due to drugs mentioned above , immunotherapy , biological therapy or alternatives not only have non - satisfactory results but also produce adverse effects or important secondary side effects . for this reason , we suggest to evaluate the biodrug , collagen - polyvinylpyrrolidone ( fibroquel ®, reg . no . 210m95 ssa ) in ra or oa patients . based on the fact that the addition of extracellular matrix proteins to t lymphocyte cultures is capable of modulating t cell response ( easter d w , hayt d b , ozkan a n . immunosuppression by a peptide from the gelatin binding domain of human fibronectin . j surg res 1988 ; 45 : 370 - 5 ; rybski j a , lause d b , reese a c . effect of fibronectin on antigen - induced lymphoproliferation and antibody synthesis in rats . j leuk biol 1989 ; 45 : 35 - 45 ; rueg c r , chiquet - ehrismann r , alkan s s . tenascin , an extracellular matrix protein , exerts immunomodulatory activities . proc natl acad sci usa 1989 ; 86 : 7437 - 41 ; furuzawa - carballeda j , alcocer - varela j , díaz de león l . collagen - pvp decreases collagen turnover in synovial tissue cultures from rheumatoid arthritis patients . ann n y acad sci 1999 ; 878 : 508 - 602 ); that oral administration of type ii collagen ( thompson hsg , staines na . gastric administration of type ii collagen delays the onset and severity of collagen - induced arthritis in rats . clin exp immunol 1985 ; 64 : 581 - 6 ; trentham d e , dynesius - trentham r a , orav e j , combitchi d , lorenzo c , sewell k l , hafler d a , weiner h l . effects of oral administration of type ii collagen on rheumatoid arthritis . science 1993 ; 261 : 1727 - 30 ) or type i or iii collagen ( zhang z j , lee ch s y , lider o , weiner h l . suppression of adjuvant arthritis in lewis rats by oral administration of type ii collagen . j immunol 1990 ; 145 : 2489 - 94 ) modulates peripheral immune system in ra and also that collagen - pvp has anti - inflammatory properties , as mention below . collagen - pvp is a y - irradiated mixture of pepsinized porcine type i collagen and pvp in a citric buffer , that stabilizes ph . in culture medium at 37 ° c . and neutral ph , collagen - pvp does not form a gel like other collagens and its electrophoretic , physicochemical and pharmacological properties are modified by the covalent binding between protein and pvp . it has been demonstrated in vitro and in vivo that the components alone ( collagen and pvp ) do not have the same properties than collagen - pvp ( chimal - monroy j , bravo - ruiz t , krötzsch - gómez f e , díaz de león l . implantes de fibroquel aceleran la formación de hueso nuevo en defectos óseos inducidos experimentalmente en craneos de rata : un estudio histologico . rev biomed 1997 ; 8 : 81 - 8 ). this biodrug has demonstrated to modulate collagen metabolism , pro - inflammatory cytokine expression , to improve skin wound repair , as well as other tissues . previous data have been determined by experiments performed in wistar rats and humans , where intralesional treatment of collagen - pvp of surgical wounds stimulates an increase of the granulation tissue on day 7 after surgery and tissues exhibit better skin architecture at day 28 , when compared to non treated group . improvement include cutaneous appendages presence in the wounded zone ( sebaceous glands and hair follicles ) together with a normal skin like collagen bundle arrangement ( krötzsch - gómez f e , guerrero - padilla e , díaz de león l . morphological studies on the effects of fibroquel during wound of surgical wounds in rats . j cell biochem 1993 ; suppl , 17e : 137r506 ). femoral diaphisary fractures were performed in wistar rats , after that 0 . 2 ml of collagen - pvp were administered in situ during the 3 first days after lesion . bone consolidation parameters were evaluated and 67 % of the treated animals showed total bone repair at day 30 vs . only 20 % for the control group . histological analysis demonstrated an early turnover of the mesenchymal cells in the collagen - pvp treated group by cartilage tissue first , and later by osteoblasts and trabecular bone ( days 16 and 23 ). also , it was determined higher osteopontin and osteonectin expression , meanwhile type i collagen and fibronectina were similar in experimental and control groups . results suggest that collagen - pvp modulates mesenchymal cell growth factors and extracellular matrix protein expression , stimulating migration , proliferation and differentiation of chondrogenic and osteogenic cells , improving bone repair ( almazán díaz a , de la cruz garcia j c , lira romero j m , arrellin g , chimal monroy j , díaz de león l , furuzawa - carballeda j , krötzsch gómez f : investigaci6n experimental de la regeneración ósea en fémures de rata después de la aplicación de colágena i polimerizada : estudio radiológico , histológico e inmunohistoquimico . rev mex ortop traum 1996 ; 10 : 142 - 52 ; chimal - monroy j , bravo - ruiz t , furuzawa - carballeda g j . lira r j m , de la cruz g j c , almazán d a , krötzsch - gómez f e , arrellin r g , díaz de león l . collagen - pvp accelerates new bone formation of experimentally induced bone defects in rat skull and promotes the expression of osteopontin and sparc during bone repair of rat femora fractures . ann ny acad sci 1998 ; 857 : 232 - 6 ). also , collagen - pvp effect was evaluated in diaphisary fractures of tibia in a phase i clinical trial in 20 patients ( 10 experimental and 10 placebo ). the study included early closed fractures and all of them were stabilized in the first 7 days . collagen - pvp or placebo ( 0 . 