Scandinavian Journal of Rheumatology
ISSN: 0300-9742 (Print) 1502-7732 (Online) Journal homepage: http://www.tandfonline.com/loi/irhe20
Chloroquine Treatment in Rheumatoid Arthritis Frank A. Wollheim, Arne Hanson & Carl-Bertil Laurell To cite this article: Frank A. Wollheim, Arne Hanson & Carl-Bertil Laurell (1978) Chloroquine Treatment in Rheumatoid Arthritis, Scandinavian Journal of Rheumatology, 7:3, 171-176, DOI: 10.3109/03009747809095649 To link to this article: http://dx.doi.org/10.3109/03009747809095649
Published online: 12 Jul 2009.
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Date: 23 March 2016, At: 16:01
Scand J Rheumatology 7: 171-176, 1978
CHLOROQUINE TREATMENT IN RHEUMATOID ARTHRITIS Correlation of Clinical Response t o Plasma Protein Changes and Chloroquine Levels
Frank A. Wollheim, Arne Hanson and Carl-Bertil Laurel1
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From the Division of Rheumatology, Department of Medicine and the Department of Clinical Chemistry, University of Lund, Malmo General Hospital, Malmo, Sweden
ABSTRACT. 15 patients with active RA were observed over a 3-month period after starting chloroquine treatment. Clinical condition, plasma levels of chloroquine and levels of 15 individual plasma proteins were checked monthly. Nine patients responded favourably to therapy, 6 failed to respond. The responders had lower initial CRP, orosomucoid and ceruloplasmin levels, whereas their IgA and IgM levels were slightly elevated. Significantreductions in the levels of CRP, haptoglobin, orosomucoid, fibrinogen and ceruloplasmin occurred in the responder group of patients. Alfal-antitrypsin, antichymotrypsin C3 and C4 levels within the normal range were frequently encountered despite other clear-cut signs of activity. The chloroquine levels did not differ between responders and non-responders, the mean concentrationsbeing 1.04 and 1.6 pmol/l respectively. This study has also demonstrated that in selected cases, despite active joint disease, all acute phase proteins may be normal. Finally, it was obvious that chloroquine, even when inducing remission, only brought about a partial normalization of the plasma protein pattern.
Chloroquine therapy has a documented effect on rheumatoid arthritis (RA) ( 2 , 5 , 9, 20) and is widely used in Scandinavia. However, its moderate eff-
cacy and the attendant risk of serious eye complications (4, 12, 19) have reduced its popularity. Chloroquine retinopathy seems to be dose related (4,19) and is hardly ever a problem if one uses a maximum dose of only 75 g per year in patients not over 60 years of age and without evidence of liver disease (7). This study was concerned with the monitoring of patients during the initial phase of chloroquine therapy, with plasma levels of both chloroquine and a variety of individual plasma proteins, in an attempt to correlate such parameters with clinical response. MATERIAL AND METHODS Fifteen consecutive patients examined in the out-patient clinic for complaints of active RA were selected. None was taking any other slow reacting antirheumatic drug such as gold, penicillamine or cytotoxic agents. Some clinical data are shown in Table I. Ten of the patients were women; 13 had a positive Waaler-Rose test. The ages
Table I. Clinical data in 15 patients with active RA before the study Patient 1
2 3 4 5 6 7 8 9 10 11 12 13 14 15
Duration (years)
WaalerRose
18 1
+ + + ++ + + + + + + + +
Age
Sex
54 63 65 47 22 50 52 60 57 55 69 30 56
F F F M F F F M M
2 112 26 30 2 4
F F F F
7 6 17 2 14
54
57
M M
1
1
ESR 40
40 65 41 51
80 35 62 85 82 75 8 54 47 66
Functional class (Steinbrocker) I1 I1 I1 I1 I I11 I1 I1 I1 111 111 I1 I1 I1 I1 Scand J Rheumatology 7
172
F . A. Wollheim et al.
Table 11. Findings in clinicti1 ptrruniters, resitlting in responder-non responder
cluss~‘’cation
NT =not tested, R =responder, NR =non-responder Patient number
Before
After 3 0
8 9 10
9 12 19 I1 4 5 5 9 7 12
11
18
12 13 14 15
8
19 0 9 4 12
1 2 3 4
5 6 7
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Joint index
18 13 12
Subjective improvement
Relapse after treatment
Criteria for response N present : N tested
Classification of patient
Yes Yes Yes No Yes No No Yes No Yes No Yes Yes Yes No
NT Yes Yes No No No No Yes Yes NT No Yes
2:2 3:3 3:3 0 :3 2:3 0 :3 0 :3 3:3 1.3 2:2 0 :3 3:3 2:2 2:2 0 :3
R R R NR R NR NR R NR R NR R R R NR
NT NT No
ranged between 22 and 69 years, and the duration of disease from 6 months to 30 years. Disease activity was assessed from the history and the presence of active synovitis on joint palpation according to a modified Ritchie index (21). Clinical assessment was made initially and after 3 months’ treatment, and again 2 months after stopping chloroquine administration. None of the patients was taking oral corticosteroids. No change in the consumption of non-steroidal antirheumatic drugs of the analgesic type was allowed during the study period. Chloroquine was administered orally in a standard dose of 250 mg=one tablet at noon. Blood samples were collected monthly in the morning. in tubes containing EDTA. Plasma was frozen at -20°C until analysed. Cloroquine analyJis Determination of serum chloroquine was performed by a fluorometric method described by Bergquist et al. (3). An Aminco-Bowman spectrophotofluorometer was used for the determinations.
