La artritis reumatoide (AR) es la artropatía inflamatoria crónica más frecuente, afecta aproximadamente el 0.5% - 1% de la población general y causa una progresiva destrucción articular, discapacidad y disminución de la expectativa de vida. La etiología de la AR es desconocida y su patogenia solo parcialmente conocida al día de hoy. En los últimos años se han estudiado e identificado múltiples factores de riesgo para su desarrollo. Sabemos que intervienen factores genéticos y ambientales y que la interacción de ambos puede ser determinante en el desarrollo de la enfermedad. Entre los factores ambientales el tabaco ha sido ampliamente estudiado y actualmente se lo reconoce como el factor de riesgo no genético más importante para el desarrollo de AR, siendo este efecto particularmente importante en aquellos sujetos que presentan una susceptibilidad genética (presencia del epitopo reumatoide (ER)). Estudios más recientes ponen de manifiesto que el consumo de tabaco puede influir además en la expresión clínica de la enfermedad, determinar un curso evolutivo más grave y una mayor destrucción articular, aunque no todos los estudios son concordantes en estos últimos aspectos. El objetivo general de esta tesis fue analizar el efecto del consumo de tabaco en la expresión clínica y curso evolutivo de la artritis reumatoide en una cohorte de pacientes con artritis reumatoide de reciente comienzo. Para esto se llevó a cabo un estudio prospectivo en una cohorte de pacientes con artritis reumatoide de inicio (menos de dos años desde el inicio de los síntomas). En ellos se analizaron las características epidemiológicas, clínicas, serológicas y radiológicas basales y periódicamente, cada tres meses, hasta los dos años de evolución. Estas variables fueron comparadas entre aquellos pacientes fumadores y los no fumadores. Se observó que los pacientes con AR fumadores son con mayor frecuencia son portadores del epitopo reumatoide, lo que sugiere la existencia de una relación genético-ambiental en el desarrollo de la AR. En nuestra serie no hemos podido observar relación entre el consumo de tabaco y la presencia de ACPA. Desde el punto de vista de la expresión clínica de la AR, los pacientes fumadores presentaron un debut de su enfermedad más temprano que los no fumadores. La actividad clínica y biológica de la enfermedad y discapacidad que presentaron tanto al momento del debut de la AR como tras dos años de seguimiento fueron similares entre fumadores y no fumadores. El tabaco no parece influir en la expresión clínica de la enfermedad (a corto plazo). En cuanto a la destrucción articular, el tabaco demostró ser un factor predictor independiente de destrucción articular, junto con el sexo femenino y la presencia del ER. No obstante la magnitud de este efecto sería moderada. La prevalencia de ACPA en la población sana, tanto si son fumadores o no lo son, es del 1.9%. En grandes fumadores el consumo de tabaco no determina una mayor producción de ACPA. Sin embargo los grandes fumadores con EPOC sí tendrían una mayor predisposición a la producción de ACPA, aunque a títulos bajos. La implicación y relevancia clínica de los mismos debe ser aún estudiada en mayor profundidad.

