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Pharmaceutics2021; 13(9); doi: 10.3390/pharmaceutics13091438

Sustained Intra-Articular Release and Biocompatibility of Tacrolimus (FK506) Loaded Monospheres Composed of [PDLA-PEG1000]-b-[PLLA] Multi-Block Copolymers in Healthy Horse Joints.

Abstract: There is an increasing interest in controlled release systems for local therapy in the treatment of human and equine joint diseases, aiming for optimal intra-articular concentrations with no systemic side effects. In this study, the intra-articular tolerability and suitability for local and sustained release of tacrolimus (FK506) from monospheres composed of [PDLA-PEG1000]-b-PLLA multiblock copolymers were investigated. Unloaded and tacrolimus-loaded (18.4 mg tacrolimus/joint) monospheres were injected into the joints of six healthy horses, with saline and hyaluronic acid (HA) in the contralateral joints as controls. Blood and synovial fluid were analysed for the tacrolimus concentration and biomarkers for inflammation and cartilage metabolism. After an initial burst release, sustained intra-articular tacrolimus concentrations (>20 ng/mL) were observed during the 42 days follow-up. Whole-blood tacrolimus levels were below the detectable level (<0.5 ng/mL). A transient inflammatory reaction was observed for all substances, evidenced by increases of the synovial fluid white blood cell count and total protein. Prostaglandin and glycosaminoglycan release were increased in joints injected with unloaded monospheres, which was mitigated by tacrolimus. Both tacrolimus-loaded monospheres and HA transiently increased the concentration of collagen II cleavage products (C2C). A histologic evaluation of the joints at the endpoint showed no pathological changes in any of the conditions. Together, these results indicate the good biocompatibility of intra-articular applied tacrolimus-loaded monospheres combined with prolonged local drug release while minimising the risk of systemic side effects. Further evaluation in a clinical setting is needed to determine if tacrolimus-loaded monospheres can be beneficial in the treatment of inflammatory joint diseases in humans and animals.
Publication Date: 2021-09-10 PubMed ID: 34575514PubMed Central: PMC8465142DOI: 10.3390/pharmaceutics13091438Google Scholar: Lookup
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  • Journal Article

Summary

This research summary has been generated with artificial intelligence and may contain errors and omissions. Refer to the original study to confirm details provided. Submit correction.

The research study examines the effectiveness and tolerability of using tacrolimus-loaded monospheres for treating joint diseases in humans and horses, reducing systemic side effects and maintaining optimal intra-articular drug concentrations.

Objective of the Research

  • The research aimed to investigate the suitability and tolerability of tacrolimus (FK506) – a drug used in joint disease treatment – when loaded onto monospheres. The researchers explored these monospheres’ potential for localised and sustained drug release within the joints.

Methodology

  • The study treated the joints of six healthy horses with monospheres, both loaded and unloaded with tacrolimus, then compared the results with joints treated with saline and hyaluronic acid (HA) controls.
  • They analyzed synovial fluid and blood samples to monitor tacrolimus concentration, inflammation markers, and cartilage metabolism indicators.

Findings

  • After an initial burst release, the researchers observed sustained intra-articular concentrations of tacrolimus (>20 ng/mL) over a 42-day follow-up. This demonstrates that the drug stays in the joint, potentially providing a longer-lasting treatment.
  • Whole-blood tacrolimus levels remained undetectable, indicating minimal systemic side effects.
  • A temporary inflammation was observed in the synovial fluid as the white blood cell count and total protein increased. This reaction was seen with all substances, not just the test therapy.
  • Release of prostaglandin and glycosaminoglycan was increased in joints treated with unloaded monospheres, but the effect was reduced when tacrolimus was present.
  • Injection of tacrolimus-loaded monospheres and HA temporarily increased the concentration of a cartilage breakdown product (Collagen II cleavage products or C2C), indicating some cartilage degradation that might be linked to the inflammation.
  • Final histologic assessment showed no pathological changes in any of the treatments, implying no adverse effects within the joint.

Conclusion

  • These findings demonstrate the potential benefits of tacrolimus-loaded monospheres for localized, extended joint disease treatment with minimal systemic side effects, suggesting good biocompatibility. The research has cleared the path for further evaluations in a clinical setting to assess potential benefits for treating humans and animals with inflammatory joint diseases.

