Angiotensin-converting enzyme inhibitors (ACEi) have immunomodulating properties and have been suggested to protect against endothelial injury, for example myocardial infarction and reperfusion injury. We tested whether two ACEi (captopril and enalapril), differing in a thiol group, protected human umbilical vein endothelial cells (HUVEC) from cytotoxicity induced by polymorphonuclear neutrophils (PMN) in vitro, when cells were activated by tumour necrosis factor- (TNF) or the arachidonate derivative lipoxin-A(4) (LXA(4)), using separate cytotoxicity pathways. When Cr-51 labelled HUVEC were treated with captopril (0-500m) or enalapril (0-100m) for 2h and then activated by TNF (100ng/ml) for 24h, a significant, dose-dependent reduction of Cr-51 release was observed. Similarly, captopril reduced Cr-51 release when LXA(4) (0.1m) was used to stimulate PMN for 4h. Among previously defined mechanisms of significance for the cytotoxic reaction, expression of ICAM-1, but not intracellular Ca2+ changes in PMN or PMN adherence to HUVEC, were reduced by ACEi treatment. Moreover, both ACEi inhibited HUVEC surface expression of TNF receptor I (but not II). Thus, these ACEi, particularly captopril, interfere with PMN-induced cytotoxicity for endothelial cells by modulating pro-inflammatory surface receptors, which is a novel effect that might be explored for further therapeutic approaches.

ObjectiveTo compare EuroQol 5-Dimensions (EQ-5D) utility and quality-adjusted life-years (QALYs) in patients with early, methotrexate (MTX) refractory rheumatoid arthritis (RA), randomised to addition of infliximab (IFX) or sulfasalazine and hydroxychloroquine (SSZ+HCQ).MethodsRA-patients with symptoms <1 year were enrolled between 2002 and 2005 at 15 Swedish centres. After 3–4 months of MTX monotherapy, patients with a remaining DAS28>3.2 were randomised to addition of IFX or SSZ+HCQ and followed for 21 months. EQ-5D profiles were collected every 3 months. Between-group comparisons of utility change and accumulated QALYs were performed, using last observation carried forward (LOCF) following protocol breach. Missing data were imputed by linear interpolation or LOCF. Sensitivity analyses applying baseline observation carried forward (BOCF) or restricted to completers were conducted.ResultsOf 487 patients initially enrolled, 128 and 130 were randomised to IFX or SSZ+HCQ, respectively. Mean utility in the IFX and SSZ+HCQ groups increased from 0.52 (SD 0.27) and 0.55 (SD 0.27) at randomisation to 0.66 (SD 0.25) and 0.63 (SD 0.27) at 21 months (adjusted mean difference favouring IFX 0.04; 95% CI −0.01, 0.09; p=0.15). Average accumulated QALYs were 1.10 (SD 0.37) and 1.07 (SD 0.42) in the IFX and SSZ+HCQ groups, respectively (adjusted mean difference favouring IFX 0.07; 95%CI −0.01, 0.14; p=0.07). BOCF analysis showed similar results, while differences were reversed, though remained statistically non-significant among completers. Dropout rates in the IFX/SSZ+HCQ groups were 30%/43% (p=0.01).ConclusionsComparing addition of IFX or SSZ+HCQ to MTX in active early RA, no statistically significant differences in utility or QALY gain could be detected over 21 months.Trial registrationRegistered in WHO database at the Karolinska University Hospital, number CT20080004.

