Department of Medical Pharmaceutics, Graduate School of Medicine and Pharmaceutical Sciences for Research, University of Toyama, Japan.
Chronobiol Int. 2011 Apr;28(3):267-74. doi: 10.3109/07420528.2011.553017.
Methotrexate (MTX) is the most important drug for treating rheumatoid arthritis (RA). It has been stated that cytokines play an important role in the pathogenesis of RA, and that cytokine levels increase and show 24-h rhythms in RA patients. Previously, we found that arthritis was relieved after the administration of MTX at specific times in synchronization with the 24-h rhythm of tumor necrosis factor (TNF)-α in collagen-induced arthritis (CIA) animals. Based on our findings in an earlier study of the dosing time-dependent effects of MTX in MRL/lpr mice, which develop autoimmune disorders that share similarities with human RA, we examined here the utility of MTX chronotherapy in Japanese RA patients. In an initial animal modeling study, we collected blood from MRL/lpr mice at different times (2, 6, 10, 14, 18, or 22 hours after the light was turned on [HALO]), and we measured TNF-α mRNA expression in leukocytes. MTX was administered to the mice at two different dosing times (6 or 18 HALO), and various blood parameters were measured to estimate arthritis activity. TNF-α mRNA levels showed a clear 24-h rhythm with a peak at 22 HALO and a trough at 18 HALO after RA had developed. In these MRL/lpr mice, inflammation and TNF-α were markedly reduced when the MTX dosing time was matched to the time (18 HALO) when the TNF-α level began to increase. We then applied these findings to Japanese RA patients by switching them from the standard MTX three times/wk (day 1: after breakfast and supper; day 2: after breakfast schedule), to chronotherapy, in which the dose and number of doses/wk were not changed but MTX was administered once-a-day at bedtime. Disease Activity Score (DAS)28, modified health assessment questionnaire (MHAQ), and adverse effects were assessed. With MTX chronotherapy, DAS28, which is commonly used to quantitatively assess RA symptoms, was significantly improved at all follow-up clinical visit times compared with the baseline (vs. 1 mo: p = .0197, 2 mos: p = .0107, 3 mos: p = .0087). Significant symptom recovery was observed in 41.2% of patients, and 23.5% of patients achieved clinical remission during the 3 mos of follow-up. Functional capacity of RA patients, as indicated by the MHAQ, was markedly improved by chronotherapy. There were no severe adverse effects. Thus, we demonstrated (i) inflammation and plasma TNF-α concentrations were significantly reduced in MRL/lpr mice treated with MTX at 18 HALO, the time when TNF-α mRNA level began to increase; and (ii) MTX bedtime chronotherapy was safe, markedly reduced disease activity, and improved the functional capacity of RA patients. The findings on RA patients show that bedtime MTX chronotherapy can improve RA symptoms compared to the current standard dosing methods.
甲氨蝶呤（MTX）是治疗类风湿关节炎（RA）最重要的药物。已经指出细胞因子在 RA 的发病机制中起重要作用，并且 RA 患者的细胞因子水平升高并显示出 24 小时节律。以前，我们发现关节炎在胶原诱导的关节炎（CIA）动物的 TNF-α 24 小时节律同步时，在特定时间给予 MTX 后得到缓解。基于我们在 MRL/lpr 小鼠中 MTX 剂量依赖性作用的早期研究结果，MRL/lpr 小鼠发生与人类 RA 相似的自身免疫疾病，我们在此检查了 MTX 时间疗法在日本 RA 患者中的应用。在最初的动物模型研究中，我们在不同时间（开灯后 2、6、10、14、18 或 22 小时）从 MRL/lpr 小鼠中采集血液，并测量白细胞中的 TNF-α mRNA 表达。将 MTX 分别在两个不同的给药时间（6 或 18 HALO）给予小鼠，并测量各种血液参数以估计关节炎活动度。TNF-α mRNA 水平显示出明显的 24 小时节律，在 RA 发展后，在 22 HALO 时达到峰值，在 18 HALO 时达到谷值。在这些 MRL/lpr 小鼠中，当 MTX 给药时间与 TNF-α 水平开始升高的时间（18 HALO）匹配时，炎症和 TNF-α 明显减少。然后，我们通过将这些发现应用于日本 RA 患者，将他们从标准的每周 3 次 MTX（第 1 天：早餐和晚餐后；第 2 天：早餐后方案）转换为时间疗法，其中剂量和每周给药次数不变，但 MTX 在睡前每天给药一次。评估疾病活动评分（DAS）28、改良健康评估问卷（MHAQ）和不良反应。在 MTX 时间疗法中，DAS28 通常用于定量评估 RA 症状，与基线相比，在所有随访临床就诊时间均有显著改善（与 1 个月相比：p =.0197，2 个月：p =.0107，3 个月：p =.0087）。在 3 个月的随访期间，41.2%的患者症状明显缓解，23.5%的患者达到临床缓解。RA 患者的功能能力，如 MHAQ 所示，通过时间疗法明显改善。没有严重的不良反应。因此，我们证明了（i）在 18 HALO 时给予 MTX 治疗的 MRL/lpr 小鼠中，炎症和血浆 TNF-α 浓度明显降低，此时 TNF-α mRNA 水平开始升高；和（ii）MTX 睡前时间疗法是安全的，可显著降低疾病活动度，并改善 RA 患者的功能能力。RA 患者的发现表明，与当前的标准给药方法相比，睡前 MTX 时间疗法可以改善 RA 症状。
