A Grom

Algorithm development for corticosteroid management in systemic juvenile idiopathic arthritis trial using consensus methodology

BackgroundThe management of background corticosteroid therapy in rheumatology clinical trials poses a major challenge. We describe the consensus methodology used to design an algorithm to standardize changes in corticosteroid dosing during the Randomized Placebo Phase Study of Rilonacept in Systemic Juvenile Idiopathic Arthritis Trial (RAPPORT).MethodsThe 20 RAPPORT site principal investigators (PIs) and 4 topic specialists constituted an expert panel that participated in the consensus process. The panel used a modified Delphi Method consisting of an on-line questionnaire, followed by a one day face-to-face consensus conference. Consensus was defined as ≥ 75% agreement. For items deemed essential but when consensus on critical values was not achieved, simple majority vote drove the final decision.ResultsThe panel identified criteria for initiating or increasing corticosteroids. These included the presence or development of anemia, myocarditis, pericarditis, pleuritis, peritonitis, and either complete or incomplete macrophage activation syndrome (MAS). The panel also identified criteria for tapering corticosteroids which included absence of fever for ≥ 3 days in the previous week, absence of poor physical functioning, and seven laboratory criteria. A tapering schedule was also defined.ConclusionThe expert panel established consensus regarding corticosteroid management and an algorithm for steroid dosing that was well accepted and used by RAPPORT investigators. Developed specifically for the RAPPORT trial, further study of the algorithm is needed before recommendation for more general clinical use.

Relationship of cell-free urine MicroRNA with lupus nephritis in children.

BackgroundMicroRNAs (miRNAs) are involved in the post-transcriptional regulation of genes. The objective of this study was to investigate whether select urinary cell-free microRNA’s may serve as biomarkers in children with active lupus nephritis (LN) and to assess their relationship to the recently identified combinatorial urine biomarkers, a.k.a. the LN-Panel (neutrophil gelatinase associated lipocalin, monocyte chemotactic protein 1, transferrin, and beta-trace protein).MethodsmiRNAs (125a, 127, 146a, 150 and 155) were measured using real-time polymerase chain reaction in the urine pellet (PEL) and supernatant (SUP) in 14 patients with active LN, 10 patients with active extra-renal lupus, and 10 controls. The concentrations of the LN-Panel biomarkers (neutrophil gelatinase associated lipocalin, monocyte chemotactic protein-1, transferrin, beta-trace protein) was assayed. Traditional laboratory and clinical measures of LN and lupus (complements, protein to creatinine ratio; Systemic Lupus Erythematosus Disease Activity Index) were also measured.ResultsAll tested miRNAs in the SUP, but not the PEL, were associated with the LN-Panel biomarkers (0.3 < |r Pearson| < 0.73; p < 0.05), miRNA125a, miRNA127,miRNA146a also with C3 and dsDNA antibody levels (|r Pearson| > 0.24; p < 0.05), and miRNA146a with the renal domain of the SLEDAI (|r Pearson| = 0.32; p < 0.05). Mean miRNA levels of patients with active LN did not statistically (P > 0.05) differ from those of SLE patients without LN or controls.ConclusionLevels of cell-free miR-125a, miR-150, and miR-155 in the urine supernatant are associated with the expression of LN-Panel biomarkers and some LN measures. These miRNA’s may complement, but are unlikely superior to the LN-Panel for estimating concurrent LN activity.

Aberrant tRNA processing causes an autoinflammatory syndrome responsive to TNF inhibitors

