The changes in serum tumor necrosis factor alpha in patients with rheumatoid arthritis

Nội dung text: The changes in serum tumor necrosis factor alpha in patients with rheumatoid arthritis

1. Journal of military pharmaco-medicine n 08-2017 THE CHANGES IN SERUM TUMOR NECROSIS FACTOR ALPHA IN PATIENTS WITH RHEUMATOID ARTHRITIS Nguyen Huy Thong*; Doan Van De*; Nguyen Dang Dung** SUMMARY Objectives: To evaluate serum levels of tumor necrosis factor (TNF)-α in rheumatoid arthritis (RA) patients and to assess the correlations of this cytokine with clinical and laboratory parameters. Subjects and methods: 86 patients with RA and 30 healthy volunteers were enrolled in the study. Disease activity was determined by disease activity score (DAS28) in patients with RA. The serum levels of TNF-α cytokine was measured by fluorescence covalent microbead immunosorbent assay (FCMIA). Results: Serum TNF-α levels was significantly decreased in RA patients comparing with controls (p < 0.001). Serum TNF-α showed no significant correlations with mesurements of disease activity. Conclusions: Patients with RA had a significantly lower TNF-α cytokine than that of healthy controls, and serum TNF-α cytokine was not associated with disease activity mesurements. However, further follow-up studies involving larger samples are required to clarify precise role of this cytokine in development and progress of disease. * Keywords: Rheumatoid arthritis; TNF-α; Biomarkers. INTRODUCTION cell activation, angiogenesis, activation of chondrocyte of metalloproteinase production, Rheumatoid arthritis (RA) is a chronic osteoclast activation [2], thus it may be inflammatory disease characterized by joint related to disease activity of RA. swelling, joint tenderness, and destruction Several disease activity indices based of synovial joints, leading to severe on different clinical, laboratory, and physical disability and premature mortality [1]. measures have been introduced. Most of Cytokine networks play a fundamental these, including the Disease Activity Score role in the processes that cause inflammation, (DAS), the modified DAS in 28 joints articular destruction of RA [2]. TNF-α is a (DAS28), the Simplified Disease Activity key cytokine in the pathogenesis of RA Index (SDAI), the Clinical Disease Activity that involved in chronic synovial inflammation Index (CDAI), rely on either quantitative and articular destruction. joint counts, patient-reported outcomes or TNF-α induces the production of other both, and erythrocyte sedimentation rate proinflammatory cytokines, including IL-1 (ESR) and serum CRP, those have some and IL-6. It also induces the production limitations and can be influeced by aging, and release of chemokines, hepcidine, sex and conditions other than RA (eg., acute phase response as well as endothelial osteoarthritis, fibromyalgia, anemia) [3, 4]. * 103 Military Hospital ** Vietnam Military Medical University Corresponding author: Nguyen Huy Thong (bsthong103(@gmail.com) Date received: 10/07/2017 Date accepted: 26/09/2017 180
2. Journal of military pharmaco-medicine n 08-2017 The aim of this study was: To evaluate assessment of disease activity and provider serum levels of TNF-α in RA patients and global assessment of disease activity its role in assessing disease activity. were evaluated using a 10-cm horizontal visual analog scale (VAS). We also calculated SUBJECTS AND METHODS SDAI (Simplified Disease Activity Index) 1. Subjects. and CDAI (Clinical Disease Activity Index). * Patients: Erythrocyte sedimentation rate (ESR) and This study was carried out at Department C-reactive protein (CRP) were recorded. of Rheumatology and Endocrinology of 103 * Laboratory analysis: Military Hospital between May 2012 and Blood samples of patients and controls June 2015. were collected and put in a sterile plain Eighty six patients, 75 women and tube and stored frozen at -80 