K. Amano

Upregulated expression and function of integrin adhesive receptors in systemic lupus erythematosus patients with vasculitis.

Upregulation of integrin adhesive receptors has been implicated in various pathological conditions. We examined expression and function of integrin adhesive receptors on peripheral blood lymphocytes from patients with systemic lupus erythematosus (SLE), particularly those with the complication of vasculitis, and found that VLA-4 and LFA-1 expression was increased in SLE patients with vasculitis, while LFA-1 but not VLA-4 expression was increased in those without vasculitis. These results suggested a role of VLA-4 in the pathogenesis of vasculitis in SLE. Functional studies further demonstrated that adhesion to cytokine-activated human umbilical cord vein endothelial cells and to the CS-1 alternatively spliced domain of fibronectin was significantly increased in SLE patients with vasculitis. Analysis of the functional epitopes on the alpha 4 chain demonstrated that antigen densities of all the functional epitopes were increased in those with vasculitis, indicating that the increased expression of VLA-4 resulted from the increased number of VLA-4 molecules, and was not secondary to an increase in one particular functional epitope. Immunoprecipitation studies further support these results. Interestingly, high molecular weight bands associated with VLA-4 were observed in about half of the SLE patients with vasculitis. These results introduce a possibility that upregulation of integrin adhesive receptors has a potential role in the pathogenesis of vasculitis in SLE.

Prediction of efficacy of anti-TNF biologic agent, infliximab, for rheumatoid arthritis patients using a comprehensive transcriptome analysis of white blood cells.

Introduction of biologics, such as infliximab, to the therapy of rheumatoid arthritis (RA) patients has revolutionized the treatment of this disease. However, biomarkers for predicting the efficacy of the drug at an early phase of treatment for selecting real responders have not been found. We here present predictive markers based on a thorough transcriptome analysis of white blood cells from RA patients. RNA from whole blood cells of consecutive 42 patients before the first infusion was analyzed with microarrays for training studies. Samples from the subsequent 26 consecutive patients were used for a prospective study. We categorized the results into no inflammation and residual inflammation groups using the serum C-reactive protein (CRP) level at 14weeks after the first infusion. The accuracy of prediction in our study was 65.4%.

Defective expression and tyrosine phosphorylation of the T cell receptor zeta chain in peripheral blood T cells from systemic lupus erythematosus patients

We have reported that tyrosine phosphorylation and expression of the T cell receptor zeta chain (TCR ζ) was decreased in two systemic lupus erythematosus (SLE) patients with an abnormal TCR ζ lacking exon‐7. To examine further the TCR ζ defect and any possible relationship with specific clinical features, we studied the expression of TCR ζ in peripheral blood T cells from 44 patients with SLE, 53 with other rheumatic diseases (30 rheumatoid arthritis (RA), 11 systemic sclerosis (SSc) and 12 primary Sjögrens syndrome(SjS)) and 39 healthy individuals. Flow cytometric analysis demonstrated a significant decrease in the expression of TCR ζ in SLE (P < 0·001), but not in the other rheumatic diseases. Immunoprecipitation experiments confirmed that the expression of TCR ζ in SLE T cells was decreased dramatically (normal: 111·4 ± 22·6%, SLE: 51·6 ± 37·4%, P < 0·0001). The decrease in TCR ζ did not correlate with disease activity, or with the dose of prednisolone (PSL). There were, however, three SLE patients in whom the level of TCR ζ expression normalized after treatment, suggesting that mechanisms responsible for the TCR ζ defect appear to be heterogeneous. These results confirm the defective expression and altered tyrosine phosphorylation of TCR ζ in a large proportion of SLE patients, suggesting that it may play an important role in T cell dysfunction in SLE.

Efficacy and safety of cyclosporine A in patients with refractory systemic lupus erythematosus in a daily clinical practice.

We investigated the efficacy and safety of cyclosporine A (CsA; targeted serum trough level: 80—150 ng/ml) in a daily clinical practice for treating patients with systemic lupus erythematosus (SLE), who had been, or were expected to be, refractory to glucocorticoids (GCs) and other immunosuppressants. Fifty-nine patients with SLE receiving CsA were observed for at least 6 months (21.5 months on average). A significant reduction of proteinuria was noted 2 weeks after initiation of treatment in patients with nephritis, resulting in a clinical response in five of eight patients in the GC dose-up group and 11 of 18 patients in the stable GC dose group, respectively. Notably, the mean score for disease activity on the SLE Disease Activity Index decreased significantly from 8.6 ± 5.3 to 4.4 ± 2.5 after CsA treatment in patients in the stable GC dose group (n = 40). Moreover, the mean flare rate decreased by approximately 60% with CsA. Side effects of CsA appeared in 32.2% of patients and all of them subsided through dose reduction or discontinuation (n=8) of CsA. Consequently, the cumulative 2-year survival rate of CsA was 75%. The results suggest that CsA should be considered for patients with SLE refractory to GCs. Lupus (2010) 19, 162—169.

