 patient years)p-value18-421: Underweight1,2422.01,1950.00.56613,0794.53,4860.90.13612: Normal18,7982.219,6380.0<0.000142,2340.947,3400.10.00493: Overweight16,5362.615,1140.00.000124,8930.524,0090.10.23824: Obese +10,3110.68,4530.00.287426,6000.620,3200.30.461443-671: Underweight1,25427.46830.00.00402,42030.91,99018.50.11412: Normal27,0378.626,5692.0<0.000145,46715.950,4236.1<0.00013: Overweight42,4284.343,8720.7<0.000142,62010.843,2534.1<0.00014: Obese +31,4782.530,8520.80.000745,3396.039,8762.4<0.000168-921: Underweight93630.343210.30.15051,53270.91,23926.60.00032: Normal15,89111.315,0214.5<0.000118,30842.318,71718.6<0.00013: Overweight21,3717.323,1371.8<0.000119,14926.219,76012.9<0.00014: Obese +11,2165.611,3961.90.002114,45320.013,6148.7<0.0001

Disclosure of Interests:

Ellen Berni Consultant of: Employed by Pharmatelligence, which carries out consultancy work for AstraZeneca and other pharmaceutical companies., Philip Ambery Shareholder of: AstraZeneca, Employee of: AstraZeneca, Samuel Adamsson Eryd Shareholder of: AstraZeneca, Employee of: AstraZeneca, Sara Jenkins-Jones Consultant of: Employed by Pharmatelligence, which carries out consultancy work for AstraZeneca and other pharmaceutical companies., Mary Brown Shareholder of: AstraZeneca, Employee of: AstraZeneca, Carol Astbury Shareholder of: AstraZeneca, Employee of: AstraZeneca, Phillip Hunt Shareholder of: AstraZeneca, Employee of: AstraZeneca, Craig Currie Consultant of: Director of Pharmatelligence, which carries out consultancy work for AstraZeneca and other pharmaceutical companies

Bupropion SR for smoking cessation in smokers with cardiovascular disease: a multicentre, randomised study

AIMS

To investigate the safety and efficacy of bupropion sustained release (bupropion SR) in promoting abstinence from smoking in subjects with cardiovascular disease (CVD).

METHODS

Six hundred twenty-nine subjects with CVD who smoked >/=10 cigarettes/day were randomised in a double-blind, multicentre study to receive bupropion SR (150 mg twice daily) or placebo for 7 weeks, with a follow-up of 52 weeks. Primary efficacy endpoint: continuous abstinence from smoking from weeks 4 to 7. Secondary endpoints: continuous abstinence (weeks 4-12, 4-26 and 4-52) and weekly point prevalence abstinence. All participants received brief motivational support. Safety was evaluated throughout the study.

RESULTS

Continuous smoking abstinence rates from weeks 4 to 7 were significantly higher in subjects receiving bupropion SR compared with placebo (43 vs. 19%, odds ratio [OR]=3.27, 95% confidence interval [CI] 2.24-4.84; P<0.001). Continuous abstinence rates from weeks 4 to 26 and 4 to 52 continued to be more than double for bupropion SR compared with placebo (27 vs. 11%; 22 vs. 9%, P<0.001). Weekly point prevalence abstinence was significantly higher for participants who received bupropion SR compared with placebo at weeks 3, 7, 26 and 52 (P<0.001). In both groups, there were no clinically significant changes in blood pressure and heart rate throughout the treatment phase. Overall, 6% of the participants (n=36) discontinued study medication due to an adverse event (bupropion SR, n=17; placebo, n=19).

CONCLUSIONS

After 7 weeks of bupropion SR treatment, more than twice as many smokers with CVD had quit smoking at 1 year compared with placebo. The safety profile of bupropion SR was similar to that previously observed in general smoking populations.

