••••••••
`
`VOLUME 23, NO. 2
`-
`0 FEBRUARY 1980 (cid:9)
`
`
`/771-----7-7----)t)
`
`'414'
`
`a
`
`a
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`rfo
`
`1.1
`
`Pr
`
`17.
`
`04
`
`Official Journal
`
`the
`Am • rican
`Section
`
`Rheumatism
`the Artb
`
`Association
`Foundation
`
`U
`
`U
`
`33 4
`
`11,1
`
`‘.4
`
`Thiz atE a
`at t- s
`
`a
`
`Arthritis Foundation
`Atlanta, Georgia
`
`r.
`
`71
`
`it
`
`Layz
`
`.13
`
`F.
`
`.23
`
`1:13
`
`Ex. 1087 - Page 1
`
`

`

`ARTHRITIS AND RHEUMATISM AMERICAN RHEUMATISM
`ASSOCIATION
`Editor
`J. Claude Bennett, M.D.
`University of Alabama in Birmingham
`University Station
`Birmingham, Alabama 35294
`
`A Section of the Arthritis Foundation
`3400 Peachtree Rd. N.E., Atlanta, Georgia 30326
`
`Associate Editors
`Gene V. Ball, M.D.
`Max D. Cooper, M.D.
`William J. Koopman, M.D.
`Edward J. Miller, Ph.D.
`Lennart Roden, M.D.
`Robert M. Stroud, M.D.
`
`Editorial Board
`K. Frank Austen, M.D., Boston
`Rodney Bluestone, M.D., Los Angeles
`Giles G. Bole, Jr., M.D., Ann Arbor
`Alan S. Cohen, M.D., Boston
`John L. Decker, M.D., Bethesda
`Virgil Hanson, M.D., Los Angeles
`Edward D. Harris, Jr., M.D., Hanover
`Evelyn V. Hess, M.D., Cincinnati
`David S. Howell, M.D., Miami
`Gene G. Hunder, M.D., Rochester
`David Koffler, M.D., Philadelphia
`Stephen M. Krane, M.D., Boston
`Henry G. Kunkel, M.D., New York
`E. Carwile LeRoy, M.D., Charleston
`Michael D. Lockshin, M.D., New York
`Donald E. McCollum, M.D., Durham
`Frederic C. McDuffie, M.D., Atlanta
`Stephen E. Malawista, M.D., New Haven
`Mart Mannik, M.D., Seattle
`William Martel, M.D., Ann Arbor
`Jane H. Morse, M.D., New York
`Carl M. Pearson, M.D., Los Angeles
`Donald Resnick, M.D., San Diego
`Gerald P. Rodnan, M.D., Pittsburgh
`Shaun Ruddy, M.D., Richmond
`Jane G. Schaller, M.D., Seattle
`Peter H. Schur, M.D., Boston
`John T. Sharp, M.D., Danville
`Clement B. Sledge, M.D., Boston
`Ralph Snyderman, M.D., Durham
`Leon Sokoloff, M.D., Stony Brook
`Mary Betty Stevens, M.D., Baltimore
`Norman Talal, M.D., San Francisco
`Eng M. Tan, M.D., Denver
`Ralph C. Williams, Jr., M.D., Albuquerque
`Robert J. Winchester, M.D., New York
`
`President
`Daniel J. McCarty, M.D.
`Medical College of Wisconsin
`Milwaukee, Wisconsin
`
`Vice-President and President-Elect
`Giles G. Bole, Jr., M.D.
`University of Michigan
`Ann Arbor, Michigan
`
`Second Vice-President
`Nathan J. Zvaifler, M.D.
`University of California at
`San Diego
`San Diego, California
`
`Secretary-Treasurer
`Frank R. Schmid, M.D.
`Northwestern University
`Chicago, Illinois
`
`Executive Secretary
`Lynn Bonfiglio
`Assistant Executive Secretary
`Angel Fortenberry
`
`Committee for the Publication of
`Arthritis and Rheumatism
`E. Carwile LeRoy, M.D., Chairman, Charleston
`Edgar S. Cathcart, M.D., Boston
`Ronald P. Messner, M.D., Minneapolis
`Paul H. Plotz, M.D., Bethesda
`Eng M. Tan, M.D., Denver
`
`Production Staff
`Jerelyn Jordan, Managing Editor
`Daphna Gregg, Assistant Managing Editor
`Drema McCord, Circulation
`Gwen Stinson, Editorial Assistant
`Nancy Weinberg, Editorial Assistant
`
`Published monthly by the Arthritis Foundation, 3400 Peachtree Rd. N.E., Atlanta, Georgia 30326. Printed in the United States.
`Second Class Postage paid at Atlanta, Georgia, and additional offices. ISSN 0004-3591.
`SUBSCRIPTION RATES: $20.00 per year for members, as part of the yearly dues, $35.00 for nonmembers within the U.S.A., and
`$40.00 for nonmembers elsewhere. Students, fellows, interns, and residents in North America: $20.00 per year. (A letter giving
`qualifying data must accompany such orders.) Single copies: $5.00, except for special issues. Copyright 1980 the Arthritis Founda-
`tion, Atlanta, Georgia. All rights reserved.
`
`This rna-a•ial wascopiad
`at t- a\LV E' may ba
`5- (cid:9)
`_ Lo•pyright Laws
`
`Ex. 1087 - Page 2
`
`

