Noriyuki Kurata

Sequential changes of KL-6 in sera of patients with interstitial pneumonia associated with polymyositis/dermatomyositis

OBJECTIVE KL-6 is a mucin-like high molecular weight glycoprotein, which is strongly expressed on type II alveolar pneumocytes and bronchiolar epithelial cells. It has been demonstrated that the KL-6 antigen is a useful marker for estimating the activity of interstitial pneumonia. In this study, it is hypothesised that serum KL-6 is a useful marker to evaluate the activity of interstitial pneumonia associated with polymyositis/dermatomyositis (PM/DM). METHODS KL-6 was measured in sera in 16 patients diagnosed with PM/DM. Five had non-specific interstitial pneumonia (NSIP), three had diffuse alveolar damage (DAD), and eight had no pulmonary involvement, and 10 were normal non-smokers as a control group. The correlation was also evaluated between the KL-6 level and each clinical course in patients with pulmonary involvement associated with PM/DM. Immunohistochemical analysis using monoclonal anti-KL-6 antibody was also performed. RESULTS KL-6 concentrations in sera of patients with interstitial pneumonia associated with PM/DM were significantly high compared with those of PM/DM without interstitial pneumonia, and normal non-smokers. KL-6 concentrations in sera in patients with DAD significantly increased compared with those of other groups. KL-6 values in sera changed according to the progression or improvement of interstitial pneumonia. Immunohistochemical study using pulmonary tissues obtained from patients with DAD demonstrated that the hyaline membrane, proliferating type II pneumocytes, bronchial epithelial cells and some endothelial cells in pulmonary veins were stained by antihuman KL-6 antibody. CONCLUSION These data demonstrate that measurement of serum KL-6 was a useful marker to evaluate the activity of acute interstitial pneumonia associated with PM/DM.

Association of Higher Methotrexate Dose With Lymphoproliferative Disease Onset in Rheumatoid Arthritis Patients

Methotrexate (MTX) is used as an anchor drug for rheumatoid arthritis (RA). Lymphoproliferative disease (LPD) occasionally develops in patients treated with MTX, and is known as MTX‐associated LPD (MTX‐LPD). Although MTX‐LPD occurs mainly in RA patients, it has not been established if MTX administration is an independent risk factor for LPD in RA patients. We examined the clinical characteristics of MTX‐LPD in Japanese RA patients and attempted to determine the risk factors for MTX‐LPD development.

Changes in foot function, disease activity, and disability after forefoot resection arthroplasty in patients with rheumatoid arthritis

The purpose of this study was to investigate the changes in foot function, disease activity, and disability in patients with RA after resection arthroplasty of the forefoot (arthroplasty). Arthroplasty was performed on 11 patients with RA. All study patients underwent clinical assessment to measure disease activity (Disease Activity Score in 28 Joints-C-reactive protein, DAS28-CRP), disability (Health Assessment Questionnaire-Disability Index, HAQ-DI) and foot function (Foot Function Index, FFI) at the following stages: preoperatively and 1, 3, and 12 months after surgery. Following arthroplasty, foot function improved significantly, as assessed by FFI total and subscales (pain, disability, and limitation of activity) (P<0.001, P<0.001, P<0.001, and P=0.002, respectively). Disease activity was significantly improved in relation to DAS28-CRP and its subscales of number of swollen joints and patient global assessment (PtGA) (P=0.033, P=0.008, and P=0.038, respectively). There was no significant difference in disability, as assessed by the HAQ-DI and its subscale, HAQ-walking (P=0.150 and P=0.597, respectively). Foot function improved significantly after arthroplasty, and was maintained at 12 months postoperatively. Additionally, our study showed that disease activity and its subscale PtGA improved after arthroplasty.

THU0209 Lymphocyte subsets in biopsy specimen are associated with spontaneous regression of lymphoproliferative disorders in rheumatoid arthritis patients treated with methotrexate