Suppression of tumorigenicity in the human prostate cancer cell line M12 via microcell-mediated restoration of chromosome 19

Previously we immortalized human, nontransformed prostate epithelial cells with SV40 large T-antigen (SV40TAg) and derived increasingly aggressive sublines from the immortalized line. The progression of the tumorigenic sublines to metastatic capacity was accompanied by the formation of an unbalanced translocation between chromosomes 16 and 19, resulting in loss of 19p and proximal 19q. To test whether the tumorigenic and/or metastatic phenotype was causally related to this genetic alteration, we restored a neo-tagged human chromosome 19 to M12 cells by microcell-mediated transfer and assessed their growth. In vitro, the resultant hybrids grew more slowly in monolayer culture and showed a significant reduction in anchorage-independent growth as compared to M12neo controls. In vivo, all mice (13/13) injected subcutaneously (SC) with control M12neo cells developed tumors after 9-15 days. In contrast, 9/15 mice injected SC with microcell-transferred chromosome 19 hybrid cells failed to form tumors, with 6/15 producing very small tumors after 120 days. Analysis of three of these six tumors showed consistent, new chromosomal changes. Furthermore, in one of the tumors, loss of a chromosome 19 was noted in 40% of the cells. After intraprostatic injections of the hybrid cells, only 2/7 mice developed microscopic tumors, with no metastases. These data suggest the presence of a gene or genes on chromosome 19 that function to suppress growth.

The effect of sulphasalazine on neutrophil superoxide generation in rheumatoid arthritis

The production of superoxide by the peripheral blood neutrophils of 19 patients with active rheumatoid arthritis was measured during treatment with sulphasalazine (SASP). The response to drug treatment was determined by change in plasma viscosity, CRP, early morning stiffness and articular index over a 10-point scale. Of the 19 patients studied, eight were considered to have responded well to SASP and seven to have responded poorly or not at all. Over the treatment period, plateau levels of superoxide production fell in seven of the eight responders (P = 0.028) compared with a non-significant fall in 3/7 of the non-responder groups. The initial rate of superoxide production also fell in the responder group, but this was not statistically significant. Initial values in both the responder and non-responder groups were comparable with those seen for normal controls. Analysis of drug levels showed all patients to be compliant with drug treatment; however, drug levels and neutrophil activity were not correlated. Studies of the effect of SASP and sulphapyridine on superoxide production in vitro showed no difference between good and poor responders. These results suggest that there is no inherent difference between good and poor responders regarding the susceptibility of their neutrophils to SASP. SASP's action on neutrophils, therefore, appears not to be its main mechanism of disease-modifying activity in RA.

Urinary glucaric acid excretion in rheumatoid arthritis: influence of disease activity and disease modifying drugs

OBJECTIVE

To examine if a correlation exists between cytochrome P-450 enzyme induction and disease activity in patients with rheumatoid arthritis (RA), measuring urinary excretion of D-glucaric acid (GA) as an index of phase II drug metabolism.

METHODS

Patients with RA were treated with sulphasalazine, sodium aurothiomalate, or D-penicillamine in standard dose regimens, for 24 weeks. Patients with ankylosing spondylitis (AS) or non-inflammatory arthritis (NIA) acted as controls. The urinary GA:creatinine ratio was measured at 0, 12, and 24 weeks of treatment.

RESULTS

Patients with RA had a slightly greater urinary GA:creatinine ratio than patients with AS or NIA at baseline; this increased during treatment with disease modifying antirheumatic drugs (DMARDs). Sulphasalazine treatment had a greater effect on GA excretion than sodium aurothiomalate or D-penicillamine; this difference was statistically significant between weeks 0 and 12 (p = 0.01). Gamma glutamyltranspeptidase concentration showed a weak correlation with GA excretion between weeks 0 and 12 (p = 0.03), but all other measurements of changes in disease activity (plasma viscosity, C reactive protein, platelets, and articular index) were found not to correlate with GA excretion between weeks 0-12 or 0-24.

CONCLUSION

The increased excretion of GA in patients with RA receiving DMARD treatment is probably the result of an indirect effect on hepatic metabolism bearing no relationship to disease activity.

Polymorphic acetylation: lack of influence of rheumatic disease activity and concomitant drug administration

Acetylation polymorphisms have been linked with a tendency to develop rheumatic diseases. We investigated the effect of changes in the disease activity of patients with rheumatoid arthritis (RA) during disease-modifying antirheumatic drug (DMARD) treatment, and on the capacity of these patients to acetylate the sulphonamide sulphadimidine. Fifty-four patients with RA treated with gold, sulphasalazine or D-penicillamine, 12 patients with AS and 16 patients with non-inflammatory arthritis (NI) were investigated over a 24-week period. The capacity of these individuals to acetylate sulphadimidine was determined at baseline and after 12 and 24 weeks. Although there was a tendency for sulphadimidine acetylation to increase in patients with RA from a median of 84.5% [interquartile range (IQR) 77.0-95.0%] at baseline to 90.5% (IQR 77.5-96.0%) at week 24, this failed to reach statistical significance. In contrast, the trend in patients with AS or NI was towards a decrease in acetylation. There was no correlation between changes in disease activity and sulphadimidine acetylation during DMARD intervention.