Background Adding infliximab (IFX) or sulfasalazine+hydroxychloroquine (SSZ+HCQ) to methotrexate (MTX) in patients with active, early rheumatoid arthritis (RA), resulted in superior radiographic outcome in the IFX group,[1] while disease-activity, utility and work loss improved in both arms, without detectable between-group differences at 21 months[1-3]. Objectives To evaluate the cost-effectiveness of biologic vs. conventional combination treatment in early RA-patients responding insufficiently to MTX. Methods This multicenter, randomised, controlled, open-label trial enrolled RA-patients (symptoms<1y) in Sweden between 2002 and 2005. After 3-4 months of MTX monotherapy, patients with a remaining DAS28>3.2 were randomised to addition of IFX or SSZ+HCQ. The incremental cost-effectiveness ratio (ICER=€/quality-adjusted life-year [QALY]) was assessed during 21 months from randomisation. Costs of RA-related medications, non-primary healthcare utilisation and work loss were retrieved from nationwide registers, while EuroQol 5-Dimensions utility was collected quarterly. Undiscounted analyses including all patients were performed from the societal (human capital method) and healthcare perspectives. Confidence intervals were estimated by non-parametric bootstrapping. Results Of 487 patients initially enrolled, 128 and 130 were randomised to biologic and conventional treatment, respectively. The biologic group had higher drug and healthcare costs (€27,487 vs. 10,364; adjusted mean difference 16,956 [95%CI 14,647;19,162]), while no difference was seen in productivity losses (€33,804 vs. 29,220; 3,961 [-3,986;11,850]), resulting in higher societal cost, as compared to the conventional treatment arm (€61,291 vs. 39,584; 20,916 [12,800;28,660]). Mean accumulated QALYs were 1.10 in the biologic and 1.12 in the conventional treatment group (adjusted mean difference 0.01 [95%CI -0.07;0.08]). The resulting ICER, comparing the biologic to the conventional treatment option, was €2,404,197/QALY from the societal (Figure), and €1,948,919/QALY from the healthcare perspective. Image/graph Conclusions In early MTX-refractory RA, the addition of IFX, as compared to addition of SSZ+HCQ, was not cost-effective over 21 months at willingness to pay levels generally considered acceptable. References van Vollenhoven RF, et al. Lancet 2012;379:1712-1720. Karlsson JA, et al. Ann Rheum Dis 2012. Nov 29 [Epub ahead of print]. Eriksson JK, et al. ACR 2011; Abstract no: 459. Disclosure of Interest None Declared

Keratins (K) constitute the epithelial intermediate filaments. Among them, K7/K19 are widely used markers of the regenerative liver response termed ductular reaction (DR) that consists of activated biliary epithelial cells (BECs) and hepatic progenitor cells (HPCs) and correlates with liver disease severity. In the present study we aimed to characterize K23 in the liver.We analyzed the expression and localization of K23 in the digestive system under basal conditions as well as in various human and mouse liver diseases/stress models. Cell culture studies were used to study factors regulating K23 expression.In untreated mice, K23 was restricted to biliary epithelia. It was (together with K7/K19) markedly upregulated in three different DR/cholestatic injury models, i.e., multidrug resistance protein 2 (Mdr2) knockouts, animals treated with 3,5-diethoxycarbonyl-1,4-dihydrocollidine or subjected to bile duct ligation. K23 levels correlated with the DR marker Fn14 and immunofluorescence staining showed a distinct co-localization with K7/K19. In chronic human liver disease, K23 expression increased in patients with a more prominent inflammation/fibrosis. A dramatic upregulation (>200 times) was observed in patients with acute liver failure (ALF) and end-stage primary biliary cholangitis (PBC). Patients with alcoholic liver cirrhosis displayed increased K23 serum levels. In primary hepatocytes as well as hepatobiliary cell lines, treatment with TNF-related weak inducer of apoptosis (TWEAK), and the type I acute phase inducer interleukin (IL)-1β but not the type II inducer IL-6 elevated K23 expression.K23 represents a specific, stress-inducible DR marker, whose levels correlate with liver disease severity. K23 may represent a useful non-invasive DR marker.Ductular reaction represents a basic response to liver injury and correlates with liver disease severity. Our study identifies K23 as a novel ductular reaction marker in mice and humans.

