Christof Iking-Konert

Effectiveness and safety of the interleukin 6-receptor antagonist tocilizumab after 4 and 24 weeks in patients with active rheumatoid arthritis: the first phase IIIb real-life study (TAMARA)

Objectives To confirm the effectiveness and safety of the interleukin 6-receptor antagonist tocilizumab in patients with rheumatoid arthritis (RA) in a setting close to real-life medical care in Germany. Methods A multicentre open-label phase IIIb study was undertaken. Patients with active RA with a 28-joint Disease Activity Score (DAS28) >3.2 despite previous disease-modifying antirheumatic drugs (DMARDs) were treated with tocilizumab 8 mg/kg every 4 weeks. The primary end point was the proportion of patients achieving LDAS ≤3.2 at week 24; secondary end points included American College of Rheumatology (ACR), European League Against Rheumatism (EULAR) or Clinical Disease Activity Index (CDAI) responses and decrease in acute phase. Analyses in subgroups such as rheumatoid factor (RF)-positive versus RF-negative patients and patients with an inadequate response to treatment with DMARDs (DMARD-IR) versus those with an inadequate response to tumour necrosis factor (TNF) antagonists (TNF antagonist-IR) were performed. Safety was assessed by adverse event documentation. Results 286 patients were treated and 83.6% completed the study. 41.6% had previously been treated with TNF antagonists. 57% of the intention-to-treat patients achieved the primary end point of LDAS, 47.6% achieved DAS remission <2.6 and a EULAR ‘good response’ was achieved by 54.9%; ACR50/70 response rates at week 24 were 50.7% and 33.9%, respectively. The mean±SD decrease in CDAI from baseline to week 24 was 71±29%. C reactive protein levels normalised rapidly within 1 week. Major improvements in fatigue, pain and morning stiffness were observed in the first 4 weeks and further improved until week 24. DAS28, EULAR and ACR responses at week 24 did not differ between RF-positive and RF-negative patients. TNF antagonist-naive patients responded better than patients who had previously failed on TNF antagonists. The safety profile of tocilizumab was comparable to that previously observed in the phase III trial programme. Serious infections were observed in 3.1% of patients. Conclusions Tocilizumab is highly effective in a setting close to real-life medical care with a rapid and sustained improvement in signs and symptoms of RA. A manageable safety profile was seen over the 24-week study period.

Preliminary results of safety and efficacy of the interleukin-1 receptor antagonist anakinra in patients with severe lupus arthritis

Background: Joint involvement occurs in most patients with systemic lupus erythematosus (SLE), and severe lupus arthritis is often refractory to conventional treatments. Anakinra is used in the treatment of rheumatoid arthritis, but its therapeutic potential has not been proved in patients with SLE. Objective: To determine the safety/tolerability and efficacy of anakinra in patients with SLE with leading joint involvement. Methods: In patients with SLE with active polyarthritis and no other uncontrolled systemic/organ manifestations, 100 mg/day anakinra was self administered subcutaneously for 3 months. Disease activity was assessed by VAS, number of swollen/tender joints, ECLAM score, and serological and immunological measures. Results: Four patients with SLE were studied; anakinra was safe in all four patients and no drug related serious adverse events occurred. A subjective benefit was seen in all patients and a trend towards better activity measures after 4 weeks. After an initial response, one patient left the study because of an arthritic flare after 6 weeks. Conclusion: In this study anakinra was apparently safe and well tolerated and led to clinical and serological improvement. Anakinra might be an interesting alternative in individual patients with lupus arthritis not responding to conventional treatments.

Autoantibodies against aquaporin-4 in patients with neuropsychiatric systemic lupus erythematosus and primary Sjögren's syndrome.