Phenotype/genotype relationships for the cytochrome P450 enzyme CYP2D6 in rheumatoid arthritis: influence of drug therapy and disease activity

OBJECTIVE

To determine whether particular genotypes for the cytochrome P450 enzyme CYP2D6, a polymorphic enzyme, are associated with susceptibility to rheumatoid arthritis (RA) and whether CYP2D6 enzyme activity is altered as a result of the disease or its treatment.

METHODS

CYP2D6 genotypes and metabolic phenotypes were determined for 53 patients with RA and 73 healthy controls. Genotyping was carried out by restriction fragment length polymorphism analysis with the restriction enzyme XbaI and by 2 separate polymerase chain reaction assays; phenotyping was by analysis of in vivo metabolism of the probe drug debrisoquin.

RESULTS

No significant difference in the distribution of overall genotypes between the 2 groups was observed. When the frequency of individual alleles was investigated, a significant difference in allele frequency for the CYP2D6D allele (p < 0.005) was observed with fewer patients with RA showing this mutation. Metabolic phenotypes were broadly similar between the patients and controls. However, a number of the patients with RA showed higher than expected metabolic ratios for their particular genotype due to interference by the analgesic dextropropoxyphene in the phenotyping procedure.

CONCLUSION

Our findings demonstrate that CYP2D6 activity is not impaired in RA.

A clinical and biochemical assessment of methotrexate in rheumatoid arthritis

Low-dose methotrexate has gained widespread acceptance as a second-line agent in rheumatoid arthritis (RA). The Leeds Human Model Screening System (LHMSS) is a validated screening mechanism allowing the rapid evaluation of compounds for their potential as anti-rheumatic agents, the results of which have been confirmed in longer term studies. We have evaluated methotrexate in patients with RA using the LHMSS at a maintenance dose of 10mg/week. Significant change occurred in four out of eleven variables over a 24-week period (p < 0.01). This degree of change is greater than that seen with nonsteroidal anti-inflammatory agents but less than with other recognised second-line agents such as D-penicillamine, suggesting that methotrexate may have less potential as a second-line agent than D-penicillamine.

Urinary excretion of pyridinium crosslinks of collagen correlated with joint damage in arthritis

The urinary excretion of the collagen crosslinking compounds pyridinoline and deoxypyridinoline have been determined in patients with morphologically different subgroups of OA and RA. There was no significant difference in pyridinoline or deoxypyridinoline excretion when patients with four grades of severity of OA were compared, although the median excretion of pyridinoline and deoxypyridinoline for the OA group as a whole was raised above values found in a healthy control population. Patients with severe or late (burnt-out) RA were found to have a significantly greater excretion of pyridinoline and deoxypyridinoline than patients with early (< 6 months duration) or mild RA.

Sequential study of bacterial antibody levels and faecal flora in rheumatoid arthritis patients taking sulphasalazine

Faecal and serum samples were collected from 31 patients with active RA during treatment with DMARD sulphasalazine (SASP). These were examined for changes in faecal flora and antibodies to bacterial antigens respectively. Faecal counts of Clostridium perfrigens but not Escherichia coli or total aerobic or anaerobic counts fell significantly after 2 weeks of treatment, this decrease being maintained throughout the treatment period. There was, however, no relationship between changes in the faecal carriage of this micro-organism and response to drug treatment, as assessed using clinical and biochemical indicators of disease activity. Changes in antibody levels to antigen preparations of this organism were also unrelated to response to drug treatment. These results suggest that the anti-rheumatic properties of SASP are independent of its antibacterial effect on bacteria in the bowel and also that neither faecal carriage of, nor antibody responses to this bacterium are involved in disease pathogenesis. Antibody levels to an antigen preparation of Cl. perfringens were found to be significantly lower in those patients who respond well to SASP than those patients who show poor response; this may prove useful as a clinical marker for predicting those patients likely to respond to SASP therapy.