Statistics The Wilcoxon matched-pairs signed-rank test was used, and a probability of 2% was accepted as significant. The Student’s t-test was used when applicable.
RESULTS Table I1 shows the results of the clinical exarninations: 4 patients with 3 of 3 criteria, 4 with 2 of 2 and one with 2 of 3 were considered to be responders. One patient with 1 of 3 and 5 with none of 3 criteria were classified as non-responders. It was thus possible to divide the patients into 9 responders and 6 non-responders, based solely on clinical pararneters.
ESR R
PIasma protein analysis All specific plasma proteins were analysed by electroimmunoassay (17). For immunoglobulins, the variants of Grubb were used (10, I I).
rnrn/l
Responder-non responder classification Patients showing I ) improvement on joint examination, 2) improvement in subjective parameters such as stiffness, pain, and feeling of well-being, and 3) deterioration after stopping the drug were called “responders”. If any two of the criteria applied the subjects were also called “responders”. Changes in routine hematology or sedimentation rate (ESR) were nor used in this classification.
LO
NR
hr
GO
20
, L
. B
. 12
. 16 W
.
L
. 8
.
12
,
It W
Fig. I. Erythrocyte sedimentation rates ( E S R ) in re-
sponders (R) and non-responders ( N R ) during the course of chloroquine treatment.
Chloroquine treatment in rheumatoid arthritis
173
OROSWCOIO
R
NR
Y O
100
200
50
100
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I 8
4
16
12
8
L
4 I
It N
12
Fig. 2 a . C-reactive protein ( C R P ) during the course of chloroquine treatment. R =responders, NR=nonresponders.
L
12
8
16
W
12
16
W
FIBRINOGEN
5wg/1
R
8
Fig. 2 b. Orosomucoid during chloroquine treatment.
HAPTOGLOBIN 911
4
R
NR
NR
8
8
6
G
L
L
2
2
L
1
4
0
12
16
W
L
8
12
It
W
8
12
16 W
4
8
12
16
W
Fig. 2 c . Haptoglobin during chloroquine treatment.
Fig. 2 d . Fibrinogen levels during the course of chloroquine treatment.
Fig. 1 shows changes in ESR in responders and non-responders. The mean intial ESR levels did not vary significantly between the groups, 50 and 64 mm respectively; in contrast the means were 26 and 59 after 12 weeks' treatment. The reduction among responders was significant ( p =0.02) Table 111 shows the initial and 12-week levels of seven acute phase reactants, namely CRP, haptoglobin, orosomucoid, alfa,-antitrypsin, fibrinogen, ceruloplasmin and antichymotrypsin. Among these, CRP was the most elevated and showed the most pronounced reduction in responders, 76%. Fibrinogen was elevated in all but one case, but the response to treatment, although significant, was not marked, only 14%. Orosomucoid, haptoglobin and ceruloplasmin also showed significant reductions in responders to chloroquine. Alfa,-antitrypsin changed only slightly ( p=0.02), and antichymotrypsin did not change significantly.
Among non-responders CRP tended to increase despite high starting levels. The other reactants remained unchanged. CRP, orosomucoid and ceruloplasmin levels were significantly higher initially in non-responders. The variation of CRP, orosomucoid, haptoglobin and fibrinogen in individual cases is given in Fig. 2. The IgG, IgA and IgM levels did not change significantly with treatment. IgA and IgM were slightly higher in responders (p=0.02). The complement component C4 did not change during treatment, whereas C3 decreased somewhat (p=0.02) in responders. C4 was elevated in only 1 of 9 responders and in 4 of 6 non-responders. Low C4 levels were seen in 2 non-responders. Alfa,-macroglobulin levels were normal and constant in both groups. Albumin levels in the lower normal range were seen in both groups, with slightly subnormal levels occurring only occasionally among non-responders. Scund J Rherirntrtology 7
174
F. A . Wollheim et al.
Table 111. Levels of 12 plasma proteins before and after 12 weeks treatment with chloroquine in 9 responding and 6 non-responding patients S.D.=standard deviation Defference
Non-responders (N=6)
S.D.
%
0
7.6 0.75 30.2
-76 0.01 -29 0.01 -20 0.01
0.95
-14
0.06 24.6 33.9 3.2 1.28 0.58 26.2 29.6
-12 0.01 -22 0.02 - 1 1 N.S. -8 N.S. -14 N.S. -12 N.S. -12 0.02 -3 N.S.
