CLINICAL RESEARCH e-ISSN 1643-3750 © Med Sci Monit, 2015; 21:2305-2315 DOI: 10.12659/MSM.893865
Combination of Azathioprine and Aminosalicylate Treatment Prevent Risk of Cardiovascular Disease in Women with Ulcerative Colitis by Reducing Inflammation
Received: 2015.02.13 Accepted: 2015.04.20 Published: 2015.08.07
Authors’ Contribution: Study Design A Data Collection B Analysis C Statistical Data Interpretation D Manuscript Preparation E Literature Search F Collection G Funds
ABCDEF 1 BCD 1 BC 1 BC 1 BC 1 BC 2
ABDEF 3
ABCDEF 1
Lana Claudinez dos Santos Aline Villela Costa Lorrayne Gonçalves Lopes Alda Jusceline Leonel Edenil Costa Aguilar Maria de Lourdes Meirelles Noviello Maria de Lourdes de Abreu Ferrari Jacqueline I. Alvarez-Leite
1 Department of Biochemistry and Immunology, Institute of Biological Sciences, Federal University of Minas Gerais, Belo Horizonte, Brazil 2 Department General Pathology, Institute of Biological Sciences, Federal University of Minas Gerais, Belo Horizonte, Brazil 3 Department of Internal Medicine and ALFA Institute of Gastroenterology, Clinical Hospital of the Federal University of Minas Gerais, Belo Horizonte, Brazil
Corresponding Author: Source of support:
Lana Claudinez dos Santos, e-mail: [email protected] CNPq (Conselho Nacional de Desenvolvimento Científico e Tecnológico), FAPEMIG (Fundação de Amparo à pesquisa de Minas Gerais) and PRPq (Pro-Reitoria de Pesquisa)-UFMG
Background:
Material/Methods:
Results:
Conclusions:
Ulcerative colitis (UC) is a chronic inflammatory bowel disease with involvement of the immune system. Chronic inflammatory diseases have been associated with increased risk of cardiovascular disease (CVD) but few studies have assessed this risk in patients with UC and the influence of drug treatment. Thus, we evaluated the risk of development of CVD in women with UC in clinical remission, considering the drug treatment. Twenty-one women with UC participated in this study: 12 used aminosalicylates (ASA group) and 9 used azathioprine added to aminosalicylates (AZA+ASA group). The healthy control group was matched for age. We evaluated blood pressure, body composition, and biochemical and immunological parameters. Compared to the respective control group, the UC groups showed expansion of body fat and less lean body mass. Blood pressure, pro-inflammatory cytokines, nitric oxide, C reactive protein, erythrocyte sedimentation rate (ESR), and anti-oxidized LDL antibodies were higher in UC groups. Only AZA+ASA group showed increased anti-inflammatory cytokines (IL-10 and TGF-b). Framingham scores showed higher risk of CVD in UC groups. UC groups were compared and women treated with azathioprine showed reduction of total protein, globulin, ESR, and lymphocytes, with increased IL-6, TNF, IL-10, and TGF-b. Our data suggest that women with UC in clinical remission have a higher risk for development of atherosclerosis and CVD when compared to the control group, while women treated with azathioprine seem more protected than those treated only with aminosalicylates, due to better regulation of the inflammatory process.
