References & Notes
1. K.L. Sewell and D.E. Trentham, Lancet 341. 283 (1993).
2. D.E. Trentham, A.S. Townes, A.H. Kang, J. Exp. Med. 146, 857, (1977).
3. J.S. Courtenay, M.J. Dallman, A.D. Dayan, A. Martin, B. Mosedale Nature 283, 666 (1980); E.S. Cathcart et al., Lab. Invest. 54, 26 (1986).
4. N.A. Andriopoulos et al., Arthritis Rheum. 19, 613 (1976); D.E. Trentham, R.A. Dynesius, R.E. Rocklin, J.R. David, N Engl. J. Med. 299, 327 (1978); A. Tarkowski, L. Klareskog, H. Carlsten, P. Herberts, W.J. Koopman, Arthritis Rheum. 32, 1087 (1989).
5. P.M. Brooks, Lancet 341, 286 (1993).
6. P.J. Higgins and H.L. Wiener, J. Immunol. 140, 440 (1988).
7. D. Bitar and C.C. Whitacre, Cell. Immunol. 112, 364 (1988); C.C. Whitacre, I.E. Gienapp, C.G. Orosz, D. Bitar, J. Immunol. 147, 215 (1991).
8. R.B. Nussenblatt et al, J. Immunol. 144, 1689 (1990).
9. O. Lider, M.B. Santos, C.S.Y. Lee, P.J. Higgins, H.L. Weiner, ibid. 142, 748 (1989).
10. A. Miller, O. Lider, H.L. Weiner J. Exp. Med. 174, 791 (1991); S.J. Khoury, W.W. Hancock, H.L. Weiner, ibid. 176, 1355 (1992); A. Miller, O. Lider, A. Roberts, M.B. Sporn, H.L. Weiner, Proc. Natl. Acad. Sci. U.S.A. 89, 421 (1992).
11. Z.J. Zhang, L. Davidson, G. Eisenbarth, H.S. Weiner, Proc. Natl. Acad. Sci. U.S.A. 88, 10252 (1991).
12. H.L. Weiner et al., Science 259, 1321 (1993).
13. C. Nagler-anderson, L.A. Bober, M.E. Robinson, G.W. Siskind, G.J. Thorbecke, Proc. Natl. Acad. Sci. U.S.A. 83, 7443 (1986); h.s.g. Thompson and N.A. Staines, Clin. Exp. Immunol. 64, 581 (1986).
14. Z.J. Zhang, C.S.Y. Lee, O. Lider, H.L. Weiner, J. Immunol. 145, 2489 (1990).
15. Native type II collage, isolated from sternal cartilage of chicks rendered lathyritic by administration of 8-aminopropionitrile (2), was used to treat the first rive subjects in the phase I pilot study. Subsequent patients in the pilot trial and in the double-blind study received type II collagen purified from non arthritic chicken sternal cartilage by the identical technique (2) and obtained from Genzyme (Boston, MA). Preparations were analyzed for purity by standard biochemical methods (2, 35) and tested for arthritogenicity and toxicity in rats (2) with findings of batch-to-batch equivalency. Collagen was stored in a lyophilized state (2) at -20C with desiccant. The protein was solubilized in 0.1 M acetic acid for -12 hours at 4 C, sterilized by membrane filtration, and aliquoted into individual 1.0-ml doses in sterile tubes. Tubes sufficient for about 2 weeks of treatment were delivered on ice to patients and maintained under refrigeration until use. For oral administration, the 1.0-ml aliquot was added to 4 to 6 ounces (118 to 177 ml) of cold orange juice and the mixture drunk immediately. Orange juice provided an additional acid vehicle to inhibit precipitation of collagen and masked the taste of acetic acid. All dosing occurred in the morning on an empty stomach at least 20 min before breakfast or ingestion of other fluids. Smoking was not permitted during this interval.
16. M.E. Weinblatt et al., N. Engl. J. Med. 312, 818 (1985); K.L. Sewell et al., Arthritis Rheum., in press.
17. R.S. Pinals, A.T. Masi, R.A. Larsen, Arthritis Rheum, 24, 1308(1981).
18. The following requirements determined eligibility: (i) American Rheumatism Association (ARA) criteria for classic or definite rheumatoid arthritis (16); (ii) onset of the disease at age 16 or older; (iii) age of at least 18 years; (iv) ARA functional class unresponsive to at least one immunosuppressive (Table 1); and (vi) severe active disease defined by at least three of the following: at least nine painful or tender joints, at least six swollen joints, at least 45 min of morning stiffness, or at least 28 mm/hour ESR. Exclusion criteria included a degree of structural joint damage not amenable to physical rehabilitation if inflammation subsided after treatment or a serious concurrent medical problem. Some patients (n=39) represented referrals for treatment of refractory disease by rheumatologists outside Boston; others (n-10) had received experimental therapy for rheumatoid arthritis in the past.
19. The study was approved by the Beth Israel Hospital Committee on Clinical Investigations and conducted under an investigator-initiated Investigational New Drug (IND) permit from the U.S. Food and Drug Administration.
