{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,5,8]],"date-time":"2026-05-08T17:06:20Z","timestamp":1778259980456,"version":"3.51.4"},"reference-count":55,"publisher":"MDPI AG","issue":"11","license":[{"start":{"date-parts":[[2025,5,29]],"date-time":"2025-05-29T00:00:00Z","timestamp":1748476800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["IJMS"],"abstract":"<jats:p>Medical ozone is a redox regulator with beneficial effects in oxidative etiology diseases such as rheumatoid arthritis (RA). The aim of this study is to conduct a holistic review of different pharmacological trials involving ozone in model diseases, as well as the clinical responses of RA patients. The ROS (reactive oxygen species) involved in RA and their relationship with the main pathological pathways of this autoimmune disease are considered here. The integrative analysis of experimental results from animals with clinical findings reveals that both methotrexate (MTX) and medical ozone share common mechanisms via adenosinergic regulation. This finding enables us to propose a new pharmacological mechanism in the treatment of RA. We conclude that MTX + medical ozone combined therapy reduces ROS overproduction and the generation of proinflammatory cytokines and decreases anti-cyclic citrullinate peptide levels by a mutual mechanism involving adenosine A1 receptors.<\/jats:p>","DOI":"10.3390\/ijms26115256","type":"journal-article","created":{"date-parts":[[2025,5,30]],"date-time":"2025-05-30T06:14:27Z","timestamp":1748585667000},"page":"5256","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":1,"title":["Medical Ozone Increases Methotrexate Effects in Rheumatoid Arthritis Through a Shared New Mechanism Which Involves Adenosine"],"prefix":"10.3390","volume":"26","author":[{"given":"Olga Sonia","family":"Le\u00f3n Fern\u00e1ndez","sequence":"first","affiliation":[{"name":"Pharmacy and Food Institute, University of Havana, Havana 13603, Cuba"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0605-4838","authenticated-orcid":false,"given":"Gabriel Takon","family":"Oru","sequence":"additional","affiliation":[{"name":"Pharmacy and Food Institute, University of Havana, Havana 13603, Cuba"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0328-016X","authenticated-orcid":false,"given":"Renate","family":"Viebahn-Haensler","sequence":"additional","affiliation":[{"name":"Medical Society for the Use of Ozone in Prevention and Therapy, D-76473 Iffezheim, Germany"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Gilberto","family":"L\u00f3pez Cabreja","sequence":"additional","affiliation":[{"name":"National Institute of Rheumatology, Ministry of Public Health, Havana 19210, Cuba"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Irainis","family":"Serrano Espinosa","sequence":"additional","affiliation":[{"name":"National Institute of Rheumatology, Ministry of Public Health, Havana 19210, Cuba"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Mar\u00eda Elena","family":"Corrales V\u00e1zquez","sequence":"additional","affiliation":[{"name":"Clinical Laboratory of the Surgical and Clinical Teaching Hospital \u201c10 de Octubre\u201d, Faculty of Medical Sciences, Ministry of Public Health, Havana 19210, Cuba"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1968","published-online":{"date-parts":[[2025,5,29]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","unstructured":"L\u00f3pez-Armada, M.J., Fern\u00e1ndez-Rodr\u00edguez, J.A., and Blanco, F.J. (2022). Mitochondrial Dysfunction and Oxidative Stress in Rheumatoid Arthritis. Antioxidants, 11.","DOI":"10.3390\/antiox11061151"},{"key":"ref_2","doi-asserted-by":"crossref","unstructured":"Souliotis, V.L., Vlachogiannis, N.I., Pappa, M., Argyriou, A., Ntouros, P.A., and Sfikakis, P.P. (2020). DNA Damage Response and Oxidative Stress in Systemic Autoimmunity. Int. J. Mol. Sci., 21.","DOI":"10.3390\/ijms21010055"},{"key":"ref_3","doi-asserted-by":"crossref","unstructured":"W\u00f3jcik, P., Gegotek, A., \u017darkovi\u0107, N., and Skrzydlewska, E. (2021). Oxidative Stress and Lipid Mediators Modulate Immune Cell Functions in Autoimmune Diseases. Int. J. Mol. Sci., 22.","DOI":"10.3390\/ijms22020723"},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"15","DOI":"10.1038\/s41413-018-0016-9","article-title":"Rheumatoid arthritis: Pathological mechanisms and modern pharmacologic therapies","volume":"6","author":"Guo","year":"2018","journal-title":"Bone Res."