Neurologic manifestations occur in up to 70% of patients with systemic lupus erythematosus (SLE) and in 20% of patients with Sjögren’s syndrome (SS) and are associated with significant morbidity. There is as yet no biologic marker that specifically indicates neurologic involvement in rheumatic diseases. In the literature to date, the association between nervous system manifestations of SLE and autoantibodies against ribosomal P proteins and N-methyl-Daspartate receptor has been inconsistently demonstrated (1). Transverse myelopathy is a rare but serious condition reported in patients with SLE and SS (2,3). In sera from some of these patients, an IgG autoantibody marker, called NMOIgG, has been recently detected (4,5). NMO-IgG was initially identified by immunohistochemistry using brain tissue in sera from patients with neuromyelitis optica (NMO; also known as Devic’s disease), a severe demyelinating disorder of the central nervous system (CNS) that primarily affects the spinal cord and the optic nerves (6). In patients presenting with isolated longitudinally extensive transverse myelitis (LETM) involving at least 3 vertebral segments, as revealed using magnetic resonance imaging, and in patients with recurrent optic neuritis (ON), the presence of NMO-IgG indicates severe disease course with frequent relapses (7,8). NMO-IgG is not detectable in the sera of patients with multiple sclerosis (MS) (6). The antigenic target of NMO-IgG is aquaporin-4 (AQP-4), the most abundant water channel in the CNS (9). To detect these autoantibodies, assays employing recombinant AQP-4 have been repeatedly shown to be more sensitive than immunohistochemistry in CNS tissue (10). In order to evaluate the significance of NMO-IgG/ AQP-4 antibodies as potential markers of neurologic involvement in rheumatic conditions, we collected serum samples from patients with SLE (n 48) and SS (n 44), 28 and 22 of whom showed neurologic manifestations, respectively (Table 1). All patients fulfilled the American College of Rheumatology (ACR) classification criteria for SLE and SS (11,12). SLE patients with neurologic involvement fulfilled the ACR case definitions for neuropsychiatric lupus syndromes (13). Blood was drawn from 3 SLE patients (2 with LETM and 1 with LETM and recurrent ON) within 7 days of onset of a relapse. In the other SLE subsets, the time intervals between the serum sampling and the onset of the first neurologic symptoms or, in cases of relapses, the onset of the last relapse were as follows: TM, 1 year; LETM, 1–7 years (median 4 years); recurrent ON, 1 year; chorea, 1 year; psychosis/depression, 4–20 years (median 9.5 years); seizure disorders, 13 and 20 years. The duration of symptoms in SLE patients with polyneuropathy was 2–12 years (median 5 years). In patients with SS, time intervals were 7 and 8 years in 2 patients with TM and concomitant monophasic ON, 5 years in 1 patient with TM alone, and 13 years in both patients with LETM. Symptoms were present for 1–8 years (median 3 years) in SS patients with polyneuropathy. Samples were analyzed both by immunohistochemistry using native primate cerebellum, cerebrum, and optic nerve tissue sections and, for the first time in patients with SLE and SS, by means of a recombinant immunofluorescence assay (rIFA) using AQP-4–transfected HEK cells fixed in formalin. In direct comparison with the original procedure for the detection of NMO-IgG as described by Lennon et al (6), the rIFA exhibited an increase in sensitivity of 12.5% (overall sensitivity 78.1%; specificity 100%) in an earlier study based on 183 samples from NMO patients and relevant neurologic disease controls, including MS (14). Serum samples were classified as being positive or negative for NMO-IgG/AQP-4 antibodies by 2 independent investigators who were unaware of the clinical data. Testing was performed for diagnostic purposes in all cases. In SLE and SS, NMO-IgG/AQP-4 antibodies were found exclusively in patients with neurologic involvement comprising LETM or recurrent ON (Table 1). In the SLE cohort, autoantibodies against AQP-4 were detected in all of these patients, whereas NMO-IgG was found in 6 of 7 individuals, once more indicating a higher sensitivity of the recombinant cell substrate compared with immunohistochemistry. Antibody titers as determined by AQP-4–transfected HEK cells ranged from 1:10–1:1,000 in the 5 patients with LETM. The titer was 1:100 in the patient with recurrent ON and 1:3,200 in the patient with LETM and recurrent ON. In the SS group, 1 of the 2 patients with LETM was positive for NMO-IgG/AQP-4 antibodies, at a titer of 1:1,000. None of the SLE and SS patients without neurologic involvement or symptoms other than LETM or recurrent ON tested positive for NMO-IgG/AQP-4 antibodies (i.e., at a starting dilution of 1:10, antibodies were not detected in the serum samples from these patients). Our data demonstrate that autoantibodies against AQP-4 generally are not a marker for neurologic involvement in SLE and SS. Consistent with the findings of previous reports, our observations strongly support the notion that the presence of autoantibodies against AQP-4 is highly correlated with a distinct clinical phenotype, i.e., LETM and recurrent ON, which together are typical for NMO (6–8). Apparently, autoantibodies against AQP-4 are a marker for NMO that may occur either as an isolated syndrome or as part of a rheumatologic disease like SLE or SS. Of particular interest is the fact that 2 of the AQP-4–positive SLE patients (1 with LETM and 1 with recurrent ON) also had myasthenia gravis. This observation further supports the concept of coexisting independent, antibody-mediated autoimmune disorders in the same patient. It can be argued that the long intervals between the onset of neurologic symptoms and the time of blood sampling in most of the patients might have influenced the serologic findings. However, it is known from NMO patients with long-term followup that AQP-4 antibodies are detectable in the serum during relapse as well as during remission, suggesting that AQP-4 antibody testing can be of diagnostic relevance independently of disease activity (15). In clinical practice, myelitis and ON occurring in patients with SLE and SS can be