2 ml ) were administered intralesionally during surgery at days 1 , 7 and 30 , through the surgical wound . at day 30 , 80 % of the patients treated with collagen - pvp reported pain absence and the other 20 % mild pain . in contrast , 50 % of the control group patients exhibited moderate pain and the other 50 % mild pain . also , collagen - pvp treated group did not show inflammatory signs in the damaged area , but 50 % of the control group showed it . besides , serum alkaline phosphatase was increased in the collagen - pvp treated group , when compared with controls . at day 30 , radiographic bone repair according to meller scale , was grade i and ii in the 100 % of collagen - pvp treated patients at days 30 and 90 , respectively ; different to controls where they were 50 % and 100 % grade i at days 30 and 90 , respectively . bone repair of the collagen - pvp treated group was appropriate , all patients tolerated bipedal displacement , and there were not knee or ankle movement limitation . all these patients exhibited progressive walk before week 12 , and none of them required specific rehabilitation . control group also exhibited bone repair , although they did not tolerate bipedal displacement without external support at the same 12 week . four of them required specific rehabilitation due to muscle atrophy . in summary , collagen - pvp accelerate bone repair process by up regulation of osteopontine , osteonectin and alkaline phosphatase , whom favors differentiation to the mesenchymal tissue towards cartilage , hypertrophic cartilage later and finally to bone tissue . perhaps that regulation was due to down modulation of pro - inflammatory cytokine expression ( mainly il - 1 y tnf - α ), adhesion molecules ( elam - 1 , vcam - 1 e icam - 1 ) and some proteinases and in consequence early pain control because prostaglandin synthesis regulation ( de la cruz garcia j c . efecto de la colágena tipo i polimerizada al 1 % inyectable en la consolidación ósea ( reporte preliminar ). tesis . hospital de traumatologia y ortopedia de “ lomas verdes ”. unam . 1997 ). patients with tibia pseudoarthrosis aged 6 to 72 years old received 1 ml of collagen - pvp or placebo during 6 weeks . after treatment , from the collagen - pvp treated group 16 patients ( 51 . 6 %) exhibited excellent bone repair ( grade iii , according to meller scale ), in 12 patients ( 38 . 7 %) was good ( grade 11 ) and only in 3 of them ( 9 . 68 %) was not appropriate ( grade 1 ). meanwhile in the placebo treated group no bone repair was observed in any of the treated patients . histological analysis showed appropriate osteoblastic activity in the collagen - pvp treated group . besides pain was diminished in patients treated with the copolymer , may be through inflammatory factor modulation , via cox ( prostaglandin production ), and in consequence patients showed strength and appropriate muscle tone in the affected limb ( bermúdez - hickey r , nésme - ávila w , ruiz - flores l , suárez e . tratamiento de la pseudoartrosis de tibia con colágeno - polivinilpirrolidona . rev mex ortop traum 1999 ; 13 : 148 - 51 ). clinical experience in dermal fibotic diseases associated to chronic inflammation : collagen - pvp treatment of hypertrophic scarring or morphea . intralesional injection of biodrug once per week during 1 to 3 months in human hypertrophic scars or scleroderma lesions diminishes pruritus , pain , erythema , volume , and inflammatory infiltrates . it makes that tissue architecture resembles normal skin . moreover , the biodrug modulates ecm turnover , mainly types i and iii collagen , and down - regulates the expression level of il - 1 □, tnf -□, pdgf and vcam - 1 ( krötzsch - gómez f e , furuzawa - carballeda j , reyes - márquez r , quiróz - hernández e and díaz de león l . cytokine expression is downregulated by collagen - polyvinylpyrrolidone in hypertrophic scars . j invest dermatol , 1998 ; 111 : 828 - 834 . furuzawa - carballeda j , krötzsch e , espinosa - morales r , alcalám , barile - fabris l . subcutaneous administration of collagen - polyvinylpyrrolidone down - regulates il - 1β , tnf - α , tgf - β1 , elam - 1 and vcam - 1 expression in scleroderma skin lesions . clinical and experimental dermatology . 2005 ; 30 : 83 - 86 ). collagen - pvp immunomodulating effect was also observed in scleroderma skin lesions , due to treated lesions at the same posology prescribed above during 3 months , improved texture and appearance skin . histologically , collagen - pvp - treatment recovered cutaneous appendages , type iii collagen in papillary dermis and type i / iii collagen proportion , whilst thick bundles of type i collagen decreased . it was also determined by immunohistochemistry that , collagen - pvp down - regulated il - 1β and elam - 1 expression ( barile l , furuzawa - carballeda j , krötzsch - gömez fe , espinosa - morales r , alcalá m , díaz de león l . comparative study of collagen - polyvinylpyrrolidone vs . triamcinolone acetate in systemic sclerosis . clin exp rheumatol 1998 ; 16 : 370 ). based on the results that collagen - pvp down - regulates some proinflammatory cytokines , adhesion molecules and collagen turnover in skin fibrotic disorders , associated with chronic inflammation , we suspected that the