ABSTRACT BACKGROUND: Arthritis is increasingly becoming a public health concern as it is the leading cause of disability. Glucosamine and chondroitin, which are alternative dietary supplements, are commonly marketed for persons with joint pain. The purpose of this study is to examine if self-reported 12-month and past 30-day use of glucosamine and/or chondroitin among persons with any arthritis, unspecified arthritis, and rheumatoid arthritis is associated with reports of past 12-month improved health and reports of past 30-day joint pain, aching, and stiffness, respectively. METHODS: The 2012 National Health Interview Survey (NHIS), a nationally representative cross-sectional household interview survey, was used for this study. The adult sample consisted of 34,525. Subgroup analyses were conducted on 7,654 respondents with any arthritis, 6,016 with unspecified arthritis, and 898 with rheumatoid arthritis. The independent variables were defined as the use of glucosamine only, chondroitin only, or glucosamine and chondroitin one or more times in the past 12 months and past 30 days. The dependent variables were defined as self-reported past 12 month improved health and past 30 day joint pain, aching, and stiffness. Descriptive, bivariate, and multivariate analyses were conducted using SAS 9.4 accounting for the complex survey design, computing missing values as missing completely at random for variance estimation. All multivariate logistic regression models included sociodemographics, use of other observed alternative therapies, and other chronic conditions. RESULTS: Approximately 21.8% of U.S adults had any arthritis, 17.0% had unspecified arthritis and 2.5% had rheumatoid arthritis. Among persons with any arthritis, approximately 3.7% used glucosamine, 0.4% used chondroitin, and 3.4% used both glucosamine and chondroitin within the past 12 months while approximately 5.1% used glucosamine, 0.6% used chondroitin, and 0.4% used both glucosamine and chondroitin within the past 30 days. Among persons with unspecified arthritis, approximately 3.7% used glucosamine, 0.5% used chondroitin, and 3.8% used both glucosamine and chondroitin within the past 12 months while 5.5% used glucosamine, 0.5% used chondroitin, and 0.4% used both glucosamine and chondroitin within the past 30 days. Among persons with rheumatoid arthritis, approximately 2.4% used glucosamine, 0.3% used chondroitin, and 2.1% used both glucosamine and chondroitin within the past 12 months while approximately 2.9% used glucosamine, 0.7% used chondroitin, and 0.5% used both glucosamine and chondroitin within the past 30 days. Women used more of all supplements (past 12 months and past 30 days) except past 12 month use of chondroitin among persons with any arthritis. Persons 56 to 70 years old had the highest proportion of past 12 month and 30 day supplement use among persons with unspecified arthritis. After adjusting for sex, age, race, BMI, poverty level, other health conditions, and other CAM therapies (acupuncture, energy, mind-body, and chiropractic/osteopathic therapies), the use of chondroitin only (adjusted OR= 0.6; p= <0.01) and the use of both glucosamine and chondroitin (adjusted OR= 5.7; p= <0.01) during the past 30 days was associated with self-reported past 30 day joint pain, aching, and stiffness among persons with any arthritis. After adjusting for age, BMI, poverty level, region, other health conditions, and other CAM therapies (acupuncture, energy, mind-body, and chiropractic/osteopathic therapies), the use of chondroitin only was also associated with past 30 day joint pain, aching, and stiffness among persons with unspecified arthritis (adjusted OR= 0.5; p= 0.02). CONCLUSION: Chondroitin alone was associated reports of past 30 day joint pain, aching, and stiffness among persons with any arthritis and unspecified arthritis highlighting a potential effective role and use for this supplement. In addition, the use of both glucosamine and chondroitin were associated with reports of past 30 day joint pain, aching, and stiffness among persons with any arthritis. Marketing may play a role in these relationships and should be further examined.