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"1493","DOI":"10.1007\/s40744-021-00365-1","article-title":"Differentiating Psoriatic Arthritis from Osteoarthritis and Rheumatoid Arthritis: A Narrative Review and Guide for Advanced Practice Providers","volume":"8","author":"Saalfeld","year":"2021","journal-title":"Rheumatol. Ther."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"501","DOI":"10.1159\/000493390","article-title":"Rheumatoid arthritis: A brief overview of the treatment","volume":"27","author":"Bullock","year":"2018","journal-title":"Med. Princ. Pract."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"195","DOI":"10.1038\/s41584-020-00570-2","article-title":"How the tissue microenvironment affects inflammation in RA","volume":"17","author":"Buckley","year":"2021","journal-title":"Nat. Rev. Rheumatol."},{"key":"ref_8","unstructured":"Rilling, S.H. (1993). 30 years of ozone\/oxygen therapy: A historical perspective. Proc. Elev. Ozone Congr., M-1-3\u2013M-1-6."},{"key":"ref_9","doi-asserted-by":"crossref","unstructured":"Malatesta, M., Tabaracci, G., and Pellicciari, C. (2024). Low-Dose Ozone as a Eustress Inducer: Experimental Evidence of the Molecular Mechanisms Accounting for Its Therapeutic Action. Int. J. Mol. Sci., 25.","DOI":"10.3390\/ijms252312657"},{"key":"ref_10","first-page":"191","article-title":"Ozone treatment reduces markers of oxidative and endothelial damage in an experimental diabetes model in rats","volume":"44","author":"Re","year":"2001","journal-title":"Pharmacol. Res."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"425","DOI":"10.1080\/01919512.2012.718949","article-title":"Ozone Oxidative Postconditioning Protects Against the Injury Associated with Alcohol Withdrawal Syndrome in Rats","volume":"34","author":"Vaillant","year":"2012","journal-title":"Ozone Sci. Eng."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"151","DOI":"10.1016\/j.ejphar.2005.08.020","article-title":"Therapeutic efficacy of ozone in patients with diabetic foot","volume":"523","author":"Re","year":"2005","journal-title":"Eur. J. Pharmacol."},{"key":"ref_13","doi-asserted-by":"crossref","unstructured":"Fern\u00e1ndez, O.S.L., Oru, G.T., Viebahn-H\u00e4nsler, R., Cabreja, G.L., Espinosa, I.S., and Fern\u00e1ndez, E.G. (2022). Medical ozone arrests oxidative damage progression and regulates vasoactive mediator levels in elderly patients (60\u201370 years) with oxidative etiology diseases. Front. Physiol., 13.","DOI":"10.3389\/fphys.2022.1029805"},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"289","DOI":"10.1080\/09629359890983","article-title":"Ozone oxidative preconditioning: A protection against cellular damage by free radicals","volume":"7","author":"Merino","year":"1998","journal-title":"Mediat. Inflamm."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"101138","DOI":"10.1016\/j.arr.2020.101138","article-title":"Ozone: A natural bioactive molecule with antioxidant property as potential new strategy in aging and in neurodegenerative disorders","volume":"63","author":"Scassellati","year":"2020","journal-title":"Ageing Res. Rev."