Original Article

Hematological Improvement of Patients with Active Rheumatoid Arthritis by β-D-Mannuronic Acid (M2000) as a Novel NSAID with Immunosuppressive Property


The aim of this study was to investigate the effect of β-D-mannuronic acid (M2000) on hematological parameters in patients with active rheumatoid arthritis. This study was conducted on 25 patients with active rheumatoid arthritis (RA) (identifier: IRCT2014011213739N2). M2000 was administered orally for anemic and non-anemic RA patients at a dose of 500 mg twice daily for 12 weeks. The patients were permitted to continue the conventional treatments excluding NSAIDs. Blood samples were collected at baseline, 4 and 12 weeks after drug administration and were tested for hematological parameters. Moreover, serum levels of TNF-α and IL-6 were analysed before and after M2000 therapy compared to healthy controls using enzyme linked immunosorbent assay method. We found a significant increase in the count of red blood cells and also hemoglobin (Hb) concentration (0.9 g/dL) in anemic patients after 12 weeks of M2000 therapy (p<0.02 and p<0.01, respectively). Furthermore, our results showed an improvement in Hb level (0.45 g/dL) even in non-anemic patients who were treated by M2000 (p<0.04). The leukocytosis in RA patients, significantly decreased in both anemic and non-anemic patients after 12 weeks of M2000 therapy (p<0.02 and p<0.03, respectively). The percent of neutrophils significantly increased in anemic patients (p<0.01) while in non-anemic patients it significantly decreased after 12 weeks of M2000 therapy (p<0.01). The serum levels of IL-6 and TNF-α significantly decreased after 12 weeks of M2000 therapy (p<0.01 and p<0.04, respectively). M2000 improves hematological parameters in RA patients by its potent inhibitory effect on serum levels of TNF-α and IL-6.

Weiss G, Goodnough LT. Anemia of chronic disease. N Engl J Med 2005; 352(10):1011-23.

2. Han C, Rahman MU, Doyle MK, Bathon JM, Smolen J, Kavanaugh A, et al. Association of anemia and physical disability among patients with rheumatoid arthritis. J Rheumatol 2007; 34(11):2177-82.

3. Wilson A, Yu HT, Goodnough LT, Nissenson AR. Prevalence and outcomes of anemia in rheumatoid arthritis: a systematic review of the literature. Am J Med 2004; 116(7): 50-7.

4. Bowman, S. Hematological manifestations of rheumatoid arthritis. Scand J Rheumatol 2002; 31(5): 251-9.

5. Agrawal S, Misra R, Aggarwal A. Anemia in rheumatoid arthritis: high prevalence of iron-deficiency anemia in Indian patients. Rheumatol Int 2006; 26(12):1091-5.

6. Means RT Jr, Krantz SB. Progress in understanding the pathogenesis of the anemia of chronic disease. Blood 1992; 80(7): 1639-47.

7. Raj DS. Role of interleukin-6 in the anemia of
chronic disease. Semin Arthritis Rheum 2009; 38(5):382–8.

8. Papadaki HA, Kritikos HD, Valatas V, Boumpas DT, Eliopoulos GD. Anemia of chronic disease in rheumatoid arthritis is associated with increased apoptosis of bone marrow erythroid cells: improvement following anti–tumor necrosis factor-α antibody therapy. Blood 2002; 100(2):474-82.

9. Nemeth E, Rivera S, Gabayan V, Keller C Taudorf S, Pedersen BK, et al. IL-6 mediates hypoferremia of inflammation by inducing the synthesis of the iron regulatory hormone hepcidin. J Clin Invest 2004; 113(9):1271-6.

10. Laftah AH, Ramesh B, Simpson RJ, Solanky N, Bahram S, Schümann K, et al. Effect of hepcidin on intestinal iron absorption in mice. Blood 2004; 103(10):3940-4.

11. Andrews NC Anemia of inflammation: the cytokine-hepcidin link. J Clin Invest 2004; 113(9):1251-3.

12. Smolen JS, Landewe´ R, Breedveld FC, Dougados M, Emery P, Gaujoux-Viala C, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs. Ann Rheum Dis 2010; 69(6):964-75.

13. Song S-NJ, Tomosugi N, Kawabata H, Ishikawa T, Nishikawa T, Yoshizaki K. Down-regulation of hepcidin resulting from long-term treatment with an anti–IL-6 receptor antibody (tocilizumab) improves anemia of inflammation in multicentric Castleman disease. Blood 2010; 116(18):3627-34.

14. Doyle MK, Rahman MU, Han C, Han J, Giles J, Bingham CO 3rd, et al. Treatment with infliximab plus methotrexate improves anemia in patients with rheumatoid arthritis independent of improvement in other clinical outcome measures—a pooled analysis from three large, multicenter, double-blind, randomized clinical trials. Semin Arthritis Rheum 2009; 39(2):123–31.

15. Atzeni F, Gianturco L, Talotta R, Varisco V, Ditto MC, Turiel M, et al. Investigating the potential side effects of anti-TNF therapy for rheumatoid arthritis: cause for concern? Immunotherapy 2015; 7(4):353-61.

16. Emna Gaies, Nadia Jebabli, Sameh Trabelsi, Issam Salouage, Rim Charfi, Mohamed Lakhal and Anis Klouz. Methotrexate side effects: review article. J Drug Metab Toxicol 2012; 3(125):2.

17. Prey S, Paul C. Effect of folic or folinic acid supplementation on methotrexate‐associated safety and efficacy in inflammatory disease: a systematic review. Br J Dermatol 2009; 160(3):622-8.