Objectives To characterise the clinical features, immune manifestations and molecular mechanisms in a recently described autoinflammatory disease caused by mutations in TRNT1, a tRNA processing enzyme, and to explore the use of cytokine inhibitors in suppressing the inflammatory phenotype. Methods We studied nine patients with biallelic mutations in TRNT1 and the syndrome of congenital sideroblastic anaemia with immunodeficiency, fevers and developmental delay (SIFD). Genetic studies included whole exome sequencing (WES) and candidate gene screening. Patients’ primary cells were used for deep RNA and tRNA sequencing, cytokine profiling, immunophenotyping, immunoblotting and electron microscopy (EM). Results We identified eight mutations in these nine patients, three of which have not been previously associated with SIFD. Three patients died in early childhood. Inflammatory cytokines, mainly interleukin (IL)-6, interferon gamma (IFN-γ) and IFN-induced cytokines were elevated in the serum, whereas tumour necrosis factor (TNF) and IL-1β were present in tissue biopsies of patients with active inflammatory disease. Deep tRNA sequencing of patients’ fibroblasts showed significant deficiency of mature cytosolic tRNAs. EM of bone marrow and skin biopsy samples revealed striking abnormalities across all cell types and a mix of necrotic and normal-appearing cells. By immunoprecipitation, we found evidence for dysregulation in protein clearance pathways. In 4/4 patients, treatment with a TNF inhibitor suppressed inflammation, reduced the need for blood transfusions and improved growth. Conclusions Mutations of TRNT1 lead to a severe and often fatal syndrome, linking protein homeostasis and autoinflammation. Molecular diagnosis in early life will be crucial for initiating anti-TNF therapy, which might prevent some of the severe disease consequences.

FRI0528 Canakinumab in Systemic Juvenile Idiopathic Arthritis: Impact on the Rate and Clinical Presentation of Macrophage Activation Syndrome

Background Canakinumab is a fully human, selective, anti-IL-1β monoclonal antibody approved for the treatment of patients with systemic juvenile idiopathic arthritis (SJIA). In the phase III trials, macrophage activation syndrome (MAS), a potentially fatal complication of SJIA, was reported as an adverse event (AE) in both canakinumab and placebo group patients. This prompted Novartis to form an independent expert MAS Adjudication Committee (MASAC) to develop methodology to identify and review potential MAS events. Objectives To assess the impact of canakinumab on incidence of MAS in SJIA patients. Methods A periodic search of the canakinumab SJIA clinical study databases and the separate serious AE safety database was performed using MASAC-specified screening AE terms (cut-off date 31 May 2012). MASAC-specified laboratory criteria were also used to search clinical study databases. MAS events were then adjudicated blinded to treatment by the MASAC as either probable, possible, or unlikely MAS, or insufficient information loosely based on the diagnostic criteria by Ravelli et al.2 and personal experience. MAS rates were expressed as numbers of probable or possible MAS events per 100 patient-years (pt-yr). Results Forty-three potential MAS events were identified for adjudication (12 reported as MAS AEs and 31 by screening database searches). Nine events were adjudicated as probable, 5 as possible and 29 as unlikely MAS. Of the 9 probable MAS events, 7 occurred in the canakinumab and 2 in the placebo group, and all were also reported as a MAS AE by the treating physician. SJIA was well controlled in all 7 canakinumab patients