20. Because of the possibility that patients would receive ineffective therapy or a placebo, study medication was begun immediately after the patient discontinued immunosuppressive drugs (Table 1); patients receiving parenteral gold were not entered because prolonged carryover effects could influence the outcome. Patients remained on their NSAID, prednisone dose (less than or equal to 10 mg/day), or both, during the 3-month treatment period. NSAID substitution, increases in NSAID or prednisone dose, or initiation of any other antirheumatic therapy with the exception of analgesic agents and intraarticular steroids represented protocol violations. If applicable, patients were requested to practice contraception.
21. A biostatistician (E.J.O.) randomized each patient to either the active or placebo treatment group in blocks of six, stratified by functional class (28) severity.
22. The placebo consisted of 1.0-ml doses of 0.1 M acetic acid subjected to membrane filtration.
23. Three investigators (D.C., C.L., and K.L.S.) obtained the randomization and prepared medication but did not have access to clinical data. No unblinding occurred.
24. Conventional instruments were used to measure RA activity (16). Assistive devices were permitted for walk times. The clinical investigator cared for the patients during the trial and was responsible for safety monitoring. Laboratory safety assessment was performed immediately before randomization and at 2, 4, 8, and 12 weeks thereafter. The assessment comprised a complete blood count, differential and platelet count, liver and renal function tests, prothrombin and partial thromboplastin times, urinalysis, and ESR. HLA typing was performed for the alleles of the A,B, C and DR/DQ loci (36). Serum immunoglobulin M (IgM) rheumatoid factor titers were determined by nephelometry and IgG antibody titers to native type II collagen (expressed as -log2) by enzyme-linked immunosorbent assay (37) immediately before and at the end of collagen or placebo administration.
25. Before unbinding, decisions were made concerning the analysis of five subjects (8%) that failed to complete the study. One was noncompliant and withdrew for personal reasons on day 40 after only a baseline examination. This patient was excluded from analysis and had been randomized to collagen. Four discontinued their study medication before the end of the 3-month treatment because of worsening arthritis. They were assigned the worst score in the sample for the remainder of the study and included in the analysis. All four had been randomized to placebo. One protocol violation occurred with a patient who increased the daily dose of prednisone from 5 mg to 10 mg just before month 2. Because the patient continued to do poorly and the 10-mg dose was consistent with eligibility requirements, the patient was included in the analyses; the patient had been randomized to collagen. No steroid injections or other problems with compliance occurred.
26. Comparisons between collagen- and placebo-treated patients were performed with the Wilcoxon rank-sum test for continuous measures (such as the number of swollen joints), the Fisher's exact test for dichotomous measures (such as narcotic usage), and the x2 trend test for functional class and patient and physician assessments. All measured end points such as the number of swollen joints were compared with entry values before testing; qualitative measures, such as patient and physician assessments and functional class, are presented and analyzed without adjustment for baseline responses. The Student's paired t test was used to assess whether changes in the collagen group represented significant improvements over baseline values. Reported P values were two-sided.
27. Complete resolution is a more rigorous extension of RA remission criteria (17), preformulated because of the magnitude of improvement in some patients in the initial trial, and is defined by the following conditions: no swollen or tender joints, no morning stiffness or afternoon fatigue, absent arthritis on physician and patient appraisals, functional class I status, and normal ESR (<28 mm/hour) while off prednisone.
28. O. Steinbrocker, C.H. Traeger, R.C. Batterman, J. Am. Med. Assoc. 140, 659 (1949).
29. Rather than assigning the placebo patients who withdrew from the trial the worst observed value (25), they were given the value from their last visit. Because one of the four dropped out before the 1-month follow-up, that patient was removed from all analyses, reducing the sample size to 28 collagen and 30 placebo patients. By this analysis, the number of tender joints, joint-tenderness index, walk time, patient assessment of severe or very severe disease, and analgesic use was significantly (P is less than or equal to 0.05) improved in the collagen group compared with the placebo group.
30. H.J. Williams et al., Arthritis Rhuem. 31, 702 (1988).
31. Analysis of variance showed no significant interaction between treatment effectiveness (as measured by changes in the number of swollen joints, tender joints, or walk time) and any characteristic in Table 1.
32. R. Nussenblatt, personal communication.
33. A. Friedman and H.L. Weiner, J. Immunol. 150, 4A (1993): H.L. Weiner et al., Ann. Rev. Immunol., in press.
34. A. Al-Sabbagh, A. Miller, R.A. Sorbel, H.L. Weiner, Neurology 42 (suppl.3), 346 (1992).
35. S.M. Helfgott, R.A. Dynesius-Trentham, E. Brahn, D.E. Trenthma, J. Exp. Med. 162, 1531 (1985).
36. G.M. Kammer and D.E. Trentham, Arthritis Rheum. 27, 489 (1984).
37. S.M. Helfgott et al., Lancet 337, 387 (1991).
38. Supported by NIH grants MO1 RRO1032 and AG00294 and by a grant from Autoimmune Inc. We thank E. Milford and C.B. Carpenter for HLA-typing. In accordance with disclosure guidelines of the Harvard Medical School, D.A.H. and H.L.W. have a financial interest in Autoimmune Inc.
Trentham DE, Dynesius-Trentham RA, Orav EJ, et al. Effects of Oral Administration of Type II Collagen on Rheumatoid Arthritis. Science 1993; 261:1727-1730.