Responders ( N =9)
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Protein (normal range)
0
CRP mg/l(5) Haptoglobin g/l(0.45-2.75) Orosomucoid 5% of standard (5Crl50 Fibrinogen g/l(2.04.4) Ceruloplasmin (0.22-0.48) g/l Alfa,-antitrypsin % of standard (70-130) Antichymotrypsin 92 of standard (75-125) I& g/l(7-15) IgA g/l (0.5-3.0) IgM gll(O.4-2.0) C3 % of standard (70-130) C4 9%of standard (65-170)
S.D. 12
24.I 2.1 159 5.1
29.8 1.O 29.2 1.3 0.49 0.006 121 25.1 102 21.9 13 3.4 2.99 0.6 1.70 0.51 I26 25.4 122 32.6
Chloroquine levels are shown in Fig. 3. It is obvious that unresponsiveness is not correlated to lower plasma levels, the mean level among responders in the third month of treatment being 1.04 pmolll versus 1.60 among non-responders. Only 2 patients experienced side reactions from chloroquine, one gastrointestinal and one CNS. Their levels were 2.55 and I .8 respectively.
DISCUSSION Assessment of disease activity in RA is of profound importance for proper evalutation of prognosis and selection of therapy. In this study the disease activity reducing capacity of chloroquine was utilized, in an attempt to test the usefulness of plasma proteins in such assessment. As no control group was included, a n y changes could be due either to the treatment or else represent a spontaneous remission. The fact that at least 5 of 9 “responders” relapsed, whereas 5 of 6 “non-responders” did not deteriorate when chloroquine administration was discontinued, however, does support the validity of the classification. The material is small, but repeated analysis of a series of acute phase proteins allows one to conclude that active RA may occur without any clearcut increase in a n y acute phase reactant. In agreement with earlier investigators, we found CRP to be the most sensitive protein indicator of activity (8).It was also the most closely related to Jc a t i d .I R h t ~ i r t n n r o l i i 7~ ~
5.9 1.5 128 4.4 0.43 93.6 90 11.9 2.56 I .49 111
118
P
S.D
S.D
12
36.8 24.1 58.3 2.8 0.67 3.0 220 34.1 224 6.3 1.5 6.0 0.61 0.05 0.57 132 27.0 132 148 50.3 148 13.3 5.2 12.8 2.3 0.44 2.37 1.12 0.25 0.96 139 17.4 137 148 148 69
0.01
30.5 1.0 33.8 1.3 0.05 28.0 52.2 5.6
0.55 0.23 28.0 64.7
therapeutic response. It is of considerable interest that Amos et al. (1) recently found a correlation between CRP and radiological progression in RA. The relatively small increase in antichymotrypsin was a surprise finding that distinguishes the rheumatic activity from the usual acute inflammatory processes (14). Alfa,-antitrypsin and C4 also often do not rise in plasma in proportion to haptoglobin or CRP. It is known that low complement levels in RA are signs of severe disease (13) and one assumes consumption by immune complexes activating along the classical pathway. Whether a similar consumption of antichymotrypsin of alfa,-antitrypsin occurs in rheumatoid lesions is not known.
CHLOROOUINE
R
wwlfl
A 2
2
1
1
L
8
12
16
20
L
8
12
16 20 WEEKS
Chloroquine levels 12 hours or more after the last intake in responders ( R ) and non-responders ( N R ) taking a standard dose of 250 mg chloroquine phosphate daily. SR means side reaction. Fig. 3.
Chloroquine treatment in rheumatoid arthritis
I75
of value in avoiding overdosage and side effects, but cannot explain why some patients do not respond to the drug. Difference
Difference responder/ non-responder
%
P
t
P
+85 +7 +2
0.05 N.S. N.S. N.S. N.S. N.S. N.S. N.S. N.S. N.S. N.S. N.S.
4.67 1.67 3.57 1.60 4.20 0.83 2.10 0.12 2.45 2.93 1.17 0.86
0.01 N.S. 0.01 N.S. 0.01 N.S. N.S. N.S. 0.02 0.02 N.S. N.S.
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-5 -3 0 0 -4 -3 -14 -1.5 0
Several drugs are known to influence plasma protein levels and ESR in RA, among them glucocorticosteroids (18). None of the patients in this study were taking steroids, however, which excludes this as an explanation for the normal plasma levels of acute phase proteins. Prostaglandin E has recently been claimed to induce increased hepatic synthesis of plasma proteins characteristic of the inflammatory response. The common use of inhibitors of prostaglandin synthetase in RA could be suspected to modify the plasma protein profile. However, McConkey et al. could find no effect of indomethacin treatment on ESR, haptoglobin, or CRP (18). Whereas chloroquine treatment is known to reduce titres of rheumatoid factor (15), we could find only insignificant changes in Ig levels. The RF titres were not monitored in this investigation. It was a surprise to find lower IgA and IgM levels among the non-responders. Plasma determinations of chloroquine have been used only infrequently in the past. Laaksonen et al. (16) found a considerable interindividual spread in plasma concentrations in children taking standard doses of either chloroquine or hydroxychloroquine. The occurrence of keratopathy seemed to correlate with high plasma levels. Domeij-Nyberg et al. (6) reported a higher incidence of non-ocular side effects at higher concentrations. Our results indicate that higher plasma levels did not correlate to better therapeutic response. Thus plasma determinations are probably
ACKNOWLEDGEMENTS This study was supported financially by the Alfred Osterlunds Stiftelse and Greta och Johan Kocks Stiftelser.