and all developed classic clinical features of MAS. Of the 7 canakinumab patients, 6 reported MAS in the setting of an active infection. The MAS events were not associated with a change in concomitant therapy. The time period between the first injection of canakinumab and the onset of MAS ranged between 13 days to 1.7 years (median, 83 days). The rate for MASAC adjudicated probable MAS was 2.5/100 pt-yr and 7.7/100 pt-yr for the canakinumab and placebo groups, respectively with no statistically significant difference between groups (diff=-5.2, 95% CI, -16.0, 5.7). When events adjudicated as either probable or possible MAS were combined, the rate for the canakinumab group was 4.3/100 pt-yr and 7.7/100 pt-yr for the placebo group with no between-group difference (diff=-3.4, 95% CI, -14.3, 7.6). Five of the 7 patients adjudicated as probable MAS recovered completely and 2 (1 canakinumab and 1 placebo) died from complications of MAS and/or infection. Conclusions Canakinumab does not appear to have an effect on the incidence of MAS or its clinical presentation. MAS occurred even in those patients in whom underlying SJIA was well controlled with canakinumab treatment. As often seen in MAS, active infection was the most common associated trigger in this group. References Ruperto N, et al.N Engl J Med 2012;367(25):2396-406. Ravelli A, et al.J Pediatr.2005;146(5):598-604. Disclosure of Interest A. Grom Consultant for: Novartis, Roche, NovImmune, H. Brunner Consultant for: Novartis, Roche, Janssen, Astrazenca, UCB, Celegene, Pfizer, GSK, Speakers bureau: Novartis, N. Ruperto Grant/research support: To Gaslini hospital from Abbott, Astrazeneca, BMS, Centocor Research and developement, Eli Lilly and company, “ranscesco Angelini”, GSK, Italfarmaco, Novartis, Pfizer, Roche, Sanofi Aventis, Schwarz Biosciences GmBH, Xoma, Wyeth, Speakers bureau: Astrazeneca, Bristol Myers and Squibb, Janssen Biologics B.V., Roche, Wyeth, Pfizer, A. Martini Grant/research support: From Bristol Myers and Squibb, Centocor Research & Development, Glaxo Smith & Kline, Novartis, Pfizer Inc, Roche, Sanofi Aventis, Schwarz Biosciences GmbH to Gaslini hospital to support PRINTO research activities, Consultant for: From Bristol Myers and Squibb, Centocor Research & Development, Glaxo Smith and Kline, Novartis, Pfizer Inc, Roche, Sanofi Aventis, Schwarz Biosciences GmbH to Gaslini hospital to support PRINTO research activities, Employee of: Gaslini hospital, Speakers bureau: Abbott, Bristol Myers Squibb, Astellas, Boehringer, Italfarmaco, MedImmune, Novartis, NovoNordisk, Pfizer, Sanofi, Roche, Servier, D. Lovell Grant/research support: National Institutes of Health- NIAMS, Consultant for: Astra-Zeneca, Centocor, Amgen, Bristol Meyers Squibb, Abbott, Pfizer, Regeneron, Roche, Novartis, UCB, Forest Research Institute, Horizon, Johnson & Johnson, Speakers bureau: Novartis, Roche, V. Pascual Consultant for: Served on the MAS adjudication committee for Novartis and is an author on the following patent: # 8221748; Compositions and methods for the treatment of systemic onset juvenile idiopathic arthritis with IL1 antagonists (issued on 7/17/2012), Speakers bureau: Served on the MAS adjudication committee for Novartis and is an author on the following patent: # 8221748; Compositions and methods for the treatment of systemic onset juvenile idiopathic arthritis with IL1 antagonists (issued on 7/17/2012), K. Lheritier Shareholder of: Novartis, Employee of: Novartis Pharma AG, K. Abrams Shareholder of: Novartis, Employee of: Novartis Pharmaceutical Corporation, N. Ilowite Consultant for: Novartis, Janssen DOI 10.1136/annrheumdis-2014-eular.3070