Objectives: Cyclophosphamide (CYC) and corticosteroids are generally considered standard induction therapy for antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV). However, a subset of patients are refractory or intolerant to this treatment. Rituximab, a chimeric anti-CD20 antibody, has emerged as a second-line therapy, although controlled studies are scarce in patients with relapsing or refractory disease.Methods: We report 16 patients with AAV who received rituximab for refractory or relapsing vasculitis having previously received CYC. The treatment protocols were 375 mg/ m(2) x IV in five patients, 1000mg x II in six patients, and 500 mg x II in five patients, all in combination with corticosteroids. A majority of patients used other concurrent immunosuppression, most commonly mycophenolate mofetil. Disease activity was assessed using the Birmingham Vasculitis Activity Score (BVAS 2003) at baseline and during follow-up together with C-reactive protein (CRP) and ANCA. Complete remission was defined as a BVAS score of 0 and partial remission as a reduction in BVAS of at least 50%.Results: Twelve patients achieved complete remission, three patients partial remission, and one patient died during follow-up (median of 20 months, range 3-48 months). Six patients relapsed and received rituximab again. Four of these were positive for capture proteinase 3 (PR-3) ANCA but negative with conventional PR-3 ANCA upon retreatment. Seven patients had an adverse event, including two hepatitis B reactivations and one fatal sepsis.Conclusion: Treatment with rituximab in AAV was associated with prolonged remission in a subset of patients otherwise difficult to manage.

OBJECTIVE:To determine whether emerging cardiovascular risk factors such as anti-apolipoprotein A-1 (anti-apoA-1) immunoglobulin (Ig)G and oxidized low density lipoprotein (oxLDL) are associated with cardiovascular disease (CVD), carotid intima-media thickness (IMT), and disease activity in rheumatoid arthritis (RA).METHOD:We determined the aforementioned associations in 69 RA patients with disease duration of 5 years and 46 controls matched by age, sex, and smoking status. Anti-apoA-1 IgG and oxLDL were measured by enzyme-linked immunosorbent assay (ELISA). Carotid arteries were examined by ultrasound. Disease Activity Score calculated on 28 joints (DAS28) was used to assess disease activity.RESULTS:CVD prevalence was higher among RA patients than controls (17% vs. 2%, p = 0.01) but there was no difference in IMT (median: 0.67 vs. 0.66, p = 0.33). RA patients had a higher anti-apoA-1 IgG prevalence than controls (20% vs. 0%, p = 0.001). Anti-apoA-1 IgG and oxLDL levels were higher in cases than controls [median: 0.33 vs. 0.175 optical density (OD), p = 0.03; and 121 vs. 37.2 U/L, p = 0.0001, respectively]. Anti-apoA-1 IgG-positive patients had higher levels of oxLDL (median: 140.5 vs. 112 U/L, p = 0.01) than those tested negative. Receiver operating characteristic (ROC) curve analysis showed that only anti-apoA-1 IgG was a modest but significant predictor of CVD [area under the curve (AUC) = 0.65, p = 0.03] in RA patients. oxLDL was significantly associated with RA disease activity, whereas anti-apoA-1 IgG was not.CONCLUSIONS:Anti-apoA-1 IgG could be a marker of CVD in RA, whereas oxLDL levels seem to reflect RA disease activity. Other causes of CVD than a general increase in atherosclerosis (as determined by IMT measurements) including plaque stability may therefore be of importance to explain the increased incidence of CVD in RA.

BACKGROUND:New treatment strategies for early rheumatoid arthritis are evolving rapidly. We aimed to compare addition of conventional disease-modifying antirheumatic drugs (sulfasalazine and hydroxychloroquine) with addition of a tumour necrosis factor antagonist (infliximab) to methotrexate in patients with early rheumatoid arthritis.METHODS:We undertook a randomised trial in 15 rheumatology units in Sweden. We enrolled patients with early rheumatoid arthritis (symptom duration <1 year) and administered methotrexate (up to 20 mg per week). After 3-4 months, those who had not achieved low disease activity but who could tolerate methotrexate were randomly allocated by computer addition of either sulfasalazine and hydroxychloroquine or infliximab. Primary outcome was achievement of a good response according to European League Against Rheumatism (EULAR) criteria at 12 months. Patients were followed up to 24 months; here, we present findings at 12 months. Analysis was by intention to treat and we used non-responder imputation. The Swefot (Swedish Pharmacotherapy) study is registered in the WHO database at the Karolinska University Hospital, number CT20080004.FINDINGS:487 patients were initially enrolled. Of 258 who had not achieved low disease activity with methotrexate, 130 were allocated sulfasalazine and hydroxychloroquine and 128 were assigned infliximab. 32 of 130 (25%) patients allocated sulfasalazine and hydroxychloroquine achieved the primary outcome compared with 50 of 128 (39%) assigned infliximab (risk ratio 1.59 [95% CI 1.10-2.30], p=0.0160). Adverse events were balanced fairly well between the two groups and accorded with known adverse events of the drugs used. No deaths occurred in either group.INTERPRETATION:In patients with early rheumatoid arthritis in whom methotrexate treatment failed, addition of a tumour necrosis factor antagonist to methotrexate monotherapy is clinically superior to addition of conventional disease-modifying antirheumatic drugs.FUNDING:Swedish Rheumatism Association, Schering-Plough.

