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Autoimmunity Reviews 7 (2008) 223 228 www.elsevier.com/locate/autrev

Circadian rhythms in arthritis: Hormonal effects on the immune/inflammatory reaction

Maurizio Cutolo a,, Rainer H. Straub b
b

Research Laboratory and Academic Unit of Clinical Rheumatology, Department of Internal Medicine, University of Genova, Viale Benedetto XV, 6, IT-16132 Genova, Italy Laboratory of Experimental Rheumatology and Neuroendocrino-Immunology, Department of Internal Medicine I, University Hospital Regensburg, 93042 Regensburg, Germany Available online 3 December 2007

Abstract Biological signaling and rhythms occur in a complex network with participation and interaction of the central nervous system, the autonomic nervous system, the endocrine glands, peripheral endocrine tissues and the immune system. It is a clinical observation that patients affected by chronic immune/inflammatory conditions (i.e. rheumatoid arthritis/RA) exhibit circadian, circamensual (females) and circannual rhythms of disease-related symptoms. Proinflammatory cytokines exhibit a peculiar rhythmicity, in particular serum TNF and serum IL-6, and together with other relevant immunological parameters display an elevation in the early morning hours in patients with RA. As a matter of fact, RA patients particularly experience joint pain, morning stiffness, and functional disability in the early morning hours. Since circadian rhythmicity of neuroendocrine pathways is closely coupled to immune/inflammatory reactions, new aspects at least concerning RA management are suggested. In particular, further investigations will indicate whether timed release of immunosuppressive/antiinflammatory drugs will have increased efficacy and whether dosages can be reduced below critical levels above which adverse events appear. 2007 Elsevier B.V. All rights reserved.
Keywords: Rheumatoid arthritis; Circadian rhythms; Circannual rhythms; Hormones; Immune response; Cortisol

Contents 1. 2. 3. 4. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . Circadian rhythms of hormones . . . . . . . . . . . . . . . . . Circadian rhythms of the immune response . . . . . . . . . . . Links between rhythms of hormones and the immune response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 224 224 225 226

Corresponding author. Tel.: +39 010 353 7994; fax: +39 010 353 8885. E-mail addresses: mcutolo@unige.it (M. Cutolo), rainer.straub@klinik.uni-regensburg.de (R.H. Straub). 1568-9972/$ - see front matter 2007 Elsevier B.V. All rights reserved. doi:10.1016/j.autrev.2007.11.019

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5. Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Take home messages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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1. Introduction Biological processes and functions are well organized in time, as evidenced by the expression of ultradian (high frequency), circadian (approximately 24-h), circamensual (approximately monthly), and circannual (approximately yearly) rhythms and by the changes that occur with menarche, reproduction, and menopause [1]. These rhythms are mainly maintained on the basis of cyclical changes depending on the light dark cycle [2]. Biological signaling and rhythms occur in a complex network with participation and interaction of the central nervous system, the autonomic nervous system, the endocrine glands, peripheral endocrine tissues and the immune system. This network is responsible for the clinical observation that patients affected by chronic immune/inflammatory conditions exhibit circadian, circamensual (females) and circannual rhythms of disease-related symptoms. The relationship has been studied also in patients with rheumatoid arthritis (RA) [3,4]. Concerning the circadian rhythms, it is the clinical experience of rheumatologists that RA patients particularly experience joint pain, morning stiffness, and functional disability in the early morning hours. It is also remarkable that these diurnal variations demonstrate large amplitudes, with the patient's condition being poor in the early morning and disease activity being mild or moderate in the early evening. Since circadian rhythmicity of neuroendocrine pathways is tightly coupled to immune/inflammatory responses, an explanation of daily rhythms of arthritis-related symptoms has been recently reported [5]. 2. Circadian rhythms of hormones The cycle of the hypothalamicpituitaryadrenal axis (HPA axis) regulating cortisol synthesis shows a maximum in the early morning hours at 8:00 AM and a nadir at midnight (Fig. 1A). Interestingly, in healthy subjects, bone-resorbing activity is highest between 5:00 AM and 7:00 AM, which conforms to cortisol and tumor necrosis factor (TNF)/interleukin-6 (IL-6) rhythms [6]. However, the cortisol rhythm in patients with RA whose disease activity is relatively low to moderate does not differ from that in healthy subjects (Fig. 1A). This is

