Pathophysiology and immunolgical basis of axial spondyloarthritis

Biomarkers for successful tapering of a tumor necrosis factor inhibitor in patients with radiographic axial spondyloarthritis: A pilot study

Background

Tumor necrosis factor inhibitors are the most widely used biological disease-modifying antirheumatic drugs for radiographic axial spondyloarthritis. After achieving remission with tumor necrosis factor inhibitor treatment, experts recommend tapering tumor necrosis factor inhibitor. However, biomarkers for successful tumor necrosis factor inhibitor tapering in radiographic axial spondyloarthritis have not been identified.

Objectives

To identify biomarkers associated with successful tumor necrosis factor inhibitor tapering in patients with radiographic axial spondyloarthritis.

Design

We prospectively collected blood samples from radiographic axial spondyloarthritis patients at single tertiary hospital.

Methods

Patients with radiographic axial spondyloarthritis who achieved remission (axial spondyloarthritis disease activity score < 1.3) after treatment with tumor necrosis factor inhibitor were enrolled. Baseline demographics, medication history, and laboratory data were collected when the tumor necrosis factor inhibitor dose was tapered. The percentage of helper T cell subtypes (Th1/Th2/Th17/Th22) in peripheral blood, and serum levels of tumor necrosis factor-α, interleukin-12, IL-17A, IL-22, IL-23, interferon (IFN)-γ, soluble CD14, and zonulin, were measured. Patients were assigned to tumor necrosis factor inhibitor tapering success (axial spondyloarthritis disease activity score < 2.1) or failure (axial spondyloarthritis disease activity score ⩾ 2.1) groups according to disease activity (assessed at 12 weeks posttumor necrosis factor inhibitor tapering).

Results

Twenty radiographic axial spondyloarthritis patients were enrolled (median age, 31.0 years; 65% males). Most (80%) were positive for human leukocyte antigen-B27. The change of axial spondyloarthritis disease activity score in the tumor necrosis factor inhibitor-tapering failure group was 1.36, while that in the tumor necrosis factor inhibitor-tapering success group was 0.07. The percentage of Th1 and Th17 cells was significantly lower, and that of Th2 cells higher, in the tumor necrosis factor inhibitor-tapering success group. In addition, serum levels of IL-12, IL-17A, IL-22, IFN-γ, tumor necrosis factor-α, zonulin, and soluble CD14 were significantly lower in the tumor necrosis factor inhibitor-tapering success group.

Conclusion

Patients with radiographic axial spondyloarthritis who achieve successful tumor necrosis factor inhibitor tapering had lower percentages of Th1 and Th17 cells, a higher percentage of Th2 cells, and lower serum levels of IL-12, IL-17A, IL-22, IFN-γ, tumor necrosis factor-α, zonulin, and soluble CD14 at the time of tumor necrosis factor inhibitor tapering. These findings may help to identify patients with radiographic axial spondyloarthritis for whom tumor necrosis factor inhibitor tapering is appropriate.

JAK inhibition and axial spondyloarthritis: new steps on the path to understanding pathophysiology

Axial spondyloarthritis (axSpA) is a chronic inflammatory disease that predominantly affects the sacroiliac joints and spine. Tumor necrosis factor (TNF) and interleukin (IL)-17A are key cytokines in disease pathogenesis and are established axSpA treatment targets. Recently, axSpA treatment options have been complemented by Janus kinase inhibitors (JAKi), which inhibit various cytokines without directly impacting TNF or IL-17 signaling. The effect of JAKi on axSpA remains under investigation: besides a JAK2-mediated (and potentially tyrosine kinase 2 [TYK2]-mediated) effect on the IL-23/IL-17 axis, emerging evidence suggests γδ T cells, type 3 innate lymphoid cells, and mucosa-associated invariant T cells, which are dependent on IL-7 and/or IL-15 and thus on JAK1, are strongly inhibited by JAKi used to treat axSpA. This review summarizes potential effects of JAKi on axSpA and shows evidence from pre-clinical/clinical studies. Greater understanding of the mechanisms of action of available treatments may improve knowledge of axSpA and pave the road for future therapies.

The Causal Relationships and Therapeutic Targets of Plasma Proteins in Ankylosing Spondylitis

Objective: The purpose of this study was to assess the causal effects of circulating plasma proteins on ankylosing spondylitis (AS) and to explore potential therapeutic targets. Methods: The study used protein quantitative trait loci (pQTLs) for thousands of plasma proteins from nine genome-wide association studies (GWAS) as instrumental variables. The relationship between genetically predicted plasma proteins and AS was assessed through Mendelian randomization (MR) analysis. Further analyses, including colocalization analysis, Steiger filtering analysis, protein-altering variant assessment, protein-protein interaction (PPI), and pathway enrichment analysis, were conducted to validate the robustness and causal direction of the results, as well as to investigate the protein functions and potential drug targets. Results: Nine unique proteins were found to have strong causal associations with AS. Steiger filtering analysis confirmed that all associations identified by MR analysis have a direct causal link from the proteins to AS. Colocalization analysis identified four unique proteins-Interleukin-6 receptor alpha (IL-6Rα), Interleukin-23 receptor (IL-23R), Thrombospondin-2 (THBS2), and Interleukin-1 receptor type 2 (IL-1R2)-that share the same causal variants with AS. PPI and pathway enrichment analysis revealed the potential roles of these proteins in inflammatory responses and immune regulation. Moreover, these proteins were valuable drug targets or considered druggable. Conclusions: This study has identified multiple plasma proteins associated with AS, revealing the important roles of these proteins in the pathogenesis of AS and providing potential therapeutic targets for AS.