Serum proteome profiling detects myelodysplastic syndromes and identifies CXC chemokine ligands 4 and 7 as markers for advanced disease

Myelodysplastic syndromes (MDS) are among the most frequent hematologic malignancies. Patients have a short survival and often progress to acute myeloid leukemia. The diagnosis of MDS can be difficult; there is a paucity of molecular markers, and the pathophysiology is largely unknown. Therefore, we conducted a multicenter study investigating whether serum proteome profiling may serve as a noninvasive platform to discover novel molecular markers for MDS. We generated serum proteome profiles from 218 individuals by MS and identified a profile that distinguishes MDS from non-MDS cytopenias in a learning sample set. This profile was validated by testing its ability to predict MDS in a first independent validation set and a second, prospectively collected, independent validation set run 5 months apart. Accuracy was 80.5% in the first and 79.0% in the second validation set. Peptide mass fingerprinting and quadrupole TOF MS identified two differential proteins: CXC chemokine ligands 4 (CXCL4) and 7 (CXCL7), both of which had significantly decreased serum levels in MDS, as confirmed with independent antibody assays. Western blot analyses of platelet lysates for these two platelet-derived molecules revealed a lack of CXCL4 and CXCL7 in MDS. Subtype analyses revealed that these two proteins have decreased serum levels in advanced MDS, suggesting the possibility of a concerted disturbance of transcription or translation of these chemokines in advanced MDS.

The US7 score is sensitive to change in a large cohort of patients with rheumatoid arthritis over 12 months of therapy

Purpose To determine the sensitivity to change of the US7 score among RA patients under various therapies and to analyze the effect of each therapeutic option over 1 year. To estimate predictors for development of destructive bone changes. Methods Musculoskeletal ultrasound (US7 score), DAS28, CRP and ESR were performed in 432 RA patients at baseline and after 3, 6 and 12 months. The cohort was divided into four sub-groups: first-line DMARDs (Group 1; 27.3%), therapy switch: DMARDs to second DMARDs (Group 2; 25.0%), first-line biologic after DMARDs therapy (Group 3; 35.4%) and therapy change from biologic to second biologic (Group 4; 12.3%). Results The US7 synovitis and tenosynovitis sum scores in grey-scale (GSUS) and power Doppler ultrasound (PDUS) as well as ESR, CRP decreased significantly (p<0.05) after 12 months in group 1 to 3. Group 1+2 also illustrated a significant change of DAS28 after 1 year (p<0.001). Only in Group 4, the US7 erosion sum score decreased significantly from 4.3 to 3.6 (p=0.008) after 1 year. Predictors capable of forecasting US erosions after one year were: higher score of US7 synovitis (p<0.001), of US7 erosions in GSUS (p<0.001), as well as of DAS28 (p<0.001) at baseline. Conclusions The comparable developments of the US7 score with clinical and laboratory data illustrates its potential to reflect therapeutic response. Therefore, the novel US7 score is sensitive to change. Patients who switched from one biologic to another exhibited a significant decline in erosions after 12 months, while the erosions scores in the other groups were stable.