the case with regard to the period, the amplitude, and the time point of the minimum and peak of the cycle. On the contrary, this rhythm can be highly disturbed in RA patients when disease is in a very active stage, leading to a flattening of the response curve, and two peaks appear, in the morning and the afternoon [7]. Interestingly, RA patients with high disease activity show elevated serum cortisol levels, which are, however, inadequately low in relation to their inflammatory condition [7]. Since cortisol is the most potent endogenous antiinflammatory substance, its up-regulation in the early morning is most probably related to inhibition of inflammation during the day, and its down-regulation during the evening and night is linked to an increase of inflammation during the early morning. Besides cortisol, two other night hormones, melatonin and prolactin (Fig. 1B and C), show a clear 24-h rhythm and have been linked to stimulation of the immune system, which would lead to an increase in proinflammatory conditions in RA, as recently showed in RA patients treated at night with melatonin [810]. The typical circadian rhythm of melatonin exhibits a maximum at 3:00 AM, which is quite similar to that of prolactin. When data from all available studies are combined, the rhythms of these two hormones are not shown to be markedly different in patients with RA as compared with healthy controls (Fig. 1 B and C) [5]. However, one study demonstrated that serum levels of melatonin reached a peak two hours earlier in RA patients than in controls [11]. In RA patients, melatonin levels exhibited a wide plateau lasting 23 h, an effect not observed in healthy controls [11]. After the peak was reached, melatonin levels decreased similarly in RA patients and healthy subjects. Furthermore, in a study of subjects from a northern European country, serum levels of melatonin appeared to be elevated in patients with RA as compared with controls [12]. In addition, serum levels of prolactin have been found during the night to be significantly higher in RA patients compared with controls, and this has been confirmed by others [13]. Both elevated melatonin and elevated prolactin will probably establish a more proinflammatory environment exactly at the time point when cortisol levels are lowest, and this is particularly true because the ratio of

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Fig. 1. Circadian rhythms of serum cortisol (A), serum melatonin (B), serum prolactin (C), serum interleukin-6 (D), disease-related stiffness (E), and disease-related pain (F). The data are given as % of the 24 h mean (modified according to [7]). The red lines and symbols give the data of RA patients, and the black lines and symbols give the data of healthy subjects.

prolactin to cortisol peaks at 2:00 AM in RA patients [13]. Both hormones, prolactin and melatonin, induce a Th1 immune response and may thus lead to an unwanted increase in related cellular immune phenomena in RA patients during the night [14]. In healthy subjects, the circadian rhythm of cortisol levels is similar in women as compared to men, whereas a sex difference for prolactin and melatonin has not been investigated [15]. Recently the pituitary gland has been suggested to regulate prolactin rhythms as integration of photoperiodic signals mediated by melatonin [16]. 3. Circadian rhythms of the immune response Proinflammatory cytokines exhibit a peculiar rhythmicity, in particular serum TNF and serum IL-6 (Fig. 1D). In healthy subjects, the peak value of TNF is reached at 3:00 AM and that of IL-6 at 6:00 AM in agreement with the sequence of TNF-induced IL-6 secretion that is observed in in vitro studies. Furthermore, a similar sequence of IL-6 and IL-6-dependent secretion of fibrinogen has been documented, with

maximum fibrinogen levels at 10:00 AM [17]. In patients with RA, the peak level of TNF has been reported to appear at 6:00 AM and that of IL-6 at 7:00 AM, as a consequence both cytokines show a time shift of the peak value towards the morning. In healthy subjects, serum TNF and IL-6 levels are 25 pg/ml whereas in RA patients these levels are 2050 pg/ml. Therefore, it becomes evident that the amplitude of the curve is much higher and the curve necessarily must be broadened for RA patients as compared with controls. In healthy subjects, serum levels of TNF and IL-6 have already begun to decrease around 6:00 AM and 9:00 AM, respectively, whereas in RA patients these levels remain elevated until 10:00 AM and 11:00 AM, respectively. The observation that the amplitude is higher and the curve broadened for these proinflammatory cytokines in RA patients versus controls despite the similarity of the circadian curves for serum cortisol, with similar amplitude and shape, indicates inadequate cortisol secretion in relation to inflammation in RA [18]. It is interesting that serum levels of IL-2 and interferon-gamma (IFN) demonstrate peak levels between midnight and 2:00 AM in healthy subjects

