Rogier M. Thurlings

Synovial tissue research: a state-of-the-art review

The synovium is the major target tissue of inflammatory arthritides such as rheumatoid arthritis. The study of synovial tissue has advanced considerably throughout the past few decades from arthroplasty and blind needle biopsy to the use of arthroscopic and ultrasonographic technologies that enable easier visualization and improve the reliability of synovial biopsies. Rapid progress has been made in using synovial tissue to study disease pathogenesis, to stratify patients, to discover biomarkers and novel targets, and to validate therapies, and this progress has been facilitated by increasingly diverse and sophisticated analytical and technological approaches. In this Review, we describe these approaches, and summarize how their use in synovial tissue research has improved our understanding of rheumatoid arthritis and identified candidate biomarkers that could be used in disease diagnosis and stratification, as well as in predicting disease course and treatment response.

Morphea and Eosinophilic Fasciitis: An Update

Morphea, also known as localized scleroderma, encompasses a group of idiopathic sclerotic skin diseases. The spectrum ranges from relatively mild phenotypes, which generally cause few problems besides local discomfort and visible disfigurement, to subtypes with severe complications such as joint contractures and limb length discrepancies. Eosinophilic fasciitis (EF, Shulman syndrome) is often regarded as belonging to the severe end of the morphea spectrum. The exact driving mechanisms behind morphea and EF pathogenesis remain to be elucidated. However, extensive extracellular matrix formation and autoimmune dysfunction are thought to be key pathogenic processes. Likewise, these processes are considered essential in systemic sclerosis (SSc) pathogenesis. In addition, similarities in clinical presentation between morphea and SSc have led to many theories about their relatedness. Importantly, morphea may be differentiated from SSc based on absence of sclerodactyly, Raynaud’s phenomenon, and nailfold capillary changes. The diagnosis of morphea is often based on characteristic clinical findings. Histopathological evaluation of skin biopsies and laboratory tests are not necessary in the majority of morphea cases. However, full-thickness skin biopsies, containing fascia and muscle tissue, are required for the diagnosis of EF. Monitoring of disease activity and damage, especially of subcutaneous involvement, is one of the most challenging aspects of morphea care. Therefore, data harmonization is crucial for optimizing standard care and for comparability of study results. Recently, the localized scleroderma cutaneous assessment tool (LoSCAT) has been developed and validated for morphea. The LoSCAT is currently the most widely reported outcome measure for morphea. Care providers should take disease subtype, degree of activity, depth of involvement, and quality-of-life impairments into account when initiating treatment. In most patients with circumscribed superficial subtypes, treatment with topical therapies suffices. In more widespread disease, UVA1 phototherapy or systemic treatment with methotrexate (MTX), with or without a systemic corticosteroid combination, should be initiated. Disappointingly, few alternatives for MTX have been described and additional research is still needed to optimize treatment for these debilitating conditions. In this review, we present a state-of-the-art flow chart that guides care providers in the treatment of morphea and EF.

A single course of rituximab does not abrogate anti-infliximab antibodies in patients with rheumatoid arthritis

The development of anti-infliximab antibodies in 8% to 43% of infliximab-treated patients is associated with decreased efficiency and increased risk of adverse effects.1–3 An intervention that can diminish anti-infliximab antibody formation is therefore warranted. Rituximab, a chimeric monoclonal antibody that selectively depletes CD20-positive B lymphocytes, could potentially inhibit the human antibody response against infliximab. Therefore, we assessed the proportion of patients with rheumatoid arthritis (RA) in which treatment with rituximab resulted in the depletion of anti-infliximab antibodies. Consecutive patients with RA with detectable anti-infliximab antibodies, who were initiated on treatment with either rituximab or adalimumab, were included in this prospective controlled cohort study. …

Long-term outcome of eosinophilic fasciitis: A cross-sectional evaluation of 35 patients