T lymphocytes in patients with primary vasculitis: expansion of CD8+ T cells with the propensity to activate polymorphonuclear neutrophils

OBJECTIVES To gain insight into the immune pathogenesis of primary ANCA-associated vasculitides, the prevalence of circulating T lymphocytes expressing CD11b as a marker for activation was analysed in patients with WG or microscopic polyangiitis. METHODS; Receptor expression and IFNgamma synthesis were measured in T cells of patients with active disease by cytofluorometry and compared with expression in patients in remission and in healthy donors. RESULTS During active disease, a small but conspicuous population of CD8+CD28+CD11b+ was found which produced IFNgamma. In healthy donors and in patients in remission or undergoing immunosuppressive therapy, CD11b was exclusively associated with CD8+CD28- cells, the latter being more frequent in patients with long-lasting or severe disease. In vitro experiments confirmed that CD11b is up-regulated when T cells are activated. After multiple rounds of restimulation, the CD11b expression persists whereas CD28 expression is lost, compatible with the notion that CD8+CD28+CD11b+ represents a transient phenotype in the course of T-cell activation. The IFNgamma-producing T cells activated polymorphonuclear neutrophils (PMN) to express MHC class II, thus generating the same PMN phenotype as in patients with active ANCA-associated vasculitis. A similar PMN phenotype could be generated by cultivation with supernatants of activated T cells or by IFNgamma alone, but not by antibodies to proteinase 3. CONCLUSIONS In active primary vasculitis, a small population of CD8+ T cells, identified by the expression of CD11b, expands, producing IFNgamma. These T cells could activate PMN, thus generating a long-living and potentially destructive PMN phenotype.

ROUTINE—a prospective, multicentre, non-interventional, observational study to evaluate the safety and effectiveness of intravenous tocilizumab for the treatment of active rheumatoid arthritis in daily practice in Germany

OBJECTIVE To evaluate the tolerability, effectiveness and utilization of tocilizumab for the treatment of RA in a usual care setting. METHODS ROUTINE was a prospective, non-interventional, observational 52-week study performed at 174 sites throughout Germany. RA patients were selected and treated according to label. Study objectives included the targeted documentation of infections, other adverse events, and various effectiveness outcomes (e.g. DAS28, clinical disease activity). Statistical analyses were performed primarily based on the data as observed. RESULTS A total of 850 patients (75% women, mean age: 56 ± 13 years, mean RA duration: 10.3 ± 8.6 years) were enrolled. Most patients (79%) were pretreated with TNF-inhibitors, whereas 21% were pretreated with conventional DMARDs only. Most common DMARD pretreatments were MTX (79%), LEF (68%), adalimumab (53%) and etanercept (50%). At baseline, 60.5% of patients received tocilizumab in combination with any other RA drugs, while 39.5% were treated in monotherapy. Mean baseline DAS28 was 5.5 ± 1.3, and this decreased to 2.6 ± 1.6 at week 52. At week 52, good EULAR response was achieved in 62.3%, low disease activity state in 66.4%, and DAS28 remission in 55.1% of patients (adjusted relative frequencies). 35.3% of patients discontinued the study prematurely; common reasons were lack of effectiveness (10.5%) and intolerability (7.3%). Any infections and severe infections occurred in 37.6% and 7.2% of patients, respectively (N = 836); serious infections were seen in 5.3% (N = 850). Event rates of any, severe and serious infections were 70.3, 9.8 and 4.4 events/100 patient-years, respectively. CONCLUSION Tocilizumab administered in a real-life setting showed clinically meaningful improvements and a safety profile that was consistent with data reported from pre-approval Phase III studies.