High levels of interferon-gamma (IFNγ) in macrophage activation syndrome (MAS) and CXCL9 levels as a biomarker for IFNγ production in MAS

Objectives Given the similarities between primary and secondary HLH (sec-HLH), including MAS, we measured levels of IFNg, IFNg-related chemokines (CXCL9, CXCL10, CXLC11), and IL-6 in patients with sec-HLH, and in patients with systemic Juvenile Idiopathic Arthritis (sJIA) with or without MAS at sampling and evaluated their relation to disease activity. In addition, we evaluated the correlation between serum levels of IFNg and of the three IFNg related chemokines with themselves and with laboratory parameters of disease activity in patients with active MAS.

S100A12 as diagnostic tool in the differential diagnosis of sJIA associated MAS vs. hereditary or acquired HLH

8th International Congress of Familial Mediterranean Fever and Systemic Autoinflammatory Diseases

OP0283 Microrna 125A-5P has Increased Expression in Active Systemic Juvenile Idiopathic Arthritis and is an Essential Modulator of Regulatory Macrophage Phenotypes in Vitro

Background Systemic juvenile idiopathic arthritis (SJIA) is an autoinflammatory disease of childhood, characterized by a predominance of mononuclear phagocytic effector cells, compared to the lymphocyte driven pathogenesis seen in other autoimmune JIA subtypes. Monocytes respond to their local cytokine milieu by adopting specific polarization phenotypes with distinct functions. These phenotypes include M1 (classical) activation as well as several forms of alternative activation, including M2b and M2c which have potent immunoregulatory properties. Previous data has shown that monocytes in SJIA patients have a novel phenotype, with features of both classical activation and immunoregulatory phenotypes. Controlling factors of monocyte/macrophage differentiation in SJIA are unknown. MicroRNA serve as transcriptional negative regulators which fine-tune gene expression programs, and have been implicated in the differentiation of monocytes/macrophages. However, miRNA expression in SJIA has not been examined. Methods CD14+ monocytes were isolated from children with active SJIA and clinically inactive disease (CID), and quantified miRNA expression using TaqMan MicroRNA Array (Life technologies). Freshly isolated human monocytes or THP1 macrophage-like cells were polarized in vitro using LPS and interferon-γ (M1), IL-4 (M2a), LPS plus immune complexes (M2b), and IL-10 or TGF-β (M2c). For experiments modulating expression of mir125a-5p, THP1 cells were treated with either mir125a-5p-specific or negative control antagomir (RiboBio) or transfected with miR125a-5p or negative control mimic (Dharmacon) prior to polarization with the indicated conditions. Gene expression was determined using real-time PCR or TaqMan assays. Results We identified mir125a-5p as the most highly upregulated microRNA in monocytes from children with active SJIA compared to those with CID (relative expression 16.8 vs. 3.0, p<0.05). In addition, expression of mir-125a-5p significantly correlated with markers of disease activity, including ferritin (R=0.73, p<0.001) and the presence of systemic features such as rash and hepatomegaly. Expression of mir125a-5p was significantly increased in both primary human monocytes and THP1 macrophage-like cells after polarization with M2b or M2c conditions, but was not altered by M1 polarization. Interestingly, we found that mir125a-5p was dispensable for M1 polarization, as treatment with a specific microRNA antagomir did not alter expression of MIG, I-TAC, TNF-α or IL-6. However, mir125a-5p was essential for M2b polarization, as antagomir treatment significantly reduced expression of the M2b-specific chemokine CCL1 by 56%. Conversely, transfection of a mir125a-5p mimic into THP1 cells resulted in enhanced M2b polarization with increased expression of CCL1, IL-6, as well as of the M2c marker CD163. Transfection of mir125a-5p mimic also altered M1 polarization by increasing production of CCL1. Conclusions Our data demonstrated increased levels of mir125a-5p in active SJIA and correlation with disease activity. We also showed that mir125a-5p serves as a key regulator of the polarization of immunomodulatory macrophages. Taken together, these data suggest that mir125a-5p could serve as an important diagnostic and therapeutic target in SJIA. Disclosure of Interest G. Schulert: None declared, N. Fall: None declared, N. Shen: None declared, S. Thornton: None declared, A. Grom Grant/research support from: Novartis, NovImmune, Consultant for: Novartis, Roche

Tapering and withdrawal of tocilizumab in patients with systemic juvenile idiopathic arthritis in inactive disease: results from an alternative dosing regimen in the TENDER study

The TENDER clinical trial is a 3-part, 5-year, phase 3 study of tocilizumab (TCZ) in patients with active systemic juvenile idiopathic arthritis (sJIA). After 2 years of treatment, sJIA patients who have maintained clinically inactive disease (CID) for 3 months are given the option to participate in an alternative TCZ dosing regimen aimed at spacing the infusions and eventually withdrawing TCZ.

PReS-FINAL-2139: Tapering and withdrawal of tocilizumab in patients with systemic JIA in inactive disease: results from an alternative dosing regimen in the tender study

The TENDER clinical trial is a three-part, 5-year, phase 3 study with tocilizumab (TCZ) in active systemic JIA (sjia). After 2 years of treatments, sjia patients who have maintained clinically inactive disease for 3 months are given the option to participate in an alternative TCZ dosing regimen aimed at spacing the infusions and eventually withdrawing TCZ.

Macrophage activation syndrome (MAS) in juvenile systemic lupus erythematosus (JSLE): an underrecognized complication?

Open Access Poster presentation Macrophage activation syndrome (MAS) in juvenile systemic lupus erythematosus (JSLE): an underrecognized complication? A Parodi*1, S Davi1, AB Pringe2, S Magni-Manzoni3, P Miettunen4, B BaderMeunier5, G Espada6, S Ozen7, D Wright8, C Magalhaes9, P Woo10, R Kubchandani11, A Grom12, H Michels13, C Wouters14, CE Toro Gutierrez16, G Sterba15, K Hayward17, D Guseinova18, A Fischer19, E Cortis20, M Vivarelli20, A Pistorio1, N Ruperto1, I Sala1, A Martini21 and A Ravelli21