Optimizing the assessment of disease activity during treatment with anti-rheumatoid drugs

Clinical trials in RA usually involve the use of several laboratory assessments of disease activity. Their use is not universal and the relative value of many novel assessments has not been determined in relation to existing clinical and laboratory methods. This study attempts to investigate the value of established and novel assessments of disease activity during treatment with accepted DMARDs. Over a 48-week study period, changes in cytidine deaminase (CD), beta 2-microglobulin, alpha 1-acid glycoprotein (alpha 1-AGP), serum antibodies to Clostridium perfringens alpha-toxin, pre-albumin and caeruloplasmin were compared to a group of established clinical and laboratory assessments including plasma viscosity, CRP haemoglobin and platelet count during treatment with the established second-line drugs, D-penicillamine (n = 20), sulphasalazine (n = 17), gold (n = 12) and hydroxychloroquine (n = 18). Overall, the assessments showing the greatest degree of change were plasma viscosity, articular index, summated change score, platelet count, CD, white cell count, alpha 1-AGP, CRP and pain score. The assessments showing the greatest degree of change were not homologous between the treatment groups and no single assessment was outstanding for a particular drug treatment.

Phthalylsulphathiazole in rheumatoid arthritis

Sixteen patients with active rheumatoid arthritis were treated with phthalylsulphathiazole (4 g/day) over a period of 24 weeks. Although there was some statistically significant improvement in plasma viscosity, IgM, pain score, morning stiffness and summated change score, this was either intermittent or not maintained. Five patients withdrew from the trial before completion, four (25%) with non-serious adverse reactions and one patient from lack of efficacy; only one patient elected to remain on the drug beyond the 24-week period. Low free and total sulphathiazole serum concentrations were found, confirming that most of the drug remained within the gut. This investigation suggests, certainly at the dose used, that phthalylsulphathiazole does not have the properties of a second-line agent. Higher doses of the drug will not be ethically feasible.

Human nocturnal blood melatonin and liver acetylation status

The human dark phase melatonin concentrations exhibit a wide range of values. In an attempt to explain this variation, we measured 2250-2305 h melatonin levels by radioimmune assay in eleven fast and eleven slow acetylator phenotypes. No statistical difference between the two groups existed, suggesting therefore that such variations are not due to acetylator status. The study revealed a negative relationship between body weight or area and nocturnal melatonin concentration. No correlation was found between dark phase melatonin levels and age, anxiety, depression, or sleep rating.

Methylsulphasalazine in rheumatoid arthritis

Methylsulphasalazine, which differs from sulphasalazine by the addition of one methyl group, may provide the benefits of the parent drug with fewer side-effects in rheumatoid arthritis (RA). We describe the outcome of its use in RA. Of 21 patients entered into the study, 10 successfully completed 6 months of therapy; five developed adverse effects, four withdrew for reasons unrelated to drug treatment and two stopped because of inefficacy. No serious adverse effects were reported. A statistically significant improvement in most clinical assessments was observed from weeks 8-12 onwards. Significant improvement in plasma viscosity was observed and there was a trend towards improvement in serum CRP, histidine and IgM concentrations. There was a good correlation between mean serial changes in clinical and biochemical assessments indicating that the drug may exhibit the properties of a second-line agent. Median steady-state serum concentrations of methylsulphasalazine and methylsulphapyridine were 26.6 micrograms/ml and 2.85 micrograms/ml respectively.

Comparison of the single dose pharmacokinetics of sulphasalazine in rheumatoid arthritis and inflammatory bowel disease

The pharmacokinetics of sulphasalazine and its principal metabolites in rheumatoid arthritis (RA) and inflammatory bowel disease (IBD) were compared. Patients with RA had a significantly greater concentration of plasma sulphapyridine than patients with IBD (medians 14.0 micrograms/ml and 7.4 micrograms/ml respectively). Patients with RA also tended to maintain a higher plasma sulphapyridine concentration with time, as determined by the area under the curve (AUC), but a lower plasma sulphasalazine AUC than patients with IBD. It is suggested that more sulphasalazine may be presented to the lower bowel for cleavage to sulphapyridine and 5-aminosalicylic acid in patients with RA than in IBD. Patients with RA may also have impaired metabolism of sulphapyridine as a consequence of their disease. Together these factors may contribute to higher peak circulating sulphapyridine concentrations and may be responsible for the higher incidence of side effects of sulphasalazine treatment in patients with RA than in patients with IBD.