Cite This Article

APA
Cokelaere SM, Groen WMGAC, Plomp SGM, de Grauw JC, van Midwoud PM, Weinans HH, van de Lest CHA, Tryfonidou MA, van Weeren PR, Korthagen NM. (2021). Sustained Intra-Articular Release and Biocompatibility of Tacrolimus (FK506) Loaded Monospheres Composed of [PDLA-PEG1000]-b-[PLLA] Multi-Block Copolymers in Healthy Horse Joints. Pharmaceutics, 13(9). https://doi.org/10.3390/pharmaceutics13091438

Publication

ISSN: 1999-4923
NlmUniqueID: 101534003
Country: Switzerland
Language: English
Volume: 13
Issue: 9

Researcher Affiliations

Cokelaere, Stefan M
  • Department of Clinical Sciences, Faculty of Veterinary Medicine, Utrecht University, Yalelaan 112, 3584 CM Utrecht, The Netherlands.
  • Sporthorse Medical Diagnostic Centre, Hooge Wijststraat 7, 3584 RC Heesch, The Netherlands.
Groen, Wilhelmina M G A C
  • Department of Clinical Sciences, Faculty of Veterinary Medicine, Utrecht University, Yalelaan 112, 3584 CM Utrecht, The Netherlands.
Plomp, Saskia G M
  • Department of Clinical Sciences, Faculty of Veterinary Medicine, Utrecht University, Yalelaan 112, 3584 CM Utrecht, The Netherlands.
de Grauw, Janny C
  • Department of Clinical Sciences, Faculty of Veterinary Medicine, Utrecht University, Yalelaan 112, 3584 CM Utrecht, The Netherlands.
van Midwoud, Paul M
  • Innocore Pharmaceuticals, L.J. Zielstraweg 1, 9713 GX Groningen, The Netherlands.
Weinans, Harrie H
  • Department of Orthopaedics, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands.
van de Lest, Chris H A
  • Department of Clinical Sciences, Faculty of Veterinary Medicine, Utrecht University, Yalelaan 112, 3584 CM Utrecht, The Netherlands.
  • Department of Biomolecular Health Sciences, Cell Biology and Histology, Faculty of Veterinary Medicine, Utrecht University, Yalelaan 2, 3584 CM Utrecht, The Netherlands.
Tryfonidou, Marianna A
  • Department of Clinical Sciences, Faculty of Veterinary Medicine, Utrecht University, Yalelaan 112, 3584 CM Utrecht, The Netherlands.
van Weeren, P René
  • Department of Clinical Sciences, Faculty of Veterinary Medicine, Utrecht University, Yalelaan 112, 3584 CM Utrecht, The Netherlands.
Korthagen, Nicoline M
  • Department of Clinical Sciences, Faculty of Veterinary Medicine, Utrecht University, Yalelaan 112, 3584 CM Utrecht, The Netherlands.
  • Department of Orthopaedics, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands.

Grant Funding

  • LLP-22 / Dutch Arthritis Society

Conflict of Interest Statement

Innocore Pharmaceuticals provided the monospheres for this study. InnoCore Pharmaceuticals had no influence on the decision to publish the results. The funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript or in the decision to publish the results.