18. Peeters HR, Jongen-Lavrencic M, Vreugdenhil G, Swaak AJ. Effect of recombinant human erythropoietin on anaemia and disease activity in patients with rheumatoid arthritis and anaemia of chronic disease: a randomised placebo controlled double blind 52 weeks clinical trial. Ann Rheum Dis 1996; 55(10):739-44.

19. Macdougall IC, Cooper AC. Hyporesponsiveness to erythropoietic therapy due to chronic inflammation. Eur J Clin Invest 2005; 35(Suppl3):32-5.

20. Mirshafiey A, Rehm B, Abhari RS, Borzooy Z, Sotoude M, Razavi A. Production of M2000 (β-d-mannuronic acid) and its therapeutic effect on experimental nephritis. Environ Toxicol Pharmacol 2007; 24(1):60-6.

21. Mirshafiey A, Cuzzocrea S, Rehm B, Mazzon E, Saadat F, Sotoude M. Treatment of experimental arthritis with M2000, a novel designed non‐steroidal anti‐inflammatory drug. Scand J Immunol 2005; 61(5):435-41.

22. Mirshafiey A, Cuzzocrea S, Rehm BH, Matsuo H. M2000: a revolution in pharmacology. Med Sci Monit 2005; 11(8):PI53-PI63.

23. Mirshafiey A, Matsuo H, Nakane S, Rehm BH,
Koh CS, Miyoshi S. Novel immunosuppressive
therapy by M2000 in experimental multiple
sclerosis. Immunopharmacol Immunotoxicol 2005; 27(2):255-65.

24. Mirshafiey A, Rehm B, Sotoude M, Razavi A, Abhari RS, Borzooy Z. Therapeutic approach by a novel designed anti-inflammatory drug, M2000, in experimental immune complex glomerulonephritis. Immunopharmacol Immunotoxicol 2007; 29(1):49-61.

25. Fattahi MJ, Abdollahi M, Agha Mohammadi A, Rastkari N, Khorasani R, Ahmadi A, et al. Preclinical assessment of β-d-mannuronic acid (M2000) as a non-steroidal anti-inflammatory drug. Immunopharmacol Immunotoxicol 2015; 37(6):535-40.

26. Arnett FC, Edworthy SM, Bloch DA, McShane DJ,
Fries JF, Cooper NS, et al. The American Rheumatism Association 1987 revised criteria for the classification
of rheumatoid arthritis. Arthritis Rheum 1988; 31(3):315-24.

27. Prevoo ML, van’t Hof MA, Kuper HH, van Leeuwen MA, van de Putte LB, van Riel PL. Modified disease activity scores that include twenty-eight-joint counts. Development and validation in a prospective longitudinal study of patients with rheumatoid arthritis. Arthritis Rheum 1995; 38(1):44–8.

28. Nkrumah B, Nguah SB, Sarpong N, Dekker D, Idriss A, May J, et al. Hemoglobin estimation by the HemoCue® portable hemoglobin photometer in a resource poor setting. BMC Clin Path 2011; 11:5.

29. Zhu A, Kaneshiro M, Kaunitz JD. Evaluation and treatment of iron deficiency anemia: a gastroenterological perspective. Dig Dis Sci 2010; 55(3):548-59.

30. Fosslien E. Adverse effects of nonsteroidal anti-inflammatory drugs on the gastrointestinal system. Ann Clin Lab Sci. 1998; 28(2):67-81.

31. Maury CP, Andersson LC, Teppo AM, Partanen S, Juvonen E. Mechanism of anaemia in rheumatoid arthritis: demonstration of raised interleukin 1 beta concentrations in anaemic patients and of interleukin 1
mediated suppression of normal erythropoiesis and proliferation of human erythroleukaemia (HEL) cells in vitro. Ann Rheum Dis 1988; 47(12):972-8.

32. Takashina N, Kondo H, Kashiwazaki S. Suppressed serum erythropoietin response to anemia and the efficacy of recombinant erythropoietin in the anemia of rheumatoid arthritis. J Rheumatol 1990; 17(7):885-7.

33. Dainiak N, Hardin J, Floyd V, Callahan M, Hoffman R. Humoral suppression of erythropoiesis in systemic lupus erythematosus (SLE) and rheumatoid arthritis. Am J Med 1980; 69(4):537-44.

34. Hashimoto M, Fujii T, Hamaguchi M, Furu M, Ito H, Terao C, et al. Increase of hemoglobin levels by anti-IL-6 receptor antibody (tocilizumab) in rheumatoid arthritis. PloS one 2014; 9(5):e98202.

35. Farr M, Scott DL, Constable TJ, Hawker RJ, Hawkins CF, Stuart J. Thrombocytosis of active rheumatoid disease. Ann Rheum Dis 1983; 42(5):545-9.

36. Dayer JM, Choy E. Therapeutic targets in rheumatoid arthritis: the interleukin-6 receptor. Rheumatology 2010; 49(1):15-24.

IssueVol 16, No 5 (2017) QRcode
SectionOriginal Article(s)
Anemia Inflammation Interleukin Mannuronic acid M2000 Rheumatoid arthritis Therapy

Rights and permissions
Creative Commons License This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
How to Cite
Ahmadi H, Jamshidi AR, Mahmoudi M, Gharibdoost F, Vojdanian M, Fattahi MJ, Rastkari N, Aghazadeh Z, Mirshafiey A. Hematological Improvement of Patients with Active Rheumatoid Arthritis by β-D-Mannuronic Acid (M2000) as a Novel NSAID with Immunosuppressive Property. Iran J Allergy Asthma Immunol. 2017;16(5):433-442.