Background: Eosinophilic fasciitis (EF) is a connective tissue disease with an unknown long‐term course. Objective: To evaluate presence and determinants of residual disease damage in patients with EF after long‐term follow‐up. Methods: Patients with biopsy‐proven EF were included for this cross‐sectional study. Outcome measures included the Physicians Global Assessment of Disease Activity, Physicians Global Assessment of Damage (PhysGA‐D), skin pliability scores, passive range of motion, and health‐related quality of Life (HRQoL) questionnaires. Results: In total, 35 patients (24 of whom were female [68.6%]) with a median age of 60 years participated. All patients had detectable residual damage. Impairment of HRQoL, assessed by the Dermatology Quality of Life Index and the 36‐Item Short‐Form Survey, correlated to the extent of residual damage. The PhysGA‐D score at participation correlated to signs of severe disease at presentation, such as increased C‐reactive protein level (Spearmans rho [rs ] = 0.486, P = .006), involvement of the neck (rs = 0.528, P = .001) and trunk (rs = 0.483, P = .003), prolonged time to disease remission (rs = 0.575, P = .003), and presence of concomitant morphea (rs = 0.349, P = .040). Lastly, maximum methotrexate dose correlated negatively to PhysGA‐D score at study participation (rs = ‐0.393, P = .022). Limitations: Sample size. Conclusion: All patients with EF had detectable residual damage. Impairment of HRQoL correlated to the extent of residual damage. Advanced age and signs of severe disease at presentation were associated with the severity of residual damage.

Functional Tissue Analysis Reveals Successful Cryopreservation of Human Osteoarthritic Synovium

Osteoarthritis (OA) is a degenerative joint disease affecting cartilage and is the most common form of arthritis worldwide. One third of OA patients have severe synovitis and less than 10% have no evidence of synovitis. Moreover, synovitis is predictive for more severe disease progression. This offers a target for therapy but more research on the pathophysiological processes in the synovial tissue of these patients is needed. Functional studies performed with synovial tissue will be more approachable when this material, that becomes available by joint replacement surgery, can be stored for later use. We set out to determine the consequences of slow-freezing of human OA synovial tissue. Therefore, we validated a method that can be applied in every routine laboratory and performed a comparative study of five cryoprotective agent (CPA) solutions. To determine possible deleterious cryopreservation-thaw effects on viability, the synovial tissue architecture, metabolic activity, RNA quality, expression of cryopreservation associated stress genes, and expression of OA characteristic disease genes was studied. Furthermore, the biological activity of the cryopreserved tissue was determined by measuring cytokine secretion induced by the TLR ligands lipopolysaccharides and Pam3Cys. Compared to non frozen synovium, no difference in cell and tissue morphology could be identified in the conditions using the CS10, standard and CryoSFM CPA solution for cryopreservation. However, we observed significantly lower preservation of tissue morphology with the Biofreeze and CS2 media. The other viability assays showed trends in the same direction but were not sensitive enough to detect significant differences between conditions. In all assays tested a clearly lower viability was detected in the condition in which synovium was frozen without CPA solution. This detailed analysis showed that OA synovial tissue explants can be cryopreserved while maintaining the morphology, viability and phenotypical response after thawing, offering enhanced opportunities for human in vitro studies.

Predictive value of serum calprotectin (S100A8/A9) for clinical response after starting or tapering anti-TNF treatment in patients with rheumatoid arthritis

Objectives Calprotectin (S100A8/A9) has been correlated with disease activity in rheumatoid arthritis (RA). The aim of this study was to investigate the predictive value of serum calprotectin for clinical response after starting and tapering anti-tumour necrosis factor treatment in RA. Methods Serum samples and clinical outcomes were derived from two longitudinal RA studies. At baseline (starting or tapering of adalimumab or etanercept), calprotectin levels were determined by ELISA. In the Biologic Individual Optimised Treatment Outcome Prediction (BIO-TOP) study, treatment effect was assessed after 6 months using the European League Against Rheumatism (EULAR) response criteria. In the Dose Reduction Strategies of Subcutaneous TNF Inhibitors (DRESS) study, patients were classified at 18 months as being successfully dose reduced, discontinued or not able to reduce the dose. Area under the receiver operating characteristic curves (AUC) were generated to evaluate the predictive value of calprotectin and logistic prediction models were created to assess its added value. Results In the BIO-TOP study, calprotectin levels were higher in responders (n=50: 985 ng/mL (p25–p75: 558–1417)) compared with non-responders (n=75: 645 ng/mL (p25–p75: 415–973), p=0.04). AUC for predicting EULAR good response was 0.61 (95% CI 0.50 to 0.71). The prediction model with calprotectin (AUC 0.77, 95% CI 0.68 to 0.85) performed similarly to the baseline model (AUC 0.74, 95% CI 0.65 to 0.82, p=0.29). In the DRESS study, calprotectin levels were similar between the three groups (n=47; n=19; n=36) and calprotectin was not predictive for clinical response after tapering. Conclusions Serum calprotectin has some predictive value for clinical response after starting anti-TNF treatment, although it has no added value to other clinical factors. In patients with low disease activity, serum calprotectin is not predictive for clinical response after tapering anti-TNF treatment. Trial registration number NTR4647 (BIO-TOP study) and NTR3216 (DRESS study); Pre-results.