REFERENCES 1. Amos, R. S., Constable, T. J., Crockson, R. A., Crockson, A. P. & McConkey, B.: Rheumatoid arthritis: relation of serum C-reacitve protein and erythrocyte sedimentation rates to radiographic changes. Br Med J i: 195, 1977. 2. Bagnall, A. W.: The value of chloroquine in rheumatoid arthritis. Canad Med Assoc J 77: 182, 1957. 3. Bergquist, Y., Domeij-Nyberg, B., Hellstrom, L. & Frisk-Holmberg, M.: Samband mellan koncentration av klorokin i serum och biverkningar hos reumatiker. (Abstract.) Acta SOCMedicor Suec 85: 248, 1976. 4. Bemstein, H. N.: Chloroquine ocular toxicity. Surv Ophtalmoll2: 415, 1%7. 5. Cohen, A. S. & Calkins, E. A.: A controlled study of chloroquine as an antirheumatic agent. Arthr & Rheum I: 297, 1958. 6. Domeij-Nyberg, B., Bergquist, Y., Hellstrom, L. & Jansson, F.: Skall klorokinterapi individualiseras? KlorokinnivB i serum hos 100 vuxna reumatiker. (Abstract.) Acta SOCMedicor Suec84: 441, 1975. 7. Elman, A., Gullberg, R., Nilsson, R., Rendahl, I. & Wachtmeister, L.: Chloroquine retinopathy in patients with rheumatoid arthritis. Scand J Rheumatol 5: 161, 1976. 8. Farr, M., Kendall, M. J., Young, D.W., Meynell, M. J. & Hawkins, C. F.: Assessment of rheumatoid activity based on clinical features and blood and synovial fluid analysis. Ann Rheum Dis36: 163, 1976. 9. Freedman, A. & Steinberg, V. L.: Chloroquine in rheumatoid arthritis. A double blindfold trial of treatment for one year. Ann Rheum Dis 19: 243, 1%0. 10. Grubb, A.: Quantitation of IgG by electrophoresis in agarose gels containing antibodies. Scand J Clin Lab Invest 26: 249, 1970. 11. Gmbb, A.: Crossed immunoelectrophoresis and electroimmunoassay of IgM. J Immunol 112: 1420. 1974. 12. Hobbs, H. E., Sorby, A. & Freedman, A.: Retinopathy following chloroquine therapy. Lancet ii: 478, 1959. 13. Hunder, G. G. & McDuffie, F. C.: Hypocomplementemia in rheumatoid arthritis. Am J Med .54:461, 1973. 14. Johansson, B. G., Kindmark, C-O., Trell, E. Y. & Wollhein, F. A.: Sequential changes of plasma proteins after myocardial infarction. Scand J Clin Lab Invest 29: Suppl. 124: 117, 1972. IS. Klinefelter, H. F. & Achurra, A.: Effect of gold salts
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F. A . Wollheim et al.
and antimalarials on the rheumatoid factor in rheumatoid arthritis. Scand J RheumatolZ: 177, 1973. 16. Laaksonen, A.-L., Koskiahde, V. & Juva, K.: Dosage of antimalarial drugs for children with juvenile rheumatoid arthritis and systemic lupus erythematosus. A clinical study with determination of serum concentrations of chloroquine and hydrocNoroquine . Scand J Rheumatol3 ;103, 1974. 17. Laurell, C.-B.: Electroimmunoassay. Scand J Clin Lab Invest 29: Suppl. 124: 21, 1972. 18. McConkey, B., Crockson, R. A., Crockson, A. P. & Wilkinson, A. R.: The effects of some antiinflammatory drugs on the acute-phase proteins in rheumatoid arthritis. Quart J Med, New Series 42:785, 1973. 19. Nylander, U.: Ocular damage in chloroquine therapy. Acta Ophtalmol, Suppl. 92, 1%7.
20. Popert, A. J., Meijers, K. A. E., Sharp, 1. & Bier, F.: Chloroquine diphosphate in rheumatoid arthritis. Ann Rheum Dis20: 18, 1961. 21. Ritchie, D. M., Boyle, J. A., McInnes, J. M., Jasani, M. K., Dalakos, T. G., Grieveson, P. & Buchanan, W. W.: Clinical studies with an articular index for the assessment of joint tenderness in patients with rheumatoid arthritis. Quart J Med37: 393, 1968. Submitted for publication April 25, 1978
Frank A. Wollheim Division of Rheumatology General Hospital S-214 01 Malmo Sweden
ISSN: 0300-9742 (Print) 1502-7732 (Online) Journal homepage: http://www.tandfonline.com/loi/irhe20
Chloroquine Treatment in Rheumatoid Arthritis Frank A. Wollheim, Arne Hanson & Carl-Bertil Laurell To cite this article: Frank A. Wollheim, Arne Hanson & Carl-Bertil Laurell (1978) Chloroquine Treatment in Rheumatoid Arthritis, Scandinavian Journal of Rheumatology, 7:3, 171-176, DOI: 10.3109/03009747809095649 To link to this article: http://dx.doi.org/10.3109/03009747809095649
Published online: 12 Jul 2009.