},{"key":"ref_16","doi-asserted-by":"crossref","unstructured":"Travagli, V., and Iorio, E.L. (2023). The Biological Molecular Action of Ozone Its Derivatives: State-of-the-Art Enhanced Scenarios Quality Insights. Int. J. Mol. Sci., 24.","DOI":"10.3390\/ijms24108465"},{"key":"ref_17","doi-asserted-by":"crossref","unstructured":"Clavo, B., Mart\u00ednez-S\u00e1nchez, G., Rodr\u00edguez-Esparrag\u00f3n, F., Ro-dr\u00edguez-Abreu, D., Galv\u00e1n, S., Aguiar-Bujanda, D., D\u00edaz-Garrido, J.A., Ca\u00f1as, S., Torres-Mata, L.B., and Fabelo, H. (2021). Modulation by Ozone Therapy of Oxidative Stress in Chemotherapy-Induced Peripheral Neuropathy: The Background for a Randomized Clinical Trial. Randomized Clin. Trial. Int. J. Mol. Sci., 22.","DOI":"10.3390\/ijms22062802"},{"key":"ref_18","doi-asserted-by":"crossref","unstructured":"Cisterna, B., Costanza, M., Nodari, A., Gali\u00e8, M., Zanzoni, S., Bernardi, P., Covi, V., Tabaracci, G., and Malatesta, M. (2020). Ozone Activates the Nrf2 Pathway and Improves Preservation of Explanted Adipose Tissue In Vitro. Antioxidants, 9.","DOI":"10.3390\/antiox9100989"},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"753","DOI":"10.1007\/s10067-016-3528-y","article-title":"Factors influencing the choice of first- and second-line biologic therapy for the treatment of rheumatoid arthritis: Real-life data from the Italian LORHEN registry","volume":"36","author":"Monti","year":"2017","journal-title":"Clin. Rheumatol."},{"key":"ref_20","doi-asserted-by":"crossref","unstructured":"Jing, W., Liu, C., Su, C., Liu, L., Chen, P., Li, X., Zhang, X., Yuan, B., Wang, H., and Du, X. (2023). Role of reactive oxygen species and mitochondrial damage in rheumatoid arthritis and targeted drugs. Front. Immunol., 14.","DOI":"10.3389\/fimmu.2023.1107670"},{"key":"ref_21","doi-asserted-by":"crossref","unstructured":"Wang, D.F., Cao, X., Ye, Q., Wang, Q., Zhang, M., and Xiao, C. (2022). The Role of Reactive Oxygen Species in the Rheumatoid Arthritis-Associated Synovial Microenvironment. Antioxidants, 11.","DOI":"10.3390\/antiox11061153"},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"502","DOI":"10.1016\/j.ejmech.2018.09.027","article-title":"Side effects of methotrexate therapy for rheumatoid arthritis: A systematic review","volume":"158","author":"Wang","year":"2018","journal-title":"Eur. J. Med. Chem."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"373","DOI":"10.1002\/acr.20372","article-title":"Safety and efficacy of etanercept beyond 10 years of therapy in North American patients with early and longstanding rheumatoid arthritis","volume":"63","author":"Weinblatt","year":"2011","journal-title":"Arthritis Care Res."},{"key":"ref_24","doi-asserted-by":"crossref","unstructured":"Sartori, N.S., Picon, P., Papke, A., Neyeloff, J.L., and da Silva Chakr, R.M. (2019). A population-based study of tuberculosis incidence among rheumatic disease patients under anti-TNF treatment. PLoS ONE, 14.","DOI":"10.1371\/journal.pone.0224963"},{"key":"ref_25","doi-asserted-by":"crossref","unstructured":"Magni, G., and Ceruti, S. (2020). Adenosine Signaling in Autoimmune Disorders. Pharmaceuticals, 13.","DOI":"10.3390\/ph13090260"},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"311","DOI":"10.1055\/s-0029-1191011","article-title":"Eine medizinische Verwendbarkeit von Ozon","volume":"11","author":"Wolff","year":"1915","journal-title":"Dtsche. Med. Wschr."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"322","DOI":"10.1080\/01919512.2016.1191992","article-title":"Ozone in Medicine: Clinical Evaluation and Evidence Classification of the Systemic Ozone Applications, Major Autohemotherapy and Rectal Insufflation, According to the Requirements for Evidence-Based Medicine","volume":"38","year":"2016","journal-title":"Ozone Sci. Eng."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"534","DOI":"10.1016\/j.jvir.2009.12.393","article-title":"A Metaanalysis of the Effectiveness and Safety of Ozone Treatments for Herniated Lumbar Discs","volume":"21","author":"Steppan","year":"2010","journal-title":"J. Vasc. Interv. Radiol."},{"key":"ref_29","first-page":"65","article-title":"Medical ozone prevents inflammatory effects from carrageenan-induced knee joint synovitis in rats through A1 adenosine receptor, as well as lipid and protein oxidative damages","volume":"5","author":"Oru","year":"2018","journal-title":"J. Sci. Res. Stud."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"318","DOI":"10.1016\/j.ejphar.2013.07.034","article-title":"Ozone oxidative postconditioning ameliorates joint damage and decreases pro-inflammatory cytokine levels and oxidative stress in PG\/PS-induced arthritis in rats","volume":"714","author":"Vaillant","year":"2013","journal-title":"Eur. J. Pharmacol."