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(18). These two cytokines, similar to TNF, induce a Th1 immune response, as has also been reported for growth hormone and prolactin. Thus, particularly during the night, Th1 immune responses develop inducing a preponderance of cellular immunity [4]. Cortisol and norepinephrine (both mediators of the SNS), in contrast, support a Th2 immune response and the levels of these factors are particularly low between 11:00 PM and 5:00 AM [26]. Interestingly, a circadian rhythm exists for immunoglobulins in RA, which has nicely been demonstrated for IgA rheumatoid factor (peak at 8:00 AM) and IgM rheumatoid factor (peak at 2:00 AM) [5]. Finally, circulating immune complexes exhibit a circadian rhythmicity in RA, with a peak between 6:00 AM and 9:00 AM [19]. In conclusion, several relevant immunological parameters display an elevation in the early morning hours in patients with RA, which follows the rhythms of neuroendocrine mediators. 4. Links between rhythms of hormones and the immune response Recently, a lag time has been demonstrated between increase in IL-6 levels and increase in cortisol levels (plus 60120 min) or ACTH levels (plus 60 min) in patients with RA [20]. Many independent studies confirm the occurrence of this lag phase between IL-6 and cortisol in both healthy subjects and RA patients. Similarly, there is a lag time between increase in serum cortisol levels and increase in serum TNF levels (5 h in healthy subjects, 2 h in patients with RA). Therefore, it is possible that increases in cytokine levels during the early night drive the increase of cortisol secretion and, most probably, also the activity of the SNS [21]. In turn, these two systems may then inhibit increased cytokines in the morning hours and during the day. On the other hand, around midnight, the decreases in levels of cortisol which inhibit secretion of IL-6, TNF, and other cytokines together with the increases in levels of melatonin, growth hormone, and prolactin, drive nocturnal increases of TNF, IFN, IL-2, IL-12, and IL-6 [9,2123]. In summary, a strong connection between changes in cytokines and hormones levels, most probably, lead to up and down-regulation of peripheral immune responses, permitting to RA-relevant cytokines such as TNF, IFN, IL-2, and IL-6 to drive the local proinflammatory process in joints and secondary lymphoid organs in the early morning hours. The clinical consequence is that the increased inflammatory conditions stimulate edema formation via bradykinin/prostaglandins/substance P and also pain sensitization

[21]. These unwanted side effects (i.e. edema formation) of elevated circulating proinflammatory cytokines ultimately lead to symptoms of stiffness, pain, and functional disability in the morning (Fig. 1E and F). In addition, TNF and IL-6 play an important role in the worsening of symptoms of several RA-related comorbidities, such as cardiovascular disease, osteoporosis, depression, and sleep disturbances, all of which demonstrate maximum severity during the night and in the early morning hours [21]. The coupling of important neuroendocrine immunologic mediators (HPA axis together with SNS) and uncoupling of other factors (HPA axis/SNS versus prolactin, melatonin, growth hormone, TNF, IL-6, etc.) has the evolutionarily conserved meaning to overcome infectious diseases, particularly during the night, with the final result to activate the immune system [24]. In summary, an important finding in RA is increased secretion of prolactin/melatonin and inadequately low secretion of cortisol; circadian curves of cortisol in fact are very similar to those in healthy subjects. The expected increased cortisol secretion, in order to dampen exaggerated proinflammatory cytokine secretion in RA, is only visible in patients with very high disease activity [6,7]. In any case, the somewhat higher cortisol levels observed in patients with very active disease are not sufficient to alleviate the disease process in RA. This inadequacy of cortisol secretion support that treatment with exogenous glucocorticoids at the beginning of RA, during disease flares, or during smoldering inflammation in mild-to-moderate RA can be viewed as a substitution therapy for the functionally disturbed HPA axis. Based on these neuroendocrine immune links, other circamensual and circannual rhythms have been observed in RA patients. For example, a relation of menstrual (hormonal) cycle phase to clinical symptoms of RA is well established [25]. On the other hands, significantly altered 25-(OH)D serum levels were observed in RA patients with a circannual rhythm in winter and summer time and these levels showed a significant correlation (negative) with RA clinical status [26]. This paper cannot cover all the interesting details of this subject, and the interested reader is referred to the literature [2740]. 5. Conclusions Since circadian rhythmicity of neuroendocrine pathways is closely coupled to immune/inflammatory reaction, the timed release of neuroendocrine factors and modulation of the immune/inflammatory response according to biological rhythms represents a new aspect at least of RA management. Further investigations will indicate