Unmet needs in axial spondyloarthritis. Proceedings of the French spondyloarthritis taskforce workshop

The progress observed over the last 30 years in the field of axial spondyloarthritis (axSpA) has not made it possible to answer all the current questions. This manuscript represents the proceedings of the meeting of the French spondyloArthitiS Task force (FAST) in Besançon on September 28 and 29, 2023. Different points of discussion were thus individualized as unmet needs: biomarkers for early diagnosis and disease activity, a common electronic file dedicated to SpA nationwide, a better comprehension of dysbiosis in the disease, a check-list for addressing to the rheumatologist, adapt patient reported outcomes thresholds for female gender, implementation of comorbidities screening programs, new imaging tools, in research cellular and multi omics approaches, grouping, at a nationwide level, different cohorts and registries, therapeutic strategy studies, consensual definition of difficult to treat disease and management, preclinical stage of the disease, mastering AI as a tool in the various aspects of research. These elements may represent a framework for the research agenda in axSpA for the years to come.

Polymorphic variation of the DEFB1 gene might contribute to the development of ankylosing spondylitis: a preliminary study

BACKGROUND

Ankylosing spondylitis (AS) is an inflammatory disease that affects the spine and can cause peripheral arthritis, enthesitis, and dactylitis, as well as extra-articular manifestations such as uveitis and inflammatory bowel disease. β-Defensins are antimicrobial peptides involved in the activation and regulation of several immune cell types that may influence the inflammatory response in AS. The aim was to analyze the association and interaction of two functional variants of the DEFB1 gene in AS patients, and their role with inflammatory markers.

METHODS AND RESULTS

The rs11362 and rs1800972 variants were genotyped using TaqMan probes in Mexican AS patients and controls. C-reactive protein (CRP) levels and erythrocyte sedimentation rate (ESR) were quantified. SPSS software was used for statistical analysis and multifactor dimensionality reduction (MDR) for interactions. The AA and GG genotypes were associated with AS risk in the age- and sex-adjusted model (OR = 6.89, P = 0.008 and OR = 3.43, P = 0.046, respectively); furthermore, the A-G haplotype showed a significant association with AS risk (OR = 2.94, P = 0.012). ESR and CRP were elevated in carriers of the AA genotype compared to the GA and GG genotypes of the rs11362 variant (20.89 ± 9.78 vs. 5.63 ± 4.61 and 4.10 ± 2.65 mm/h, P < 0.0001; and 10.92 ± 14.09 vs. 2.14 ± 2.02 and 2.15 ± 2.13 mg/L, P < 0.001, respectively). Using the MDR method, strong interactions of the rs11362 variant with sex were identified in the adjusted and unadjusted models.

CONCLUSIONS

These results suggest that the DEFB1 gene may play a key role in AS pathogenesis.

A systematic review and meta-analysis of the efficacy and safety of iguratimod in the treatment of inflammatory arthritis and degenerative arthritis

Objective

To assess the efficacy and safety of iguratimod (IGU) in the treatment of inflammatory arthritis and degenerative arthritis.

Methods

Initially, randomized controlled trials (RCTs) on using IGU in treating inflammatory arthritis and degenerative arthritis were systematically gathered from various databases up to February 2024. Subsequently, two researchers independently screened the literature, extracted data, assessed the risk of bias in included studies, and conducted a meta-analysis using RevMan 5.4 software.

Results

Fifty-four RCTs involving three inflammatory arthritis were included, including ankylosing spondylitis (AS), osteoarthritis (OA), and rheumatoid arthritis (RA). For AS, the meta-analysis results showed that IGU may decrease BASDAI (SMD -1.68 [-2.32, -1.03], P < 0.00001) and BASFI (WMD -1.29 [-1.47, -1.11], P < 0.00001); IGU may also decrease inflammatory factor [ESR: (WMD -10.33 [-14.96, -5.70], P < 0.0001); CRP: (WMD -10.11 [-14.55, -5.66], P < 0.00001); TNF-α: (WMD -6.22 [-7.97, -4.47], P < 0.00001)]. For OA, the meta-analysis results showed that IGU may decrease VAS (WMD -2.20 [-2.38, -2.01], P < 0.00001) and WOMAC (WMD -7.27 [-12.31, -2.24], P = 0.005); IGU may also decrease IL-6 (WMD -8.72 [-10.00, -7.45], P < 0.00001). For RA, the meta-analysis results showed that IGU may improve RA remission rate [ACR20: (RR 1.18 [1.02, 1.35], P = 0.02); ACR50: (RR 1.32 [1.05, 1.64], P = 0.02); ACR70: (RR 1.44 [1.02, 2.04], P = 0.04)] and decrease DAS28 (WMD -0.92 [-1.20, -0.63], P < 0.00001); IGU may also decrease inflammatory factors [CRP: (SMD -1.36 [-1.75, -0.96], P < 0.00001); ESR: (WMD -9.09 [-11.80, -6.38], P < 0.00001); RF: (SMD -1.21 [-1.69, -0.73], P < 0.00001)]. Regarding safety, adding IGU will not increase the incidence of adverse events.