biodrug could have the same effect on inflamed synovial tissue cultures from ra patients . assays showed a marked proliferation of purified lymphocytes when cultured in plates with phytohaemaglutinin ( pha ) or with pha and collagen - pvp in serum - free culture system . moreover , no proliferation above baseline was observed when cells were cultures with collagen - pvp alone . these results suggest that the biodrug was not able to stimulate lymphocyte proliferation . the scge assay or “ comet assay ” was carried out with a cell suspension of lymphocytes embedded in an agar gel sandwich on a microscope slide , lysed and electrophoresed for a short time under alkaline conditions . lysis removes cell contents except for the nuclear material and dna remains highly supercoiled in the presence of a small amount of non - histone protein ; when placed in alkali , it starts to unwind from sites of strand breakage . cells with increased dna damage display increased migration of dna from the nucleus towards the anode under an electrical current , giving the appearance of a “ comet tail ”. in this work , the analysis of dna damage has demonstrated that cultures incubated with or without collagen - pvp did not induce any change in dna migration in lymphoid cell cultures . therefore , these data suggest that the exposure to collagen - pvp did not have a genotoxic effect . safety , follow - up , clinical evaluation and laboratory tests have been performed in healthy volunteers and patients with hypertrophic scars or scleroderma . hematological tests ( white blood cells index , blood chemistry , serum calcium levels ), urinalysis , liver function test did not show differences before and after collagen - pvp administration . these findings indicate that the treatment did not induce any adverse immediate clinical reaction . total serum samples were tested by means of elisa for reactivity against porcine type i collagen or collagen - pvp . serum samples from 110 healthy volunteers no treated with the biodrug were used as a negative control to establish baseline levels of reactivity . serum samples from 37 ssc patients were used as a positive control , because previous reports have identified circulating human anti - collagen antibodies in several patients . serum samples from 44 individuals treated with collagen - pvp , were used to examine serologic reactivity to collagen - pvp , these samples were plotted according to the number of collagen - pvp doses ( less than 5 , 6 to 10 , 11 to 20 , 21 to 100 and more than 100 administrations ). also , serum sample reactivity was compared using an average group analysis according to dunnett test in at least two different dilutions . a significant difference was observed by the presence of antibodies against porcine type i collagen between healthy donors and ssc patients ( p & lt ; 0 . 05 ); no positive correlation could be determined on antibodies against collagen - pvp ( even considering factors such as the dosage , number of doses or patient age ) ( furuzawa - carballeda j , castillo i , rojas e , valverde m , díaz de león e , krótzsch e . cellular and humoral responses to collagen - polyvinylpyrrolidone administered during short and long periods in humans . can j pharmacol physiol 2003 ; 81 . 1029 - 35 ). on the other hand , the safety of the polymer , pvp , is useful in many pharmaceutical formulations , foods , cosmetics and toiletries as well as industrial applications , due to its particular physical and chemical properties ( the homopolymer of n - vinyl - 2 - pyrrolidone ) is a biologically inert and safe polymer . many studies have been shown its innocuity . pvp used in collagen - pvp is low molecular weight ( robinson et al . 1990 ). pvp used to manufacture collagen - pvp is of low molecular weight material due to it is excreted by the kidney . there are no reported adverse effects following intravenously administration as a plasma expansor , or of high doses orally , subcutaneous or intramuscular post - administration ( robinson b v , sullivan f m , bazelleca j f , schwartz s l . pvp . a critical review of the kinetics and toxicology of polyvinylpyrrolidone ( povidone ). lewis publishers , inc . 1990 ). preclinical assays in synovial tissue cultures from rheumatoid arthritis ( ra ) patients : collagen - pvp effect in synovial tissue cultures from ra patients . to evaluate whether collagen - pvp produces an effect either on cell metabolism or on cell concentration , we measured the dna content . there were no statistically significant differences in dna content when treated and control cultures were compared ( table 1 ). it is important to mention that dna content in non - ra synovium was 8 to 10 - fold lower than that determined in ra synovial tissue . there were no differences between control and collagen - pvp - treated cultures . morphological evaluation of non - ra synovium cultured with 1 % collagen - pvp showed unaltered tissue architecture on the 3 rd and 7 th culture day ( fig1 a ). the addition of collagen - pvp to non - ra synovium cultures did not modify tissue architecture , fiber collagen thickness or type i / iii collagen proportion ( fig1 b ). however , histological evaluation of synovial tissue from ra control cultures showed a variable content of inflammatory cells and fibrosis with abundant type i collagen ( red fibers in fig1 c ) at 3 rd , and 7 th culture day . in contrast , paired 1 % collagen - pvp - treated cultures showed recovery of type iii collagen ( blue fibers in fig1 d , at 7 th culture day ), similar to normal synovial tissue . relative percentage of types i and iii collagen in synovial tissue cultures from non - ra and ra patients . in order to confirm the change in the relative proportions of types i and iii collagen , duplicates of synovium homogenates at each point of culture were evaluated by interrupted gel electrophoresis and densitometric analysis . under reducing conditions , the inter - chain disulfide bonds are cleaved , releasing □ 1 ( iii ) monomers of collagen , which migrate more slowly than □ 1 ( i ) chains of type i collagen . fig2 a shows the fine band of □ 1 ( iii ) in the synovial tissue control cultures . densitometric analysis showed that the addition of collagen - pvp to non - ra synovium cultures did not produce any modification in the relative percentage of type i or type iii collagen ( fig2 b ). however , ra synovium cultures treated at 7 th day displayed a 1 . 7 fold increase in the □ 1 ( iii ) band , in a time - dependent fashion ( p & lt ; 0 . 009 , treated vs . untreated cultures ; fig2 c ). in contrast a thin type i collagen band was observed . during the progression of ra the proteolytic activity at the site of inflammation is increased . thus , synovia from 10 patients with ra and 5 non - ra patients were examined immunohistochemically in detail using specific antisera to mmp - 1 . the ra synovia showed a considerable high range in mmp - 1 distribution compared with non - ra synovia . there was no difference between treated versus control group ( fig3 d , e ). on the other hand , in ra supernatants from collagen - pvp - treated cultures , levels of total collagenolytic activity were 1 . 6 - fold lower than those in control cultures ( p & lt ; 0 . 05 ; fig3 a ). calcium - dependent collagenases ( mmps ) in supernatants from synovial tissue treated cultures were measured by the difference between the degradation of 3 h - collagen in a cacl 2 buffer and in an edta buffer ( total collagenolytic activity — calcium - independent collagenases ). this proteolytic activity exhibited slightly lower levels in supernatants from biocompound - treated cultures than untreated - ones ( fig3 b ). collagenase activity of proteinases that did not require calcium for their stability ( putatively elastase and / or g cathepsin ) was 2 . 2 - fold lower compared to untreated tissue cultures ( p & lt ; 0 . 008 ; fig3 c ). it is important to highlight that calcium - dependent as well as calcium - independent collagenolytic proteases have similar activity levels . this suggests that in ra pathogenesis , calcium - independent enzymes participate with the same magnitude to that observed for calcium - dependent enzymes . sections of ra synovium stained with anti - timp - 1 showed strong immunoreactivity in blood vessel and stromal cells in collagen - pvp - treated synovial tissue from ra patients ( fig3 g ). collagen - pvp has not any effect on synovium from non - ra patients ( fig3 f ). however , timp - 1 levels in supernatants from control cultures contained 1 . 7 - fold higher levels of the glycoprotein than treated cultures at the 7 th day ( p = 0 . 04 ; fig3 h ). adhesion molecule expression in synovial tissue cultures from non - ra and ra patients . in order to establish whether icam - 1 and vcam - 1 molecules , inflammatory markers , were modified by collagen - pvp treatment , they were detected in synovium . the icam - 1 expression in cultures from non - ra patients was similar between control and collagen - pvp - treated group ( 11 - 17 %; table 2 ). however , in treated cultures from ra patients , both icam - 1 and vcam - 1 molecules showed lower levels of intensity and immunoreactivity than control cultures ( table 2 ). the levels were statistically significant for icam - 1 at the 7 th culture day in blood vessels ( p = 0 . 03 ) and stromal cells ( p = 0 . 04 ) and the percentage of positive icam - 1 cells from treated cultures was similar to that determined for normal synovial tissue cultures ( table 2 ) [ 30 ]. in addition , vcam - 1 expression in blood vessels and stromal cells from treated cultures also showed a substantial down - regulation ( p & lt ; 0 . 05 ; table 2 ). in ra many factors are involved in synovial inflammation , where the cytokines such as il - 1 , tnf - α , il - 6 and il - 8 , have emerged as regulatory factors of particular importance . in order to establish the effect of collagen - pvp on the expression of these cytokines , we determined these proteins in the synovium by immunohistochemistry . results showed that il - 8 was expressed at significantly higher levels in non - treated synovial tissue cultures from ra patients than in non - ra and ra treated cultures ( fig4 a , b ). meanwhile il - 6 did not show any difference between ra treated cultures and control cultures ( table 2 ). since collagenolytic activity , cams and timp - 1 expression levels were down - modulated with collagen - pvp treatment , we suspected that the production of il - 1 □ and tnf - α was modified . the exogenous addition of the biodrug to non - ra tissue cultures did not produce any effect on tnf - α expression in blood vessels nor stromal cells ( fig4 c ). tnf - α expression was down - modulated by collagen - pvp in tissue from ra patients at statistical significant levels compared with non - treated cultures ( p & lt ; 0 . 