Submit your article to this journal
Article views: 11
View related articles
Citing articles: 2 View citing articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=irhe20 Download by: [University of Toronto Libraries]
Date: 23 March 2016, At: 16:01
Scand J Rheumatology 7: 171-176, 1978
CHLOROQUINE TREATMENT IN RHEUMATOID ARTHRITIS Correlation of Clinical Response t o Plasma Protein Changes and Chloroquine Levels
Frank A. Wollheim, Arne Hanson and Carl-Bertil Laurel1
Downloaded by [University of Toronto Libraries] at 16:01 23 March 2016
From the Division of Rheumatology, Department of Medicine and the Department of Clinical Chemistry, University of Lund, Malmo General Hospital, Malmo, Sweden
ABSTRACT. 15 patients with active RA were observed over a 3-month period after starting chloroquine treatment. Clinical condition, plasma levels of chloroquine and levels of 15 individual plasma proteins were checked monthly. Nine patients responded favourably to therapy, 6 failed to respond. The responders had lower initial CRP, orosomucoid and ceruloplasmin levels, whereas their IgA and IgM levels were slightly elevated. Significantreductions in the levels of CRP, haptoglobin, orosomucoid, fibrinogen and ceruloplasmin occurred in the responder group of patients. Alfal-antitrypsin, antichymotrypsin C3 and C4 levels within the normal range were frequently encountered despite other clear-cut signs of activity. The chloroquine levels did not differ between responders and non-responders, the mean concentrationsbeing 1.04 and 1.6 pmol/l respectively. This study has also demonstrated that in selected cases, despite active joint disease, all acute phase proteins may be normal. Finally, it was obvious that chloroquine, even when inducing remission, only brought about a partial normalization of the plasma protein pattern.
Chloroquine therapy has a documented effect on rheumatoid arthritis (RA) ( 2 , 5 , 9, 20) and is widely used in Scandinavia. However, its moderate eff-
cacy and the attendant risk of serious eye complications (4, 12, 19) have reduced its popularity. Chloroquine retinopathy seems to be dose related (4,19) and is hardly ever a problem if one uses a maximum dose of only 75 g per year in patients not over 60 years of age and without evidence of liver disease (7). This study was concerned with the monitoring of patients during the initial phase of chloroquine therapy, with plasma levels of both chloroquine and a variety of individual plasma proteins, in an attempt to correlate such parameters with clinical response. MATERIAL AND METHODS Fifteen consecutive patients examined in the out-patient clinic for complaints of active RA were selected. None was taking any other slow reacting antirheumatic drug such as gold, penicillamine or cytotoxic agents. Some clinical data are shown in Table I. Ten of the patients were women; 13 had a positive Waaler-Rose test. The ages
Table I. Clinical data in 15 patients with active RA before the study Patient 1
2 3 4 5 6 7 8 9 10 11 12 13 14 15
Duration (years)
WaalerRose
18 1
+ + + ++ + + + + + + + +
Age
Sex
54 63 65 47 22 50 52 60 57 55 69 30 56
F F F M F F F M M
2 112 26 30 2 4
F F F F
7 6 17 2 14
54
57
M M
1
1
ESR 40
40 65 41 51
80 35 62 85 82 75 8 54 47 66
Functional class (Steinbrocker) I1 I1 I1 I1 I I11 I1 I1 I1 111 111 I1 I1 I1 I1 Scand J Rheumatology 7
172
F . A. Wollheim et al.
Table 11. Findings in clinicti1 ptrruniters, resitlting in responder-non responder
cluss~‘’cation
NT =not tested, R =responder, NR =non-responder Patient number
Before
After 3 0
8 9 10
9 12 19 I1 4 5 5 9 7 12
11
18
12 13 14 15
8
19 0 9 4 12
1 2 3 4
5 6 7
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Joint index
18 13 12
Subjective improvement
Relapse after treatment
Criteria for response N present : N tested
Classification of patient
Yes Yes Yes No Yes No No Yes No Yes No Yes Yes Yes No
NT Yes Yes No No No No Yes Yes NT No Yes
2:2 3:3 3:3 0 :3 2:3 0 :3 0 :3 3:3 1.3 2:2 0 :3 3:3 2:2 2:2 0 :3
R R R NR R NR NR R NR R NR R R R NR
NT NT No
ranged between 22 and 69 years, and the duration of disease from 6 months to 30 years. Disease activity was assessed from the history and the presence of active synovitis on joint palpation according to a modified Ritchie index (21). Clinical assessment was made initially and after 3 months’ treatment, and again 2 months after stopping chloroquine administration. None of the patients was taking oral corticosteroids. No change in the consumption of non-steroidal antirheumatic drugs of the analgesic type was allowed during the study period. Chloroquine was administered orally in a standard dose of 250 mg=one tablet at noon. Blood samples were collected monthly in the morning. in tubes containing EDTA. Plasma was frozen at -20°C until analysed. Cloroquine analyJis Determination of serum chloroquine was performed by a fluorometric method described by Bergquist et al. (3). An Aminco-Bowman spectrophotofluorometer was used for the determinations.
