A pilot study using a staph protein A column (Prosorba) to treat refractory rheumatoid arthritis.

OBJECTIVE: To assess the safety and effectiveness of extracorporeal treatments with protein A (Prosorba) columns in the treatment of patients with severe refractory rheumatoid arthritis (RA) in an open label pilot study. METHODS: Fifteen patients with RA who had failed to respond to 2 or more disease modifying antirheumatic drugs were "washed out" for 1-3 months before enrollment into this 6 month pilot study. The treatment schedule called for patients to receive apheresis treatments across staphylococcal protein A columns once a week for 12 weeks. Clinical evaluations of RA activity, defined by Paulus criteria, were conducted at study enrollment (baseline) and monthly throughout the treatment phase. In addition, examinations were conducted at 2, 4, 8, and 12 weeks after the last treatment. Fourteen patients received all 12 scheduled treatments, while one patient received only 10 treatments due to complications secondary to pneumonia. RESULTS: Using Paulus 50% criteria, 9 of 15 (60%) patients were improved at the 4th month, and one more fulfilled >20% Paulus criteria (7%) in the 5th month after starting therapy. The study group reported an average of 2.47 adverse effects per treatment, of which the most common were joint pain and swelling and fatigue of short duration (arthritic flare). CONCLUSION: The adverse effects associated with this apheresis based treatment proved to be manageable and of short duration and resolved without sequelae. The results suggest that extracorporeal protein A therapy may have a role in the management of refractory RA, and encouraged the initiation of a larger, blinded, controlled clinical trial.

Treatment of patients with refractory rheumatoid arthritis with extracorporeal protein A immunoadsorption columns: a pilot trial.

OBJECTIVE: To evaluate the safety and effectiveness of extracorporeal immunoadsorption with protein A (PROSORBA) columns in the treatment of refractory rheumatoid arthritis (RA). METHODS: Eleven patients with refractory RA were enrolled in an open prospective trial of 24 weeks' duration. Nine patients received 15 treatments over a 12-week period, 1 patient received 15 treatments over a 15-week period, and 1 patient received 12 treatments over a 9-week period. RESULTS: Using the composite criteria of Paulus, et al, 9 patients met the > or = 50% criteria when tested at Week 13, while 4 and 2 patients met the > or = 50% and > or = 20% criteria, respectively, when tested at Week 24. In addition, most of the clinical variables in the 9 responders at Week 13 had significantly improved (p < 0.05); 8 of these responders were able to continue for the entire 24-week study without a change in their arthritic medications, and 2 met the American College of Rheumatology criteria for clinical remission at Weeks 12, and 28 and have remained in remission for 6 and 5 months, respectively. Treatment associated side effects were of short duration and resolved without sequela. Four patients became symptomatically anemic during the treatments. CONCLUSION: Our preliminary study suggests that extracorporeal immunoadsorption therapy with protein A columns was well tolerated and may be effective in the treatment of RA. Further expanded and controlled trials are indicated to explore this new therapeutic modality.

Effects of administration of an anti-CD5 plus immunoconjugate in rheumatoid arthritis. Results of two phase II studies. The CD5 Plus Rheumatoid Arthritis Investigators Group.

OBJECTIVE: To evaluate the safety and activity of an immunoconjugate of ricin A chain and anti-CD5 monoclonal antibody (anti-CD5 IC), with and without concomitant methotrexate and/or azathioprine, in the treatment of rheumatoid arthritis (RA). METHODS: Seventy-nine patients with active RA were enrolled in 2 prospective open-label protocols. RESULTS: Using composite criteria, response rates were 50-68% at 1 month and 22-25% at 6 months. Transient depletion of CD3/CD5 T cells was observed on days 2 and 5 of treatment, with reconstitution on day 15 or day 29. Treatment-associated adverse effects were common but resolved rapidly without sequelae. CONCLUSION: These findings suggest activity of anti-CD5 IC in active RA and warrant confirmation in a multicenter randomized study (currently underway).

IgG aggregates of different sizes stimulate or suppress Ig secretion by human lymphocytes in vitro.

The regulatory effects of IgG aggregates on Ig production in vitro by human peripheral blood lymphocytes were shown to be highly dependent on the aggregate size and the degree of mitogenic stimulation. Covalently linked oligometers of IgG were prepared with dimethylsuberimidate cross-linking and chromatographic separation; larger aggregates were prepared by heating (63 degrees C) and preparative zonal ultracentrifugation. The storage and culture conditions used were shown to preserve the stability of aggregate sizes. Although both positive and negative regulatory effects were seen with cells isolated directly from blood, more predictable dose-related effects were seen if cells were vigorously washed, possibly due to the removal of IgG or natural immune complexes bound by the cells in vivo. Some preparations of small IgG oligomers produced marked stimulation of Ig production, especially in cells cultured without mitogen or with suboptimal pokeweed mitogen doses. Aggregates containing six or more IgGs suppressed Ig production, especially when cells were stimulated by mitogen at optimal concentrations.

In vitro T lymphocyte proliferative response to Yersinia enterocolitica in Reiter's syndrome. Lack of response in other HLA-B27 positive individuals.

We assessed the in vitro T lymphocyte tritiated thymidine (3HTdr) incorporation response of Reiter's patients in the United States to a serotype 3 strain of Yersinia enterocolitica. The mean 3HTdr incorporation response to the formalin killed form of this strain was 27,409 +/- 5,488 counts per minute for 14 HLA-B27 positive Reiter's patients compared with 5,414 +/- 3,490 cpm for a control group of 11 HLA-B27 positive normal individuals (P less than 0.0005). This high response in Reiter's patients was observed with the formalin killed form of Y enterocolitica serotype 3, but not with a heat killed form or a rough mutant form derived from the same bacterial strain. Further, Y enterocolitica of a different serotype (serotype 8) which is not associated with reactive arthritis failed to induce the high proliferative response observed with the serotype 3 strain. This response indicates that T lymphocytes from spontaneous Reiter's patients are capable of recognizing and proliferating to determinant(s) on the formalin killed form of Y enterocolitica serotype 3. Since this bacterium is associated with Reiter's syndrome in Europe but not the United States, these data are consistent with the possibility that our patients have previously encountered these or similar determinants through unrecognized infection with other microorganisms.

Panhypogammaglobulinemia in systemic lupus erythematosus: in vitro demonstration of multiple cellular defects.

Classically, systemic lupus erythematosus (SLE) is a disease of antibody overproduction, whereas the hallmark of acquired immune deficiency is antibody underproduction. Two patients are presented in whom panhypogammaglobulinemia developed during the course of SLE. In both patients, the levels of the major immunoglobulin (Ig) classes did not fall simultaneously. Anti-DNA antibodies were present, and exacerbations of SLE nephritis occurred in both cases 6 to 8 yr after Ig levels became subnormal. One patient still requires immunosuppressive therapy for renal disease; both patients are experiencing recurrent sinopulmonary bacterial infections. In the pokeweed mitogen--stimulated Ig biosynthesis assay, both patients showed abnormal Ig production due to defective function of three cell types: hyporesponsive B cells, excessive T suppression, and subnormal T help. The latter defect is rare in common variable hypogammaglobulinemia. One patient also showed extreme suppression of Ig production by phagocytic mononuclear cells. Thus, despite the similarity in the histories, the cellular function of these two patients was not identical in vitro.