05 ; fig4 d ). moreover , collagen - pvp down - regulated tnf - α protein concentration ( 4 - fold ) in supernatants ( p & lt ; 0 . 02 ; fig4 e ). the same down - regulated pattern of il - 1β expression was observed in ra tissue treated with collagen - pvp ( p & lt ; 0 . 05 ; fig4 f ) and in supernatants ( 3 - fold ; p & lt ; 0 . 03 ; fig4 g ). cox - 1 is a constitutively enzyme that synthesized prostaglandins pathway arachidonic acid metabolism . prostaglandins likely contribute to synovial inflammation by increasing local blood flow and potentiating the effects of mediators such as bradykinin and il - 1 that induce vasopermeability . in this vein , the immunohistochemistry showed that collagen - pvp induced a negative modulation on the expression of cox - 1 in ra tissue compared with untreated cultures ( table 2 ). however , biodrug did not show effect on non - ra tissue ( table 2 ). expression of fas / apo95 and detection of dna strand breaks in apoptotic synovial cells by in situ nick translation . it has been shown that fas antigen is expressed on the surface of synovial cells and mediates cell death of the fas expressing synovial cells when stimulated with agonistic anti - fas . however , defective apoptosis is intimately associated with ra thus , the function of the fas / fasl system seems to be incapable of eliminating cells in the proliferative ra synovium . due to , we examined whether fas antigen was expressed on synovium as well as the presence of apoptotic cells . we found that fas / apo95 was predominantly up - regulated on blood vessel cells from ra synovium collagen - pvp - treated ( table 2 ). when we applied the in situ cell death detection assay for ra synovial tissues to detect apoptotic cells , tunel technique showed an up - regulation mostly in blood vessel and stromal cells ( 50 %) ( table 2 ) treated with collagen - pvp ( furuzawa - carballeda j , rodriguez - calderón r , díaz de león l , alcocer - varela j . mediators of inflammation are down - regulated while apoptosis is up - regulated in rheumatoid arthritis synovial tissue by polymerized collagen . clin exp immunol 2002 ; 130 : 140 - 9 ). demographic and clinical characteristics of patients at the time on their basal visit and last dose of collagen - pvp are summarized in table 3 . subcutaneous administration of collagen - pvp during 3 months in the 8 painful joints showed that swollen and tender joint ( ritchie index or ri ) counts ( fig5 ) have improved rapidly ( ri : δ − 10 . 2 ≅− 46 . 4 %; swollen joint count : δ − 10 . 7 ≅− 71 . 8 %). this improved was sustained during long - term therapy . besides , very similar and highly significant differences in changes in other variables of disease activity such as morning stiffness and visual analogue scale pain ( morning stiffness : δ − 32 . 3 ≅− 68 . 6 %; vas : δ − 39 . 9 ≅− 63 . 8 %; fig5 ). patients also had a statistically significant improvement in disease activity score ( das ) ( das : δ − 1 . 35 ≅− 70 . 5 %, p & lt ; 0 . 02 ). the improvement was also determined using twenty , fifty and seventy percent american college of rheumatology response criteria ( acr20 , acr50 and acr70 ). the acr20 was achieved by 80 . 0 % of patients at 3 months ( 8 from 10 patients ). similarly , 60 . 0 % of patients achieved the acr50 ( 6 from 10 patients ) and 20 . 0 %, the acr 70 ( 2 from 10 patients ) at this time ( fig6 ). the physical functional status ( spanish - had - di ), also showed a significant difference in change from their baseline values and 3 months of collagen - pvp treatment ( haq - di : δ − 0 . 5 ≅− 48 . 5 %; p & lt ; 0 . 05 , 1 vs . 13 weeks ; fig6 ). all patients have not modified their oral methotrexate and dosage of concomitant nsaids during 3 months of the study ( table 3 ). there was no change in erythrocyte sedimentation rate , hematological constants ( hemoglobin , hematocrit , blood chemistry , red blood cells count , leukocytes and platelets ), neither c reactive protein nor rheumatoid factor . none of the patients were positive for antibodies to double chain of dna and ribonucleoprotein at baseline and after treatment . radiological analysis was no different at baseline and after treatment . however , is important to mention that there was no narrowing joint space , bone erosion nor cartilage degradation ( furuzawa - carballeda j , cabral a r , zapata - zúñiga m , alcocer - varela j . subcutaneous administration of polymerized - type i collagen for the treatment of patients with rheumatoid arthritis . j rheumatol 2003 ; 30 : 256 - 9 ). in vitro study evaluated the anti - inflammatory and apoptotic effect of polymerized type i collagen ( collagen - pvp ), as well as collagen turnover in synovial tissue from ra patients . based on these results , we suggest that collagen - pvp added to ra synovium cultures , modulates collagen turnover , since the biodrug decreases collagenolytic activity , as well as timp - 1 production , and increases the amount of type iii collagen and timp - 1 to similar levels observed in normal synovium . the chronic inflammatory process is altered by collagen - pvp action , as described previously by krötzsch - gómez et al ., and barile et al ., ( krötzsch - gómez f e , furuzawa - carballeda j , reyes - márquez r , quiróz - hernández e , díaz de león l . cytokine expression is downregulated by collagen - polyvinylpyrrolidone in hypertrophic scars . j invest dermatol 