Statistics The Wilcoxon matched-pairs signed-rank test was used, and a probability of 2% was accepted as significant. The Student’s t-test was used when applicable.
RESULTS Table I1 shows the results of the clinical exarninations: 4 patients with 3 of 3 criteria, 4 with 2 of 2 and one with 2 of 3 were considered to be responders. One patient with 1 of 3 and 5 with none of 3 criteria were classified as non-responders. It was thus possible to divide the patients into 9 responders and 6 non-responders, based solely on clinical pararneters.
ESR R
PIasma protein analysis All specific plasma proteins were analysed by electroimmunoassay (17). For immunoglobulins, the variants of Grubb were used (10, I I).
rnrn/l
Responder-non responder classification Patients showing I ) improvement on joint examination, 2) improvement in subjective parameters such as stiffness, pain, and feeling of well-being, and 3) deterioration after stopping the drug were called “responders”. If any two of the criteria applied the subjects were also called “responders”. Changes in routine hematology or sedimentation rate (ESR) were nor used in this classification.
LO
NR
hr
GO
20
, L
. B
. 12
. 16 W
.
L
. 8
.
12
,
It W
Fig. I. Erythrocyte sedimentation rates ( E S R ) in re-
sponders (R) and non-responders ( N R ) during the course of chloroquine treatment.
Chloroquine treatment in rheumatoid arthritis
173
OROSWCOIO
R
NR
Y O
100
200
50
100
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I 8
4
16
12
8
L
4 I
It N
12
Fig. 2 a . C-reactive protein ( C R P ) during the course of chloroquine treatment. R =responders, NR=nonresponders.
L
12
8
16
W
12
16
W
FIBRINOGEN
5wg/1
R
8
Fig. 2 b. Orosomucoid during chloroquine treatment.
HAPTOGLOBIN 911
4
R
NR
NR
8
8
6
G
L
L
2
2
L
1
4
0
12
16
W
L
8
12
It
W
8
12
16 W
4
8
12
16
W
Fig. 2 c . Haptoglobin during chloroquine treatment.
Fig. 2 d . Fibrinogen levels during the course of chloroquine treatment.
Fig. 1 shows changes in ESR in responders and non-responders. The mean intial ESR levels did not vary significantly between the groups, 50 and 64 mm respectively; in contrast the means were 26 and 59 after 12 weeks' treatment. The reduction among responders was significant ( p =0.02) Table 111 shows the initial and 12-week levels of seven acute phase reactants, namely CRP, haptoglobin, orosomucoid, alfa,-antitrypsin, fibrinogen, ceruloplasmin and antichymotrypsin. Among these, CRP was the most elevated and showed the most pronounced reduction in responders, 76%. Fibrinogen was elevated in all but one case, but the response to treatment, although significant, was not marked, only 14%. Orosomucoid, haptoglobin and ceruloplasmin also showed significant reductions in responders to chloroquine. Alfa,-antitrypsin changed only slightly ( p=0.02), and antichymotrypsin did not change significantly.
Among non-responders CRP tended to increase despite high starting levels. The other reactants remained unchanged. CRP, orosomucoid and ceruloplasmin levels were significantly higher initially in non-responders. The variation of CRP, orosomucoid, haptoglobin and fibrinogen in individual cases is given in Fig. 2. The IgG, IgA and IgM levels did not change significantly with treatment. IgA and IgM were slightly higher in responders (p=0.02). The complement component C4 did not change during treatment, whereas C3 decreased somewhat (p=0.02) in responders. C4 was elevated in only 1 of 9 responders and in 4 of 6 non-responders. Low C4 levels were seen in 2 non-responders. Alfa,-macroglobulin levels were normal and constant in both groups. Albumin levels in the lower normal range were seen in both groups, with slightly subnormal levels occurring only occasionally among non-responders. Scund J Rherirntrtology 7
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Table 111. Levels of 12 plasma proteins before and after 12 weeks treatment with chloroquine in 9 responding and 6 non-responding patients S.D.=standard deviation Defference
Non-responders (N=6)
S.D.
%
0
7.6 0.75 30.2
-76 0.01 -29 0.01 -20 0.01
0.95
-14
0.06 24.6 33.9 3.2 1.28 0.58 26.2 29.6
-12 0.01 -22 0.02 - 1 1 N.S. -8 N.S. -14 N.S. -12 N.S. -12 0.02 -3 N.S.
