Keisuke Hagihara

The skin of patients with systemic sclerosis softened during the treatment with anti-IL-6 receptor antibody tocilizumab

Objective. SSc is an autoimmune disease characterized by fibrosis of the skin and internal organs. Although the aetiology remains uncertain, many reports have suggested that IL-6 is involved in SSc pathogenesis. Tocilizumab, an anti-IL-6 receptor antibody, is an anti-arthritis medicine that works through the blockade of IL-6 functions. To examine the effect of tocilizumab on SSc, we administered tocilizumab to two SSc patients. Methods. Two dcSSc patients were administered tocilizumab at 8 mg/kg once a month for 6 months. One patient had pulmonary fibrosis assessed by CT and spirometry, and the other had chronic renal failure caused by scleroderma renal crisis. Their skin condition was monitored with a Vesmeter and the modified Rodnan total skin score (mRTSS). Skin biopsies were obtained before and after the tocilizumab treatment to investigate the histological changes. Results. After tocilizumab treatment, both patients showed softening of the skin with reductions of 50.7 and 55.7% in the total z-score of Vesmeter hardness and 51.9 and 23.0% in the mRTSS, respectively. Histological examination showed thinning of the collagen fibre bundles in the dermis. The creatinine clearance in the patient with chronic renal failure improved from 38 to 55 ml/min. However, the fibrotic changes in the lung in the other patient remained unchanged. Conclusions. In the two cases of SSc that we report here, softening of the skin was observed during the treatment with tocilizumab.

Essential role of STAT3 in cytokine-driven NF-kappaB-mediated serum amyloid A gene expression.

Serum amyloid A (SAA) is a sensitive marker of acute‐phase responses and known as a precursor protein of amyloid fibril in amyloid A (AA) (secondary) amyloidosis. Since the serum SAA level is also closely related to activity of chronic inflammatory disease and coronary artery disease, it is important to clarify the exact induction mechanism of SAA from the clinical point of view. Here we provide evidence that STAT3 plays an essential role in cytokine‐driven SAA expression, although the human SAA gene shows no typical STAT3 response element (RE) in its promoters. STAT3 and nuclear factor κB (NF‐κB) p65 first form a complex following interleukin (IL)‐1 and IL‐6 (IL‐1+6) stimulation, after which STAT3 interacts with nonconsensus sequences at a 3′ site of the SAA gene promoters NF‐κB RE. Moreover, co‐expression of p300 with STAT3 dramatically enhances the transcriptional activity of SAA. The formation of a complex with STAT3, NF‐κB p65, and p300 is thus essential for the synergistic induction of the SAA gene by IL‐1+6 stimulation. Our findings are expected to aid the understanding of the inflammatory status of AA amyloidosis to aid development of a therapeutic strategy for this disease by means of normalization of serum SAA levels.

Transcriptional Complex Formation of c-Fos, STAT3, and Hepatocyte NF-1α Is Essential for Cytokine-Driven C-Reactive Protein Gene Expression

C-reactive protein (CRP) is a sensitive marker and mediator of inflammation, whereas IL-6 blocking therapy can normalize serum levels of CRP in chronic inflammatory diseases. We investigated the precise synergistic induction mechanism of CRP gene expression by IL-1 and IL-6 in Hep3B cells. In the early induction phase, IL-1 inhibited IL-6-mediated CRP gene expression, and NF-κB p65 inhibited the luciferase activity of pGL3-CRP by IL-1 plus IL-6 even in the presence of overexpressed STAT3. In the late induction phase, we focused on JNK and p38 activated by IL-1. SP600125 reduced the expression of the CRP gene induced by IL-1 plus IL-6. Unexpectedly, overexpression of c-Fos dramatically enhanced the luciferase activity by IL-1 and IL-6 even though the CRP gene has no AP-1 response element (RE) in its promoter. The augmentative effect of c-Fos required the presence of STAT3 and 3′-hepatocyte NF-1 (HNF-1) RE, which were eliminated by dominant negative STAT3 and HNF-1α, respectively. SB203580 inhibited the phosphorylation of c-Fos enhanced by IL-1 plus IL-6, and diminished expression of the CRP gene. Immunoprecipitation, Western blot analysis, the Supershift assay using a CRP oligonucleotide containing STAT3 and 3′-HNF-1 RE, and the chromatin immunoprecipitation assay demonstrated that c-Fos/STAT3/HNF-1α forms a complex on the CRP gene promoter. Because human fetus liver cells failed to express c-Fos/STAT3/HNF-1α showed no CRP production, transcriptional complex formation of c-Fos/STAT3/HNF-1α is essential for the synergistic induction of CRP gene expression by IL-1 plus IL-6. Our findings fully explain the clinical results of IL-6 blocking therapy and are expected to contribute to the development of a therapeutic strategy for chronic inflammatory diseases.