1998 ; 111 : 828 - 34 ; barile l , furuzawa - carballeda j , krótzsch - gómez f e , espinosa - morales r , alcalám , díaz de león l . comparative study of collagen - polyvinylpyrrolidone vs . triamcinolone acetate in systemic sclerosis . clin exp rheumatol 1998 ; 16 : 370 ), presumably due to the down - regulation of il - 1β , tnf - α , il - 8 as well as cell adhesion molecules and inducing cox - 1 activation . besides cell binding through integrin - extracellular matrix interaction generates signals that regulate mmp expression ( larjava h , lyons j , salo r , makela m , koivisto l , birkedal - hansen h , akiyama s k , yamada k m , heino j . anti - integrin antibodies induce type iv collagenase gene expression in keratinocytes . j cell physiol 1993 ; 157 : 190 - 200 ; romanic a m , madri j a . the induction of 72 kd gelatinase in t cells upon adhesion to endothelial cells is vcam - 1 dependent . j cell biol 1994 ; 125 : 1165 - 78 ; tremble p , chiquet - ehrismann r , werb z . the extracellular matrix ligands fibronectin and tenascin collaborate in regulating collagenase gene expression in fibroblasts . mol biol cell 1994 ; 5 : 4390 - 3 ; rükonen t , westermarck j , koivisto l , broberg a , kähäri v m , heino . integrin □ 2 □ 1 is a positive regulator of collagenase ( mmp - 1 ) and collagen □ 1 ( i ) gene expression . j biol chem 1995 ; 270 : 13548 - 52 ) suggesting that cell adhesion molecules can also participate in ra tissue destruction . also , down production of il - 1 □ and tnf -□ seems to stimulate synovial cell death via apoptosis in synovium cultures , the last may contributed to inhibit the outgrowth of synovial cells that eventually leads to hyperplasia or pannus formation and the destruction of ra joints ( furuzawa - carballeda j , rodriguez - calderón r , díaz de león l , alcocer - varela j . mediators of inflammation are down - regulated while apoptosis is up - regulated in rheumatoid arthritis synovial tissue by polymerized collagen . clin exp immunol 2002 ; 130 : 140 - 9 ). in conclusion , we showed that the addition of collagen - pvp to synovial tissue cultures induced a down - modulation but not an inhibition of inflammatory parameters in rheumatoid synovium . this study was seminal to consider the collagen - pvp as a coadjuvant for the ra treatment . the last affirmation was based on the knowledge that type i collagen is phylogenetically , one of the oldest extracellular matrix proteins . it possesses a very low antigenicity and it is relatively easy to metabolize . furthermore , it is able to stimulate cells to form new tissues , it means , collagen has informational character ( pohunlová h , adam m . reactivity and the fate of some composite bioimplants based on collagen in connective tissue . biomaterials 1995 ; 16 : 67 - 71 ). in 1981 , the food and drug administration ( fda ) approved the use of an injectable form of reconstituted purified bovine collagen ( zyderm ; collagen corp ., palo alto , calif .) as a medical device for augmenting the volume of soft tissues ( clark d p , hanke c w , swanson n a . dermal implants : safety of products injected for soft tissue agumentation . j am acad dermatol 1989 ; 21 : 992 - 8 ). current interest in this injectable form of collagen is focused on defining broader clinical applications and the development of new products . until now , most of the injectable collagen or collagen implants were derived from bovine dermal or tendinal atelopeptide collagen ( zyderm , zyplast and atelocollagen ) ( soo ch , rahbar g . moy r l . the immunogenicity of bovine collagen implants . j dermatol surg oncol 1993 ; 19 : 431 - 434 ; charriere g , bejot m , schnitzler l , ville g , hartmann d j . reactions to a bovine collagen implant . j am acad dermatol 1989 ; 21 : 1203 - 1208 ). however , the present study used polymerized - porcine type i collagen . it has anti - inflammatory properties ( krötzsch - gómez f e , furuzawa - carballeda j . reyes - márquez r , quiróz - hernández e , díaz de león l . cytokine expression is downregulated by collagen - polyvinylpyrrolidone in hypertrophic scars . j invest dermatol 1998 ; 111 : 828 - 34 ; barile l , furuzawa - carballeda j , krötzsch - gómez f e , espinosa - morales r . alcalá m , díaz de león l . comparative study of collagen - polyvinylpyrrolidone vs . triamcinolone acetate in systemic sclerosis . clin exp rheumatol 1998 ; 16 : 370 ). collagen - pvp which is made pepsinized porcine type i dermal collagen ( atelopeptidic ) due to it is a week immunogen . we preferred , porcine type i collagen due to pigs are among the primary animal species proposed as sources for xenografts in a variety of practical , ethical , and safety reasons including the high homology with human collagen ( weiss r a . xenografts and retroviruses . science 1999 ; 285 : 1221 - 1222 ; paradis k , langford g , long z , heneine w , sandstrom p , switzer w m , chapman l e , lockey ch , onions d , otto e . search for cross - species transmission of porcine endogenous retrovirus in patients treated with living pig tissue . science 1999 ; 1236 - 1241 ; beard h k , faulk w p , conochie l b , glynn l e . some immunological aspects of collagen . progr allergy 1977 ; 22 : 45 - 106 ). on the other hand , electrophoretic data suggest that collagen - pvp binds covalently to pvp . the covalent binding with pvp conveys both increased collagen stability and reduced collagen antigenicity . because of its