Responders ( N =9)
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Protein (normal range)
0
CRP mg/l(5) Haptoglobin g/l(0.45-2.75) Orosomucoid 5% of standard (5Crl50 Fibrinogen g/l(2.04.4) Ceruloplasmin (0.22-0.48) g/l Alfa,-antitrypsin % of standard (70-130) Antichymotrypsin 92 of standard (75-125) I& g/l(7-15) IgA g/l (0.5-3.0) IgM gll(O.4-2.0) C3 % of standard (70-130) C4 9%of standard (65-170)
S.D. 12
24.I 2.1 159 5.1
29.8 1.O 29.2 1.3 0.49 0.006 121 25.1 102 21.9 13 3.4 2.99 0.6 1.70 0.51 I26 25.4 122 32.6
Chloroquine levels are shown in Fig. 3. It is obvious that unresponsiveness is not correlated to lower plasma levels, the mean level among responders in the third month of treatment being 1.04 pmolll versus 1.60 among non-responders. Only 2 patients experienced side reactions from chloroquine, one gastrointestinal and one CNS. Their levels were 2.55 and I .8 respectively.
DISCUSSION Assessment of disease activity in RA is of profound importance for proper evalutation of prognosis and selection of therapy. In this study the disease activity reducing capacity of chloroquine was utilized, in an attempt to test the usefulness of plasma proteins in such assessment. As no control group was included, a n y changes could be due either to the treatment or else represent a spontaneous remission. The fact that at least 5 of 9 “responders” relapsed, whereas 5 of 6 “non-responders” did not deteriorate when chloroquine administration was discontinued, however, does support the validity of the classification. The material is small, but repeated analysis of a series of acute phase proteins allows one to conclude that active RA may occur without any clearcut increase in a n y acute phase reactant. In agreement with earlier investigators, we found CRP to be the most sensitive protein indicator of activity (8).It was also the most closely related to Jc a t i d .I R h t ~ i r t n n r o l i i 7~ ~
5.9 1.5 128 4.4 0.43 93.6 90 11.9 2.56 I .49 111
118
P
S.D
S.D
12
36.8 24.1 58.3 2.8 0.67 3.0 220 34.1 224 6.3 1.5 6.0 0.61 0.05 0.57 132 27.0 132 148 50.3 148 13.3 5.2 12.8 2.3 0.44 2.37 1.12 0.25 0.96 139 17.4 137 148 148 69
0.01
30.5 1.0 33.8 1.3 0.05 28.0 52.2 5.6
0.55 0.23 28.0 64.7
therapeutic response. It is of considerable interest that Amos et al. (1) recently found a correlation between CRP and radiological progression in RA. The relatively small increase in antichymotrypsin was a surprise finding that distinguishes the rheumatic activity from the usual acute inflammatory processes (14). Alfa,-antitrypsin and C4 also often do not rise in plasma in proportion to haptoglobin or CRP. It is known that low complement levels in RA are signs of severe disease (13) and one assumes consumption by immune complexes activating along the classical pathway. Whether a similar consumption of antichymotrypsin of alfa,-antitrypsin occurs in rheumatoid lesions is not known.
CHLOROOUINE
R
wwlfl
A 2
2
1
1
L
8
12
16
20
L
8
12
16 20 WEEKS
Chloroquine levels 12 hours or more after the last intake in responders ( R ) and non-responders ( N R ) taking a standard dose of 250 mg chloroquine phosphate daily. SR means side reaction. Fig. 3.
Chloroquine treatment in rheumatoid arthritis
I75
of value in avoiding overdosage and side effects, but cannot explain why some patients do not respond to the drug. Difference
Difference responder/ non-responder
%
P
t
P
+85 +7 +2
0.05 N.S. N.S. N.S. N.S. N.S. N.S. N.S. N.S. N.S. N.S. N.S.
4.67 1.67 3.57 1.60 4.20 0.83 2.10 0.12 2.45 2.93 1.17 0.86
0.01 N.S. 0.01 N.S. 0.01 N.S. N.S. N.S. 0.02 0.02 N.S. N.S.
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-5 -3 0 0 -4 -3 -14 -1.5 0
Several drugs are known to influence plasma protein levels and ESR in RA, among them glucocorticosteroids (18). None of the patients in this study were taking steroids, however, which excludes this as an explanation for the normal plasma levels of acute phase proteins. Prostaglandin E has recently been claimed to induce increased hepatic synthesis of plasma proteins characteristic of the inflammatory response. The common use of inhibitors of prostaglandin synthetase in RA could be suspected to modify the plasma protein profile. However, McConkey et al. could find no effect of indomethacin treatment on ESR, haptoglobin, or CRP (18). Whereas chloroquine treatment is known to reduce titres of rheumatoid factor (15), we could find only insignificant changes in Ig levels. The RF titres were not monitored in this investigation. It was a surprise to find lower IgA and IgM levels among the non-responders. Plasma determinations of chloroquine have been used only infrequently in the past. Laaksonen et al. (16) found a considerable interindividual spread in plasma concentrations in children taking standard doses of either chloroquine or hydroxychloroquine. The occurrence of keratopathy seemed to correlate with high plasma levels. Domeij-Nyberg et al. (6) reported a higher incidence of non-ocular side effects at higher concentrations. Our results indicate that higher plasma levels did not correlate to better therapeutic response. Thus plasma determinations are probably
ACKNOWLEDGEMENTS This study was supported financially by the Alfred Osterlunds Stiftelse and Greta och Johan Kocks Stiftelser.
