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Full Text of Harvard Study|
"Effects of Oral Administration of
Type II Collagen on Rheumatoid Arthritis"
Study performed by David E. Trentham, Roselynn A. Dynesius-Trentham, E. John Orav, Daniel Combitchi, Carlos Lorenzo, Kathryn Lea Sewell, David A. Hafler, Howard L. Weiner
Published in the prestigious journal Science September 24, 1993
|Characteristic||Collagen Treatment (n=28)||Placebo Treatment (n=31)|
50.3 = 11.9
55.1 = 12.9
|Sex (% females)||
|Disease duration (years=SD)||
9.8 = 6.2
10.3 = 8.1
|Rheumatoid factor [%, (number tested)]||
|HLA-DR 4+ [%, (number tested)]||
|Collagen II antibody [%, titer greater than or equal to 2)||
|Prednisone (%, less than or equal to 10 mg/day)||
|Immunosuppressive* withdrawn (%)||
*Methotrexate, 6-mercaptopurine, azathioprine, hydroxychloroquine, sulzasalzine, auranofin, cyclosporin, cyclophosphamide, or pencillamine. Seven patients were receiving combinations of these drugs (20). The remaining patients were not on immunosuppressive drugs at the time of entry because of prior lack of response to toxicity to at least two of the drugs.
Differences between physician assessments in collagen and placebo patients were not significant but showed trends in favor of collagen at 1 month (P = 0.066 and 2 months (P = 0.06). Qualitatively similar results were found when a two-way analysis of variance was used to adjust for prednsione use. Significant improvement was also observed among collagen-treated patients at 1, 2, and 3 months in terms of the number of swollen joints, the swollen joint index, the number of tender joints, and the tenderness index (Students t test; all P values are <0.01, except at 3 months, for the number of swollen joints, P = 0.02, and the swollen joint index, P = 0.03).
|Variable||Group||Mean value at entry (=SE)||Difference from entry at month 1||Difference from entry at month 2||Difference from entry at month 3|
|Joints Swollen (number)||Collagen||11.8 = 0.9||-2.7=0.5**||-4.1 = 1.0*||-3.1 = 1.1*|
|Joints swollen (number)||Placebo||12.0 = 0.8||2.0 = 1.4||0.9 = 1.6||1.3 = 1.4||Joints tender to pressure or painful on passive motion (number)||Collagen||15.8 = 1.3||-4.1 = 1.1*||-6.7 = 1.5||-5.4 = 1.8*|
|Joints tender to pressure or painful on passive motion (number)||Placebo||15.6 = 0.8||1.1 = 1.4||-1.1 = 1.7||-0.1 = 1.6|
|Joint-Swelling Index||Collagen||13.3 = 1.1||-3.4=0.8**||-4.8 = 1.2*||-3.1 = 1.4*|
|Joint-Swelling Index||Placebo||13.2 = 0.9||2.4 = 1.8||0.9 = 1.6||4.3 = 2.1|
|Joint-tenderness or pain index||Collagen||17.5 = 1.3||-5.0=1.2**||-7.6 = 1.7*||-5.7 = 2.0*|
|Joint tenderness or pain index||Placebo||17.2 = 1.0||1.6 = 1.8||-0.5 = 2.1||3.0 = 2.4|
|15-m walk time (s)||Collagen||13.2 = 0.6||0.0=0.3**||0.25=0.5**||0.5=0.6**|
|15-m walk time (s)||Placebo||14.9 = 0.9||1.9 = 0.6||3.8 = 1.2||20.8 = 7.5|
|Grip Strength (mmHG)|
|Right||Collagen||105 = 9||0.1 = 6.0||6.3 = 7.8||-0.9 = 8.5|
|Right||Placebo||87 = 8||-7.3 = 6.2||-8.3 = 8.4||-16.4 = 8.8|
|Left||Collagen||106=10||0.6 = 5.6||6.6 = 7.4*||-0.3 = 8.8|
|Left||Placebo||95 = 8||-8.9 = 5.8||-9.3 = 10.1||-13.8 = 9.7|
|Morning stiffness duration (min)||Collagen||155=51||64.8=106||51.2 = 100||56.4 = 92|
|Morning stiffness duration (min)||Placebo||210=55||130=76||168=108||195=100|
|Patient assessment (%)|
|Absent or mild||Collagen||21||41||23*||36*|
|Severe or very severe||Collagen||25||26||31*||39*|
|Absent or mild||Placebo||16||21||15||19|
|Severe or very severe||Placebo||48||48||62||71|
|Absent or mild||Collagen||18||41||35||32|
|Severe to very severe||Collagen||36||26||27||39|
|Absent or mild||Placebo||6||21||27||19|
|Severe to very severe||Placebo||52||48||62||68|
|ESR (mm/hour)||Collagen||39 = 6||5.1 = 2.9||4.9 = 2.8||1.7 = 3.9|
|ESR (mm/hour)||Placebo||34 =5||9.8 = 5.0||7.8 = 5.6||3.2 = 2.8|
*P < 0.05
**P < 0.01
|Variable||Entry: Collagen||Entry: Placebo||Three months: Collagen||Three months:Placebo||Worsening status*||7*||35|
*Represents an increase of 30% or more from the entry value for the joint-swelling index and the joint-tenderness or pain index (16). Comparison between groups showed significantly more deterioration in the placebo-treated patients (P is less than or equal to 0.01 by the Fisher's exact test.)
**Narcotic without anti-inflammatory properties, usually acetaminophen with codeine, propoxyphene, or pentazocine, prescribed at any time by the clinical investigator in an attempt to retain flaring patients in the trial. Comparison between groups showed significantly greater numbers of placebo treated patients requiring narcotics (P < 0.04 by the Fisher's exact test).
***Determined by American Rheumatism Association criteria for functional class (28) I, no limitation from arthritis; II, mildly restricted; III, Markedly restricted, and IV, incapacity causing virtual bed or wheelchair existence. Trend for improvement in the collagen group not significant (P = 0.10 by the x2 trend test.
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. Coutenay, 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. Nandriopoulos 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 nonlathyritic 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 tosicity 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 empt 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 Assocation (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 rhematologists 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 possiblity 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 membrance 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 rebal funtion 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 immunoglobin M (IgM) rheumatoid factor titers were determined by nephelmonetry 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 assinged 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 pccurred 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 ofr 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 chnages 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.
9 June 1993; accepted 23 August 1993
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