unique chemical nature , low molecular weight makes pvp biologically inert and safe ( clark d p , hanke c w , swanson n a . dermal implants : safety of products injected for soft tissue agumentation . j am acad dermatol 1989 ; 21 : 992 - 8 ; soo ch , rahbar g , moy r l . the immunogenicity of bovine collagen implants . j dermatol surg oncol 1993 ; 19 : 431 - 434 ). besides , the homopolymer of n - vinyl - 2 - pyrrolidone or pvp confers on the biodrug pharmaceutical properties different than those observed in collagen or pvp alone . in contrast to bovine collagen implants , we did not find any adverse side effect with collagen - pvp , such as those previously described ( hypersensitivity reactions , mild erythema , urticaria , localized swelling , and specific anti - type i collagen antibody production ) ( mcclelland m , delustro f . evaluation of antibody class in response to bovine collagen treatment in patients with urinary incontinence . j urol 1996 ; 155 : 2068 - 73 ; delustro f , fries j , kang a . immunity to injectable collagen and autoimmune disease : a summary of current understanding . j dermatol surg oncol 1988 ; 14 ( suppl i ): 57 - 65 ; singh g , fries j f . autoimmune disease and collagen dermal implants . ann int med 1994 ; 120 : 524 ; lewy r i . autoimmune disease and collagen dermal implants . ann int med 1994 ; 120 : 525 ). at difference of the study of sieper , et al ., ( 1996 ) with collagen administration we did not find any adverse effect after administration of collagen - pvp nor elevation in laboratory test ( c reactive protein , erythrocyte sedimentation rate nor rheumatoid factor ) ( sieper j , kary s , sorensen h , alten r , eggens u , hüge w , hiepe f , kühne a , listing j , ulbrich n , braun j , zink a , mitchison n a . oral type ii collagen treatment in early rheumatoid arthritis . a double - blind , placebo - controlled , randomized trial . arthritis rheum 1996 ; 39 : 41 - 9 ). the collagen - pvp administration scheme was consistent with tarkowski &# 39 ; s scheme ( 1999 ) who demonstrated that the effect of 3 daily vs . 3 weekly treatments with equivalent doses of cholera - toxin b subunit - type ii collagen conjugate on days 7 , 14 , 21 after disease induction in mice diminished significantly then incidence of arthritis compared with mice treated daily with unconjugated type ii collagen or a control cholera toxin b ( tarkowski a , sun j - b , holmdahl r , holmgren j , czerkinsky c . treatment of experimental autoimmune arthritis by nasal administration of a type ii collagen - cholera toxoid conjugate vaccine . arthritis rheum 1999 ; 42 : 1628 - 34 ). in accordance with doses ( 1 . 7 mg of collagen ), administration pathway ( subcutaneous ), and the frequency of administration , we suggest that collagen - pvp could act also , like a tolerance - inducing - molecule more effective than the other ways of administration and with less toxic effects . based on the background of collagen - pvp , we think that it generates cytokine - secreting regulatory cells more than anergy ( furuzawa - carballeda j , cabral a r , zapata - zúñiga m , alcocer - varela j . subcutaneous administration of polymerized - type i collagen for the treatment of patients with rheumatoid arthritis . j rheumatol 2003 ; 30 : 256 - 9 ). using acr criteria , the 20 % response rate with 1 . 6 ml of collagen - pvp was 80 . 0 % at month 3 . good results were seen with more demanding criteria ( 60 . 0 % response at acr50 and a 20 . 0 % response at acr70 ). these values were similar to that obtained by etanercept in a phase ii trial ( moreland l w , baumgartner s , schiff m h , et al . treatment of rheumatoid arthritis with a recombinant human tumor necrosis factor receptor ( p75 )- fc fusion protein . n engl j med 1997 ; 337 : 141 - 7 ). in most cases , there was a continuous improvement over the 12 th week , this could be taken as evidence that a longer treatment period might be more favorable . given these encouraging results and the fact that this therapy has no known side effects further studies evaluating its effectiveness , optimal doses , mechanism of action , a placebo controlled study and other pathways of administration are warranted . collagen - pvp for the treatment of patients with rheumatoid arthritis . effect of intramuscular administration in a double blind placebo - controlled study . the study was a prospective , longitudinal , double blind placebo - controlled and included 30 patients with active ra ( acr ). patients on stable doses of methotrexate were treated in a freyberg scheme with intramuscular injections of 0 . 4 ml of collagen - pvp ( 3 . 33 mg of collagen ) or 0 . 4 ml of placebo during 6 months . the primary endpoints included disease activity score ( das ) and improvement was determined using american college of rheumatology response criteria ( acr20 , 50 and 70 ) that refers a mean change in 3 from 5 evaluations including the ritchie index ( ri ), swollen joint count , spanish - health assessment questionnaire ( haq - di ), pain intensity on a visual analogue scale ( vas ) and erythrocyte sedimentation rate ( esr ) or c - reactive protein ( crp ). statistical analysis was performed using double tail mann whitney u - test . collagen - pvp was safe and well tolerated . patients had a statistically significant improvement ( p & lt ; 0 . 05 ) in collagen - pvp - treated vs . placebo at 6 months of treatment in : swollen joint count ( 8 . 