RESEARCH LETTERS
Research letters
Treatment of rheumatoid tenosynovitis with cytokine inhibitors Abhilash Jain, Fionula Brennan, Jagdeep Nanchahal Hand function depends on tendon integrity, but in rheumatoid arthritis tenosynovitis can result in tendon adhesions and rupture. Cytokine inhibitors have proved effective in rheumatoid joint disease; however, their effect on the tenosynovium is not well understood. We investigated the ability of inhibitors of tumour necrosis factor ␣ and interleukin 1 to reduce production of collagenolytic matrix metalloproteinases 1 and 13 in tenosynovial tissue obtained from patients with rheumatoid arthritis. Our data show that cytokine blockade can reduce collagenase concentrations in tenosynovial tissue, suggesting cytokine inhibitors could be effective in reduction of tendon damage.
500
Wrist joint synovium
Patient 1 Patient 2 Patient 3
400 300 200 100 0 1300
Invasive tenosynovium
1200
Lancet 2002; 360: 1565–66
THE LANCET • Vol 360 • November 16, 2002 • www.thelancet.com
1100 1000 Concentration of MMP-1 (g/L)
In about 50% of patients with rheumatoid arthritis, the tenosynovial lining of the tendon proliferates.1 This proliferation can lead to tendon rupture or, at the very least, scarring and adhesions, resulting in decreased tendon excursion and impaired function. 50% of patients with tendon involvement have tenosynovium invading the tendon, and this invasion is associated with an increase in tendon rupture.1 However, little research has focused on control of tenosynovitis with disease-modifying antirheumatoid drugs, and surgery remains the mainstay of treatment.2 Treatment based on inhibition of tumour necrosis factor ␣ (TNF␣) has proved effective in rheumatoid joint disease,3 although blockade of TNF␣ with soluble human TNF-receptor fusion protein did not seem to reduce tenosynovitis in patients with rheumatoid arthritis.2 Tendon is composed mainly of collagen type I and is very resistant to degradation by enzymes. It can, however, be degraded by the collagenolytic matrix metalloproteinase (MMP) enzymes MMP-1 and MMP-13. We have noted that tissue cultures of rheumatoid tenosynovium produced both these enzymes.4 We also showed that rheumatoid tenosynovium produced TNF␣ at concentrations comparable with rheumatoid synovial joint tissue,4 suggesting that tenosynovium might be sensitive to TNF␣ blockade. We therefore aimed to investigate the effect of TNF␣ blockade on production of MMP-1 and MMP-13 in tenosynovium of patients with rheumatoid arthritis. We obtained wrist joint synovial samples from patients with rheumatoid arthritis who were undergoing wrist extensor synovectomy. From these same patients, we also gathered separate samples of ipsilateral tenosynovium that did not breach the tendon (encapsulating tenosynovium) and that had invaded the tendon (invasive tenosynovium). The two types of tenosynovium were easily differentiated at surgery and were not in continuity. Joint synovial samples were obtained from within the capsule of the distal radioulnar and radiocarpal joints in the same patients. All patients gave informed consent, and the study was approved by the local ethics committee. Synovial tissue was digested in RPMI 1640 (Sigma, Poole, UK) containing heat-inactivated 5% (volume/volume) fetal calf serum (Flow, High
Patient Patient Patient Patient Patient
1 2 3 4 5
Patient Patient Patient Patient Patient
1 2 3 4 5
900 800 700 600 500 400 300 200 100 0 1300
Encapsulating tenosynovium
1200 1100 1000 900 800 700 600 500 400 300 200 100 0 No treatment
+IL-1ra
+anti-TNF␣
+anti-TNF␣ +IL-1ra
Production of MMP-1 in response to inhibition with interleukin-1, TNF␣, or both in wrist joint synovium (upper), invasive tenosynovium (middle), and encapsulating tenosynovium (lower) IL-1ra=interleukin-1 receptor agonist.
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For personal use. Only reproduce with permission from The Lancet Publishing Group.
RESEARCH LETTERS
Synovial sample Wrist joint Wrist and anti-TNF␣ and IL-1ra Encapsulating Encapsulating and anti-TNF␣ and IL-1ra Invasive Invasive and anti-TNF␣ and IL-1ra
MMP-1 (g/L)
Mean relative reduction on p log-transformed data (95% CI)
MMP-13 (g/L) Mean relative reduction on p log-transformed data (95% CI)
458·5 (385·7)* 167·5 (195·4) 354·4 (230·7)‡ 180·7 (249·8) 409·5 (362·2)¶ 180·4 (200·0)
.. 4·5 (2·6–7·8) .. 3·5 (1·9–6·6) .. 3·7 (2·2–6·2)
9·7 (11·6)† 5·2 (7·4) 1·3 (0·9)§ 0·9 (0·6) 6·7 (8·8)|| 3·4 (3·8)
.. <0·0001 .. 0·0008 .. 0·0001
.. 2·0 (1·3–3·2) .. 1·5 (1·1–2·0) .. 1·7 (1·0–2·7)
.. 0·005 .. 0·009 .. 0·037
IL-1ra=interleukin-1 receptor antagonist. Only samples that produced detectable concentrations of enzyme in uninhibited cultures are included. *15 patients produced detectable concentrations of enzyme (16 tested for MMP production); †14 (15); ‡14 (19); §11 (15); ¶15 (18); ||10 (16).