},{"key":"ref_31","first-page":"39","article-title":"Ozone oxidative preconditioning is mediated by A1 adenosine receptors in a rat model of liver ischemia\/reperfusion","volume":"21","author":"Ajamieh","year":"2008","journal-title":"Transplantation"},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"595","DOI":"10.1080\/10715760000301121","article-title":"Effect of ozone treatment on Reactive Oxygen Species and Adenosine production during hepatic ischemia-reperfusion","volume":"33","author":"Peralta","year":"2000","journal-title":"Free Radic. Res."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"313","DOI":"10.1016\/j.ejphar.2016.07.031","article-title":"Medical ozone increases methotrexate clinical response and improves cellular redox balance in patients with rheumatoid arthritis","volume":"789","author":"Fernandez","year":"2016","journal-title":"Eur. J. Pharmacol."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"265","DOI":"10.1254\/jjp.86.265","article-title":"Adenosine, oxidative stress and cytoprotection","volume":"86","author":"Ramkumar","year":"2001","journal-title":"Jpn. J. Pharmacol."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"2040","DOI":"10.1002\/eji.200939578","article-title":"Animal models of rheumatoid arthritis","volume":"39","author":"Asquith","year":"2009","journal-title":"Eur. J. Immunol."},{"key":"ref_36","first-page":"1463","article-title":"Differing effects of exogenous and endogenous hydrogen sulphide in carrageenan-induced knee joint synovitis in the rat","volume":"15","author":"Santos","year":"2010","journal-title":"Br. J. Pharmacol."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"3557","DOI":"10.1002\/art.11424","article-title":"Splenectomy attenuates streptococcal cell wall-induced arthritis and alters leucocyte activation","volume":"48","author":"Kimpel","year":"2003","journal-title":"Arthritis Rheum."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"1124","DOI":"10.1161\/01.CIR.74.5.1124","article-title":"Preconditioning with Ischemia: A Delay of Lethal Injury in Ischemic Myocardium","volume":"74","author":"Murry","year":"1986","journal-title":"Circulation"},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"408","DOI":"10.1080\/01919512.2012.717847","article-title":"Ozone in Medicine: The Low-Dose Ozone Concept\u2014Guidelines and Treatment Strategies","volume":"34","author":"Fahmy","year":"2012","journal-title":"Ozone Sci. Eng."},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"301","DOI":"10.1016\/j.jbspin.2018.07.004","article-title":"Methotrexate mechanism in treatment of rheumatoid arthritis","volume":"86","author":"Friedman","year":"2018","journal-title":"Jt. Bone Spine"},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"204","DOI":"10.1179\/1743132814Y.0000000445","article-title":"Ozone protective effects against PTZ-induced generalized seizures are mediated by re-establishment of cellular redox balance and A1 adenosine receptors","volume":"37","author":"Mallok","year":"2015","journal-title":"Neurol. Res."},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"663","DOI":"10.1124\/mol.53.4.663","article-title":"Oxidative stress increases A1 adenosine receptor expression by activating nuclear factor kB","volume":"53","author":"Nie","year":"1998","journal-title":"Mol. Pharmacol."},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"106433","DOI":"10.1016\/j.intimp.2020.106433","article-title":"Immunogenicand Inflammatory Responses to Citrullinated Proteins Are Enhanced Following Modification with Malondialdehyde-Acetaldehyde Adducts","volume":"83","author":"Thiele","year":"2020","journal-title":"Int. Immunopharmacol."},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"1381","DOI":"10.1016\/S1567-5769(03)00136-X","article-title":"T cell proliferative responses to malondialdehyde\/acetaldehyde haptenated protein are scavenger receptor mediated","volume":"3","author":"Willis","year":"2003","journal-title":"Int. Immunopharmacol."