The main purpose of this study was to evaluate medication use patterns (i.e., dose escalation, medication adherence, persistence, and switching) of rheumatoid arthritis (RA) patients on etanercept (ETN), infliximab (IFX) or adalimumab (ADA) and the associated healthcare utilization costs using Texas Medicaid data. Study participants were Medicaid beneficiaries (18-63 years) with an RA diagnosis (ICD-9-CM code 714.0x) who had no claim for a biologic agent in the 6-month pre-index period (July 1, 2003 - Dec 31, 2010). The index date was the first date when the patient had the first fill for any of the study TNF inhibitors (ETN, ADA or IFX) within the study identification period (Jan 1, 2004 – Aug 31, 2010). Data were extracted from July 1, 2003 to August 31, 2011. Prescription and medical claims were analyzed over an 18-month study period (i.e., 6-month pre-index and 12-month post-index periods). The primary study outcomes were adherence, persistence, dose escalation, switching and cost (i.e., total healthcare, RA-related and TNF inhibitor therapy cost). The study covariates were demographic factors (age, gender, race/ethnicity), pre-index use of other RA-related medications (pain, glucocorticoids and disease modifying antirheumatic drugs), total number of non-study RA-related medications used at index, pre-index RA and non-RA related visits, pre-index healthcare utilization cost and Charlson Comorbidity Index score. Conditional regression analyses, which accounts for matched samples, were used to address the study objectives. After propensity score matching, 822 patients (n=274/group) comprised the final sample. The mean age (±SD) was 48.9(±9.8) years, and the majority of the subjects were between 45 and 63 years (69.2%), Hispanic (53.7%) and female (88.0%). Compared to patients on ETN, the odds of having a dose escalation were ≈ 5 [Odds Ratio= 4.605 [95% CI= 1.605-12.677], p=0.0031] and ≈ 8 [Odds Ratio=7.520, [95% CI= 2.461-22.983], p=0.0004] times higher for IFX and ADA patients, respectively, while controlling for other variables in the model. Compared to ETN, patients on IFX (p=0.0171) were more adherent while adherence was comparable with patients on ADA (p=0.1144). Compared to patients on ETN, the odds of being adherent (MPR ≥ 80%) to IFX was ≈ 2 times higher [Odds Ratio= 2.437, [95% CI=1.592-3.731], p < 0.0001] while controlling for other variables in the model. Persistence to index TNF inhibitor therapy and likelihood to switch or discontinue index TNF inhibitor therapy were comparable among the 3 study groups. In addition, the duration of medication use (i.e., persistence) prior to switching or discontinuation of index therapy was comparable among the 3 study groups. Furthermore, for each of the cost variables (total healthcare, RA-related and TNF inhibitor therapy cost), costs incurred by patients on ETN were significantly lower (p < 0.01) than those incurred by ADA patients but significantly higher (p < 0.01) than those incurred by IFX patients. Finally, a positive and significant relationship (p < 0.0001) was found between RA-related healthcare cost, adherence and persistence to TNF inhibitor therapies. In conclusion, ETN was associated with lower rates of dose escalation compared to ADA or IFX. However, adherence was better and associated healthcare costs were lower with IFX. Clinicians should endeavor to work with each individual patient to identify patient-specific factors responsible for poor medication use behaviors with TNF-inhibitor therapies. Reducing the impact of these factors and improving adherence should be included as a major part of the treatment plan for each RA patient. RA patients need to be adequately educated on the importance of adhering and persisting to their TNF-inhibitor therapy as poor medication adherence/persistence negatively impacts the RA disease process. / text

Background: A computer game based Telerehabilitation platform has been developed to provide a seamless system for hand exercise and assessment in home settings for people with arthritis. The exercise program involves task-oriented training of real life object manipulation tasks performed with computer gaming. The platform will also be integrated with a telemonitoring, computer game based hand function assessment application. Objectives: 1) To determine test-retest reliability and convergent validity of the assessment application protocol in people with rheumatoid arthritis or hand osteoarthritis, 2) To conduct a pilot randomized controlled trial for assessing the feasibility, and therapeutic effects of the task-oriented training compared to conventional hand exercises, and 3) To qualitatively evaluate participants’ experiences on their respective exercise programs. Methods: Performance during three different object manipulation tasks was evaluated by the assessment application protocol on 40 people with arthritis. The performance measures were correlated with other common hand function measures. A six-week pilot randomized trial was conducted on 16 individuals with arthritis. The Arthritis Hand Function Test (AHFT), the Disabilities of Arm, Shoulder and Hand (DASH) questionnaire, exercise compliance and task performance during three object manipulation tasks were the clinical outcomes. Focus group interviews were conducted on seven participants who had before received their home exercise programs. Results: The protocol demonstrated moderate to high test-retest reliability (ICCs between 0.5-0.84) of performance measures. Spearman correlation coefficients (rho) between task performance measures and other measures of hand function were low to moderate (0.4 < rho < 0.5 to 0.7). The pilot trial was not successful in terms of participant recruitment but demonstrated feasibility of study procedures, resources, and management. Except for two dexterity sub-scales of the AHFT, there were no significant differences in other clinical measures. Exercise compliance was >85% in both groups. The qualitative study provided initial evidence on the appropriateness, acceptance, perceived benefits, and a few practical difficulties in performing each exercise program. Conclusions: The hand function assessment application warrants validation in a variety of object manipulation tasks and in different patient populations. In order to proceed to a full-fledged trial, additional recruitment strategies, and revisions in the inclusion criteria must be considered. / February 2015