References

This article includes 58 references
  1. Urwin M, Symmons D, Allison T, Brammah T, Busby H, Roxby M, Simmons A, Williams G. Estimating the burden of musculoskeletal disorders in the community: The comparative prevalence of symptoms at different anatomical sites, and the relation to social deprivation.. Ann. Rheum. Dis. 1998;57:649–655.
    doi: 10.1136/ard.57.11.649pmc: PMC1752494pubmed: 9924205google scholar: lookup
  2. Van Weeren P.R. General anatomy and physiology of joints. In: McIlwraith C.W., Frisbie D.D., Kawcak C.E., van Weeren P.R., editors. Joint Disease in the Horse. Elsevier; St. Louis, MO, USA: 2016. p. 1.
  3. Fazal S.A., Khan M, Nishi S.E., Alam F, Zarin N, Bari M.T., Ashraf G.M. A Clinical Update and Global Economic Burden of Rheumatoid Arthritis.. Endocr. Metab. Immune Disord Drug. Targets. 2018;18:98–109.
  4. Prieto-Alhambra D, Judge A, Javaid M.K., Cooper C, Diez-Perez A, Arden N.K. Incidence and risk factors for clinically diagnosed knee, hip and hand osteoarthritis: Influences of age, gender and osteoarthritis affecting other joints.. Ann. Rheum. Dis. 2014;73:1659–1664.
  5. Cross M, Smith E, Hoy D, Carmona L, Wolfe F, Vos T, Williams B, Gabriel S, Lassere M, Johns N. The global burden of rheumatoid arthritis: Estimates from the global burden of disease 2010 study.. Ann. Rheum. Dis. 2014;73:1316–1322.
  6. Goldring M.B., Goldring S.R. Osteoarthritis.. J. Cell Physiol. 2007;213:626–634.
    doi: 10.1002/jcp.21258pubmed: 17786965google scholar: lookup
  7. Pap T, Korb-Pap A. Cartilage damage in osteoarthritis and rheumatoid arthritis—two unequal siblings.. Nat. Rev. Rheumatol. 2015;11:606–615.
    doi: 10.1038/nrrheum.2015.95pubmed: 26195338google scholar: lookup
  8. O’Neill T.W., McCabe P.S., McBeth J. Update on the epidemiology, risk factors and disease outcomes of osteoarthritis.. Best Pract. Res. Clin. Rheumatol. 2018;32:312–326.
    doi: 10.1016/j.berh.2018.10.007pubmed: 30527434google scholar: lookup
  9. Losina E., Katz J.N. Improvement at Any Cost? The Art and Science of Choosing Treatment Strategies for Rheumatoid Arthritis.. Ann. Intern. Med. 2017;167:55–56.
    doi: 10.7326/M17-1176pubmed: 28554193google scholar: lookup
  10. Evans C.H., Kraus V.B., Setton L.A. Progress in intra-articular therapy.. Nat. Rev. Rheumatol. 2014;10:11–22.
    doi: 10.1038/nrrheum.2013.159pmc: PMC4402210pubmed: 24189839google scholar: lookup
  11. Van Den Boom R., van de Lest C.H.A., Bull S., Brama R.A.J., van Weeren P.R., Barneveld A. Influence of repeated arthrocentesis and exercise on synovial fluid concentrations of nitric oxide, prostaglandin E2 and glycosaminoglycans in healthy equine joints.. Equine Vet. J. 2005;37:250–256.
    doi: 10.2746/0425164054530740pubmed: 15892235google scholar: lookup
  12. Larsen C., Ostergaard J., Larsen S.W., Jensen H., Jacobsen S., Lindegaard C., Andersen P.H. Intra-articular depot formulation principles: Role in the management of postoperative pain and arthritic disorders.. J. Pharm. Sci. 2008;97:4622–4654.
    doi: 10.1002/jps.21346pubmed: 18306275google scholar: lookup
  13. Butoescu N., Jordan O., Doelker E. Intra-articular drug delivery systems for the treatment of rheumatic diseases: A review of the factors influencing their performance.. Eur. J. Pharm. Biopharm. 2009;73:205–218.
    doi: 10.1016/j.ejpb.2009.06.009pubmed: 19545624google scholar: lookup
  14. Badri W., Miladi K., Nazari Q.A., Greige-Gerges H., Fessi H., Elaissari A. Encapsulation of NSAIDs for inflammation management: Overview, progress, challenges and prospects.. Int. J. Pharm. 2016;515:757–773.
    doi: 10.1016/j.ijpharm.2016.11.002pubmed: 27829170google scholar: lookup
  15. Scott L.J., McKeage K., Keam S.J., Plosker G.L. Tacrolimus: A further update of its use in the management of organ transplantation.. Drugs. 2003;63:1247–1297.