Drug Survival and Predictors of Drug Survival for Methotrexate Treatment in a Retrospective Cohort of Adult Patients with Localized Scleroderma.

Data regarding the efficacy and safety of methotrexate (MTX) in adults with localized scleroderma (LoS) is scarce. This study gathered data from a retrospective cohort of adult patients with LoS (n?=?107), treated with MTX (1993-2015). MTX drug survival and predictors thereof were analysed. After 1 and 2 years, 26% and 63% of patients stopped MTX due to disease remission, respectively. Patients with younger age at MTX initiation (hazard ratio (HR) 1.159 (95% confidence interval (CI) 1.052-1.277)) and those with no other autoimmune diseases (HR 3.268 (95% CI 1.334-8.009)) more often stopped MTX due to disease remission. In addition, 24% of patients stopped MTX due to treatment failure within one year. Patients with circumscribed superficial LoS (HR 0.221 (95% CI 0.081-0.601)) experienced treatment failure less often than those with other LoS subtypes. Finally, adding folic acid (HR 0.184 (95% CI 0.079-0.425)) and reducing treatment delay (HR 1.056 (95% CI 1.004-1.112)) could be the most important factors in minimizing MTX treatment failure in LoS in clinical practice.

Hit hard and early: analysing the effects of high-dose methylprednisolone on nailfold capillary changes and biomarkers in very early systemic sclerosis: study protocol for a 12-week randomised controlled trial

BackgroundMounting evidence indicates that inflammatory mechanisms drive systemic sclerosis (SSc) vasculopathy and fibrosis, especially early in the disease. Therefore, patients with very early SSc could benefit from early treatments targeting inflammation. Glucocorticoids are among the most potent anti-inflammatory and immunosuppressive agents. Several studies have demonstrated a mixed response to treatment with glucocorticoids in SSc, probably because it is seldom initiated at very early stages of the disease. We hypothesise that by inhibiting the inflammatory process driving SSc disease progression, glucocorticoid treatments will induce remission in patients with very early SSc.Methods/designThis study is a 12-week, randomised, double-blind, placebo-controlled trial analysing the effects of high-dose intravenous methylprednisolone in very early SSc. Thirty patients who fulfil the criteria for very early SSc will be randomly assigned in a 2:1 ratio to receive either intravenous methylprednisolone or a placebo on three consecutive days over three consecutive months. In this study, the primary endpoint will be the change in capillary density between the baseline and after 12 weeks of treatment. The secondary outcomes of this study are a change in selected biomarkers, other changes in the nailfold capillaries, signs of established SSc and changes in physical function, general health and utilities, as reported through questionnaires.DiscussionThis trial is the first aiming to treat very early SSc and is promising because it targets the very early stages of the disease process by using an inexpensive and relatively safe treatment known to be highly effective against inflammation. The use of vasculopathy and inflammatory biomarkers as well as clinical signs and symptoms as the endpoints in our study enables us to meet the patient need for markers of disease activity. If it is possible to prevent clinically significant disease in patients with very early SSc by using a safe treatment, this will cause a paradigm shift in scleroderma care and research.Trial registrationClinicalTrials.gov Identifier: NCT03059979. Registered on 20 February 2017.

Rheumatoid arthritis patients with circulating extracellular vesicles positive for IgM rheumatoid factor have higher disease activity