Infection risks in hospital staff from blood: hazardous injury rates and acceptance of hepatitis B immunization

A questionnaire survey of 1800 clinical health care staff was undertaken to determine hazardous injury rates and uptake of hepatitis B vaccination. The overall sharps injury rate was 116 injuries per 100 staff per year. Full-time doctors had the highest rates. Surgical procedures were the commonest cause of accidental injury (58 per cent) and 30 per cent of all sharps injuries were attributable to careless handling. Injuries caused by bites and scratches from patients occurred mainly in nurses and auxilliaries in psychiatric and geriatric wards (115/100 staff per year). Twenty-four per cent of respondents had received a full course of hepatitis B vaccine and 51 per cent of the remainder were planning to have, or were in the process of receiving, a course. The most frequent reason given for not being vaccinated was lack of information about vaccination. This survey reveals injury rates higher than those observed in previous reports, particularly in doctors, and shows a need for more information and advice about hepatitis B infection and vaccination to be targeted to health care workers at risk.

Co-trimoxazole in rheumatoid arthritis: a comparison with sulphapyridine

The antirheumatoid activity of sulphasalazine and sulphapyridine may result from their antibacterial properties. The second line activity of sulphamethoxazole, in the form of cotrimoxazole (CTZ), has been investigated by treatment of 13 patients with RA for 24 weeks with CTZ (480 mg three times a day). The drug was found to be poorly tolerated, only five of the thirteen patients recruited completing the study. High circulating concentrations of sulphamethoxazole were found, with mean (SD) steady state serum concentrations reaching 54.02 (23.38) micrograms/ml. A significant reduction in serum IgM from 280 to 130 IU/l was observed, but otherwise disease activity remained unchanged or deteriorated throughout the course of the study. In contrast, patients with RA treated with sulphapyridine (1.25 g a day) showed improvement in disease activity. The results argue against an antibacterial mechanism of action for sulphasalazine and sulphapyridine in rheumatoid arthritis, unless this occurs at a site inaccessible to sulphamethoxazole.

Kinetic investigations into the possible cause of low serum histidine in rheumatoid arthritis

To investigate the cause of low serum histidine in rheumatoid arthritis (RA) single oral and intravenous doses of L-histidine were administered to patients with active RA, and to an equal number of age and sex matched control subjects. In the first study 13 patients and their controls received a 100 mg kg-1 dose of L-histidine as an aqueous slurry. Significant differences were seen in body weight, predose baseline serum histidine concentration, Cmax, t1/2, and area under curve, AUC0-infinity. In a second study six patients and six controls each received a 50 mg kg-1 dose of L-histidine both orally and intravenously on two separate occasions. The patients with RA had a lower baseline serum histidine concentration, a lower volume of distribution, and a shorter plasma half life than the controls, but these differences were not statistically significant. No difference was seen in bioavailability or clearance. Low serum histidine in RA is unlikely to be due to malabsorption from the gut, uptake by abnormal gut flora, or increased metabolism.

Sulphasalazine alone or in combination with D-penicillamine in rheumatoid arthritis

Thirty patients (22 women) with active rheumatoid arthritis participated in an open study of 6 months' treatment with either enteric-coated sulphasalazine (SASP) or SASP plus D-penicillamine (DPA). Patients were assessed at regular intervals using a number of clinical and biochemical tests designed to detect specific antirheumatic activity. There were significant improvements in clinical and laboratory variables with both regimens consistent with second-line activity. Improvements were greater and more numerous with combination therapy. At the end of the trial period, there were nine 'responders' in the SASP/DPA group but only six in the SASP group. Neither efficacy nor toxicity could be related to patient acetylator status. Nausea and dyspepsia were frequent problems with both treatment regimens but dysgeusia and thrombocytopenia were confined to the SASP/DPA group. Study withdrawals were twice as common with combination therapy. These results suggest that a combination of SASP and DPA is more potent than SASP alone but at the expense of poorer patient tolerance.