`

`Pv. NNIrn
`
`ARTHRITIS
`
`rc;
`
`RHEUMATISM
`
`OFFICIAL JOURNAL OF THE AMERICAN RHEUMATISM ASSOCIATION
`SECTION OF THE ARTHRITIS FOUNDATION
`
`VOLUME 23
`
`FEBRUARY
`
`
`NO.2
`
`137
`
`146
`
`
`153;
`
`
` 158
`
`165
`
` 172
`
`
`183
`
`
`
`190
`
`Measurement of Patient Outcome in Arthritis
`James F. Fries, Patricia Spitz, R. Guy Kraines, and Halsted R. Holman (cid:9)
`Measuring Health Status in Arthritis: The Arthritis Impact Measurement Scales
`Robert F Meenan, Paul M. _Gertman, and John H. Mason (cid:9)
`A Screening Strategy for Population Studies in Systemic Lupus Erythematosus: Series Design (cid:9)
`Matthew H. Liang, Robert F. Meenan, Edgar S. Cathcart, and Peter H. Schur (cid:9)
`The Toxicity Pattern of D-Penicillamine Therapy: A Guide to Its Use in Rheumatoid Arthritis
`Walter F. Kean, Isaac L. Dwosh, Tassos P. Anastassiades, Peter M. Ford, and H. Garfield Kelly (cid:9)
`In Vitro Penicillamine Competition for Protein-Bound Gold(I) (cid:9)
`N. Schaeffer, C. Frank Shaw, H. 0. Thompson, and R. W. Satre
`
`Double-Blind Placebo Controlled Crossover Evaluation of Levamisole in Rheumatoid Arthritis
`Bruce Miller, Paula De Merieux, Ramachandran Srinivasan, Philip Clements, Peng Fan, Joshua Levy, (cid:9)
`and Harold E. Paulus (cid:9)
`
`Diagnostic Potential of In Vivo Capillary Microscopy in Scleroderma and Related Disorders
`H. R. Maricq, E. C. LeRoy, W A. D'Angelo, T A. Medsger, Jr., G. P. Rodnan, G. C. Sharp, (cid:9)
`and J. F. Wolfe (cid:9)
`Collagen Types Synthesized in Dermal Fibroblast Cultures from Patients with Early Progressive Systemic
`Sclerosis
`Renate E. Gay, Robert B. Buckingham, Robert K. Prince, Steffen Gay, Gerald P. Rodnan, (cid:9)
`and Edward J. Miller ................ . ...............................................
`Identification of Anaplasmataceae (Haemobartonella) Antigen and Antibodies in Systemic Lupus
`Erythematosus
`Charles A. Kallick, Kaloo C. Thadhani, and Thomas W. Rice ............................................................................................ (cid:9) 197
`Salmonella Reactive Arthritis in British Columbia
`Howard B. Stein, Alnoora Abdullah, Harold S. Robinson, and Denys K. Ford ................................................... 206
`
`In Vitro Synthesis of Tissue-Specific Type II Collagen by Healing Cartilage. I. Short-Term Repair of
`Cartilage by Mature Rabbits
`Herman S. Cheung, Kenneth L. Lynch, Roger P. Johnson, and Bruce J. Brewer ................................................ 211
`Effect of Platelet Lysate on Growth and Sulfated Glycosaminoglycan Synthesis in Articular ChondrocYte
`Cultures
`Ye Chin Choi, Gregory M. Morris, and Leon (cid:9)
`Studies of Immune Functions of Patients with Systemic Lupus Erythematosus. V. T Cell Suppressor
`Function and Autologous Mixed Lymphocyte Reaction During Active and Inactive Phases of Disease
`
`Tsuyoshi Sakane, Alfred D. Steinberg, and Ira Green ........................................................................................... 225
`Review: Sternoclavicular Joint Arthritis (cid:9)
`232
`Robert A. Yood and Don L. Goldenberg (cid:9)
`Case Reports
`Left Atrial Myxoma Presenting as a Systemic Vasculitis
`William E. Byrd, Oliver P. Matthews, and Robert E. Hunt (cid:9)
`Coexistent Rheumatoid Arthritis and Chronic Tophaceous Gout
`E. Forrest Jessee, Elam Toone, Duncan S. Owen,' and Robert Irby .............................. . (cid:9)
`
`220
`
`
`
` 240
`
` 244
`
`(Contents continued opposite inside back cover)
`
`
`
`
`
`
`
`
`
`
`
`
`
`Ex. 1087 - Page 3
`
`