1 ± 3 . 7 vs . 17 . 9 ± 4 . 8 ), ri ( 10 . 7 ± 3 . 3 vs . 17 . 8 ± 5 . 4 ), morning stiffness ( 9 . 4 ± 4 . 6 vs . 37 . 8 ± 6 . 7 ), rheumatoid factor ( 207 . 7 ± 179 . 1 vs . 518 . 8 ± 293 . 2 ), c reactive protein ( 2 . 7 ± 3 . 9 vs . 28 . 1 ± 24 . 5 ), haq ( 46 . 7 ± 15 . 6 vs . 18 . 8 ± 13 . 7 ), das ( 3 . 5 ± 0 . 7 vs . 4 . 8 ± 0 . 9 ), acr20 ( 100 vs . 77 . 8 %), acr50 ( 67 . 6 vs . 11 . 1 %) y acr70 ( 33 . 3 vs . 0 %). serological or hematological parameters remained unchanged . there were no adverse events . collagen - polyvinylpyrrolidone exhibits an important downmodulatory effect on inflammation , on apoptosis induction , as well as collagen turnover in the synovial tissue of the patients suffering ar , perhaps through peripheral immune tolerance . this copolymer modifies , more cellular metabolism than proliferation . this is suggested since type iii collagen relative rate is increased , meanwhile type i collagen diminishes in the synovia treated with the drug , although total content of collagen is not modified . also , collagen - polyvinylpyrrolidone reduces proteolityc activity , due to calcium independent collagenases , modifying ecm protein turnover , mainly collagen and reestablishing the content of type iii collagen . the information expressed above suggests that collagen - polyvinylpyrrolidone induction of the reduction of collagenolityc activity could contribute to diminish rheumatoid synovitis secuelae , cartilage and bone invasion by inflammatory cells and their erosion and degradation . even more , collagen - polyvinylpyrrolidone induces the increase of timp - 1 in ar tissues , suggesting that ecm turnover could be diminished by a mechanism that involves mmps blockade by timp - 1 . in consequence , collagen - polyvinylpyrrolidone avoids inflammatory cell invasion and fibrosis , due to the drug downmodulates cell adhesion molecules and this effect prevents cell - cell attachment . according to this information , we suggest that collagen - polyvinylpyrrolidone immunomodulatory effects are focused to modulate adhesion molecule expression in stromal and endothelial cells through the leukocyte traffic reduction to the synovial joint . finally , in ar the copolymer downmodulates three pro - inflammatory cytokines : il - 8 , tnf - α and il - β . physiologically they can induce cox - 1 activation , an in consequence they can increase pge 2 synthesis , as well as joint cartilage and bone resorption . also , the previously mentioned cytokines , have been related to the beginning and ar sickness burst , in vitro and in vivo in a murine model . it is well known , that tnf - α and il - 1β are capable to induce synthesis and release of several other cytokines , such as gm - csf , il - 6 and il - 8 , and all of them increase mmp production and activity , diminution in elam - 1 , vcam - 1 and icam - 1 capillary expression in synovia from ar patients . in conclusion , the subcutaneous treatment of the eight more painful joints with collagen - polyvinylpyrrolidone to patients suffering ar , when they are receiving low doses of metotrexate and / or nsaids , improves sickness index ( das ) and an important change in at least 3 of the 5 following measures ( acr20 ), ritchie index ( painful joints ), inflamed joint evaluation , general assessment of the patient about the sickness activity ( haq ), the relative pain scale ( eva ), as well as acute phase proteins . collagen - polyvinylpyrrolidone treatment does not stimulate changes in blood or serum and the copolymer exhibits the advantage that is a biological copolymer that , until now , does not produce any risk for the patient , nor stimulate anti - type i collagen or anti - collagen - polyvinylpyrrolidone antibodies or anti ssa / ssb or anti - dna antibodies , even when patients have been treated during long periods ( more than 12 months ). collagen - polyvinylpyrrolidone is a safe and an efficient biomolecule for the short term ar treatment .
the invention relates to a chronic articular inflammation - modulating composition which uses collagen - polyvinylpyrrolidone . collagen turnover is modulated using collagen - pvp in patients with rheumatoid arthritis and osteoarthritis , since the biocomplex negatively regulates collagenolytic activity and increases the content of type iii collagen and timp - 1 to levels similar to those observed in normal synovia . in this way , the chronic inflammatory process is altered by the collagen - pvp , as described above , owing to the negative regulation of il - 1β , the tnf - α of il - 8 and the adhesion molecules , since said molecules can induce the expression and activation of collagenolytic enzymes , as well as the proliferation and migration of synovial cells by means of the adhesive mechanisms including the adhesion molecules , and the induction and activation of cox - 1 . in addition to cellular anchoring , the interaction of the extracellular matrix integrins generates signals which regulate the expression of m mps , suggesting that the adhesion molecules can also play a part in tissue destruction associated with rheumatoid arthritis . moreover , the decrease in the synthesis of tnf - α and il - 1β appears to stimulate the cell death of synoviocytes by means of apoptosis , which , in turn , seems to contribute to the inhibition of the proliferation of synovial cells , the formation of pannus and the destruction of the articular tissue .