Mean (SD) concentrations of MMP-1 and MMP-13 produced by dissociated rheumatoid synovial cells from wrist joint, encapsulating, and invasive tenosynovial samples
Wycombe, UK), 1 g/L of type A collagenase (Boehringer, Mannheim, Germany), and 0·15 g/L of DNAase I (Sigma) for up to 1 h at 37°C, as previously described.4 Viable cells were cultured at 106/mL in RPMI 1640 containing 5% heatinactivated fetal calf serum at 37°C (5% CO2 for 48 h) in the absence or presence of the cytokine inhibitors mouse monoclonal antibody A2 against TNF␣ (10 mg/L; Centocor, Malvern, PA, USA), interleukin-1 receptor antagonist (10 mg/L; UpJohn Laboratories, Kalamazoo, MI, USA), or both. Concentrations of MMP-1 and MMP-13 were measured in harvested supernatants by ELISA. We obtained synovial samples from six patients with a mean age of 51 years (SD 9) and mean disease duration of 16 years (6). Specimens of all three synovial tissue types were not available from all patients. Inhibition of TNF␣ reduced concentrations of MMP-1 in ten of 13 samples, whereas interleukin-1 receptor antagonist inhibited MMP-1 in eight samples (figure). Combined blockade decreased MMP-1 more than did separate inhibition in nine of 13 samples (figure). Results of cytokine blockade on MMP-13 production were difficult to interpret, because baseline concentrations of enzyme were low (data not shown). MMP-1 concentrations were more than 100 times higher than were those of MMP-13. This fact, together with the ability of MMP-1 to cleave type I collagen more effectively than MMP-13,5 suggests MMP-1 might be more important in rheumatoid tenosynovitis. Because invasive tenosynovium and joint synovium responded to combined blockade more effectively than did encapsulating tenosynovium (figure), we extended our investigation of combined inhibition of production of MMP-1 and MMP-13. We obtained tissue samples from a further 17 patients with rheumatoid arthritis with a mean age of 54 years (SD 14) and mean disease duration of 15·5 years (10). We obtained the same types of tissue samples as for the previous six patients, and all patients gave informed consent. Ethics approval was granted for this extension to our investigation. After combined cytokine inhibition, patients’ results for MMP-1 and MMP-13 were log-transformed for analysis and relative reductions calculated. We calculated differences between inhibited and uninhibited samples with Student’s paired t test, and deemed a p value of 0·05 or less to be significant. Combined inhibition resulted in a significant fall in concentrations of both MMP-1 and MMP-13 in all types of tissue (table). Concentration of MMP-1 was reduced the more effectively than that of MMP-13, with wrist joint tissue showing the highest relative reduction, whereas encapsulating and invasive tenosynovial tissue responded in an almost identical manner. Our results show that cytokine blockade can reduce the concentration of collagenase in tenosynovial tissue. We compared tenosynovium with wrist joint synovium because rheumatoid joint synovium has been well
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characterised. Many patients had evidence of both invasive and non-invasive tendon disease, providing matched specimens for analyses, overcoming difficulties associated with differences in disease activity between patients. We do not know why invasive tenosynovium enters tendon and produces more MMP-1 and MMP-13 than noninvasive tenosynovium. The differences might not simply be attributable to an increased proportion of cells producing MMPs, because the cellular composition of invasive and encapsulating tenosynovium are similar,4 but might rather be an indication of the invasive characteristics of the cells. In addition to reduction of concentrations of collagenase enzymes, individual cytokine inhibition might have further effects on the tenosynovium. The TNF␣ inhibitor infliximab downregulates the cytokine cascade, diminishes leucocyte trafficking, and reduces angiogenesis in inflamed joints.3 Although TNF␣ blockade might not decrease occurrence of clinically detectable tenosynovitis,2 our results show it could reduce tendon damage and, ultimately, rupture. Contributors A Jain, F Brennan, and J Nanchahal were responsible for study design. J Nanchahal and A Jain obtained tissue samples. A Jain was responsible for analysis of samples. All authors contributed to writing of the report.
Conflict of interest statement None declared.
Acknowledgments We thank Kiran Nanchahal (London School of Tropical Hygiene and Medicine, London, UK) for statistical advice. A Jain was funded by an Arthritis Research Campaign Clinical Research Fellowship. The sponsor had no role in study design, data collection, data analysis, data interpretation, or writing of the report. 1 2
3 4
5
Brown FE, Brown ML. Long-term results after tenosynovectomy to treat the rheumatoid hand. J Hand Surg 1988; 13A: 704–08. Kaiser MJ, Bozonnat MC, Jorgensen C, Daurès JP, Sany J. Effect of etanercept on tenosynovitis and nodules in rheumatoid arthritis. Arthritis Rheum 2002; 46: 559–60. Feldmann M, Maini R. Anti-TNF␣ therapy of rheumatoid arthritis: what have we learned? Annu Rev Immunol 2001; 19: 163–96. Jain A, Nanchahal J, Troeberg L, Green P, Brennan F. Production of cytokines, vascular endothelial growth factor, matrix metalloproteinases, and tissue inhibitor of metalloproteinases 1 by tenosynovium demonstrates its potential for tendon destruction in rheumatoid arthritis. Arthritis Rheum 2001; 44: 1754–60. Woessner JF, Nagase H. Matrix metalloproteinases and TIMPs. Oxford: Oxford University Press, 2000: 87–93.
Department of Musculoskeletal Surgery (A Jain MRCS, J Nanchahal FRCS [Plast]) and Kennedy Institute of Rheumatology (A Jain, Prof F Brennan PhD), Imperial College School of Medicine, Charing Cross Hospital Campus, Arthritis Research Campaign Building, London, UK Correspondence to: Mr Abhilash Jain, Kennedy Institute of Rheumatology, Imperial College School of Medicine, Charing Cross Hospital Campus, London W6 8LH, UK (e-mail:
[email protected])
THE LANCET • Vol 360 • November 16, 2002 • www.thelancet.com
For personal use. Only reproduce with permission from The Lancet Publishing Group.