`

`248
`
`251
`
`253
`
`... _ (cid:9)
`
`Brief Reports
`Adult Still's Disease Associated with Pregnancy
`Gerald H. Stein, Bernard Cantor, and Richard S. Panush
`Autoantibodies in Human Contacts of SLE Dogs
`David Clair, Raphael J. DeHoratius, John Wolfe, and Richard Halliwell
`Propranolol and the Treatment of Rheumatoid Arthritis
`Roy Kaplan, Charles A. Robinson, John F. Scavulli, and John H. Vaughan (cid:9)
`Letters
`Immunoblastic Lymphadenopathy and Hydroxychloroquine
`Stephen L. Schechter and Daniel Rosenblum
`Polyarteritis Nodosa Diagnosed by Endoscopic Polypectomy
`Pamela Mulshine, Leonard Calabrese, and Randall S. Krakauer (cid:9)
`Unclassified HLA-B27 Inflammatory Rheumatic Diseases: Followup of 23 Patients
`J. Sany, F Rosenberg, G. Panis, H. Serre, and J. Seignalet ................................................................................ _ (cid:9)
`Marked Synovial Sensitivity to Pricking in Behcet's Syndrome
`Alessandro Giacomello, Egisto Taccari, and Antonio zoppini ............................................................................. (cid:9)
`Clinical Experience—NSAID
`Sidney R. Block (cid:9)
`"Last" Bursitis—A Cause of Ankle Pain
`Lawrence F. Layfer (cid:9)
`Gastric Volvulus and Felty's Syndrome
`Michael A. Catalano, James A. Usselman, and John H. Vaughan ....................................................................... (cid:9)
`Bed Rest at Home for Rheumatoid Arthritis
`Richard Dean Smith (cid:9)
`
`256
`
` 257
`
`258
`
`259
`
` 260
`
` 261
`
`261
`
` 263
`
`Thiz
`
`Ex. 1087 - Page 4
`
`(cid:9)
`(cid:9)
`(cid:9)
`

`

`172
`
`DOUBLE-BLIND PLACEBO CONTROLLED
`CROSSOVER EVALUATION OF LEVAMISOLE IN
`RHEUMATOID ARTHRITIS
`
`BRUCE MILLER, PAULA DE MERIEUX, RAMACHANDRAN SRINIVASAN, PHILIP CLEMENTS,
`PENG FAN, JOSHUA LEVY, and HAROLD E. PAULUS
`
`During levamisole therapy, 14 of 20 patients with
`previously unresponsive rheumatoid arthritis had signifi-
`cant improvement (P < 0.05) in clinical measures of dis-
`ease activity, erythrocyte sedimentation rate, and rheu-
`matoid factor titer in a 32-week double-blind placebo
`controlled crossover trial. Levamisole was shown to al-
`ter antibody responses to tetanus and typhoid antigens,
`lymphocyte blastogenesis to phytohemagglutinins, and
`the number of null cells in peripheral blood. Agranulocy-
`tosis and rash resulted in discontinuation of the drug in
`one patient in each group. Though clearly effective, rou-
`tine use of levamisole as a disease suppressant in rheu-
`matoid arthritis must await more complete clarification
`of its association with agranulocytosis.
`
`Recent reports suggest that dysfunction of the
`cellular limb of the immune system may be of signifi-
`cance in the pathogenesis of rheumatoid arthritis (1-13).
`Levamisole is an agent capable of potentiating
`the activity of a suppressed immune system with prefer-
`ential effects on the cellular limb (14-19). It has been re-
`ported to be of benefit in the treatment of patients
`