oC until 11 men, with the diagnosis of RA fulfilled analysis. We used commercially available the ACR/EULAR 2010 RA classification human fluorescence covalent microbead criteria [1]. Before entering study, 43 and immunosorbent assay (FCMIA) kits for 4 patients were taking glucocorticoids and IL-6, IL-17 and TNF-α (R&D systems MN, conventional synthetic disease-modifying USA). The procedure for the FCMIA method antirheumatic drugs (DMARDs), respectively. was performed according to the instructions Patients with concomitant other rheumatic provided by the manufacturer. The levels disease, severe infection, chronic autoimmune of cytokines were recorded as a pg/mL. disease, and/or taking bio-DMARDs which * Statistical analysis: may effect laboratory and cytokine profile All statistical analyses were performed were excluded from the study. using the statistical package for the social * Healthy subject population: sciences (SPSS), version 18.0, for Windows Thirty sex-matched healthy controls (SPSS, Chicago, IL, USA). Continuous (age, mean 41.60 ± 4.57; range, 35 - 50 variables are presented as the mean ± years, 26 women and 4 men) were included standard deviation or median. The normality in the study. of the distribution for all variables was assessed by the Kolmogorov-Smirnov 2. Methods. test. Intergroup comparisons were made * Clinical assessment: using the student’s t-test for normally Disease activity was assessed by the distributed variables and and Mann- 28-joint disease activity score C-reactive Whitney U test for non-parametric variables. protein (DAS28 CRP) [5] in RA patients. To assess the correlations between Based on the DAS28 CRP, the patients variables, Sperman’s rank or Pearson’s were subdivided into 2 subgroups: low correlation analysis were used according and moderate group (DAS28 ≤ 5.1), and to data distribution. Values of p < 0.05 high group (DAS28 > 5.1). Patient global were considered statistically significant. 181
3. Journal of military pharmaco-medicine n 08-2017 RESULTS 1. Patients and demographic, clinical characteristics. Table 1: Demographic and clinical characteristics of RA patients and control. RA group (n = 86) Control group (n = 30) Mean age ± SD, min - max (years) 53.44 ± 7.30; 35 - 66 41.60 ± 4.57; 35 - 50 Sex, n (female/male) 75/11 26/4 Mean disease duration ± SD (years) 4.29 ± 5.34 Mean tender joint count ± SD (range 0 - 28) 14.13 ± 9.08; 13.00 Mean swollen joint count ± SD (range 0 - 28) 10.52 ± 7.38; 9.0 Mean morning stiffness ± SD (minutes) 37.25 ± 33.82; 30.00 Mean patient global assessment of disease 7.16 ± 2.25 activity ± SD (cm) Mean provider global assessment of disease 5.65 ± 1.92 activity ± SD (cm) Mean ESR ± SD (mm/h) 79.68 ± 44.37 7.63 ± 3.92 Mean plasma CRP ± SD (mg/L) 68.37 ± 47.24 0.52 ± 0.36 Mean, DAS28 CRP 6.19 ± 1.36; 2.81 - 8.50 DAS28 CRP Low and moderate (n; %) 17; 20.5 High (n; %) 66; 79.5 Pre-study Glucorticoids (n, %) 43 (50.6) treatment DMARDs (n, %) 4 (4.7) (DAS28 (CRP) is missing in three patients) (Abbreviations: Anti-CCP: Anti-cyclic citrulinated peptide; CRP: C-reative protein; DAS28: Disease activity score; ESR: Erythrocyte sedimentation rate) Patients and controls did not significantly differ in sex. The mean age of controls was lower than RA patients. The mean disease duration in RA patients was 4.29 ± 5.34 years. The mean DAS28 CRP was 6.19 ± 1.36 (range, 2.81 - 8.50). Seventeen (20.5%) and sixty six (79.5%) patients had low-moderate and high DAS28 CRP, respectively. 182