Background Patients with rheumatoid arthritis (RA) have a high risk for lymphoproliferative disorders (LPDs). An LPD in a patient treated with methotrexate (MTX) is known as MTX-associated LPD (MTX-LPD), which is classified among immunodeficiency-associated lymphoproliferative disorders (ID-LPD) as “other iatrogenic ID-LPD” in the 2008 World Health Organization Classification of Tumours of Haematopoietic and Lymphoid Tissues (1). We previously reported that MTX is an independent risk factor for LPD onset in Japanese patients with RA (2). In MTX-LPD, MTX withdrawal can result in spontaneous regression of LPD. In addition, limited evidence indicates that Epstein–Barr virus infection is related to spontaneous regression of MTX-LPD. No biomarker has been identified that predicts spontaneous regression of MTX-LPD. Objectives To identify a biomarker that predicts spontaneous regression of MTX-LPD in RA patients. Methods We enrolled RA patients from Kagawa Prefecture, Japan, who developed MTX-LPD during the period from June 2010 through December 2016. RA was diagnosed in accordance with the American College of Rheumatology 1987 classification criteria and was treated with disease-modifying antirheumatic drugs, including MTX. The patients were divided into two groups: those followed-up after discontinuation of MTX alone (MTX withdrawal group) and those who received chemotherapy at 1 month or later after MTX discontinuation (chemotherapy group). The following variables were compared between groups: change in peripheral lymphocyte subsets after MTX discontinuation, serum soluble interleukin-2 receptor, and lymphocyte subsets and Epstein–Barr virus–encoded RNAs in a biopsy specimen from a lesion. Results We enrolled 43 MTX-LPD patients (29 in the withdrawal group and 14 in the chemotherapy group). From among these groups, we selected 32 patients for analysis of changes in peripheral lymphocyte subsets (23 in the withdrawal group and 9 in the chemotherapy group) and 22 for analysis of lymphocyte subsets in a lesion specimen (11 each in the withdrawal group and chemotherapy group). Peripheral lymphocyte counts were significantly higher after MTX discontinuation in the withdrawal group. Analysis of lymphocyte subsets from lesion specimens revealed significantly higher CD8-positive lymphocyte counts in the chemotherapy group than in the withdrawal group. Conclusions Lymphocyte count differed before and after MTX discontinuation, and a higher CD8-positive lymphocyte count in a lesion specimen was associated with spontaneous regression of MTX-LPD. These findings may help identify a predictive marker for MTX-LPD treatment and management. References Swerdlow SH, Campo E, Harris NL, Jaffe ES, Pileri SA, Stein H, et al., WHO Classification of Tumours of Haematopoietic and Lymphoid Tissues. IARC Press, Lyon, 2008. Association of higher methotrexate dose with lymphoproliferative disorders onset in rheumatoid arthritis patients. Kameda T, Dobashi H, Miyatake N, Inoo M, Onishi I, Kurata N, Mitsunaka H, Kawakami K, Fukumoto T, Susaki K, Izumikawa M, Nakashima S, Shimada H, Takeuchi Y, Haba R, Mano S, Onishi H, Imataki O, Matsunaga T. Arthritis Care Res (Hoboken). 2014 Sep;66(9):1302–9. Disclosure of Interest None declared

AB0294 Lymphocyte Recovery after Methotrexate Discontinuation Relate To Spontaneous Regression of Mtx-Lpd in Ra Patients

Background Rheumatoid arthritis (RA) patients have a high risk of onset of lymphoproliferative disorders (LPD). Especially, LPD develop in patients treated with methotrexate (MTX) is known as MTX-associated LPD (MTX-LPD). MTX-LPD is classified among the “immunodeficiency-associated lymphoproliferative disorders (ID-LPD)” as an “other iatrogenic ID-LPD” in the 2008 WHO Classification of Tumours of Haematopoietic and Lymphoid Tissues (1). We previously reported that MTX is an independent risk factor for LPD onset in Japanese RA patients (2). Characteristic of MTX-LPD is that MTX withdrawal possibly results in spontaneous regression of the LPD. Furthermore, there are some reports that the Epstein-Barr virus (EBV) infection is related to spontaneous regression of MTX-LPD. However, enough evidence about the relation with EBV infection and spontaneous regression of MTX-LPD is not presented. In addition, biomarker predicting a spontaneous regression of MTX-LPD has not been clarified. Objectives We examined the clinical characteristics of MTX-LPD in Japanese RA patients and attempted to determine the predictive marker for spontaneous regression of MTX-LPD. Methods We enrolled 33 RA patients who developed MTX-LPD from Kagawa Prefecture, Japan between June 2010 and December 2015. Patients were diagnosed according to American College of Rheumatology 1987 classification criteria, and treated with disease modifying antirheumatic drugs (DMARDs) including MTX. We divided into patients who were followed-up after the discontinuation of MTX alone (MTX withdrawal group) and patients who were performed chemotherapy after one month or more of the MTX discontinuation (chemotherapy group). The following differences between the two groups were examined: 1) serum LDH; 2) serum CRP; 3) sIL-2 receptor; 4) lymphocyte counts before and after MTX discontinuation; 5) hemoglobin; 6) histological findings related to LPD; 7) EBV association; 8) number of LPD lesions and 9) outcome. Results There were 28 patients in the MTX withdrawal group and 5 patients in the chemotherapy group. Laboratory data such as LDH, CRP, sIL-2R, lymphocyte counts and hemoglobin showed no significant difference in two groups. Furthermore, there is no difference between two groups about EBV infection and number of LPD lesions. However, significant differences were found in the change ratio of lymphocyte between the two groups. Conclusions We revealed that the change of lymphocyte before and after the MTX discontinuation relate to spontaneous regression of the MTX-LPD. This data suggest that the recover of lymphocyte after the MTX discontinuation may become a predictive marker for MTX-LPD treatment strategy. References Swerdlow SH, Campo E, Harris NL, Jaffe ES, Pileri SA, Stein H, et al., WHO Classification of Tumours of Haematopoietic and Lymphoid Tissues. IARC Press, Lyon, 2008. Association of higher methotrexate dose with lymphoproliferative disorders onset in rheumatoid arthritis patients. Kameda T, Dobashi H, Miyatake N, Inoo M, Onishi I, Kurata N, Mitsunaka H, Kawakami K, Fukumoto T, Susaki K, Izumikawa M, Nakashima S, Shimada H, Takeuchi Y, Haba R, Mano S, Onishi H, Imataki O, Matsunaga T. Arthritis Care Res (Hoboken). 2014 Sep;66(9):1302–9. Disclosure of Interest None declared