`From the Department of Medicine, Division of Rheumatol-
`ogy, University of California, Los Angeles.
`Supported in part by USPI-IS Grant GM 15759, Southern
`California Chapter of Arthritis Foundation, Kroc Foundation, and
`Janssen Laboratories.
`Bruce Miller, MD: Assistant Clinical Professor of Medicine;
`Paula de Merieux, MD, FRCP(C): Fellow of the Canadian Arthritis
`and Rheumatism Society; Ramachandran Srinivasan, MD: Assistant
`Clinical Professor of Medicine; Philip Clements, MD: Assistant Pro-
`fessor of Medicine; Peng Fan, MD: Assistant Professor of Medicine;
`Joshua Levy, MD: Associate Professor of Medicine; Harold E. Paulus,
`MD: Professor of Medicine.
`Address reprint requests to Harold E. Paulus, MD, 1000 Vet-
`eran Avenue, Los Angeles, California 90024.
`Submitted for publication June 28, 1979; accepted in revised
`form October 22, 1979.
`
`Arthritis and Rheumatism, Vol. 23, No. 2 (February 1980)
`
`whose rheumatoid arthritis has been refractory to con-
`ventional modes of therapy. Twenty patients with rheu-
`matoid arthritis were studied to evaluate the effects of
`levamisole on clinical and laboratory parameters of effi-
`cacy and on immunologic variables and their correla-
`tion with clinical effect. The frequency and types of ad-
`verse reactions were also evaluated.
`The study was designed not only to assess the
`overall efficacy of levamisole, but also to evaluate the
`utility of the crossover design. The spectrum of effects of
`levamisole versus placebo was assessed in a parallel
`fashion during the initial 16 weeks of the study. Cross-
`over from levamisole to placebo permitted careful eval-
`uation under controlled double-blind conditions of the
`duration of effects of levamisole after its discontin-
`uation.
`
`MATERIALS AND METHODS
`Twenty patients with classic or definite rheumatoid
`arthritis (RA) by American Rheumatism Association (ARA)
`criteria were studied. All patients participated voluntarily and
`gave informed consent. Patients had had disease for 1 to 29
`years and had continued to have active disease in spite of
`treatment with one or more of the following: nonsteroidal
`antiinflammatory agents (20 patients), gold (17 patients), pen-
`icillamine (I patient), antimalarials (4 patients), immuno-
`suppressive agents (7 patients), or corticosteroids (5 patients).
`The 5 patients on corticosteroids had been on a stable or ta-
`pering daily dosage of 10 mg or less of prednisone or its equiv-
`alent for at least 4 months prior to initiation of the study and
`did not increase their dose during the study. No patients had
`received gold, penicillamine, antimalarial, or immuno-
`suppressive agents for at least 3 months prior to starting the
`study. There were no restrictions on the use of aspirin or any
`other nonsteroidal antiinflammatory agent, but the dosages of
`these medications were kept constant throughout the entire
`study period.
`
`This (cid:9)
`
`51.1a:s:t (cid:9)
`
`ied
`
`z Laws
`
`Ex. 1087 - Page 5
`
`