4. Journal of military pharmaco-medicine n 08-2017 2. Comparison of laboratory parameters among patients and healthy subjects. Figure 1: The comparison of serum TNF-α level between RA patients and controls (p, test Mann - Whiney). The mean and median of serum TNF-α of RA patients and controls was 2.37 ± 2.69; 1.68 and 3.87 ± 2.11; 3.69 pg/mL, respectively. Median of serum TNF-α concentrations in RA patients was significantly lower than that in controls group (p < 0.001). Figure 2: The correlation of serum IL-6 levels Figure 3: The correlation of serum TNF-α and serum TNF-α levels in RA patients levels and serum IL-17 levels in RA patients (numbers are Spearman correlation coefficients). (numbers are Spearman correlation coefficients). Serum TNF-α had a possitive correlation with serum IL-6 and IL-17 in RA patients (r = 0.233; p = 0.035 and r = 0.25; p = 0.023, respectively). 183
5. Journal of military pharmaco-medicine n 08-2017 3. Correlation between serum TNF-α and clinical, laboratory variables in RA patients group. Table 2: The comparision of serum TNF-α based on measurements of disease activity. Serum TNF-α levels (pg/ml) p Mean ± SD Median Joint tender count 28 1 - 4 (n = 13) 2.72 ± 3.22 2.24 0.694 ≥ 5 (n = 68) 2.33 ± 2.62 1.64 Joint swollen count 28 1 - 4 (n = 20) 2.34 ± 2.84 2.24 0.784 ≥ 5 (n = 61) 2.41 ± 2.68 1.64 DAS28 CRP Low & moderate (n = 14) 2.51 ± 3.17 1.94 0.944 High (n = 65) 2.40 ± 2.65 1.72 Table 3: The correlation of serum TNF-α levels in RA patients with measurements of disease activity. TJC28 SJC28 MS PtGA PGA CRP ESR r 0.105 0.040 0.050 -0.062 -0.131 -0.183 -0.065 Serum TNF-α p 0.352 0.725 0.664 0.585 0.245 0.102 0.600 (Abbreviations: TJC: Tender joint count; SJC: Swollen joint count; MS: Morning stiffness; PtGA: Patient global assessment of disease activity; PGA: Provider global assessement of disease activity; r: Spearman’s correlation coefficient) There were no differences according to joint tender count 28, joint swollen count 28 and DAS28 CRP. Table 4: The correlation of serum TNF-α levels with composite indices in RA patients. DAS28 CRP DAS28 ESR SDAI CDAI r 0.001 0.090 -0.009 0.024 Serum TNF-α p 0.995 0.472 0.938 0.832 (Abbreviations: SDAI: Simplified disease activity index, CDAI: Clinical disease activity index) There were not associations between the serum TNF-α levels of RA patients with measurements of disease activity. 184
6. Journal of military pharmaco-medicine n 08-2017 DISCUSSION TNF-α is a key cytokine in the pathogenesis of RA that involved in chronic synovial In the present study, level of serum inflammation and articular destruction, TNF-α cytokine was evaluated in patients thus it may influence disease activity of with RA, and associations of its with clinical RA patients. We assessed the change of and laboratory parameters. serum TNF-α according to measurements In accordance with other study [6], we of disease activity including TJC28, found that serum TNF-α was significantly SJC28 and DAS28 CRP, however we did lower in RA patients compared to healthy not found differences based on these parameters. In the present study, we also subjects ( figure 1 ). However, Kokkonen H did not observe the correlation between et al (2010) found serum TNF-α had no serum IL-6 with measurements of disease differrences between RA patients and activity such as TJC28, SJC28, morning healthy controls [7]. By contrast our results, stiffness, PtGA, PGA, ESR, plasma CRP do Prado A.D et al (2016) observed serum levels as well as composite index DAS28 α TNF- increased in RA patients compared CRP, DAS28 ESR, SDAI and CDAI. to healthy controls (p < 0.001) [8]. This Consistantly with the present study, do condition may be caused by treatment Prado A.D et al (2016) observed that before, this study including 50.6% of patients serum TNF-α had no associations with treated by glucocorticoid. Glucocorticoids joint tender count 28, joint swollen count exert potent inhibitory effects on the 28, DAS28 CRP, DAS28 ESR [8]. Keiko transcription and action of a large variety Shimamoto et al (2013) found serum of cytokines with pivotal importance in the TNF-α was not related to DAS28 CRP pathogenesis of RA. Most T helper type 1 and DS28 ESR [12]. By contrast these (Th1) proinflammatory cytokines are inhibited results, Reham Dwedar A.R.A