Up-regulation of αEβ7, a novel integrin adhesion molecule, on T cells from systemic lupus erythematosus patients with specific epithelial involvement

OBJECTIVE To determine the possible role of a novel integrin, alphaEbeta7, in the pathogenesis of systemic lupus erythematosus (SLE). METHODS Expression of alphaEbeta7 was examined on peripheral blood lymphocytes (PBL) from normal subjects (n = 25) and patients with SLE (n = 31), primary Sjogrens syndrome (n = 7), or polymyositis/dermatomyositis (n = 8) by cytofluorometry and/or immunoprecipitation. Adhesion of alphaEbeta7+ T cells to HSG epithelial cells was investigated using a confocal image analyzer. RESULTS After phytohemagglutinin stimulation, expression of alphaEbeta7 on PBL, especially on CD8+ T cells, was significantly higher in SLE patients than in normal subjects (P<0.01). Elevated alphaEbeta7 expression was associated with the presence of oral ulcers or serositis (P<0.05). Activated SLE T cells with enhanced alphaEbeta7 expression strongly adhered to HSG; this adhesion was partially blocked by anti-alphaEbeta7. CONCLUSION Expression and adhesion of alphaEbeta7 on activated PBL was significantly increased in patients with SLE with epithelial involvement. This suggests a role of this novel integrin in tissue-specific retention of activated PBL, due to increased alphaEbeta7-E-cadherin interaction, which may contribute to epithelial inflammation.

Fcγ receptor IIIb polymorphism and use of glucocorticoids at baseline are associated with infusion reactions to infliximab in patients with rheumatoid arthritis

Objective Infusion reaction is a major adverse event in patients with rheumatoid arthritis (RA) treated with infliximab. The possible factors including Fcγ receptor (FcγR) polymorphism associated with the development of infusion reactions in patients with RA receiving infliximab were prospectively examined. Methods 96 patients with RA were enrolled and scheduled to receive infliximab at a dose of 3 mg/kg at weeks 0, 2 and 6 and every 8 weeks thereafter. Genetic polymorphisms for FcγR were examined in FCGR3A 176F/V and FCGR3B NA1/2 alleles by allele-specific PCR analysis. Results An infusion reaction was observed in 17 patients (18%) during 52 weeks of treatment with infliximab. The FCGR3B NA1/NA1 genotype was found in 75% of the patients with infusion reactions and in only 37% of those without (p=0.01), whereas the FCGR3A 176F/V genotype was equally distributed in the patients with or without infusion reactions. Glucocorticoids were used in 53% of the patients who developed an infusion reaction and in 80% of those without an infusion reaction (p=0.02). A multivariable logistic regression model showed that the FCGR3B NA1/NA1 genotype and use of glucocorticoids at baseline could be used as independent predictive factors for infusion reactions (OR 6.1 (95% CI 1.9 to 24.3) and OR 0.26 (95% CI 0.08 to 0.84), respectively). The presence of anti-infliximab antibody during infliximab treatment was also associated with infusion reactions. Conclusion FCGR3B NA1/NA1 genotype, use of glucocorticoids and the presence of anti-infliximab antibody accounted for nearly all patients with RA who developed infusion reactions.

Severe acute thrombotic exacerbation in two cases with anti-phospholipid syndrome after retreatment with rituximab in phase I/II clinical trial for refractory systemic lupus erythematosus

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OP0040 Adding Tocilizumab or Switching to Tocilizumab Monotherapy in RA Patients with Inadequate Response to Methotrexate: 24-Week Results from a Randomized Controlled Study (Surprise Study)