`

`EVALUATION OF LEVAMISOLE IN RA (cid:9)
`
`173
`
`Table 1. Patient characteristics at baseline (median and range)
`
`Characteristic
`
`No. of patients
`Age, years
`Sex M:F
`Weight, kg
`Disease duration, years
`No. tender or swollen joints
`Pain score (0-100%)
`Morning stiffness, minutes
`Grip strength
`Ring size
`50-foot walking time
`Westergren ESR
`Latex fixation titer*
`
`Levamisole group
`
`Placebo group
`
`10
`50.5 (38-65)
`1:9
`61 (44.5-109)
`13.5 (2-23)
`19.5 (10-29)
`54 (30-90)
`165 (30-720)
`90(57-140)
`8.9 (5.5-9.5)
`11.5 (9-22.7)
`74.5 (30-105)
`4.5 ± 0.9
`
`10
`55.0 (37-68)
`0:10
`57 (45-69.5)
`10.0 (1-29)
`20.0 (12-28)
`57 (20-99)
`135 (0-240)
`88.5 (49-176)
`8.0 (6.25-11.25)
`11.1 (7.4-23.5)
`41.0 (14-85)
`5.1 ± 1.1
`
`* Mean and standard error of latex titer. Latex titers converted as follows: 1:20 = 0; 1:40 = 1; 1:80 = 2;
`1:160 = 3; up to 1:10,240 = 9; 1:20,480 = 10.
`
`The study was designed as a double-blind comparison
`of levamisole versus placebo with crossover comparison after
`16 weeks. Ten patients were randomly selected to receive le-
`vamisole for the initial 16 weeks and placebo for the second
`16 weeks, while the other 10 patients received therapy on the
`reverse schedule. During the levamisole phase all 20 patients
`initially received 150 mg levamisole daily. Fourteen patients
`completed the full 16-week period at this dose. One patient
`discontinued levamisole temporarily for 2 weeks during weeks
`3 and 4 because of rash but then resumed the drug at 150 mg/
`day. Two patients discontinued levamisole temporarily for 10
`and 11 days because of rash, then the drug was gradually
`reintroduced at increasing doses to a maximum of 150 mg
`daily and 100 mg daily, respectively. One patient had levami-
`sole withheld for 1 month while she was hospitalized with
`meningoencephalitis. Two patients discontinued levamisole
`permanently, one because of agranulocytosis which developed
`after 3 weeks and the other because of a severe rash devel-
`oping after 14 weeks.
`Prior to the initiation of therapy, each patient under-
`went a complete history and physical examination which in-
`cluded documentation of duration of morning stiffness, num-
`ber of swollen or tender joints (joint count), grip strength, ring
`size, 50-foot walking time, visual pain scale (20), and global
`evaluations by both the patient and the physician. These vari-
`ables were documented at weekly intervals for the first 4
`weeks and then every fourth week until the end of the initial
`16-week period. After crossover an identical assessment time-
`table was followed.
`Routine laboratory assessments included Westergren
`sedimentation rate, latex fixation test for rheumatoid factor,
`antinuclear antibody, anti-DNA, beta 1-C component of com-
`plement, total hemolytic complement, and quantitation of
`IgG, IgM, and IgA; these were performed at baseline and
`weeks 0, 8, 16, 24, and 32. Secondary delayed hypersensitivity
`was assessed by the intradermal injection of coccidiodin, his-
`toplasmin, trichophyton, Candida, and intermediate strength
`PPD at baseline and at weeks 4, 12, 17, 20, and 32. Primary
`delayed hypersensitivity was assessed by the intradermal in-
`jection of keyhole limpet hemocyanin (KLH) (0.1 mg and
`0.01 mg) during the first and third weeks of the initial study
`period. These times correspond to baseline and 2 weeks after 5
`mg of KLH was given intramuscularly. Only those patients
`
`with a negative response to the first intradermal injection (<
`10 mm in duration) were considered to be valid candidates for
`evaluation of a primary immune response and thus received
`the second injection. In addition, 0.1 cc of 10% dinitrochloro-
`benzene (DNCB) in acetone was applied to the skin over an
`area 20 mm in diameter during the first week of drug adminis-
`tration. Minor symptomatic reactions due to chemical irrita-
`tion usually cleared within 1 week. Three weeks later 0.1 cc
`applications of 1%, 0.5%, and 0.1% DNCB were placed in the
`same manner. Reactions to these solutions were recorded
`throughout the study; itching, erythema, or vesicle formation
`at the site of application were considered evidence of delayed
`hypersensitivity.
`To assess the function of the humoral immune system
`typhoid vaccine (USP 0.5 ml), tetanus toxoid (0.5 ml alum
`precipitated), and KLH (5 mg) were injected intramuscularly
`1 week after initiation of the study. Serum antibody titers to
`these antigens were measured weekly for 6 weeks thereafter.
`The proportions and absolute concentrations of B lympho-
`cytes (lymphocytes with true membrane immunoglobulin as
`detected by immunofluorescent technique) and T lympho-
`cytes (lymphocytes which form spontaneous rosettes with
`sheep erythrocytes) were determined at baseline and at weeks
`1, 16, and 32 by methods previously published (21). Lympho-
`cytes lacking the markers of B or T lymphocytes were consid-
`ered "non-B, non-T lymphocytes" or "null cells." Lympho-
`cyte responses to the mitogen phytohemagglutinin (PHA)
`were assessed before and after the in vitro addition of levami-
`sole at baseline and at weeks 2, 4, 16, 18, 24, and 32. The
`methods used in performing these studies have been detailed
`elsewhere (22).
`X-rays of hands and feet were taken at baseline and at
`weeks 16 and 32 for assessment of erosions.
`Results were statistically assessed using the Wilcoxon
`Matched Pairs Signed Rank test for intragroup changes from
`weeks 0 to 16 and 16 to 32, while the Mann Whitney U-test
`was used to assess the significance of the differences in
`changes between groups. A P value of < 0.05 was considered
`significant. For the purpose of analysis, latex fixation titers
`were converted to log values. Thus 1:20 =-- 0; 1:40 = 1; 1:80 =
`2; 1:160 = 3 up to 1:10,240 = 9 and 1:20,480 = 10. The paired
`data t-test was used to assess latex titers.
`The data were analyzed as follows: 1) differences be-
`
`this mat E'iEL,a=== 2ied
`att-s
`Sub,jart 1_ (cid:9)
`
`Laws
`
`Ex. 1087 - Page 6
`
`