MeSH Keywords:
Full-text PDF:
Adipose Tissue • Aminosalicylates • Azathioprine • Cardiovascular Diseases • Cytokines • Ulcerative Colitis http://www.medscimonit.com/abstract/index/idArt/893865
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dos Santos L.C. et al: Cardiovascular disease in ulcerative colitis © Med Sci Monit, 2015; 21: 2305-2315
CLINICAL RESEARCH
Background Ulcerative Colitis (UC) is an inflammatory bowel disease (IBD) whose etiology is only partially known. It is characterized by diffuse inflammation of the colonic mucosa, which starts in the rectum and extends continuously along the colon [1]. It is presented in variable clinical course with periods of remission or activity. In general, patients with UC have increased body fat and decreased lean body mass, increased production of inflammatory cytokines and they maintain a chronic low-grade inflammation [2–4]. Treatment of UC aims to induce and maintain remission of the active disease [1]. Cardiovascular diseases (CVD) are also chronic disorders associated with (low-grade) inflammation. Atherosclerosis is the main cause of CVD and is associated with endothelial dysfunction, increased accumulation of oxidized LDL (oxLDL), leukocytes, and smooth muscle cells in the intima of the artery, with release of inflammatory mediators (TNF, IL-6, CCL-2), resulting in the development and expansion of the atheroma plaque. Risk factors for CVD include smoking, alcohol, sedentary, diet, hypertension, and diabetes mellitus (DM) and dyslipidemia, as well as emerging factors such as total leukocytes count, levels of hemoglobin, and reactive C protein, IL-6, and fibrinogen [5–8]. Several studies have demonstrated that patients with chronic inflammatory diseases such as rheumatoid arthritis and systemic lupus erythematosus have higher incidence of cardiovascular disease (CVD) due to chronic and systemic inflammation [9–12]. Several studies have suggested that patients with IBD also have higher risk of atherosclerosis and cardiovascular events compared the healthy population [7,13–19]. However,
there are no studies evaluating this risk in UC patients when the inflammatory process is controlled. The aim of this study was to evaluate the risk of CVD in women with UC, in clinical remission, using of aminosalicylates or azathioprine and aminosalicylates and to compare the results to those obtained in healthy matched volunteers and suggest a mechanism explaining the relationship between UC and CVD.
Material and Methods The patients were selected at the Reference Center for Inflammatory Bowel Disease of the ALFA Institute of Gastroenterology, Clinical Hospital, Federal University of Minas Gerais (UFMG). Inclusion criteria included women aged 18–60 years that did not present hypertension, dyslipidemia, diabetes mellitus, hormonal disorders, or cardiovascular disease. Those presenting symptoms and signs of disease activity or using glucocorticoids or biologic agents were excluded. From 144 patients with UC monitored in the Reference Center, only 21 met the inclusion criteria, showing the high prevalence of risk factors for cardiovascular disease in this population and the presence of active disease phase (Supplementary Figure 1). UC was diagnosed by clinical, laboratory, endoscopic, and histological criteria. All participants were in clinical remission [do not fit the Truelove and Witts [20] criteria] by the use of aminosalicylates (sulfasalazine or mesalazine) (12 patients) or azathioprine combined with aminosalicylate (9 patients). Because the introduction of azathioprine could modify the immunological and inflammatory status of patients, we initially divided patients in an ASA group (aminosalicylates) and an AZA+ASA
144 UC 93 (64.6%) Women
21 (22.6%): excluded by drug treatment; 23 (24.7%): factor risk or diagnosis of CVD
1 (1.1%): age 60 years
10 (10.7%): abonded the treatment, were not found or not wanted to participated of the study
51 (35.4%) Men
21 (22.6%) participants
16 (31.4%): exclued by drug treatment; 14 (27.4%: factor risk or diagnosis of CVD; 1 (2%): age 60 years; 10 (25.5%): abandoned the treatment, were not found or not wanted to participated of the study; 3 (5.9%): possibles participants
Supplementary F igure 1. Patients with UC treated in the Reference Center for Inflammatory Bowel Disease of the ALFA Institute of Gastroenterology. Of the total of 144 patients with UC treated at the Reference Center, 93 were women and 51 were men. Among men, 48 did not meet the inclusion criteria. Among women, 21 (22.6%) were excluded for drug treatment (use of corticosteroids or biology therapy); 23 (24.7%) were excluded for risk factors or diagnosis of CVD or other diseases; 8 (8.6%) were excluded by age; 10 (10.7%) abandoned the treatment, were not found, or did not want to participate in the study, and only 21 (22.6%) women met the study criteria and wanted to participate.