REFERENCES 1. Amos, R. S., Constable, T. J., Crockson, R. A., Crockson, A. P. & McConkey, B.: Rheumatoid arthritis: relation of serum C-reacitve protein and erythrocyte sedimentation rates to radiographic changes. Br Med J i: 195, 1977. 2. Bagnall, A. W.: The value of chloroquine in rheumatoid arthritis. Canad Med Assoc J 77: 182, 1957. 3. Bergquist, Y., Domeij-Nyberg, B., Hellstrom, L. & Frisk-Holmberg, M.: Samband mellan koncentration av klorokin i serum och biverkningar hos reumatiker. (Abstract.) Acta SOCMedicor Suec 85: 248, 1976. 4. Bemstein, H. N.: Chloroquine ocular toxicity. Surv Ophtalmoll2: 415, 1%7. 5. Cohen, A. S. & Calkins, E. A.: A controlled study of chloroquine as an antirheumatic agent. Arthr & Rheum I: 297, 1958. 6. Domeij-Nyberg, B., Bergquist, Y., Hellstrom, L. & Jansson, F.: Skall klorokinterapi individualiseras? KlorokinnivB i serum hos 100 vuxna reumatiker. (Abstract.) Acta SOCMedicor Suec84: 441, 1975. 7. Elman, A., Gullberg, R., Nilsson, R., Rendahl, I. & Wachtmeister, L.: Chloroquine retinopathy in patients with rheumatoid arthritis. Scand J Rheumatol 5: 161, 1976. 8. Farr, M., Kendall, M. J., Young, D.W., Meynell, M. J. & Hawkins, C. F.: Assessment of rheumatoid activity based on clinical features and blood and synovial fluid analysis. Ann Rheum Dis36: 163, 1976. 9. Freedman, A. & Steinberg, V. L.: Chloroquine in rheumatoid arthritis. A double blindfold trial of treatment for one year. Ann Rheum Dis 19: 243, 1%0. 10. Grubb, A.: Quantitation of IgG by electrophoresis in agarose gels containing antibodies. Scand J Clin Lab Invest 26: 249, 1970. 11. Gmbb, A.: Crossed immunoelectrophoresis and electroimmunoassay of IgM. J Immunol 112: 1420. 1974. 12. Hobbs, H. E., Sorby, A. & Freedman, A.: Retinopathy following chloroquine therapy. Lancet ii: 478, 1959. 13. Hunder, G. G. & McDuffie, F. C.: Hypocomplementemia in rheumatoid arthritis. Am J Med .54:461, 1973. 14. Johansson, B. G., Kindmark, C-O., Trell, E. Y. & Wollhein, F. A.: Sequential changes of plasma proteins after myocardial infarction. Scand J Clin Lab Invest 29: Suppl. 124: 117, 1972. IS. Klinefelter, H. F. & Achurra, A.: Effect of gold salts
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and antimalarials on the rheumatoid factor in rheumatoid arthritis. Scand J RheumatolZ: 177, 1973. 16. Laaksonen, A.-L., Koskiahde, V. & Juva, K.: Dosage of antimalarial drugs for children with juvenile rheumatoid arthritis and systemic lupus erythematosus. A clinical study with determination of serum concentrations of chloroquine and hydrocNoroquine . Scand J Rheumatol3 ;103, 1974. 17. Laurell, C.-B.: Electroimmunoassay. Scand J Clin Lab Invest 29: Suppl. 124: 21, 1972. 18. McConkey, B., Crockson, R. A., Crockson, A. P. & Wilkinson, A. R.: The effects of some antiinflammatory drugs on the acute-phase proteins in rheumatoid arthritis. Quart J Med, New Series 42:785, 1973. 19. Nylander, U.: Ocular damage in chloroquine therapy. Acta Ophtalmol, Suppl. 92, 1%7.
20. Popert, A. J., Meijers, K. A. E., Sharp, 1. & Bier, F.: Chloroquine diphosphate in rheumatoid arthritis. Ann Rheum Dis20: 18, 1961. 21. Ritchie, D. M., Boyle, J. A., McInnes, J. M., Jasani, M. K., Dalakos, T. G., Grieveson, P. & Buchanan, W. W.: Clinical studies with an articular index for the assessment of joint tenderness in patients with rheumatoid arthritis. Quart J Med37: 393, 1968. Submitted for publication April 25, 1978
Frank A. Wollheim Division of Rheumatology General Hospital S-214 01 Malmo Sweden
