Monosodium urate crystal induced macrophage inflammation is attenuated by chondroitin sulphate: pre-clinical model for gout prophylaxis?

Gout is the most common cause of arthritis in men after osteoarthritis. Its prevalence is on the rise and thought to affect around 4% of the total US population[1]. Patients have fewer flares when their serum uric acid is maintained below 6.0 mg/dl[2]. However, initiation of urate-lowering therapy can often lead to an increase in the frequency and severity of flares[3, 4]. Consequently, both the European League Against Rheumatism (EULAR) and the American College of Rheumatology (ACR) have recommended the use of prophylactic agents when initiating urate-lowering therapy[5, 6]. Oral colchicine, low-dose non-steroidal anti-inflammatory drugs (NSAIDs) and daily corticosteroids have all been recommended[7], but all are associated with intolerances or adverse effects[4]. Thus, the identification of new agents for treating or preventing gout flares would be of great clinical value.

Gouty inflammation is initiated when monosodium urate (MSU) crystals are taken up by macrophages or other cells in the joints[8]. This results in assembly of the NLRP3 inflammasome, a multimeric protein complex responsible for activating caspase-1, which in turn cleaves pro-IL-1β leading to production and secretion of active IL-1β[9]. Other factors are upregulated during gouty inflammation, including IL-8 and TNFα[8].

Chondroitin Sulphate (CS), a natural glycosaminoglycan of the cartilage extracellular matrix[10], is of clinical benefit in symptomatic osteoarthritis[11] but results are mixed[12, 13]. The effects of CS have never been tested in gout. In vitro, CS has anti-inflammatory and positive effects on osteoarthritic chondrocytes, synoviocytes and subchondral bone osteoblasts[14], but its effect on macrophages is unknown. On the other hand, in vivo, CS given orally prevents hepatic NF-κB nuclear translocation, suggesting that systemic CS may elicit an anti-inflammatory effect in many tissues besides the joint[14]. There is preliminary evidence in human beings that CS may be of benefit in other diseases where inflammation is an essential component such as psoriasis and atherosclerosis[14]. The purpose of our study was to evaluate the in vitro effects of CS on MSU-stimulated cytokine production by macrophages.

All cell culture reagents, including the MSU and CS, were tested for the presence of endotoxin by our laboratory or the manufacturer, and all were found to contain less than 0.03 EU/ml endotoxin. Increasing concentrations of MSU crystals led to increasing IL-1β production (Figure 1). Specifically, MSU concentrations of 10 mg/dl and greater increased IL-1β production by macrophages; thus, concentrations of 10–20 mg/dl were used for subsequent experiments.To stringently assess the mechanism of IL-1β production in macrophages in response to MSU, cells were stimulated with a high concentration of MSU, 20 mg/dl, with pre-incubation with varying concentrations of a caspase-1 inhibitor. IL-1β production was fully inhibitable by the caspase-1 inhibitor in a dose dependent manner confirming inflammasome activation as the source of this cytokine (Figure 2).

To assess the effect of CS on MSU stimulated cytokine production, we pre-incubated THP-1 macrophages in the absence and presence of CS for 4 hours followed by stimulation with MSU 10 mg/dl. This concentration was chosen as it reliably induced IL-1β production, is representative of hyperuricemia, and is associated with a high incidence of gout[20]. IL-1β, TNFα and IL-8 were induced a mean 7-, 4- and 3-fold respectively by MSU. CS significantly inhibited IL-1β (p = 0.0029) and TNFα (p = 0.0174) production from macrophages in response to MSU (Figure 3). These results were also significant by linear trend analysis (p = 0.001 and p = 0.009 for IL-1β and TNFα respectively). Although IL-8 was similarly inhibited by CS (Figure 3), this trend was not statistically significant by ANOVA (p = 0.4147) but was significant by linear trend analysis (P = 0.05). The linear trend analyses demonstrate a reduction of inflammation by CS in a dose-dependent manner.

Three cytokines associated with gouty inflammation, IL-1β, TNFα and IL-8 were all induced by exposure of activated macrophages to MSU crystals. Macrophage exposure to CS for 4 hours prior to MSU led to a significant dose-dependent decline in production of both IL-1β and TNFα. Many of the anti-inflammatory effects of CS are thought to affect the transcription of various cytokines, such as IL-1β and TNFα. In particular, they are thought to affect various kinases, which in turn block the translocation of NFκB to the nucleus[14]. Others have suggested that NFκB could also affect IL-8 production[21]. Martinon et al. demonstrated that MSU crystals lead to IL-β production through activation of the inflammasome[22]. TNFα is also upregulated by MSU crystals in an experimental animal model of gouty arthritis, but blocking IL-1β (either pharmacologically or genetically) lessened this response[23]. In addition, IL-8, a chemotactic factor responsible for neutrophilic infiltration, was upregulated when MSU crystals were injected in the joints of rabbits; this neutrophil response and the gout related synovitis were attenuated with the use of an anti-IL-8 antibody[24].

Based on the literature, the concentrations of CS used in these experiments are comparable to those suggested to be within a physiologically achievable range[18, 19]. The data presented here suggest there may be a role for CS in preventing flares of gout due to initiation of uric acid lowering agents. To gain potential insights into whether CS might play a role in treatment of active gout flares, future studies are needed to test the effects of CS added coincidentally or after MSU stimulation. Given the low side effect profile of CS, it represents an intriguing treatment option for these scenarios in gout. In particular, CS might synergize with other established treatments for gout thereby making it possible to lower doses or discontinue traditional therapies, particularly in the subset of individuals with relative contraindications to the traditional therapies including allopurinol, NSAIDs and colchicine in the context of renal insufficiency.

A number of meta-analyses have found oral CS to be both safe and well tolerated[12, 13]. However, one must take into account both the purity and source (i.e. bovine or shark etc.) as other in vitro studies have shown that in vitro anti-inflammatory properties of CS can vary based on the preparation[25‐27]. Further studies in humans will be needed to determine if CS has a role as a treatment option for patients with gout.

A limitation of our study was the use of THP-1 cells derived from a human monocytic cell line. They are often employed in the laboratory setting because of their ease of use. However, it would be of benefit to repeat these experiments in primary peripheral monocytes or primary synovial macrophages. Although we established that IL-1β, produced by macrophages in this system, was a product of inflammasome activation, these experiments do not establish the exact target of CS inhibition. CS may be blocking NFκ-B activation, as established by others[18], which would block pro-IL-1β transcript expression. Alternatively, CS could be acting outside of the cell by blocking the interaction of MSU or extracellular matrix fragments with cell surface receptors on macrophages[28]. Still the anti-inflammatory effects of CS and other sulphated glycosaminoglycans may be mediated through sequestering of cytokines as suggested based on NMR and fluorescent spectroscopy as well as computational simulation studies[29]. Finally, CS could have pleiotropic effects on the cell, some of which have yet to be elucidated.

CS decreased MSU-mediated cytokine production from activated macrophages. In particular, IL-1β and TNFα were lowered in a dose-dependent manner by CS. Given the role of these cytokines in initiating gouty inflammation, CS may have a role as a prophylactic agent in the treatment of gout.