Conclusion

IGU might emerge as a promising and secure therapeutic modality for addressing AS, OA, and RA.

Systematic Review Registration

Identifier PROSPERO: CRD42021289249.

IL-17 inhibitors in axial spondyloarthritis. An overview

INTRODUCTION

The therapeutic armamentarium for spondyloarthritis has expanded considerably in recent years, and there is growing evidence to support the increasing use of IL-17 inhibitors (IL-17i) in axial spondyloarthritis (axSpA).

AREAS COVERED

This literature review provides an update on the role of IL-17 in the pathogenesis of axSpA, efficacy and safety from clinical trials and real-life studies on the use of IL17i in axSpA. We also review the impact of extra-musculoskeletal manifestations on the decision to treat with IL17i and the efficacy of IL17i on structural progression.

EXPERT OPINION

There are still some unanswered questions concerning the use of IL-17i in axSpA in clinical practice such as their respective place in the management of axSpA compared to TNFα inhibitors (TNFi). Their main differences rely on their specific efficacy in extra-articular manifestations such as psoriasis, uveitis, and inflammatory bowel diseases leading to the choice of the best treatment in a given patient. Regarding their real impact on structural progression, the rate of progression under IL-17i appears to be low and presumably similar to TNFi. One final question is the advantage of blocking the two IL-17 isoforms A and F compared to the single inhibition of IL-17A.

Axial Spondyloarthritis: an overview of the disease

Axial Spondyloarthritis (axSpA) is a chronic, inflammatory, immune-mediated rheumatic disease that comprises two subsets, non-radiographic and radiographic axSpA, and belongs to a heterogeneous group of spondyloarthritides (SpA). Over the years, the concept of SpA has evolved significantly, as reflected in the existing classification criteria. Considerable progress has been made in understanding the genetic and immunological basis of axSpA, in studying the processes of chronic inflammation and pathological new bone formation, which are pathognomonic for the disease. As a result, new medication therapies were developed, which bring more effective ways for disease control. This review presents a brief overview of the literature related to these aspects of disease after summarising the available information on the topic that we considered relevant. Specifically, it delves into recent research illuminating the primary pathological processes of enthesitis and associated osteitis in the context of inflammation in axSpA. The exploration extends to discussion of inflammatory pathways, with a particular focus on Th1/Th17-mediated immunity and molecular signaling pathways of syndesmophyte formation. Additionally, the review sheds light on the pivotal role of cytokine dysregulation, highlighting the significance of the IL-23/17 axis and TNF-α in this intricate network of immune responses which is decisive for therapeutic approaches in the disease.

Proteome-wide Mendelian randomization identifies therapeutic targets for ankylosing spondylitis

Background

Ankylosing Spondylitis (AS) is a chronic inflammatory disorder which can lead to considerable pain and disability. Mendelian randomization (MR) has been extensively applied for repurposing licensed drugs and uncovering new therapeutic targets. Our objective is to pinpoint innovative therapeutic protein targets for AS and assess the potential adverse effects of druggable proteins.

Methods

We conducted a comprehensive proteome-wide MR study to assess the causal relationships between plasma proteins and the risk of AS. The plasma proteins were sourced from the UK Biobank Pharma Proteomics Project (UKB-PPP) database, encompassing GWAS data for 2,940 plasma proteins. Additionally, GWAS data for AS were extracted from the R9 version of the Finnish database, including 2,860 patients and 270,964 controls. The colocalization analysis was executed to identify shared causal variants between plasma proteins and AS. Finally, we examined the potential adverse effects of druggable proteins for AS therapy by conducting a phenome-wide association study (PheWAS) utilizing the extensive Finnish database in version R9, encompassing 2,272 phenotypes categorized into 46 groups.

Results

The findings revealed a positive genetic association between the predicted plasma levels of six proteins and an elevated risk of AS, while two proteins exhibited an inverse association with AS risk (P fdr < 0.05). Among these eight plasma proteins, colocalization analysis identified AIF1, TNF, FKBPL, AGER, ALDH5A1, and ACOT13 as shared variation with AS(PPH3+PPH4>0.8), suggesting that they represent potential direct targets for AS intervention. Further phenotype-wide association studies have shown some potential side effects of these six targets (P fdr < 0.05).

Conclusion

Our investigation examined the causal connections between six plasma proteins and AS, providing a comprehensive understanding of potential therapeutic targets.