Background The efficacy and safety of tocilizumab (TCZ) is established for the treatment of rheumatoid arthritis (RA). However, when TCZ is used to treat RA patients with an inadequate response to methotrexate (MTX), it is not confirmed whether it is better to continue MTX or not. Objectives To compare the efficacy and safety of TCZ monotherapy (SWITCH) and TCZ in combination with methotrexate (ADD-ON) in Japanese RA patients with inadequate response to MTX. Methods The SURPRISE study was a multicentre, prospective, randomized, open-label study. Inclusion criteria were as follows: RA diagnosed by 1987 ACR classification criteria; DAS28-ESR ≥ 3.2; disease duration ≤ 10 years; MTX ≥ 6 mg/week for at least 8 weeks. Patients were randomized to switch to TCZ or to add on TCZ. The primary endpoint was the non-inferiority of combination therapy compared to monotherapy as assessed by the DAS28 remission rate of each group at 24 weeks with a non-inferiority margin of 10% in the per protocol set (PPS). Patients who received ≥1 dose of TCZ were assessed for safety in the full analysis set (FAS). The LOCF method was used to address the missing data on efficacy. Results 233 patients were randomized: 115 to SWITCH and 118 to ADD-ON. At baseline in FAS, mean DAS28 was 5.2±0.1 and 5.1±0.1, disease duration was 4.0±0.3 and 3.8±0.3 years, MTX was 8.4±0.2 and 8.6±0.2, and HAQ-DI was 1.0±0.1 and 1.1±0.1 in the SWITCH and ADD-ON groups, respectively. DAS28 remission at 24 weeks was 59.4% in SWITCH and 71.6% in ADD-ON in PPS (n=106 in SWITCH; n=109 in ADD-ON). The delta between groups in DAS28 remission rate was 12.1 (95% CI; -1.3 – 25.2) supporting the non-inferiority of ADD-ON to SWITCH. Moreover, ADD-ON was superior to SWITCH in terms of DAS28 remission (71.3% vs 57.7%, P=0.0372) in FAS. The rates of ACR20, 50, and 70 response in each group were 66.7%, 53.2%, and 36.0% in SWITCH and 64.3%, 48.7%, and 27.8% in ADD-ON. CDAI, SDAI, and ACR/EULAR remission rates were 27.0%, 30.6%, and 20.7% in SWITCH and 36.5%, 40.0% and 20.0% in ADD-ON. The differences between groups in ACR response rate, CDAI remission, and SDAI remission were not significant. HAQ-DI and EQ-5D were similar in both groups. Incidences of serious adverse events were 9.9% in SWITCH versus 8.7% in ADD-ON; among these were 7 incidences of serious infection (3 pneumonia, 4 other infections). Conclusions In Japanese RA patients with inadequate response to MTX, combination therapy was superior to monotherapy in efficacy as assessed using DAS28 criteria. However, results by other criteria were comparable between groups. In early stage RA, TCZ showed high response, and each of the strategies was useful. Acknowledgements All member of SURPRISE study group. Disclosure of Interest T. Takeuchi Grant/research support from: Abott, Astellas, Bristol-Myers, Chugai, Daiichi Sankyo, Eisai, Janssen, Mitsubishi Tanabe, Nippon Shinyaku, Otsuka, Pfizer, Sanofi, Santen, Takeda, Teijin, Consultant for: Astra Zeneca, Eli Lilly, Novartis, Mitsubishi Tanabe, Asahi Kasei, Paid instructor for: Abott, Bristol-Myers, Chugai, Eisai, Janssen, Mitsubishi Tanabe, Pfizer, Takeda, Y. Kaneko: None Declared, T. Atsumi Grant/research support from: Kyowa Hakko Kirin, Mitsubishi Tanabe, Chugai, Novartis, Teijin, MSD, Astellas, Sanofi, Takeda, Novo Nordisk, Otsuka, Boehringer Ingelheim, Paid instructor for: Mitsubishi Tanabe, Takeda, Chugai, Pfizer, Y. Tanaka Grant/research support from: Bristol-Myers, MSD, Chugai, Mitsubishi Tanabe, Astellas, Abbott, Eisai, Janssen, Speakers bureau: Mitsubishi Tanabe, Abbott, Eisai, Chugai, Janssen, Santen, Pfizer, Astellas, Daiichi Sankyo, GlaxoSmithKline, Astra Zeneca, Otsuka, Actelion, Eli Lilly, Nippon Kayaku, UCB Japan, Quintiles Transnational, Ono, M. Inoh: None Declared, H. Kobayashi: None Declared, K. Amano Grant/research support from: Chugai, Mitsubishi Tanabe, Astellas, Eisai, Abott, M. Miyata: None Declared, Y. Murakawa Grant/research support from: Teijin, Astellas, Bristol-Myers, Mitsubishi Tanabe, Chugai, Actelion, Takeda, Pfizer, Taisho Toyama, Eisai, Paid instructor for: Santen, Chugai, Kissei, Astellas, Mitsubishi Tanabe, Actelion, Daiichi Sankyo, Takeda, T. Fujii Grant/research support from: Chugai, A. Kawakami Grant/research support from: Chugai, Mitsubishi Tanabe, Pfizer, Takeda, Abott, Eisai, Bristol-Myers, Janssen, Astellas, Santen, Taisho Toyama, Asahi Kasei, Paid instructor for: Chugai, Mitsubishi Tanabe, Pfizer, Takeda, Abott, Eisai, Bristol-Myers, Janssen, Astellas, Santen, Taisho Toyama, Asahi Kasei, H. Yamanaka Grant/research support from: Abbott, Bristol-Myers, Chugai, Eisai, Janssen, Mitsubishi Tanabe, Otsuka, Pfizer, Takeda, UCB, Paid instructor for: Abbott, Bristol-Myers, Chugai, Eisai, Janssen, Mitsubishi Tanabe, Otsuka, Pfizer, Takeda, UCB, K. Yamamoto Grant/research support from: ImmunoFuture, Inc, N. Miyasaka Grant/research support from: Abbott, Astellas, Banyu, Chugai, Daiichi Sankyo, Eisai, Janssen, Mitsubishi Tanabe, Takeda, Teijin, T. Mimori Grant/research support from: Asahi Kasei, Astellas, Bristol-Myers, Chugai, Eisai, Merck, Mitsubishi Tanabe, Pfizer, Santen, Takeda, Speakers bureau: Chugai Pharmaceutical, Eisai, Mitsubishi Tanabe, Pfizer, Santen, Takeda