Capillaroscopy. An update

This article reports relevant innovations 2 years after the publication of the German consensus on nomenclature and procedure of capillaroscopy in this journal. Standardization: certified training courses in capillaroscopy under the patronage of the Rheumatism Academy have reached over 300 rheumatologists nationwide. Trained investigators clearly show greater agreement on findings than untrained experts even with years of experience. Normal findings were detected using the published terminology in a large cohort. Scientific application: the number of publications on capillaroscopy has risen significantly, prospective studies of smaller cohorts and the comparison to other methods regarding systemic sclerosis, Raynauds disease and also miscellaneous diseases. A large prospective multicenter European study on the capillaroscopic skin ulcer risk index (CSURI) was conducted with German participation. The role as a screening tool has been confirmed by the majority of the studies. For systemic lupus erythematosus it is also increasingly being used in the diagnostic work-up as an additional investigation. Practical application: capillaroscopy has a solid and indispensable role in the diagnostic algorithm of Raynauds disease and early diagnosis of systemic sclerosis. Videocapillaroscopy and simple USB microscopes are increasingly being used besides traditional light microscopy.

Lack of deleterious somatic mutations in the CD95 gene of plasmablasts from systemic lupus erythematosus patients and autoantibody- producing cell lines

The interaction of CD95 with its ligand CD95L is important for negative selection of B cells during the germinal center (GC) reaction. Recently, mutations confering restistance to CD95‐induced apoptosis have been described for human GC B cells. Hence, as has been demonstrated for CD95‐deficient mice, also GC‐derived autoreactive B cells carrying somatic CD95 gene mutations may potentionally survice negative selection and participate in the development of autoimmune diseases. Here, single plasmablasts (PB) which are implicated in the production of autoantibodies in systemic lupus erythematosus (SLE) patients as well as ten human B cell lines producing autoantibodies were analyzed for destructive somatic CD95 gene mutations. However, inactivating CD95 gene mutations were very rare in PB and not detected in the cell lines. Sequence analysis of V gene rearrangements amplified from single PB confirmed that the cells are (post) GC B cells and additionally demonstrated massive clonal expansion of these cells in two of four SLE patients. We conclude that CD95 gene mutations play little if any role in the generation of the pool of PB in SLE patients and that mutations in the CD95 gene are rare among autoantibody‐producing B cells in SLE and rheumatoid arthritis.

Subacute liver failure following anakinra treatment for adult-onset Still disease.

To the Editor: Anakinra is approved for the treatment of rheumatoid arthritis and it is used off-label for various other rheumatic diseases1. Although beneficial effects of anakinra on liver inflammation and regeneration have been shown2, we describe a case of subacute liver failure in a patient with adult-onset Still disease (AOSD) who had been treated with anakinra monotherapy. Three months before admission to our hospital, the 20-year-old man had been diagnosed with AOSD. Initial treatment consisted of anakinra 100 mg and prednisolone 100 mg daily. The latter had been tapered to 10 mg after achieving remission 1 week before the first symptoms of liver failure appeared. The patient developed fever and jaundice. C-reactive protein was increased to 42 mg/dl, immunoglobulin E (IgE) was elevated to 709 kU/l, and transaminases were substantially increased, with alanine transaminase levels of 1128 U/l (Figure 1a). With an INR of 2.7, coagulation was massively disturbed. Figure 1. Development of the clinical course and hematoxylin and eosin stainings of the liver biopsy. (a) Development of alanine transaminase (ALT, U/l), bilirubin … Address correspondence to Dr. Benten; E-mail: d.benten{at}uke.de