  16. Van Dieren J.M., van Bodegraven A.A., Kuipers E.J., Bakker E.N., Poen A.C., van Dekken H., Nieuwenhuis E.E.S., van der Woude C.J. Local application of tacrolimus in distal colitis: Feasible and safe.. Inflamm. Bowel Dis. 2009;15:193–198.
    doi: 10.1002/ibd.20644pubmed: 18825773google scholar: lookup
  17. Albaghdadi A.J.H., Kan F.W.K. Therapeutic Potentials of Low-Dose Tacrolimus for Aberrant Endometrial Features in Polycystic Ovary Syndrome.. Int. J. Mol. Sci. 2021;22:2872.
    doi: 10.3390/ijms22062872pmc: PMC7998611pubmed: 33808965google scholar: lookup
  18. Takeuchi T., Ishida K., Shiraki K., Yoshiyasu T. Safety and effectiveness of tacrolimus add-on therapy for rheumatoid arthritis patients without an adequate response to biological disease-modifying anti-rheumatic drugs (DMARDs): Post-marketing surveillance in Japan.. Mod. Rheumatol. 2018;28:48–57.
    doi: 10.1080/14397595.2017.1332471pubmed: 28649878google scholar: lookup
  19. Lee Y.H., Woo J.-H., Choi S.J., Ji J.D., Bae S.-C., Song G.G. Tacrolimus for the treatment of active rheumatoid arthritis: A systematic review and meta-analysis of randomized controlled trials.. Scand. J. Rheumatol. 2010;39:271–278.
    doi: 10.3109/03009740903501642pubmed: 20476867google scholar: lookup
  20. Siebelt M., van der Windt A.E., Groen H.C., Sandker M., Waarsing J.H., Müller C., de Jong M., Jahr H., Weinans H. FK506 protects against articular cartilage collagenous extra-cellular matrix degradation.. Osteoarthr. Cartil. 2014;22:591–600.
    doi: 10.1016/j.joca.2014.02.003pubmed: 24561282google scholar: lookup
  21. Magari K., Nishigaki F., Sasakawa T., Ogawa T., Miyata S., Ohkubo Y., Mutoh S., Goto T. Anti-arthritic properties of FK506 on collagen-induced arthritis in rats.. Inflamm. Res. 2003;52:524–529.
    doi: 10.1007/s00011-003-1210-8pubmed: 14991082google scholar: lookup
  22. Kino T., Hatanaka H., Miyata S., Inamura N., Nishiyama M., Yajima T., Goto T., Okuhara M., Kohsaka M., Aoki H. FK-506, a novel immunosuppressant isolated from a Streptomyces. II. Immunosuppressive effect of FK-506 in vitro.. J. Antibiot. 1987;40:1256–1265.
    doi: 10.7164/antibiotics.40.1256pubmed: 2445722google scholar: lookup
  23. Miyata S., Ohkubo Y., Mutoh S. A review of the action of tacrolimus (FK506) on experimental models of rheumatoid arthritis.. Inflamm. Res. 2005;54:1–9.
    doi: 10.1007/s00011-004-1318-5pubmed: 15723198google scholar: lookup
  24. Sakuma S., Kato Y., Nishigaki F., Sasakawa T., Magari K., Miyata S., Ohkubo Y., Goto T. FK506 potently inhibits T cell activation induced TNF-alpha and IL-1beta production in vitro by human peripheral blood mononuclear cells.. Br. J. Pharmacol. 2000;130:1655–1663.
    doi: 10.1038/sj.bjp.0703472pmc: PMC1572228pubmed: 10928971google scholar: lookup
  25. Kitahara K., Kusunoki N., Takahashi H., Tsuchiya K., Kawai S. Tacrolimus down-regulates chemokine expressions on rheumatoid synovial fibroblasts: Screening by a DNA microarray.. Inflamm. Res. 2012;61:1385–1394.
    doi: 10.1007/s00011-012-0541-8pubmed: 22885734google scholar: lookup
  26. Kang K.Y., Ju J.H., Song Y.W., Yoo D.-H., Kim H.-Y., Park S.-H. Tacrolimus treatment increases bone formation in patients with rheumatoid arthritis.. Rheumatol. Int. 2013;33:2159–2163.
    doi: 10.1007/s00296-012-2370-zpubmed: 22447331google scholar: lookup
  27. Bechstein W.O. Neurotoxicity of calcineurin inhibitors: Impact and clinical management.. Transpl. Int. 2000;13:313–326.
  28. Andoh T.F., Burdmann E.A., Bennett W.M. Nephrotoxicity of immunosuppressive drugs: Experimental and clinical observations.. Semin. Nephrol. 1997;17:34–45.
    pubmed: 9000548
  29. Curran M.P., Perry C.M. Tacrolimus: In patients with rheumatoid arthritis.. Drugs. 2005;65:993–1001.