The pathophysiology of cluster headache (CH) is supposed to involve the lower posterior part of the hypothalamus, the trigeminal nerve, autonomic nerves and vessels in the orbital/retro-orbital region. The exact connection of this hypothalamic-trigemino-autonomic-vascular axis is not fully understood. The presence of inflammation in the perivascular tissue of the retro-orbital region has been presented as a possible mechanism behind the pain and the sympatheticoplegia sometimes observed during headache attacks. In a previous study we found neither increased levels of erythrocyte sedimentation rate, C-reactive protein or acute-phase reactants nor clinical signs of a generalized inflammatory disorder. However, these tests may not be sensitive enough to detect a focal inflammatory process in the retro-orbital region. In the present study, we analysed serum levels of three soluble adhesion molecules; soluble intercellular adhesion molecule-1 (sICAM-1), soluble vascular cell adhesion molecule-1 (sVCAM-1) and soluble E-selectin (sE-selectin) in patients with episodic CH and in patients with biopsy-positive giant cell arteritis (GCA), a known vasculitic disorder of large and medium-sized arteries. A control group of healthy volunteers was also included. Within the CH group, sICAM-1, sVCAM-1 and sE-selectin showed an increasing trend in remission compared with the active CH period, but the difference was statistically significant for sE-selectin only. The mean sICAM-1 value was higher in patients with active GCA than in CH patients during the active cluster period. Compared with the healthy control group, the mean levels of soluble adhesion molecules in CH patients also tended to be higher, but statistically significantly so only for sVCAM-1. We hypothesize that CH is not a vasculitic disorder of the medium-sized arteries, but CH patients may have an immune response that reacts differently from that of healthy volunteers.

Giant cell arteritis (GCA) is a T‐cell‐dependent, antigen‐driven vasculitis of large‐ and medium‐sized arteries. Glucocorticosteroids are considered the cornerstone in GCA therapy. Such treatment e...

Objectives: The aim of this study was to investigate the influence of plasma and synovial fluid tumour necrosis factor alpha (TNFα), interleukin‐1beta (IL‐1β), IL‐6, soluble TNF receptor II (TNF‐sRII), IL‐1 receptor antagonist (IL‐1ra), soluble IL‐1 receptor II (IL‐1sRII) and IL‐10 on the effect of the TNFα antibody infliximab on temporomandibular joint (TMJ) pain in patients with active rheumatoid arthritis (RA). Methods: Fifteen patients with TMJ pain taking methotrexate were included in the study. The effect of intravenous infusions of infliximab was assessed after 14 or 22 weeks. TMJ resting and movement pain was assessed by a visual analogue scale (VAS) (0–100 mm) and samples of venous blood and TMJ synovial fluid were collected before and after treatment. Results: The effect of infliximab on TMJ pain was influenced by pretreatment plasma levels of IL‐1β, IL‐1ra, and IL‐10 as well as pretreatment levels of TMJ synovial fluid IL‐1sRII. High pretreatment levels of these cytokines and receptors as well as the presence of rheumatoid factor (RF) were associated with no or minor reduction in TMJ pain after treatment. Conclusions: Systemic treatment of RA with a combination of infliximab and methotrexate seems to be insufficient to alleviate TMJ pain in patients with RF or high pretreatment plasma levels of IL‐1β.