`

`174
`
`MILLER ET AL
`
`Table 2. Parallel comparison: efficacy of levamisole versus placebo-clinical variables weeks 0 to 16 (median and range)
`
`Variablet
`
`Morning stiffness, minutes
`
`Grip strength, mm Fig
`
`Joint countll
`
`Pain scale (0-100%)
`
`Ring sizett
`
`50-foot walking time (secs)
`
`ESR, mm/hr
`
`Latex
`
`Placebo*
`(n = 10)
`
`Levamisole*
`(n = 10)
`
`Week 0
`
`130
`(0-240)
`88.5
`(47-176)
`20.0
`(12-30)
`57
`(20-99)
`8.0
`(6.25-11.25)
`11.1
`(7.4-23.5)
`41.0
`(14-85)
`4.3 ± 0.9
`
`Week 16
`
`63
`(0-480)§
`92
`(62-169)#
`19.5
`(10-26)§
`45
`(30-86)§
`7.25
`(5.25-11.75)§
`9.5
`(5.6-20.2)tt
`45.0
`(7-80)§
`4.5 ± 0.9§
`
`Week 0
`
`165
`(30-720)
`89
`(57-140)
`19.5
`(10-29)
`54
`(30-90)
`8.85
`(5.5-13.0)
`11.5
`(9-22.7)
`74.5
`(30-105)
`5.1 ± 1.1
`
`Week 16
`
`22.5
`(0-330)11
`109
`(75-150)11
`16.0
`(5_26)**
`19
`(0-72)11
`7.65
`(4-13.0)¶
`10.3
`(7.7-18.3)11
`45.0
`(9-77)11
`3.4 ± 6.8**
`
`P value
`(A levamisole
`compared
`A placebo)t
`
`= 0.05
`
`= 0.05
`
`NS
`
`< 0.025
`
`NS
`
`NS
`
`< 0.01
`
`< 0.025
`
`* Statistical significance within each group week 0 compared to week 16. § = NS; # = P < 0.05; ** = P < 0.025 if = P < 0.02; 11= < 0.005.
`-1- Number of patients = 10 for all variables except morning stiffness in placebo group and 50-foot walking time in the levamisole group. In both
`these cases number of patients analyzed = 9.
`4: Comparison of the differences from week 0 to 16 between placebo and levamisole treated groups by Mann-Whitney U-test.
`11 Joint swelling or tenderness.
`it Ring size for each individual is the mean of all proximal interphalangeal joints.
`§§ Mean and standard error of latex titer paired data t test. Latex titers converted as follows: 1:20 = 0; 1:40 = 1; I : 80 = 2; 1: 160 = 3; up to
`1: 10,240 = 9; 1:20,480 = 10.
`
`tween observations at baseline and at the end of the initial 16-
`week period in the levamisole treated group were compared
`with similar changes in the placebo treated group (16-week
`parallel study). 2) In the group that initially received levami-
`sole then crossed over to placebo, the status at the end of 16
`weeks of levamisole was compared with the status at the end
`of 16 weeks of placebo. The object of this comparison was to
`assess the duration of carry over effect of levamisole into the
`placebo period. 3) Overall efficacy of levamisole was eval-
`uated by comparing pre-levamisole and post-levamisole status
`in all patients who completed levamisole therapy.
`At the end of the 32-week study period, II patients
`elected to continue with the double-blind trial on the medica-
`tion they had received during the second 16-week period for
`an additional 16 weeks. Six patients had been taking placebo
`and 5 levamisole when they elected to continue. Following
`completion of this extension of the double-blind study, pa-
`tients were offered entry to a nonblinded open-ended evalua-
`tion of levamisole, and 8 patients accepted. All 8 patients ini-
`tially received 150 mg on 4 days a week. Because of
`gastrointestinal intolerance, dosages were lowered in 4 pa-
`tients. After increasing reports of agranulocytosis associated
`with levamisole therapy, dosages were later reduced to 150 mg
`1 day per week.
`
`RESULTS
`
`General characteristics of patient population at
`baseline. These are listed in Table 1. Comparison of
`baseline variables showed no significant differences be-
`tween the two groups except for a higher mean erythro-
`
`cyte sedimentation rate for the group started on levami-
`sole (70.8 mm/hr) than for the placebo group (46 mm/
`hr).
`
`Clinical efficacy of levamisole: parallel study
`comparing levamisole versus placebo. At 8 weeks there
`were no significant differences between the two groups
`in clinical or laboratory variables. Table 2 outlines the
`comparison of clinical and laboratory data at 16 weeks.
`There were no statistically significant changes from
`baseline in duration of morning stiffness, joint count,
`pain score, or ring size by 16 weeks in the 10 placebo
`treated patients. In contrast, there was statistically sig-
`nificant improvement in all of these variables in the 10
`levamisole treated patients. For each variable except
`joint count, ring size, and 50-foot walking time, the de-
`gree of improvement from week 0 to 16 was signifi-
`cantly greater in the levamisole group than in the
`placebo group. Fifty-foot walking time decreased signif-
`icantly in both groups.
`Clinical laboratory variables showed the same
`trend (Table 2). No significant changes in the median
`erythrocyte sedimentation rate occurred in the placebo
`group. Mean latex titer was also unchanged at week 16.
`In the levamisole treated group, statistically significant
`reduction occurred in both these variables. The week 0-
`16 improvement for both these variables was signifi-
`cantly greater in the levamisole group.
`
`This
`
`5u Die (cid:9)
`
`1...r1 7=:: i (cid:9)
`
`'LE.:15
`
`Ex. 1087 - Page 7
`
`(cid:9)
`