  30. Sandker M.J., Duque L.F., Redout E.M., Chan A. Degradation, intra-articular retention and biocompatibility of monospheres composed of [PDLLA-PEG-PDLLA]-b-PLLA multi-block copolymers.. Acta Biomater. 2017;48:401–414.
    doi: 10.1016/j.actbio.2016.11.003pubmed: 27816621google scholar: lookup
  31. Fu K., Pack D.W., Klibanov A.M., Langer R. Visual evidence of acidic environment within degrading poly(lactic-co-glycolic acid) (PLGA) microspheres.. Pharm. Res. 2000;17:100–106.
    doi: 10.1023/A:1007582911958pubmed: 10714616google scholar: lookup
  32. Sandker M.J., Duque L.F., Redout E.M., Klijnstra E.C., Steendam R., Kops N., Waarsing J.H., van Weeren R., Hennink W.E., Weinans H. Degradation, Intra-Articular Biocompatibility, Drug Release, and Bioactivity of Tacrolimus-Loaded Poly( d- l-lactide-PEG)- b-poly( l-lactide) Multiblock Copolymer-Based Monospheres.. ACS Biomater. Sci. Eng. 2018;4:2390–2403.
  33. Petit A., Sandker M., Müller B., Meyboom R., van Midwoud P., Bruin P., Redout E.M., Versluijs-Helder M., van der Lest C.H.A., Buwalda S.J. Release behavior and intra-articular biocompatibility of celecoxib-loaded acetyl-capped PCLA-PEG-PCLA thermogels.. Biomaterials. 2014;35:7919–7928.
  34. McIlwraith C.W., Fortier L.A., Frisbie D.D., Nixon A.J. Equine Models of Articular Cartilage Repair.. Cartilage. 2011;2:317–326.
    doi: 10.1177/1947603511406531pmc: PMC4297134pubmed: 26069590google scholar: lookup
  35. McIlwraith C.W., Frisbie D.D., Kawcak C.E. The horse as a model of naturally occurring osteoarthritis.. Bone Jt. Res. 2012;1:297–309.
  36. AAEP Horse Show Committee . In: Guide to Veterinary Services for Horse Shows. 7th ed. American Association of Equine Practitioners, editor. American Association of Equine Practitioners; Lexington, KY, USA: 1999.
  37. Bertone A.L., Palmer J.L., Jones J. Synovial Fluid Cytokines and Eicosanoids as Markers of Joint Disease in Horses.. Vet. Surg. 2001;30:528–538.
    doi: 10.1053/jvet.2001.28430pubmed: 11704948google scholar: lookup
  38. De Grauw J.C., van ve Lest C.H.A., Brama P.A.J., Rambags B.P.B., van Weeren P.R. In vivo effects of meloxicam on inflammatory mediators, MMP activity and cartilage biomarkers in equine joints with acute synovitis.. Equine Vet. J. 2010;41:693–699.
    doi: 10.2746/042516409X436286pubmed: 19927589google scholar: lookup
  39. De Grauw J.C., van de Lest C.H.A., van Weeren R., Brommer H., Brama P.A.J. Arthrogenic lameness of the fetlock: Synovial fluid markers of inflammation and cartilage turnover in relation to clinical joint pain.. Equine Vet. J. 2006;38:305–311.
    doi: 10.2746/042516406777749236pubmed: 16866196google scholar: lookup
  40. De Grauw J.C., van de Lest C.H.A., van Weeren P.R. A targeted lipidomics approach to the study of eicosanoid release in synovial joints.. Arthritis Res. Ther. 2011;13:R123.
    doi: 10.1186/ar3427pmc: PMC3239362pubmed: 21794148google scholar: lookup
  41. McIlwraith C.W., Frisbie D.D., Kawcak C.E., Fuller C.J., Hurtig M., Cruz A. The OARSI histopathology initiative—Recommendations for histological assessments of osteoarthritis in the horse.. Osteoarthr. Cartil. 2010;18((Suppl. S3)):S93–S105.
    doi: 10.1016/j.joca.2010.05.031pubmed: 20864027google scholar: lookup
  42. Gawlitta D., van Rijen M.H.P., Schrijver E.J.M., Alblas J., Dhert W.J.A. Hypoxia impedes hypertrophic chondrogenesis of human multipotent stromal cells.. Tissue Eng. Part A. 2012;18:1957–1966.
    doi: 10.1089/ten.tea.2011.0657pubmed: 22563686google scholar: lookup
  43. Egeland E.J., Robertsen I., Hermann M., Midtvedt K., Størset E., Gustavsen M.T., Reisæter A.V., Klaasen R., Bergan S., Holdaas H. High Tacrolimus Clearance Is a Risk Factor for Acute Rejection in the Early Phase After Renal Transplantation.. Transplantation. 2017;101:e273–e279.
    doi: 10.1097/TP.0000000000001796pubmed: 28452920google scholar: lookup
  44. Wallis W.J., Simkin P.A., Nelp W.B., Foster D.M. Intraarticular volume and clearance in human synovial effusions.. Arthritis Rheum. 1985;28:441–449.