This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivs 3.0 Unported License
2306
Indexed in: [Current Contents/Clinical Medicine] [SCI Expanded] [ISI Alerting System] [ISI Journals Master List] [Index Medicus/MEDLINE] [EMBASE/Excerpta Medica] [Chemical Abstracts/CAS] [Index Copernicus]
dos Santos L.C. et al: Cardiovascular disease in ulcerative colitis © Med Sci Monit, 2015; 21: 2305-2315
CLINICAL RESEARCH
group (azathioprine + aminosalicylates) to determine the inflammatory profile and cardiovascular risk; later, we compared both treatments for remission to observe possible differences. The control group consisted of by healthy age-matched women. The study was approved by the Ethics Committee in Human Research of the Federal University of Minas Gerais (protocol 342/11). All participants read and signed the informed consent. Participants answered questionnaires about their clinical and family histories and lifestyle routines. Blood pressure and anthropometric data such as weight, height, body mass index (BMI), waist circumference, and body composition (body fat and body fat-free) were also obtained. After 12 h of fasting, 20 mL blood was collected for biochemical and inflammatory markers analysis. Total cholesterol, HDL-cholesterol, glycemia, total protein, albumin, hemoglobin, fibrinogen, and high-sensitive C reactive Protein (hs CRP) were assessed using commercial kits (Labstest® and Bioclin, Belo Horizonte, Brazil). The erythrocyte sedimentation rate (ESR) was measured using a Westergren pipette. LDL-cholesterol (LDLc) was calculated using the Friedewald equation. Globulin was determined as the difference between the total protein and albumin concentrations. Total and differential leukocyte count was obtained using a Neubauer chamber, and a differential count was performed on slides using a Rapid Kit Panoptic® kit (Laborclin, Paraná, Brazil). Nitric oxide (NO) concentration was measured indirectly according to Griess technique [21]. IL-6, TNF, IL-1b, IL-10, TGF-b, CCL-2, and anti-oxLDL antibodies were determined by ELISA (BD OptEIA ®, United States) [22,23]. The 10and 30-year Framingham risk scores (FRS) were determined using online calculators (http://www.framinghamheartstudy. org/), considering lipid profile or BMI. Data are presented as mean ± standard error or median. The Kolmogorov-Smirnov test was used to evaluate the distribution of the data. Unpaired Mann-Whitney, Wilcoxon, or Student’s t-tests were used for continuous variables. Categorical variables were analyzed using Fisher’s exact test. The correlation between variables was analyzed using Pearson correlation coefficient. Statistical analysis was performed using SPSS software (Statistical Package for Social Sciences) version 19.0. The level of significance was set at p
Combination of Azathioprine and Aminosalicylate Treatment Prevent Risk of Cardiovascular Disease in Women with Ulcerative Colitis by Reducing Inflammation
Received: 2015.02.13 Accepted: 2015.04.20 Published: 2015.08.07
Authors’ Contribution: Study Design A Data Collection B Analysis C Statistical Data Interpretation D Manuscript Preparation E Literature Search F Collection G Funds
ABCDEF 1 BCD 1 BC 1 BC 1 BC 1 BC 2
ABDEF 3
ABCDEF 1
Lana Claudinez dos Santos Aline Villela Costa Lorrayne Gonçalves Lopes Alda Jusceline Leonel Edenil Costa Aguilar Maria de Lourdes Meirelles Noviello Maria de Lourdes de Abreu Ferrari Jacqueline I. Alvarez-Leite
1 Department of Biochemistry and Immunology, Institute of Biological Sciences, Federal University of Minas Gerais, Belo Horizonte, Brazil 2 Department General Pathology, Institute of Biological Sciences, Federal University of Minas Gerais, Belo Horizonte, Brazil 3 Department of Internal Medicine and ALFA Institute of Gastroenterology, Clinical Hospital of the Federal University of Minas Gerais, Belo Horizonte, Brazil
Corresponding Author: Source of support:
Lana Claudinez dos Santos, e-mail: [email protected] CNPq (Conselho Nacional de Desenvolvimento Científico e Tecnológico), FAPEMIG (Fundação de Amparo à pesquisa de Minas Gerais) and PRPq (Pro-Reitoria de Pesquisa)-UFMG
Background:
Material/Methods:
Results:
Conclusions:
Ulcerative colitis (UC) is a chronic inflammatory bowel disease with involvement of the immune system. Chronic inflammatory diseases have been associated with increased risk of cardiovascular disease (CVD) but few studies have assessed this risk in patients with UC and the influence of drug treatment. Thus, we evaluated the risk of development of CVD in women with UC in clinical remission, considering the drug treatment. Twenty-one women with UC participated in this study: 12 used aminosalicylates (ASA group) and 9 used azathioprine added to aminosalicylates (AZA+ASA group). The healthy control group was matched for age. We evaluated blood pressure, body composition, and biochemical and immunological parameters. Compared to the respective control group, the UC groups showed expansion of body fat and less lean body mass. Blood pressure, pro-inflammatory cytokines, nitric oxide, C reactive protein, erythrocyte sedimentation rate (ESR), and anti-oxidized LDL antibodies were higher in UC groups. Only AZA+ASA group showed increased anti-inflammatory cytokines (IL-10 and TGF-b). Framingham scores showed higher risk of CVD in UC groups. UC groups were compared and women treated with azathioprine showed reduction of total protein, globulin, ESR, and lymphocytes, with increased IL-6, TNF, IL-10, and TGF-b. Our data suggest that women with UC in clinical remission have a higher risk for development of atherosclerosis and CVD when compared to the control group, while women treated with azathioprine seem more protected than those treated only with aminosalicylates, due to better regulation of the inflammatory process.