Rapid improvement of AA amyloidosis with humanised anti-interleukin 6 receptor antibody treatment

AA amyloidosis is a serious complication of chronic inflammatory and infectious diseases.1 Amyloid fibril deposition causes progressive deterioration in various organs. In October 2007, a 50-year-old woman was admitted to our hospital with severe diarrhoea and weight loss. She had had rheumatoid arthritis (RA) for 12 years. Despite vigorous treatment with prednisolone and disease-modifying anti-rheumatic drugs (DMARDs), including bucillamine, sulfasalazine, auranofin, leflunomide and methotrexate or tacrolimus, her disease remained active. In January 2007, treatment was started with biological drugs. Subcutaneous injection of 25 mg of etanercept twice weekly for 2 months and, subsequently, intravenous injection of 3 mg/kg infliximab for 5 months combined with 20 mg of prednisolone …

Improvement of HbA1c during treatment with humanised anti-interleukin 6 receptor antibody, tocilizumab

Type II diabetes mellitus (T2DM) and insulin resistance (IR) are associated with a systemic, chronic inflammatory response.1 Indeed, inflammatory markers such as interleukin 6 (IL-6) or C-reactive protein are independent risk factors for T2DM.2 Recent studies suggest that IL-6 is involved in the pathology of T2DM-related IR.3 Chronic exposure to IL-6 impairs insulin signalling in hepatocytes and adipocytes by stimulating the suppressor of cytokine signalling-1.3 4 Acute IL-6 infusion increases insulin sensitivity in muscle. The action of IL-6 on glucose homoeostasis is complex. Although the influence of anti-tumour necrosis factor5 6 and anti-IL-1 treatments7 on glucose homoeostasis has been reported, no reports of the influence of anti-IL-6 treatment in humans have been published. We report that HbA1c decreased in diabetic patients with rheumatoid arthritis (RA) who were treated with a humanised anti-IL-6 antibody, tocilizumab (TCZ). …

Tocilizumab Ameliorates Clinical Symptoms in Polymyalgia Rheumatica

To the Editor: Polymyalgia rheumatica (PMR) is a chronic inflammatory disorder of unknown etiology that affects the elderly1. The disease is characterized by aching and morning stiffness in the shoulders, neck, and pelvic girdles. Although the pathogenesis of PMR remains unknown, overproduction of proinflammatory cytokines has been demonstrated to contribute to its development1,2. Corticosteroids constitute the preferred treatment for PMR and prednisolone 10–20 mg/day is usually adequate. But when prednisolone is tapered, the disease sometimes flares and continuous treatment with corticosteroids is needed. As alternative therapies, methotrexate and tumor necrosis factor (TNF)-blocking agents showed promise, but the use of these drugs remains controversial1,3. Since interleukin 6 (IL-6) has been shown to play a major role in sustaining disease activity in PMR1,2,4–6, treatment of a patient with PMR refractory to corticosteroids was initiated with the humanized anti-IL-6 receptor antibody tocilizumab7. A 65-year-old woman presented in 2002 with … Address correspondence to Dr. T. Tanaka; E-mail: ttanak{at}imed3.med.osaka-u.ac.jp

Successful treatment of reactive arthritis with a humanized anti–interleukin‐6 receptor antibody, tocilizumab

Reactive arthritis is a disease with the clinical triad of arthritis, urethritis, and conjunctivitis (1). The onset of the disease is often preceded by bacterial infections of Campylobacter, Chlamydia, Salmonella, Shigella, or Yersinia, either in the urogenital or gastrointestinal tract (2,3). HLA–B27 is strongly associated with reactive arthritis, so that this disease is considered as one of the HLA–B27positive spondylarthropathies. Although the pathogenesis of reactive arthritis remains imperfectly understood, bacterial infections trigger systemic immunoreactions, and overproduction of proinflammatory cytokines has been shown to contribute to sterile joint inflammation (1–4). Several kinds of drugs are used for the management of reactive arthritis, including nonsteroidal antiinflammatory drugs (NSAIDs); disease-modifying antirheumatic drugs (DMARDs) such as sulfasalazine, methotrexate, and leflunomide; corticosteroids; and immunosuppressive drugs, including azathioprine and cyclosporine, whereas the use of antibiotics remains controversial (1–4). Infliximab, a chimeric anti–tumor necrosis factor (anti-TNF ) antibody, and etanercept, a 75-kd TNF receptor fusion protein, reportedly ameliorated symptoms in patients with reactive arthritis (5–8), as well as other HLA–B27-positive spondylarthropathies (9). However, to our knowledge, there have been no reports regarding the efficacy of the humanized anti–interleukin-6 (IL-6) receptor antibody, tocilizumab (10), for reactive arthritis. Here we report a case of reactive arthritis treated successfully with tocilizumab.