Rheumatoid arthritis (RA) is an autoimmune inflammatory disease that mainly affects synovial joints. Validated laboratory parameters for RA diagnosis are higher blood levels of rheumatoid factor IgM (IgM-RF), anti-citrullinated protein autoantibodies (ACPA), C-reactive protein (CRP) levels and erythrocyte sedimentation rate (ESR). Clinical parameters used are the number of tender (TJC) and swollen joints (SJC) and the global patient visual analog score (VAS). To determine disease remission in patients a disease activity score (DAS28) can be calculated based on SJC, TJC, VAS, and ESR (or alternatively CRP). However, subtle and better predictive changes to follow treatment responses in individual patients cannot be measured by the above mentioned parameters nor by measuring cytokine levels in blood. As extracellular vesicles (EVs) play a role in intercellular communication and carry a multitude of signals we set out to determine their value as a biomarker for disease activity. EVs were isolated from platelet-free plasma of 41 RA patients and 24 healthy controls (HC) by size exclusion chromatography (SEC). We quantified the particle and protein concentration, using NanoSight particle tracking analysis and micro-BCA, respectively, and observed no differences between RA patients and HC. In plasma of 28 out of 41 RA patients IgM-RF was detectable by ELISA, and in 13 out of these 28 seropositive RA patients (RF+RA) IgM-RF was also detected on their isolated pEVs (IgM-RF+). In seronegative RA patients (RF−RA) we did not find any RF present on pEVs. When comparing disease parameters we found no differences between RF+RA and RF−RA patients, except for increased ESR levels in RF+RA patients. However, RF+RA patients with IgM-RF+ pEVs showed significantly higher levels of CRP and ESR and also VAS and DAS28 were significantly increased compared to RA+ patients without IgM-RF+ pEVs. This study shows for the first time the presence of IgM-RF on pEVs in a proportion of RF+RA patients with a higher disease activity.

FRI0120 Serum calprotectin is not predictive for successful dose reduction or discontinuation of tnf inhibitors in ra patients with low disease activity

Background Dose reduction and discontinuation of TNF inhibitors (TNFi) have been shown feasible in a large proportion of RA patients with low disease activity.1 However, to date, no predictors for successful dose reduction or discontinuation have been identified.2 Calprotectin (a heterodimer of S100A8/S100A9) might be a promising biomarker in this context, as preliminary data showed this pro-inflammatory marker to be associated with disease activity and radiographic progression in RA and to be predictive for response in RA patients starting treatment with a TNFi.3,4 Objectives To investigate the predictive value of baseline serum calprotectin for successful TNFi dose reduction or discontinuation in RA patients with low disease activity. Methods Data was derived from the intervention arm of the DRESS (Dose REduction Strategies of Subcutaneous TNFi) study, which showed non-inferiority of a dose reduction strategy of adalimumab or etanercept compared to usual care.1 TNFi dose interval was reduced stepwise every 3 months until flare (DAS28-CRP increase >1.2 or >0.6 if current DAS28-CRP ≥3.2) or discontinuation. Patients were classified at 18 months as being successfully dose reduced, discontinued or not able to reduce the TNFi dose. At baseline, quantification of calprotectin was carried out on serum samples using ELISA. To assess the predictive value, calprotectin levels were compared between each group and receiver-operator-characteristic (ROC) curves were created. In addition, calprotectin was correlated cross-sectionally with several clinical markers for disease activity. Results Calprotectin levels were available for 102 of 121 patients randomised to the intervention group; 61% were women, 63% received etanercept and 37% received adalimumab. Overall, 46% of patients successfully reduced their TNFi dose, 19% of patients successfully discontinued their TNFi and 35% of patients could not reduce their TNFi dose. In these groups, median calprotectin levels were 599 ng/ml (p25-p75: 473–965), 629 ng/mL (p25-p75: 453–896) and 624 ng/mL (p25-p75: 514–931) (p=0.801) (Figure 1). The area under the ROC-curve was 0.52 (95% CI: 0.40–0.63) for predicting successful TNFi dose reduction, 0.53 (95% CI: 0.38–0.67) for successful TNFi discontinuation and 0.54 (95% CI: 0.42–0.66) for no dose reduction possible. Calprotectin levels were significantly but weakly correlated with C-reactive protein (CRP) levels with a Spearman ρ of 0.21 (p=0.03). No significant correlation was found between calprotectin and age, gender, DAS28-CRP, rheumatoid factor or ACPA positivity. Conclusions Serum calprotectin is not predictive for successful TNFi dose reduction or discontinuation in the context of RA patients with low disease activity, and calprotectin was only weakly correlated to CRP levels. These results might be caused by the lack of variability in calprotectin levels at baseline as all patients were in low disease activity state. References van Herwaarden et al. BMJ 2015;350:h1389. Tweehuysen et al. Arthritis Rheumatol 2016. Berner Hammer et al. Ann Rheum Dis 2010;69(1):150–4. Choi et al. Ann Rheum Dis 2015;74(3):499–505. Disclosure of Interest N. Den Broeder: None declared, L. Tweehuysen: None declared, T. Vogl: None declared, N. van Herwaarden: None declared, F. van den Hoogen Consultant for: Biogen, Celltrion, Janssen, Mundipharma and Sandoz, R. Thurlings: None declared, A. den Broeder Consultant for: AMGEN