Objectives: To determine whether the tumour necrosis factor‐α (TNF‐α) antagonist adalimumab (Humira®) can be efficacious after secondary loss of efficacy (i.e. loss of clinical response in patients who had initially demonstrated clinical response) to infliximab (Remicade®) or etanercept (Enbrel®).Patients and methods: We studied 36 patients from the Stockholm TNF‐α follow‐up registry (STURE) who received adalimumab after secondary loss of efficacy to infliximab (group A, n = 27) or etanercept (group B, n = 9), and 26 patients who were started on adalimumab as the first TNF‐α antagonist (group C).Results: In group A, the baseline disease activity score 28 (DAS28) at infliximab institution was 5.5±0.2. During infliximab treatment, the mean best DAS28 was 3.7±0.2 (p<0.001), but increased to 5.2±0.3 when infliximab was stopped. After 3 months on adalimumab, the mean DAS28 decreased to 4.5±0.3 (p<0.003), and then to 4.2±0.2 at 6 months (p<0.001). In group B, the baseline DAS28 at etanercept institution was 6.6±0.5. During etanercept treatment, the mean best DAS28 was 4.6±0.5 (p<0.01), but increased to 5.7±0.4 by the time etanercept was stopped. After 3 months on adalimumab, the mean DAS28 decreased to 4.8±0.3 (p<0.005), and to 4.1±0.2 at 6 months (p<0.001). In group C, the mean baseline DAS28 was 5.6±0.3. After 6 months of adalimumab therapy, the DAS28 decreased to 3.5±0.4 (p<0.001). ACR20 responses with adalimumab in groups A, B, and C were similar (70–78%).Conclusions: For patients with secondary loss of efficacy from infliximab or etanercept, switching to adalimumab can restore a good clinical response.

The aims were to investigate the effect of intravenous infusions of the tumor necrosis factor-α (TNF-α) antibody infliximab on symptoms and signs of temporomandibular joint (TMJ) involvement in relation to effects on synovial fluid and plasma proinflammatory TNF-α, interleukin-1β (IL-1β) and interleukin-6 as well as antiinflam matory soluble TNF receptor II (TNF-sRII), interleukin-1 receptor antagonist (IL-1ra), soluble IL-1 receptor II (IL-1sRII) and interleukin-10 (IL-10) in patients with active rheumatoid arthritis (RA). Nineteen patients with TMJ involvement taking methotrexate were included in the study. TMJ and general joint pain intensity as well as pain on mandibular movements, tenderness to digital palpation, pressure pain threshold and maximum mouth-opening capacity were assessed in a clinical examination. The effect of infliximab was assessed after 2 and 14 or 22 weeks. TMJ synovial fluid and venous blood were collected for cytokine analysis at all occasions while determination of erythrocyte sedimentation rate and C-reactive protein were performed at baseline and at long-term follow-up only. Reduction of TMJ pain was associated with raised levels of synovial fluid TNF-sRII and IL-1sRII as well as raised plasma levels of IL-1ra and IL-10. Decreased erythrocyte sedimentation rate was associated with decreased tenderness to digital palpation. Reduced general joint pain intensity was associated with reduced plasma levels of IL-6 and C-reactive protein. In conclusion, systemic treatment with a combination of infliximab and methotrexate reduces TMJ pain in RA in association with an increase in anti-inflammatory cytokines and receptors in synovial fluid and plasma.

Chronic granulomatous disease (CGD) is caused by mutations in the phox-family of superoxide ion generating enzymes. The clinical manifestations of CGD include increased infection susceptibility, a lupus like dermatitis and inflammatory bowel disease. The severe consequences of this rare disorder need to be handled by specialists, experienced in the care of CGD patients. Many CGD manifestations are due to the lack of superoxide ions, but some also to deficient pumping of protons to the extracellular space. An excessive inflammatory component, e.g. the granuloma formation in various organs, might be secondary to impaired superoxide ion dependent inactivation of inflammatory mediators. CGD can be successfully treated by hematopoietic stem cell transplantation, and gene therapy might become an alternative in the future.