`

`EVALUATION OF LEVAMISOLE IN RA (cid:9)
`
`175
`
`Table 3. Carry over of levamisole effect: comparison of clinical and laboratory variables during
`administration of placebo and following 16 weeks of levamisole (median and range)
`
`Variable
`
`Week 16
`(end of levamisole)
`
`Week 32
`(end of placebo)
`
`Morning stiffness, minutes
`n = 8
`Grip strength, mm
`n = 9
`Joint count
`n = 7
`Pain scale, 0-100%
`n = 9
`Ring size
`n = 9
`50-foot walking time, seconds
`n = 9
`ESR, mm/hr
`n = 10
`Latext
`n = 10
`
`22.5
`(0-210)
`109,5
`(75-150)
`16
`(5-26)
`19.0
`(0-72)
`7.65
`(4-13)
`10.3
`(7.7-18.3)
`45
`(9-77)
`3.40 ± 2.64
`
`75
`(5-720)
`107
`(56-116)
`18
`(11-26)
`25
`(4-85)
`7.5
`(3.75-12.5)
`11.5
`(6.7-22.0)
`62
`(18-80)
`5.5 ± 1.05
`
`* P = Significance of the change from week 16 to week 32.
`t Mean and standard error.
`
`P*
`
`NS
`
`< 0.025
`
`NS (< 0.1 > 0.05)
`
`< 0.01
`
`NS
`
`< 0.05
`
`< 0.05
`
`< 0.01
`
`Carryover of levamisole effect. The arthritis of
`the 10 patients who started with levamisole became
`somewhat worse after blinded crossover to placebo.
`Nonetheless, at week 32 the measured parameters con-
`tinued to be better than at week 0. The results of analy-
`sis of carryover effect are given in Table 3. Both grip
`strength (P < 0.025) and pain score (P < 0.01) showed
`significant deterioration after crossover from levamisole
`to placebo. The ESR and latex fixation titers had in-
`creased significantly (P < 0.05) at 16 weeks of placebo.
`Joint count and duration of morning stiffness both
`showed trends toward deterioration, but in neither case
`
`was the degree of deterioration statistically significant.
`There was not significant increase in ring size or 50-foot
`walking time after crossover from levamisole to pla-
`cebo.
`
`Overall clinical efficacy of levamisole. When the
`changes from the beginning to the end of levamisole
`treatment were evaluated for all 18 patients completing
`levamisole therapy, highly statistically significant im-
`provement occurred in duration of morning stiffness,
`grip strength, joint count, pain scale, ring size, mean
`ESR, and latex fixation titers (Table 4). Overall, 14 pa-
`tients improved (70%), 3 deteriorated (15%), and 1 re-
`
`Table 4. Overall efficacy of levamisole: comparison of pre-levamisole values to values after 16 weeks
`levamisole for all 18 patients (median and range)
`
`Variable
`
`Pre-levamisole
`
`16 weeks levamisole
`
`Morning stiffness, minutes
`
`Grip strength, mm Hg
`
`Joint count
`
`Pain scale, 0-1006/0*
`
`Ring size
`
`50-foot walking time
`
`ESR, mm/hr
`
`Latext
`
`108
`(30-720)
`91
`(57-169)
`19
`(10-29)
`50
`(30-90)
`8.25
`(5.25-13.0)
`10.5
`(5.6-22.7)
`52.5
`(7-105)
`4.52 ± 0.77
`
`22.0
`(0-720)
`111
`(75-183)
`15.5
`(5-26)
`26.5
`(0-72)
`7.25
`(4-13.0)
`10.4
`(5.05-18.3)
`39.5
`(4-89)
`3.05 ± 0.55
`
`<0.05
`
`<0.005
`
`<0.025
`
`<0.005
`
`<0.005
`
`<0.025
`
`<0.005
`
`<0.005
`
`* 100% = worst possible pain.
`t For conversion see Materials and Methods. Mean and standard error.
`
`This ^Tata•ial (cid:9)
`at (cid:9)
`E' (cid:9)
`
`z (cid:9)
`
`iad
`s e
`Laws
`
`Ex. 1087 - Page 8
`
`