AB0197 Evaluation of Serum IL-10 and IP-10 Levels Is Useful as Prognostic Biomarkers for Selection of IL-6R Antibody (TCZ) Prior To Tumor Necrosis Factor (TNF) Inhibitor in Rheumatoid Arthritis Treatment

Background Biomarkers of response to treatment in rheumatoid arthritis (RA) are sorely needed given the large inter-individual variability in efficacy of the available drugs. However, there is few reported to distinguish between responses to the different biologics (Bio) 1). Some authors think it will be difficult to obtain good predictive biomarkers for the efficacy of Bio before administration. Consequently, it is important that we identify the novel biomarker to predict the efficacy of these agents before the administration of Bio. Objectives To identify a serum biomarker for prediction of the response to Bio in patients with RA, we investigated whether serum cytokine level before treatment with Bio may represent useful prognostic biomarkers for TNF inhibitor (GLM) or IL-6R antibody (TCZ) treatment in bio-naïve RA. Methods To identify a serum biomarker for prediction of the response to Bio in patients with RA, we performed serum cytokines analysis in RA patients before and after Bio treatment with TCZ and GLM. At the first, we enrolled 10 responder and 10 poor-responder RA patients treated with Bio. 29 cytokines levels before treatment were measured using MILLIPLEX MAP Human Cytokine/Chemokine®. According to analysis of these 29 cytokines, IL-17, IL-6, IL-10 and IP-10 were eliminated as candidates for novel biomarker to predict the effectiveness of RA treatment. Then we enrolled 41 bio-naïve RA patients before administration of TCZ (n=27) or GLM (n=14). We measured these four serum cytokines before and after treatment with each Bio using ELISA. At baseline and 24 weeks after Bio-therapy with TCZ or GLM, we assessed DAS28 and measured serum levels of IL-17, IL-6, IL-10 and IP-10 using commercial ELISA kits. Responders and non-responders were defined as patients who had clinical remission (CR; DAS28 <2.6) and non-CR (DAS28 >2.6) at 24 week after administration of Bio. Wilcoxon two samples test was performed to compare cytokine levels. Results Mean age was 57.6±15.9, 70.6±14.7 years old and mean disease duration was 77.1±86.2, 114.0±142.6 months in TCZ and GLM patients, respectively. Disease activity of RA was 4.78±0.98 and 4.23±0.76 with DAS28 in TCZ and GLM patients, respectively. In CR group of TCZ (n=19), the serum IP-10 and IL-10 levels decreased compared with non-CR group by ELISA, significantly (P<0.05). As for RA patients treated with TCZ, IP-10 levels were significantly higher in responders. As for RA patients treated with GLM, responders showed a trend toward higher levels of baseline IL-10 compared to non- responders, while IP-10, IL-17 and IL-6 differences did not reach statistical significance. Conclusions In our study, the serum levels of IP-10 and IL-10 before Bio administration appeared to be associated with favorable responses to TCZ. Furthermore, these cytokines including IP-10 were not associated to response of GLM treatment. It is suggested that bio-naïve RA with low serum IP-10 levels might be treated with TCZ better than TNFi (GLM). References Gibbons LJ, Hyrich KL. Biologic therapy for rheumatoid arthritis: clinical efficacy and predictors of response. BioDrugs. 2009; 23(2): 111–24. Acknowledgement None. Disclosure of Interest None declared

FRI0056 Serum IL-10 and IP-10 Levels is an Important Predictor of Response to Tocilizumab in Bio-Naïve RA Patients