et al (2015) by glucocorticoids, including interleukin reported serum TNF-α had a negative (IL)-1β, IL-2, IL-3, IL-6, TNF, interferon-γ [9]. relation to DAS28 (r = -0.404, p = 0.045) [13]. Thus, there are many controversial In the current study, serum TNF-α had studies regarding the relationship between a significantly positive correlation with serum TNF-α as an assessing role of serum IL-6 and serum IL-17 (figure 2 and disease activity and measurements of figure 3 ). In consistent of our observation, disease activity in RA patiets, so we need Manicourt D.H et al (1993) [10] and Zhao more studies with larger sample number P.W et al (2014) [11] also reported that to discover this interesting correlation. serum TNF-α had a positive correlation Our study has some limitations. The with serum IL-6 and serum IL-17. These sample size of patients was relatively small, studies supports the concept that TNF-α and the patients were on drug treatment plays a key role in pathogenesis of RA by including glucorticoids DMARDs. In fact, stimulating pro-inflammation cytokines our study had a cross-sectional design, including IL-6, IL-17 [2]. and cytokines profile had wide range. 185
7. Journal of military pharmaco-medicine n 08-2017 CONCLUSION 7. Kokkonen H, I. Soderstrom, J. Rocklov et al. Up-regulation of cytokines and chemokines Our study demonstrated a significantly predates the onset of RA . Arthritis Rheum. lower of serum TNF-α in RA patients 2010, 62 (2), pp.383-391. comparing with healthy controls. However, 8. do Prado A.D, M.C. Bisi, D.M. Piovesan we did not find any associations between et al. Ultrasound power Doppler synovitis is serum TNF-α levels and measurements associated with plasma IL-6 in established of disease activity in RA patients. rheumatoid arthritis . Cytokine. 2016, 83. Ultrasound power Doppler synovitis is REFERENCES associated with plasma IL-6 in established RA. pp.27-32. 1. Aletaha D, T. Neogi, A.J Silman et al. 9. Gary S. Firestein. Kelley’s Textbook of RA classification criteria: an American College th of Rheumatology/European League Against Rheumatology. 9 ed. Glucocorticoid therapy, Rheumatism collaborative initiative . Arthritis ed. Johannes W.G. Jacobs. Johannes W.J. Rheum. 2010, 62 (9), pp.2569-2581. Bijlsma. Elsevier Saunders. Philadelphia. 2013. 2. Brennan F.M, I.B. McInnes. Evidence 10. Manicourt D.H, R. Triki, K. Fukuda et that cytokines play a role in RA . J Clin Invest. al. Levels of circulating tumor necrosis factor 2008, 118 (11), pp.3537-3545. alpha and interleukin-6 in patients with RA. Relationship to serum levels of hyaluronan 3. Gabay C, I. Kushner. Acute-phase and antigenic keratan sulfate . Arthritis Rheum. proteins and other systemic responses to 1993, 36 (4), pp.490-499. inflammation . N Engl J Med. 1999, 340 (6), pp.448-454. 11. Zhao P.W, W.G. Jiang, L. Wang et al. 4. Pollard L.C, G.H. Kingsley, E.H. Choy et Plasma levels of IL-37 and correlation with al. Fibromyalgic RA and disease assessment . TNF-alpha, IL-17A, and disease activity Rheumatology. Oxford. 2010, 49 (5), pp.924-928. during DMARD treatment of RA . PLoS One. 2014, 9 (5), p.e95346. 5. Prevoo M.L, M.A. van 't Hof, H.H. Kuper et al. Modified disease activity scores that 12. Shimamoto K., T. Ito, Y. Ozaki et al. include twenty-eight-joint counts. Development Serum interleukin 6 before and after therapy and validation in a prospective longitudinal with tocilizumab is a principal biomarker in study of patients with rheumatoid arthritis . patients with RA . J Rheumatol. 2013, 40 (7), Arthritis Rheum. 1995, 38 (1), pp.44-48. pp.1074-1081. 6. Selaas O, H.H. Nordal, A.K. Halse et al. 13. Reham Dwedar A.R.A, Hala A. Raafat. Serum markers in RA: A longitudinal study of Does novel IL-33 correlates with TNF-α in patients undergoing infliximab treatment . RA and SLE? . Egyptian Journal of Medical 2015, p.276815. Microbiology. 2015, 24, pp.13-20. 186