`

`176 (cid:9)
`
`MILLER ET AL
`
`Placebo (cid:9)
`
`Lev ami sol e (cid:9)
`
`P1 acebo
`
`160 -
`
`140
`
`120
`
`100
`
`100
`
`80
`
`60 _
`
`40 (cid:9)
`
`
`
`1500 _
`
`1400 _
`
`+1 (cid:9)
`
`1300
`
`1200
`
`1100
`
`•
`•
`
`240 -
`
`200 _
`
`160 -
`
`120 -
`
`340 _
`
`300 -
`
`260 -
`
`220 -
`
`180
`
`140
`
`
`0
`
`C3
`
`CH50
`
`IgG
`
`IgM
`
`16
`0
`
`32
`16
`
`Weeks
`
`32
`
`Figure 1. Complement and immunoglobulin levels during levamisole
`and placebo therapy. There were no significant changes in C3, total
`hemolytic complement, or immunoglobulin levels during levamisole
`or placebo therapy when compared to baseline, except for a fall in
`IgG levels during the placebo period in the group started on placebo
`and a fall in IgM levels during levamisole therapy in the group start-
`ing on levamisole (P < 0.05). In both cases baseline values were un-
`usually high.
`
`This —atarial
`a "..11.". a- (cid:9) —
`at (cid:9)
`Suble=t
`
`mained unchanged. No patient achieved a full remis-
`sion. Two patients did not complete the study because
`of adverse effects.
`Immunologic variables: immunoglobulins and
`complement. There were no significant differences be-
`tween the levamisole and placebo treated groups at 16
`weeks, or between weeks 0, 16, and 32 in either the le-
`vamisole to placebo or placebo to levamisole treatment
`groups with regard to the third component of com-
`plement, total hemolytic complement, or serum IgA lev-
`els (Figure 1). When compared to baseline, serum IgG
`showed a significant reduction at week 16 of placebo in
`the group treated initially with placebo, and serum 1gM
`showed a significant reduction at week 16 of levamisole
`in the group treated initially with levamisole (Figure 1).
`Though statistically significant, these changes are consid-
`ered to merely reflect the abnormally high initial values.
`Cell mediated immune responses. Primary de-
`layed hypersensitivity to KLH was assessed at week 3 in
`the 16 patients with a negative skin test at week 1. Injec-
`tion of both 0.1 mg and 0.01 mg KLH yielded no signif-
`icant differences in mean induration between the group
`on levamisole versus the group on placebo P = 0.1 and
`P < 0.2 respectively. Similarly, neither the number of
`responders nor the total amount of induration differed
`significantly between the levamisole and placebo groups
`for any of the three concentrations of DNCB used to
`test for primary sensitization. Analysis of secondary de-
`layed hypersensitivity responses to 5 antigens yielded no
`significant differences between the two groups or within
`either group at weeks 0, 16, and 32. Thus, by using total
`combined induration in response to the 5 antigens
`pooled, there was no significant difference between le-
`vamisole and placebo groups at week 16. Again, there
`was no significant difference from baseline in total in-
`duration in response to these 5 antigens in all 18 pa-
`tients after 16 weeks of treatment with levamisole. Fur-
`thermore, in looking at skin test conversion, there was a
`total of 6 conversions from negative to positive (10 mm
`induration). Three patients were receiving placebo at
`the time of conversion and 3 were receiving levamisole.
`Only one patient converted from negative to positive
`while on levamisole, then reverted to negative when
`crossed over to placebo.
`In vitro lymphocyte response to suboptimal
`amounts of PHA was found to be significantly lower at
`baseline in lymphocytes from these RA patients than
`from normal controls (1,280 versus 2,600 cpm P <
`0.001). This decreased responsiveness was found to be
`enhanced both by the in vitro addition of levamisole at
`baseline before levamisole therapy and without in vitro
`addition of drug following 16 weeks of in vivo levami-
`
`Ex. 1087 - Page 9
`
`(cid:9)
`

`

`EVALUATION OF LEVAMISOLE IN RA (cid:9)
`
`177
`
`Table 5. Effect of levamisole on lymphocyte subpopulations
`
`Lymphocyte subpopulation
`
`Percent
`
`Total lymphocyte count*
`B lymphocyte*
`T lymphocyte*
`Non-B, non-T lymphocyte]
`
`100
`11 ± 2
`66 ±- 3
`22
`
`Pre-levamisole
`
`After 16 weeks of levamisole
`
`Absolute
`concentration,
`per mm3
`
`1973 ± 206
`145 ± 21
`1139 ± 160
`692 ± 56
`
`Absolute
`concentration,
`per mm3
`
`1830 ± 246
`167 ± 29
`1192 ± 180
`460 ± 63§
`
`Percent
`
`100
`10 ± 1
`67 ± 3
`20
`
`* Number of patients = 16.
`t Number of patients = 9.
`All values are given as mean ± standard error.
`§ P < 0.05, 16 weeks of levamisole versus baseline.
`
`sole therapy. Moreover, this enhancement was in both
`instances significantly greater (P < 0.05) in patients who
`had a moderate to marked clinical improvement on le-
`vamisole as opposed to those with minimal or no clini-
`cal response. These data have been separately reported
`(22). In summary, after 16 weeks of levamisole therapy
`there was 34.5 ± 5.5% enhancement over baseline in pa-
`tients with good clinical response versus 23.2 ± 2.8% en-
`hancement for those with poor or no clinical response.
`Similarly there was a 44.8 ± 4.8% enhancement in vitro
`at baseline for the former group compared with 32.7 ±
`2.9% for those not responding clinically to levamisole.
`Enumeration studies showed no significant
`changes in absolute number or in percentages of T cells
`or B cells at any time in either group. However, the
`number of non-T and non-B (null) cells had decreased
`significantly at weeks 8 and 16 (P < 0.05) (Table 5).
`Humoral immune responses. Following injection
`of KLH, tetanus, and typhoid H and 0 antigens, serum
`antibody titers to at least 3 of these antigens increased in
`all 20 patients. The magnitude of the increase was simi-
`lar in both levamisole and placebo treated patients. Ti-
`ters peaked at 2 to 4 weeks then began to decline. Fol-
`lowing crossover to the alternate drug, titers continued
`to decline in all 10 patients crossed from levamisole to
`placebo; however in