    doi: 10.1002/art.1780280413pubmed: 3885961google scholar: lookup
  45. Pitsillides A.A., Will R.K., Bayliss M.T., Edwards J.C. Circulating and synovial fluid hyaluronan levels. Effects of intraarticular corticosteroid on the concentration and the rate of turnover.. Arthritis Rheum. 1994;37:1030–1038.
    doi: 10.1002/art.1780370708pubmed: 8024612google scholar: lookup
  46. Hilton H., Affolter V.K., White S.D. Evaluation of four topical preparations for the treatment of cannon hyperkeratosis in a horse.. Vet. Dermatol. 2008;19:385–390.
  47. González-Medina S. Equine eosinophilic keratitis: An emergent ocular condition?. Equine Vet. Educ. 2019;31:609–616.
    doi: 10.1111/eve.12937google scholar: lookup
  48. Kershner R.P., Fitzsimmons W.E. Relationship of FK506 whole blood concentrations and efficacy and toxicity after liver and kidney transplantation.. Transplantation. 1996;62:920–926.
  49. Ogata H., Matsui T., Nakamura M., Iida M., Takazoe M., Suzuki Y., Hibi T. A randomised dose finding study of oral tacrolimus (FK506) therapy in refractory ulcerative colitis.. Gut. 2006;55:1255–1262.
    doi: 10.1136/gut.2005.081794pmc: PMC1860021pubmed: 16484504google scholar: lookup
  50. Owens J.G., Kamerling S.G., Stanton S.R., Keowen M.L., Prescott-Mathews J.S. Effects of pretreatment with ketoprofen and phenylbutazone on experimentally induced synovitis in horses.. Am. J. Vet. Res. 1996;57:866–874.
    pubmed: 8725815
  51. Kalinski P. Regulation of Immune Responses by Prostaglandin E2.. J. Immunol. 2012;188:21–28.
    doi: 10.4049/jimmunol.1101029pmc: PMC3249979pubmed: 22187483google scholar: lookup
  52. Cokelaere S.M., Plomp S.G.M., de Boef E., de Leeuw M., Bool S., van de Lest C.H.A., van Weeren P.R., Korthagen N.M. Sustained intra-articular release of celecoxib in an equine repeated LPS synovitis model.. Eur J. Pharm. Biopharm. 2018;128:327–336.
    doi: 10.1016/j.ejpb.2018.05.001pubmed: 29729412google scholar: lookup
  53. Johnston G.C.A., Wood K.A., Jackson K.V., Perkins N.R., Zedler S.T. Evaluation of the inflammatory response to two intra-articular hyaluronic acid formulations in normal equine joints.. J. Vet. Pharmacol. Ther. 2020;43:38–49.
    doi: 10.1111/jvp.12818pubmed: 31660636google scholar: lookup
  54. De Grauw J.C., van de Lest C.H., van Weeren P.R. Inflammatory mediators and cartilage biomarkers in synovial fluid after a single inflammatory insult: A longitudinal experimental study.. Arthritis Res. Ther. 2009;11:1–8.
    doi: 10.1186/ar2640pmc: PMC2688180pubmed: 19272138google scholar: lookup
  55. Kulkarni P., Deshpande S., Koppikar S., Patil S., Ingale D., Harsulkar A. Glycosaminoglycan measured from synovial fluid serves as a useful indicator for progression of Osteoarthritis and complements Kellgren-Lawrence Score.. BBA Clin. 2016;6:1–4.
  56. Frisbie D.D., Al-Sobayil F., Billinghurst R.C., Kawcak C.E., McIlwraith C.W. Changes in synovial fluid and serum biomarkers with exercise and early osteoarthritis in horses.. Osteoarthr. Cartil. 2008;16:1196–1204.
    doi: 10.1016/j.joca.2008.03.008pubmed: 18442931google scholar: lookup
  57. Van der Windt A.E., Jahr H., Farrell E., Verhaar J.A.N., Weinans H., van Osch G.J.V.M. Calcineurin inhibitors promote chondrogenic marker expression of dedifferentiated human adult chondrocytes via stimulation of endogenous TGFbeta1 production.. Tissue Eng. Part A. 2010;16:1–10.
    doi: 10.1089/ten.tea.2009.0082pubmed: 19604038google scholar: lookup
  58. Van der Windt A.E., Haak E., Kops N., Verhaar J.A.N., Weinans H., Jahr H. Inhibiting calcineurin activity under physiologic tonicity elevates anabolic but suppresses catabolic chondrocyte markers.. Arthritis Rheum. 2012;64:1929–1939.
    doi: 10.1002/art.34369pubmed: 22231955google scholar: lookup