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whether timed release of immunosuppressive/antiinflammatory drugs (i.e. corticosteroids) will lead to increased efficacy and reduced dosages below critical levels above which adverse events appear. Take home messages Biological signaling and rhythms occur in a complex network with participation and interaction of the central nervous system, the autonomic nervous system, the endocrine glands, peripheral endocrine tissues and the immune system Proinflammatory cytokines exhibit a peculiar rhythmicity, in particular serum TNF and serum IL-6, and together with other relevant immunological parameters display an elevation in the early morning hours in patients with rheumatoid arthritis (RA) by following the rhythms of neuroendocrine mediators. RA patients particularly experience joint pain, morning stiffness, and functional disability in the early morning hours since during the night, both elevated melatonin and elevated prolactin seem to establish a more proinflammatory environment closely at the time point when cortisol (antiinflammatory steroid) levels are lowest. It might well be that timed release of immunosuppressive/antiinflammatory drugs will display increased efficacy and that dosages of these drugs might be reduced below critical levels above which adverse events appear. References
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[29]

[30] [31]

[32]

[33]

[34]

Antibodies directed against ribosomal P proteins cross-react with phospholipids Anti-ribosomal P protein (anti-P) antibodies are marker antibodies in systemic lupus erythematosus (SLE). Their association with psychiatric or neurological manifestations has been proposed, but remains controversial. Antiphospholipid antibodies are the hallmark of a syndrome that may comprise a number of neurological manifestations. Thus, anti-phospholipid antibodies have both been associated with central nervous system involvement and their co-existence in the same sera was reported. Here, Caponi L. et al. (Clin Exp Immunol 2007; 150: 140-3) verified the ability of purified anti-P antibodies to bind different phospholipids and phospholipidsbinding proteins in solid-phase assays. Anti-P antibodies from five of eight patients bound cardiolipin (CL) when saturated with fetal calf serum (FCS); in three cases anti-CL antibodies were also detected in the flow-through. No anti-P eluate, nor any corresponding flow-through, bound beta (2)-glycoprotein I alone or prothrombin. Moreover, no anti-P eluate bound CL when the plates were blocked with bovine serum albumin in the absence of FCS. Anti-P antibodies with anti-CL activity bound both ssDNA and dsDNA and also nucleosomes in three patients. This data indicates a great heterogeneity of anti-P antibodies that appear to be overlapped partially with the other autoantibody populations detected frequently in SLE.

Up-regulation of TRAIL mRNA expression in peripheral blood mononuclear cells from patients with active systemic lupus erythematosus It is recently suggested that tumor necrosis factor-related apoptosis-inducing ligand (TRAIL) is involved in the pathogenesis of systemic lupus erythematosus (SLE). In this study, Komatsuda A. et al. (Clin Immunol 2007; 125: 26-9) examined whether expression levels of TRAIL depend on SLE activity. To estimate TRAIL mRNA expression levels in peripheral blood mononuclear cells (PBMC), quantitative RT-PCR analyzes of PBMC from 18 SLE patients and 20 healthy subjects were performed. Serum soluble TRAIL (sTRAIL) concentrations were measured by ELISA. The mean TRAIL mRNA expression level and serum sTRAIL concentration in SLE patients were significantly higher than those in healthy controls. Expression levels of TRAIL mRNA correlated with the SLE disease activity index and circulating immune complex levels, while serum sTRAIL concentrations did not. These results indicate that increased expression of TRAIL mRNA in PBMC closely correlates with SLE activity and suggest an important role for TRAIL in the pathogenesis of SLE.