Quantification of hardness, elasticity and viscosity of the skin of patients with systemic sclerosis using a novel sensing device (Vesmeter): a proposal for a new outcome measurement procedure

OBJECTIVES No objective method to measure skin involvement in SSc has been established. We developed a novel method using a computer-linked device to simultaneously quantify physical properties of the skin such as hardness, elasticity and viscosity. METHODS Skin hardness was calculated by measuring the depth of an indenter pressed onto the skin. The Voigt model was used to calculate skin elasticity, viscosity, visco-elastic ratio and relaxation time by analysing the waveform of skin surface behaviour. The results were compared with the modified Rodnan skin score (mRSS) obtained at 17 sites on the bodies of 20 SSc patients and 20 healthy controls. A functional assessment questionnaire was administered to determine how skin hardness represents a patients disability. We also examined intra- and inter-observer variability to determine the reliability of this method. RESULTS The crude hardness obtained with this device correlated well with the standard hardness specified by the American Society for Testing and Materials (ASTM, r = 0.957). A close relationship between hardness and total mRSS was also observed (r = 0.832). Skin elasticity correlated positively, and relaxation time negatively with mRSS. Functional disability correlated more closely with skin hardness (r = 0.643) than with mRSS (r = 0.517). Intra- and inter-observer variabilities were 7.63 and 19.76%, respectively, which were lower than those reported for mRSS. CONCLUSIONS Increases in hardness and elasticity as well as shortening of relaxation time constitute objective characteristics of skin involvement in SSc. The system devised by us proved to be able to assess skin abnormalities of SSc with high reliability.

Interleukin-16 Promotes Cardiac Fibrosis and Myocardial Stiffening in Heart Failure with Preserved Ejection Fraction

Background Chronic heart failure (CHF) with preserved left ventricular (LV) ejection fraction (HFpEF) is observed in half of all patients with CHF and carries the same poor prognosis as CHF with reduced LV ejection fraction (HFrEF). In contrast to HFrEF, there is no established therapy for HFpEF. Chronic inflammation contributes to cardiac fibrosis, a crucial factor in HFpEF; however, inflammatory mechanisms and mediators involved in the development of HFpEF remain unclear. Therefore, we sought to identify novel inflammatory mediators involved in this process. Methods and Results An analysis by multiplex-bead array assay revealed that serum interleukin-16 (IL-16) levels were specifically elevated in patients with HFpEF compared with HFrEF and controls. This was confirmed by enzyme-linked immunosorbent assay in HFpEF patients and controls, and serum IL-16 levels showed a significant association with indices of LV diastolic dysfunction. Serum IL-16 levels were also elevated in a rat model of HFpEF and positively correlated with LV end-diastolic pressure, lung weight and LV myocardial stiffness constant. The cardiac expression of IL-16 was upregulated in the HFpEF rat model. Enhanced cardiac expression of IL-16 in transgenic mice induced cardiac fibrosis and LV myocardial stiffening accompanied by increased macrophage infiltration. Treatment with anti-IL-16 neutralizing antibody ameliorated cardiac fibrosis in the mouse model of angiotensin II-induced hypertension. Conclusion Our data indicate that IL-16 is a mediator of LV myocardial fibrosis and stiffening in HFpEF, and that the blockade of IL-16 could be a possible therapeutic option for HFpEF.

Preventative Effect of a Flavonoid, Enzymatically Modified Isoquercitrin on Ocular Symptoms of Japanese Cedar Pollinosis

BACKGROUND Flavonoids are nutrients that exert anti-allergic effects. We investigated the preventative effect of enzymatically modified isoquercitrin (EMIQ), a flavonoid, to relieve the symptoms of Japanese cedar pollinosis. METHODS In a parallel-group, double-blind placebo-controlled study design, 24 subjects with Japanese cedar pollinosis took 100mg EMIQ or a placebo for 8 weeks, starting 4 weeks prior to the onset of pollen release. Subjective symptoms, ADL scores and the usage of drugs were recorded daily, and the QOL score was obtained every 4 weeks. Blood sampling was performed before and after the study to measure serum levels of IgE and flavonoids. RESULTS During the entire study period, ocular symptom + medication score for the EMIQ group was significantly lower (p < 0.05) than that of the placebo group. When limited to the period, ocular symptom scores (p < 0.05, weeks 5-6), and ocular congestion scores (p < 0.05, weeks 5-6) for the EMIQ group was significantly lower than that for the placebo group while other scores for the EMIQ group, such as ocular itching scores (p = 0.09, weeks 4-5), lacrimation scores (p = 0.07, weeks 5-6), and ocular congestion scores (p = 0.06, weeks 4-5), all tended to be lower. However no significant differences were found in nasal symptoms between the two groups. Serum concentrations of IgE were not significantly downregulated but the serum concentrations of quercetin and its derivatives were elevated significantly by the intake of EMIQ. CONCLUSIONS Intake of the quercetin glycoside EMIQ proved to be effective for the relief of ocular symptoms caused by Japanese cedar pollinosis.