MeSH Keywords:
Full-text PDF:
Adipose Tissue • Aminosalicylates • Azathioprine • Cardiovascular Diseases • Cytokines • Ulcerative Colitis http://www.medscimonit.com/abstract/index/idArt/893865
3103
2
This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivs 3.0 Unported License
6
2305
53
Indexed in: [Current Contents/Clinical Medicine] [SCI Expanded] [ISI Alerting System] [ISI Journals Master List] [Index Medicus/MEDLINE] [EMBASE/Excerpta Medica] [Chemical Abstracts/CAS] [Index Copernicus]
dos Santos L.C. et al: Cardiovascular disease in ulcerative colitis © Med Sci Monit, 2015; 21: 2305-2315
CLINICAL RESEARCH
Background Ulcerative Colitis (UC) is an inflammatory bowel disease (IBD) whose etiology is only partially known. It is characterized by diffuse inflammation of the colonic mucosa, which starts in the rectum and extends continuously along the colon [1]. It is presented in variable clinical course with periods of remission or activity. In general, patients with UC have increased body fat and decreased lean body mass, increased production of inflammatory cytokines and they maintain a chronic low-grade inflammation [2–4]. Treatment of UC aims to induce and maintain remission of the active disease [1]. Cardiovascular diseases (CVD) are also chronic disorders associated with (low-grade) inflammation. Atherosclerosis is the main cause of CVD and is associated with endothelial dysfunction, increased accumulation of oxidized LDL (oxLDL), leukocytes, and smooth muscle cells in the intima of the artery, with release of inflammatory mediators (TNF, IL-6, CCL-2), resulting in the development and expansion of the atheroma plaque. Risk factors for CVD include smoking, alcohol, sedentary, diet, hypertension, and diabetes mellitus (DM) and dyslipidemia, as well as emerging factors such as total leukocytes count, levels of hemoglobin, and reactive C protein, IL-6, and fibrinogen [5–8]. Several studies have demonstrated that patients with chronic inflammatory diseases such as rheumatoid arthritis and systemic lupus erythematosus have higher incidence of cardiovascular disease (CVD) due to chronic and systemic inflammation [9–12]. Several studies have suggested that patients with IBD also have higher risk of atherosclerosis and cardiovascular events compared the healthy population [7,13–19]. However,
there are no studies evaluating this risk in UC patients when the inflammatory process is controlled. The aim of this study was to evaluate the risk of CVD in women with UC, in clinical remission, using of aminosalicylates or azathioprine and aminosalicylates and to compare the results to those obtained in healthy matched volunteers and suggest a mechanism explaining the relationship between UC and CVD.