Measurement of the cross linking compound, pyridinoline, in urine as an index of collagen degradation in joint disease

An enzyme linked immunoassay (ELISA) for the collagen cross link, pyridinoline, has been developed using affinity purified antibodies, with a sensitivity down to about 0.1 ng of cross link. Measurements of urinary pyridinoline were made in patients with rheumatoid arthritis (RA), osteoarthritis (OA), and a control group showing no signs of joint disease. Expressed relative to creatinine values, pyridinoline was significantly increased in both RA and OA groups compared with controls: these differences were much larger than could be attributed to any age related effects or to changes in urinary creatinine concentrations. These findings were confirmed by analysis of a series of 24 h urine collections which showed that the total pyridinoline excretions were significantly higher in both RA and OA groups than in the controls. As pyridinoline is much more prevalent in cartilage than in bone collagen, measurement of this compound in urine may provide an index for monitoring the increased joint destruction that occurs in arthritic disease.

Prednisolone pharmacokinetics in patients with rheumatoid arthritis, polymyalgia rheumatica and asthma

The pharmacokinetic profile of a single 10 mg oral dose of prednisolone was studied in three groups of six patients with rheumatoid arthritis (RA), polymyalgia rheumatica (PMR) and bronchial asthma (BA) who were already receiving steroid therapy. A fourth group of age and sex-matched normal controls was also studied. Kinetic parameters (including elimination half-life, area under the plasma concentration curve, apparent volume of distribution and total body clearance) were similar for all four groups but there was considerable inter-subject variability. The correlations between these kinetic parameters and age, body weight and serum albumin were poor. The results suggest that any differences in the effects of corticosteroids in these inflammatory diseases are unlikely to be due to pharmacokinetic factors. The duration of steroid therapy and the reduction in patient mobility would appear to be more likely explanations for the reduction in bone mass observed in patients with RA.

A study to determine the active moiety of sulphasalazine in rheumatoid arthritis

Thirty patients with active rheumatoid arthritis (RA) participated in an open study of 6 months' treatment with either 5-aminosalicylic acid (5-ASA) or sulphapyridine (SP), the two moieties of sulphasalazine (SASP). Patients were assessed at regular intervals using clinical and biochemical tests designed to detect specific antirheumatic activity. Patients taking SP showed significant improvement in disease activity, but those taking 5-ASA did not improve, despite the fact that high serum concentrations of 5-ASA and acetyl 5-ASA were achieved. These results suggest that SP is the active moiety of SASP. Its possible mode of action is discussed. Nausea was a frequent problem in patients taking SP. Unless this can be overcome, SP is unlikely to offer any therapeutic advantages over SASP in the treatment of RA.

5-Aminosalicylic acid or sulphapyridine. Which is the active moiety of sulphasalazine in rheumatoid arthritis?

Thirty patients with active rheumatoid arthritis participated in an open study of 6 months' treatment with either 5-aminosalicylic acid or sulphapyridine, the two moieties of sulphasalazine. Patients were assessed at regular intervals using a number of clinical and biochemical tests designed to detect specific antirheumatic activity. Patients taking sulphasalazine showed significant improvement in most parameters of disease activity, but those taking 5-aminosalicylic acid did not improve despite the fact that high serum concentrations of 5-aminosalicylic acid and acetyl 5-aminosalicylic acid were achieved. These results suggest that sulphapyridine is the active moiety of sulphasalazine. Its possible mode of action is discussed. Nausea was a frequent problem in patients taking sulphapyridine. Unless this problem can be overcome, sulphapyridine is unlikely to offer any therapeutic advantages over sulphasalazine in the treatment of rheumatoid arthritis.

A double-blind controlled trial of etretinate (Tigason) and ibuprofen in psoriatic arthritis

Etretinate (Tigason) and ibuprofen have been compared in a double-blind controlled trial in psoriatic arthritis to see if we could confirm a specific action for this vitamin A derivative suggested from earlier uncontrolled studies. Eleven out of 20 patients completed 24 weeks of therapy with etretinate (up to 0.5 mg/kg/day) whereas only 1/20 patients completed 24 weeks of therapy with ibuprofen alone. Etretinate improved skin lesions, and this may have encouraged patients to persist with it. Improvement of statistical significance was seen for articular index in both groups. In addition significant improvement in ESR, haemoglobin, C-reactive protein, and histidine occurred in the etretinate group. The main side effects of etretinate (which may preclude its use at a higher dose in this condition) included cracked and dried lips and sore mouth.