},{"key":"ref_45","first-page":"1004","article-title":"Medical Ozone Reduces the Risk of \u03b3-Glutamyl Transferase and Alkaline Phosphatase Abnormalities and Oxidative Stress in Rheumatoid Arthritis Patients Treated with Methotrexate","volume":"1","author":"Oru","year":"2017","journal-title":"SMJ Arthritis Res."},{"key":"ref_46","doi-asserted-by":"crossref","unstructured":"Schmidt, S., Messner, C.J., Gaiser, C., H\u00e4mmerli, C., and Suter-Dick, L. (2022). Methotrexate-Induced Liver Injury Is Associated with Oxidative Stress, Impaired Mitochondrial Respiration, and Endoplasmic Reticulum Stress In Vitro. Int. J. Mol. Sci., 23.","DOI":"10.3390\/ijms232315116"},{"key":"ref_47","first-page":"13303","article-title":"The protective effect of intraperitoneal medical ozone preconditioning and treatment on hepatotoxicity induced by methotrexate","volume":"8","author":"Aslaner","year":"2015","journal-title":"Int. J. Clin. Exp. Med."},{"key":"ref_48","doi-asserted-by":"crossref","unstructured":"Vincenzi, F., Pasquini, S., Borea, P.A., and Varani, K. (2020). Targeting Adenosine Receptors: A Potential Pharmacological Avenue for Acute and Chronic Pain. Int. J. Mol. Sci., 21.","DOI":"10.3390\/ijms21228710"},{"key":"ref_49","doi-asserted-by":"crossref","unstructured":"Bhagavatham, S.K.S., Khanchandani, P., Kannan, V., Potikuri, D., Sridharan, D., Pulukool, S.K., Naik, A.A., Dandamudi, R.B., Divi, S.M., and Pargaonkar, A. (2021). Adenosine deaminase modulates metabolic remodeling and orchestrates joint destruction in rheumatoid arthritis. Sci. Rep., 11.","DOI":"10.1038\/s41598-021-94607-5"},{"key":"ref_50","doi-asserted-by":"crossref","first-page":"R53","DOI":"10.1186\/ar1914","article-title":"Suppression of inflammation by low-dose methotrexate is mediated by adenosine A2A receptor but not A3 receptor activation in thioglycollate-induced peritonitis","volume":"8","author":"Montesinos","year":"2006","journal-title":"Arthritis Res. Ther."},{"key":"ref_51","doi-asserted-by":"crossref","unstructured":"Pasquini, S., Contri, C., Borea, P.A., Vincenzi, F., and Varani, K. (2021). Adenosine Inflammation: Here There Everywhere. Int. J. Mol. Sci., 22.","DOI":"10.3390\/ijms22147685"},{"key":"ref_52","doi-asserted-by":"crossref","unstructured":"Konishi, H., Kanou, E., Yukimatsu, R., Inui, M., Sato, M., Yamamoto, N., Nakano, M., and Koshiba, M. (2022). Adenosine inhibits TNF\u03b1-induced MMP-3 production in MH7A rheumatoid arthritis synoviocytes via  A2A receptor signaling. Sci. Rep., 12.","DOI":"10.1038\/s41598-022-10012-6"},{"key":"ref_53","doi-asserted-by":"crossref","unstructured":"Pasquini, S., Contri, C., Cappello, M., Borea, P.A., Varani, K., and Vincenzi, F. (2022). Update on the recent development of allosteric modulators for adenosine receptors and their therapeutic applications. Front. Pharmacol., 13.","DOI":"10.3389\/fphar.2022.1030895"},{"key":"ref_54","doi-asserted-by":"crossref","first-page":"41","DOI":"10.1007\/s12291-008-0010-x","article-title":"Lipid peroxidation and antioxidant status in patients with rheumatoid arthritis","volume":"23","author":"Surapneni","year":"2008","journal-title":"Indian J. Clin. Biochem."},{"key":"ref_55","doi-asserted-by":"crossref","first-page":"315","DOI":"10.1152\/physrev.00029.2006","article-title":"Nitric oxide and peroxinitrite in health and disease","volume":"87","author":"Pacher","year":"2007","journal-title":"Physiol. Rev."}],"container-title":["International Journal of Molecular Sciences"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/1422-0067\/26\/11\/5256\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,9]],"date-time":"2025-10-09T17:43:36Z","timestamp":1760031816000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/1422-0067\/26\/11\/5256"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,5,29]]},"references-count":55,"journal-issue":{"issue":"11","published-online":{"date-parts":[[2025,6]]}},"alternative-id":["ijms26115256"],"URL":"https:\/\/doi.org\/10.3390\/ijms26115256","relation":{},"ISSN":["1422-0067"],"issn-type":[{"value":"1422-0067","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,5,29]]}}}