Material and Methods The patients were selected at the Reference Center for Inflammatory Bowel Disease of the ALFA Institute of Gastroenterology, Clinical Hospital, Federal University of Minas Gerais (UFMG). Inclusion criteria included women aged 18–60 years that did not present hypertension, dyslipidemia, diabetes mellitus, hormonal disorders, or cardiovascular disease. Those presenting symptoms and signs of disease activity or using glucocorticoids or biologic agents were excluded. From 144 patients with UC monitored in the Reference Center, only 21 met the inclusion criteria, showing the high prevalence of risk factors for cardiovascular disease in this population and the presence of active disease phase (Supplementary Figure 1). UC was diagnosed by clinical, laboratory, endoscopic, and histological criteria. All participants were in clinical remission [do not fit the Truelove and Witts [20] criteria] by the use of aminosalicylates (sulfasalazine or mesalazine) (12 patients) or azathioprine combined with aminosalicylate (9 patients). Because the introduction of azathioprine could modify the immunological and inflammatory status of patients, we initially divided patients in an ASA group (aminosalicylates) and an AZA+ASA
144 UC 93 (64.6%) Women
21 (22.6%): excluded by drug treatment; 23 (24.7%): factor risk or diagnosis of CVD
1 (1.1%): age 60 years
10 (10.7%): abonded the treatment, were not found or not wanted to participated of the study
51 (35.4%) Men
21 (22.6%) participants
16 (31.4%): exclued by drug treatment; 14 (27.4%: factor risk or diagnosis of CVD; 1 (2%): age 60 years; 10 (25.5%): abandoned the treatment, were not found or not wanted to participated of the study; 3 (5.9%): possibles participants
Supplementary F igure 1. Patients with UC treated in the Reference Center for Inflammatory Bowel Disease of the ALFA Institute of Gastroenterology. Of the total of 144 patients with UC treated at the Reference Center, 93 were women and 51 were men. Among men, 48 did not meet the inclusion criteria. Among women, 21 (22.6%) were excluded for drug treatment (use of corticosteroids or biology therapy); 23 (24.7%) were excluded for risk factors or diagnosis of CVD or other diseases; 8 (8.6%) were excluded by age; 10 (10.7%) abandoned the treatment, were not found, or did not want to participate in the study, and only 21 (22.6%) women met the study criteria and wanted to participate.
This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivs 3.0 Unported License
2306
Indexed in: [Current Contents/Clinical Medicine] [SCI Expanded] [ISI Alerting System] [ISI Journals Master List] [Index Medicus/MEDLINE] [EMBASE/Excerpta Medica] [Chemical Abstracts/CAS] [Index Copernicus]
dos Santos L.C. et al: Cardiovascular disease in ulcerative colitis © Med Sci Monit, 2015; 21: 2305-2315
CLINICAL RESEARCH
group (azathioprine + aminosalicylates) to determine the inflammatory profile and cardiovascular risk; later, we compared both treatments for remission to observe possible differences. The control group consisted of by healthy age-matched women. The study was approved by the Ethics Committee in Human Research of the Federal University of Minas Gerais (protocol 342/11). All participants read and signed the informed consent. Participants answered questionnaires about their clinical and family histories and lifestyle routines. Blood pressure and anthropometric data such as weight, height, body mass index (BMI), waist circumference, and body composition (body fat and body fat-free) were also obtained. After 12 h of fasting, 20 mL blood was collected for biochemical and inflammatory markers analysis. Total cholesterol, HDL-cholesterol, glycemia, total protein, albumin, hemoglobin, fibrinogen, and high-sensitive C reactive Protein (hs CRP) were assessed using commercial kits (Labstest® and Bioclin, Belo Horizonte, Brazil). The erythrocyte sedimentation rate (ESR) was measured using a Westergren pipette. LDL-cholesterol (LDLc) was calculated using the Friedewald equation. Globulin was determined as the difference between the total protein and albumin concentrations. Total and differential leukocyte count was obtained using a Neubauer chamber, and a differential count was performed on slides using a Rapid Kit Panoptic® kit (Laborclin, Paraná, Brazil). Nitric oxide (NO) concentration was measured indirectly according to Griess technique [21]. IL-6, TNF, IL-1b, IL-10, TGF-b, CCL-2, and anti-oxLDL antibodies were determined by ELISA (BD OptEIA ®, United States) [22,23]. The 10and 30-year Framingham risk scores (FRS) were determined using online calculators (http://www.framinghamheartstudy. org/), considering lipid profile or BMI. Data are presented as mean ± standard error or median. The Kolmogorov-Smirnov test was used to evaluate the distribution of the data. Unpaired Mann-Whitney, Wilcoxon, or Student’s t-tests were used for continuous variables. Categorical variables were analyzed using Fisher’s exact test. The correlation between variables was analyzed using Pearson correlation coefficient. Statistical analysis was performed using SPSS software (Statistical Package for Social Sciences) version 19.0. The level of significance was set at p