Rheumatoid arthritis (RA) is a progressive disease, often leading to disability. Because the disease course develops rapidly during the first years after diagnosis, more knowledge is needed about the early disease course to minimize later disability. This thesis describes the course of disability in early RA such as hand function, pain intensity, activity limitation and sick leave. In addition, this thesis compares disability between women and men and compares disability between RA patients and referents. This thesis is primarily based on data from the 320 patients that were included in the multi-centre project in Sweden called ‘Early interventions in rheumatoid arthritis’ (TIRA). A wide range of outcome variables was registered between 1996 and 2006 during regular follow-ups from time for diagnosis through the eight-year follow-up. Outcome regarding disease activity and disability of RA patients still remaining in TIRA at the three and five year follow-up respectively are used in this thesis. Data concerning sick leave were obtained for the patients during six years (1993-2001) – three years before and three years after diagnosis. Referents were included in two of the studies. Data regarding disability in referents were obtained according to hand function and activity limitation using the Health Assessment Questionnaire (HAQ). Data for sick leave were obtained for six years in referents, for the same period as the RA patients. For most variables, disability in RA was most pronounced at time of diagnosis but before intervention started. Disability was then reduced already at the 3-month follow-up and thereafter affected but stable during the following five years. The exception was participation, reflected by sick leave, a variable that was stable from inclusion to three years from diagnosis. Activity limitation, pain intensity and sick leave in RA that represents different aspects of disability were explained by other aspects of disability and contextual factors rather than by disease activity. RA affects women and men differently in some aspects. Women had more severe course of activity limitations than men according to HAQ. Men were more affected than women in range of motion, although the differences were small in a clinical perspective. However, pain intensity and frequency of sick leave did not differ between women and men. Patients with RA have pronounced disability in relation to referents although several variables improve soon after diagnosis. This discrepancy refers to hand function as well as activity limitations and sick leave. The frequency of sick leave increased during the year before diagnosis in relation to referents and was thereafter high compared to sick leave in referents.

Rheumatoid arthritis (RA) is a major cause of progressive joint damage and disability, and is associated with decline in quality of life, reduced ability to work and increased health care utilisation. The economic consequences of the disease are substantial for the individuals and their families and for the society as a whole. This thesis describes a 5-year follow up of 320 patients with early RA, enrolled between January 1996 and April 1998 in the Swedish multi-centre inception cohort TIRA (early interventions in rheumatoid arthritis). Health status, function and costs were investigated. Predictors of high costs were calculated, and an algorithm was constructed to predict future need for TNFinhibitor treatment in patients not responding to traditional disease-modifying antirheumatic drugs (DMARDs). Clinical and laboratory data, measures of functional capacity and self-reported assessments were collected regularly. In addition, patients completed biannual/annual questionnaires concerning all health care utilisation and days lost from work due to the disease. Within 3 months, improvements were seen regarding all variables assessing disease activity and functional ability, but 15% of the patients had sustained high or moderate disease activity throughout the study period. The scores of ‘health assessment questionnaire’ (HAQ) were similar for men and women at baseline, but had a less favourable course in women, who also had DMARDs more frequently prescribed. Ambulatory care accounted for 76% of the direct costs during the first year. Women had more ambulatory care visits and higher usage of complementary medicine compared to men. Men ≥65 years had low costs compared to younger men and compared to women of all ages. In multiple logistic regression tests, HAQ, high levels of IgM-class rheumatoid factor (RF), and poor hand function increased the odds of incurring high direct costs. Poor hand function and pain increased the odds of incurring high indirect costs. Indirect costs exceeded direct costs all three years. The average direct costs were €3,704 (US$ 3,297) year 1 and €2,652 (US$ 2,360) year 3. All costs decreased over the years, except those for medication and surgery. The indirect costs were €8,871 (US$ 7,895) year 1 and remained essentially unchanged, similarly for both sexes. More than 50% were on sick leave or early retirement at inclusion. Sick leave decreased but was offset by increase in early retirement. 14 patients (5%) were prescribed TNF-inhibitors at the 3- year follow up, thus increasing drug costs substantially. However, they incurred higher costs even before prescription of anti-TNF therapy. At the 5-year follow-up (2001-2003), 31 patients (12%) were prescribed TNFinhibitors. Baseline values of erythrocyte sedimentation rate, C-reactive protein, anti-CCP antibodies and morning stiffness were significantly higher in this group. These patients were also to a larger extent RF-positive and carriers of the ‘shared epitope’ (SE). Anti-TNF treated patients were significantly younger and more often women. For men, a predictive model was constructed using baseline data including SE+ and IgA-RF &gt;100 U/L and anti-CCP &gt;240 U/L yielding a specificity of 98% and a sensitivity of 71%. For women, disease activity score (DAS28) at the 3-month follow-up proved to be a better predictor, and the final model comprised SE+ and 3-month DAS28&gt;5.2, giving a specificity of 95% and a sensitivity of 59%.