Background The efficacy of biologics is different on respective RA patients. Therefore we have to select the best one among all biologics for each RA patient. On the other hand, there is few report about good predictive biomarker for the efficacy of biologics before administration1,2. Consequently, it is important that we identify the novel biomarker to predict the efficacy of these agents before the administration of biologics. In our facility, we investigated the serum cytokines of responder or poor responder RA patients treated with Tocilizumab (TCZ). Thirty-three serum cytokine levels before TCZ administration were measured using MILLIPLEX MAP Human Cytokine/Chemokine®. In these serum cytokines, we extracted IL-17, IL-6, IL-10, IL-13 and IP-10 as novel biomarker to predict the effectiveness of TCZ. Objectives We focused on serum cytokines such as IL-17, IL-6, IL-10, IL-13 and IP-10 in Bio-naïve RA patients treated with TCZ, and reveal characteristics of biomarkers to predict the efficacy of this biologics. Methods We enrolled 27 bio-naïve RA patients before TCZ administration. We measured these five serum cytokines using ELISA. We divided these 27 bio-naïve RA patients into clinical remission (CR; DAS28 ESR <2.6) and non-CR (DAS28 ESR >2.6) group at week 24, and compared these cytokines in two groups. Results Mean age was 57.6±15.9 years old and mean disease duration was 77.1±86.2 months. Disease activity of RA before TCZ administration was 4.48±0.87 and 5.01±1.26 with DAS28 ESR in CR (n=19) and non-CR (n=8), respectively. There was no difference in patient profile between two groups. In CR group, the serum IL-10 and IP-10 levels increased compared with non-CR group by ELISA, significantly (P<0.05). There is no difference between two groups in the levels of IL-17, IL-6 and IL-13. Conclusions In our study, the serum levels of IL-10 and IP-10 before TCZ administration were different between CR and non-CR at week 24 with Bio-naïve RA patients. We suggest that serum IL-10 and IP-10 levels could predict the efficacy of TCZ on bio-naïve RA patients. References Gibbons LJ, Hyrich KL. Biologic therapy for rheumatoid arthritis: clinical efficacy and predictors of response. BioDrugs. 2009; 23(2): 111-24. Chen DY, Chen YM, Chen HH, Hsieh CW, Lin CC, Lan JL. Increasing levels of circulating Th17 cells and interleukin-17 in rheumatoid arthritis patients with an inadequate response to anti-TNF-α therapy. Arthritis Res Ther. 2011 Jul 30; 13 (4): R126. Disclosure of Interest None declared

THU0124 Higher Methotrexate Dose May Increase the Frequency of Lymphoproliferative Disorders in Rheumatoid Arthritis Patients

Background Rheumatoid arthritis (RA) is a systemic inflammatory disease that is characterized by synovitis and the destruction of articular structures of multiple joints. The goal of treatment for RA is to control the progression of these articular lesions. MTX is an antirheumatic drug that is expected to have an excellent suppressive effect on articular destruction. Recently, MTX has been used as an anchor drug for the treatment of RA (1). On the other hand, RA patients have a high risk of onset of lymphoproliferative disorders (LPD) (2). Although MTX-LPD occurs mainly in RA patients, it has not been established if MTX administration is an independent risk factor for LPD in RA patients. Objectives We examined the clinical characteristics of MTX-LPD in Japanese RA patients and attempted to determine the risk factors for MTX-LPD development. Methods We performed a nested case-control study on RA patients. We enrolled 5,783 RA patients from Kagawa Prefecture, Japan between June 2003 and Dec 2013. Patients were diagnosed according to American College of Rheumatology 1987 classification criteria, and treated with disease modifying antirheumatic drugs (DMARDs) including MTX. In age and gender matched patients, we separated patients who did not develop LPD under MTX treatment (MTX non-LPD group) from those that did (MTX-LPD group), and conducted a comparative examination. We used multivariate analysis to determine the independent risk factors for MTX-LPD onset. Results There were 33 patients in the MTX-LPD group and 145 patients in the MTX non-LPD group. The number of patients with DMARDs (except MTX) treatment showed no significant difference in two groups. Furthermore, there was no difference between two groups about that with corticosteroid and biologics treatment. Also, the complication rates for Sjögrens syndrome did not differ significantly. Using univariate analysis, significant differences were found in the duration of RA disease, Steinbrocker staging classification and mean MTX dose between the two groups. Multivariate analysis of the parameters extracted by univariate analysis revealed that the mean MTX dose was a risk factor for MTX-LPD after adjusting for age. Conclusions We revealed the mean MTX dose was demonstrated to be an independent risk factor regarding MTX-LPD onset in RA patients. This data strongly suggest that the treatment with higher MTX dose promotes LPD onset in Japanese RA patients. References Heldmann F, Braun J. Perioperative use of methotrexate. Clin Exp Rheumatol 2010; 28 (Suppl 61): S110–3. Ekström K, Hjalgrim H, Brandt L, Baecklund E, Klareskog L, Ekbom A, et al. Risk of malignant lymphomas in patients with rheumatoid arthritis and in their first-degree relatives. Arthritis Rheum 2003; 48: 963–70. Disclosure of Interest : None declared DOI 10.1136/annrheumdis-2014-eular.4752