Therapeutic targets of misguided T cells in systemic lupus erythematosus.

It is widely accepted that T cells with defective function play a central role in the pathogenesis of systemic lupus erythematosus (SLE). The detailed molecular mechanism underlying the aberrant function of SLE T cells is now being revealed. The TCR zeta chain, transcription factor, elf-1, inflammation signal transducer NF-kB, and PKC theta have been identified as the responsible molecules. In contrast to the defective signal transduction molecules, surface structures such as adhesion molecules, and co-stimulators have been reported to increase in their expression and function. Glucocorticoids and immunosuppressive agents have greatly improved the outcome of acute diseases and 5-year survival rate. However, it is suggested that long-term survival and quality of life appears to be unsatisfactory. Although the medical management of SLE is not sufficient to warrant long-term survival of young patients, recent progress in anti-cytokine biologics therapy against rheumatoid arthritis (RA) has facilitated searching for the molecular targets of SLE. In this report, we briefly review the molecular basis of SLE pathogenesis, and discuss possible therapeutic targets in this disease, focusing particularly on signal transduction and adhesion molecules in T cells.

Efficacy and safety of multitarget therapy with cyclophosphamide and tacrolimus for lupus nephritis: a prospective, single-arm, single-centre, open label pilot study in Japan.

Background Pulsed cyclophosphamide or mycophenolate mofetil for lupus nephritis has limited efficacy. We previously reported a case of mixed-class IV + V lupus nephritis successfully treated with cyclophosphamide and tacrolimus. This study assessed the efficacy and safety of multitarget therapy with cyclophosphamide and tacrolimus for the treatment of lupus nephritis. Methods In a prospective, single-arm, open label pilot study, we recruited 15 patients aged 18–64 years with active lupus nephritis who met the American College of Rheumatology criteria for a diagnosis of systemic lupus erythematosus (1997). The treatment protocol was a starting dose of prednisolone of 0.6−1.0 mg/kg/day for 2 weeks and then tapered to a maintenance dose, intravenous cyclophosphamide (500 mg biweekly for 3 months) and tacrolimus (3.0 mg/day). Tacrolimus was continued as maintenance therapy. Complete remission was defined as a spot urine protein/creatinine ratio of < 0.5 g/gCr with no active urine casts and a serum creatinine level that was either normal or within 30% of a previously abnormal baseline level. We retrospectively compared results for the study patients with those of 18 historical controls conventionally treated with cyclophosphamide and prednisolone. Results At baseline, the mean patient age was 41.5 ± 14.6 years (male:female ratio 2:13), urine protein/creatinine ratio 3.9 ± 2.3 g/gCr and serum creatinine 84.6 ± 34.6 µmol/L. Lupus nephritis classifications included classes IV (n = 8), III + V (n = 1), IV + V (n = 5) and unclassified (n = 1). Eleven patients completed the treatment protocol and four withdrew. At 6 months, 12 of 15 (80.0%) had achieved complete remission using intention-to-treat analysis, significantly more than historical controls (seven of 18 patients, 38.9%). A transient increase in serum creatinine and gastric symptoms occurred in three cases. One patient withdrew due to cytomegalovirus antigenemia and severe diabetes, and one patient died of thrombotic microangiopathy. Conclusions Multitarget therapy with cyclophosphamide and tacrolimus can be a therapeutic option for lupus nephritis. Clinical trials registration Combination therapy of tacrolimus and intravenous cyclophosphamide for remission induction of lupus nephritis, UMIN: 000004893, URL: https://upload.umin.ac.jp/cgi-open-bin/ctr/ctr.cgi?function=brows&action=brows&type=summary&recptno=R000005830&language=E. Date of registration: 18 January 2011.