published_or_final_version / abstract / toc / Pharmacology / Master / Master of Philosophy

Katecholamine beeinflussen durch direkte Stimulation über adrenerge Rezeptoren die Funktion von Immunzellen. Ziel der Untersuchungen an Patienten mit Rheumatoider Arthritis war es, das Expressionsprofil unterschiedlicher adrenerger Rezeptorsubtypen in CD4(+)T-Lymphozyten dieser Patienten zu bestimmen. Zur Quantifizierung der Expression wurden semiquantitative RT-PCR-Analysen durchgeführt. Die Untersuchung zeigte, dass alpha1-adrenerge Rezeptoren in CD4(+)-T-Lymphozyten von RA-Patienten exprimiert werden. Es scheint eine Korrelation zwischen bestimmten extraartikulären Organmanifestationen (z.B. Sicca-Sydrom und Tenosynovitis) und der Expression alpha1-adrenerger Rezeptoren zu bestehen. Die gefundene differenzielle Expression der Rezeptoren in CD4(+)-T-Lymphozyten von RA-Patienten legen vertiefende Untersuchungen zur Relevanz des adrenergen Systems bei der Lymphozytenfunktionsmodulation nahe.

High output of prostaglandins (PGs) are the hallmark of inflammatory and immune reactions. A rate-limiting step in the production of PGs is the presence of the enzyme cyclooxygenase (COX). COX exists as two isoforms: COX-1 which is constitutively expressed in most cells and COX-2 which is inducible by LPS, proinflammatory cytokines and other stimuli in cells involved in inflammation. The objective of this study was to determine the effect of nonsteroidal antiinflammatory drugs and proinflammatory cytokines on COX-2 expression in human macrophages. COX-2 specific (NS-398) and non-specific (aspirin, indomethacin and naproxen) inhibitors showed no effect on COX mRNA and protein expression induced by LPS. In contrast, the drugs markedly inhibited COX activity as measured by the accumulation of PGE2. The induction of COX-2 mRNA expression by LPS was rapid and sustained. However, LPS only transiently stimulated the transcription of COX-2 gene and activation of the transcription factor NF-kappaB. LPS stimulated the release of IL-1beta and TNF-alpha but these cytokines had no autocrine effect on the transcriptional or post-transcriptional regulation of COX-2. The presence of LPS was essential for the maintenance of high levels of long-lived COX-2 mRNA. As IFN-gamma is a major macrophage activating factor, we determined the role of this cytokine on COX-2 expression induced by exogenous IL-1beta. IFN-gamma-primed macrophages showed significantly lower levels of COX-2 mRNA, protein and PGE2 production compared to non-primed cells. IFN-gamma specifically decreased the transcriptional activation of COX-2 gene by IL-1beta but not by LPS without affecting the rate of mRNA decay. These results demonstrate that sustained production of PGE2 by macrophages in an inflammatory milieu can occur through the stabilization of COX-2 mRNA and revealed a role for IFN-gamma as an anti-inflammatory cytokine counteracting the expression of COX-2. A better understanding of COX-2 regulation will

Genome-wide Association (GWA) studies have become a widely used method for analyzing genetic data. It is useful in detecting associations that may exist between particular alleles and diseases of interest. This thesis investigates the dataset provided from problem 1 of the Genetic Analysis Workshop 16 (GAW 16). The dataset consists of GWA data from the North American Rheumatoid Arthritis Consortium (NARAC). The thesis attempts to determine a set of single nucleotide polymorphisms (SNP) that are associated significantly with rheumatoid arthritis. Moreover, this thesis also attempts to address the question of whether the one-sided alternative hypothesis that the minor allele is positively associated with the disease or the two-sided alternative hypothesis that the genotypes at a locus are associated with the disease is appropriate, or put another way, the question of whether examining both alternative hypotheses yield more information.