Janus kinase-targeting therapies in rheumatology: a mechanisms-based approach

Macrophage Activation Syndrome: Not Just for Rheumatologists Anymore

SYNOPSIS

Macrophage activation syndrome (MAS) is a term that was originally used to describe a hyperinflammatory syndrome that developed in some patients with rheumatologic diseases. It is now clear that MAS and hemophagocytic lymphohistiocytosis (HLH) are defined by the same core pattern of clinical symptoms and share an underlying pathophysiology of impaired cytolytic activity and IFNγ-driven cytokine storm. Given that these disorders are highly related, lessons learned from the management of MAS can provide insights into effective approaches for HLH, particularly the strategy to employ anti-cytokine therapies early in the disease course.

Mucosal implications of oral Jak3-targeted drugs in COVID patients

The JAK family, particularly JAK3, plays a crucial role in immune signaling and inflammatory responses. Dysregulated JAK3 activation in SARS-CoV-2 infections has been associated with severe inflammation and respiratory complications, making JAK inhibitors a viable therapeutic option. However, their use raises concerns regarding immunosuppression, which could increase susceptibility to secondary infections. While long-term adverse effects are less of a concern in acute COVID-19 treatment, patient selection and monitoring remain critical. Furthermore, adverse effects associated with oral JAK3 inhibitors necessitate the exploration of alternative strategies to optimize therapeutic efficacy while minimizing risks. This review highlights the role of JAK3 in immune and epithelial cells, examines the adverse effects of oral JAK3 inhibitors in COVID-19 and other treatments, and discusses alternative therapeutic strategies for improving patient outcomes.

JAK inhibitors for the management of rheumatic diseases when antiphospholipid syndrome co-exists: case-based safety considerations

JAK inhibitors (JAKi) are small molecules that interact with JAK proteins, modulating the JAK-STAT signaling pathway, which plays a significant, though not yet fully understood, role in immune regulation. Due to the breadth of their mechanism of action, JAKi have shown promising results in the treatment of various immune-mediated diseases across different fields such as rheumatology or dermatology, and may represent a valuable therapeutic option for patients with multiple coexisting immune-mediated conditions. However, recent years have seen growing concerns regarding their use due to an observed increase in cardiovascular and thromboembolic events compared to anti-TNF drugs, which may complicate administration in patients with additional associated risk factors.Given the possible increase in thromboembolic events among patients treated with JAKi, various regulatory agencies advise against their use in patients with additional risk factors, such as advanced age or a prior thromboembolic event. This poses challenges in conditions like antiphospholipid syndrome (APS), an acquired hypercoagulability disorder mediated by antibodies, where thromboembolic events are a hallmark feature. To date, no publications have formally evaluated the safety of JAKi in APS patients in real-world clinical practice.Through a case-based approach, we aim to highlight the safety of these drugs for patients with APS and coexisting immune-mediated diseases, while emphasizing the importance of a careful assessment of additional risk factors and shared decision-making with the patient.

A systematic review of tumor necrosis factor-α blockers, anti-interleukins, and small molecule inhibitors for dissecting cellulitis of the scalp treatment

BACKGROUND

Dissecting cellulitis of the scalp (DCS) is a type of neutrophilic scarring alopecia identified by the development of folliculitis with clusters of perifollicular pustules and then progresses to abscesses and intercommunicating sinus formation. In the absence of evidence-based guidelines, the treatment of DCS remains a therapeutic challenge. Our study aimed to assess the safety and efficacy of biologics, including tumor necrosis factor-α (TNF-α) blockers, anti-interleukins (ILs), and small molecule inhibitors, including Janus kinase (JAK) inhibitors and phosphodiesterase inhibitors in treating DCS.

METHODS

PubMed/Medline, Scopus, and Ovid Embase databases were systematically searched until February 4th, 2024. Study selection was restricted to case reports, case series, cohort studies, and clinical trials published in English-language. NIH and Murad et al.'s quality assessment tools were utilized for critical appraisal.

RESULTS

A total of 34 articles involving 81 patients met the inclusion criteria. The immunomodulators studied for the treatment of DCS include adalimumab, infliximab, certolizumab pegol, ustekinumab, secukinumab, guselkumab, risankizumab, tildrakizumab, apremilast, upadacitinib, and baricitinib. Our findings implied that TNF-α blockers and IL inhibitors were associated with clinical improvement in most individuals with moderate-to-severe DCS, especially in those who had failed earlier treatments. Moreover, certolizumab pegol could be a safe option for DCS in pregnancy. In addition, the prescription of small molecule inhibitors, including JAK inhibitors and apremilast in DCS patients, demonstrated a significant amelioration in DCS symptoms with a desirable safety profile. Nevertheless, the available data was limited, warranting further investigation. Besides, all aforementioned immunomodulators are still debated for their effectiveness on hair regrowth and reversing the scarring process.

CONCLUSIONS

The application of immunomodulators in treating DCS was associated with satisfactory outcomes, although there is still a need to assess the long-term safety and effectiveness of these therapeutic agents in preventing disease progression and new flare-ups.

JAK-STAT Signaling in Autoimmunity and Cancer

The JAK-STAT pathway is an essential cell survival signaling that regulates gene expressions related to inflammation, immunity and cancer. Cytokine receptors, signal transducer and activator of transcription (STAT) proteins, and Janus kinases (JAKs) are the critical component of this signaling cascade. When JAKs are stimulated by cytokines, STAT phosphorylation, dimerization, and nuclear translocation occur, which eventually impacts gene transcription. Dysregulation of JAK-STAT signaling is linked with various autoimmune diseases, including rheumatoid arthritis, psoriasis, and inflammatory bowel disease. This pathway is constitutively activated in human malignancies and leads to tumor cell survival, proliferation, and immune evasion. Oncogenic mutations in the JAK and STAT genes have been found in solid tumors, leukemia, and lymphoma. Targeting the JAK-STAT pathway is a viable and promising therapeutic strategy for the treatment of autoimmune diseases and cancers.

Impact of NSAIDs corticosteroids DMARDs biologics and their comparisons with natural products in C-reactive proteins (CRP) linked cardiovascular disorders

An important part of the pathophysiology of atherosclerosis is the involvement of inflammatory processes, which mediate various stages of the formation of atheroma, from the first leukocyte recruitment to the final rupture of the unstable atherosclerotic plaque. Acute phase reactant C-reactive protein (CRP), which represents varying degrees of inflammation, has been identified as a separate risk factor for several cardiovascular diseases (CVD), particularly unstable coronary syndrome. We hypothesize that CRP is a direct cause of CVD in addition to being an inflammatory marker. Therefore, therapies aimed at lowering CRP should be beneficial for both primary and secondary CVD prevention. It has been demonstrated that the use of many drugs, particularly statins, alters CRP levels while also lowering cardiovascular events. The use of inflammatory biomarkers aids in the discovery of CVDs and tracks the assessment, prognosis, and administration of treatment. An acute-phase protein called C-reactive protein (CRP) is created in response to pro-inflammatory cytokines. CRP is a key modulator of atherosclerosis and a biomarker of the inflammatory response. It is also regarded as a CVD risk factor since it actively promotes the growth of atherosclerotic plaque, instability, and consequent clot. Patients with intermediate risk for cardiovascular diseases have been using the plasma concentration of hsCRP (high sensitivity CRP) as a biomarker for disease prognosis since 2010.

Advances in pharmacotherapy of juvenile idiopathic arthritis

INTRODUCTION

Juvenile Idiopathic Arthritis (JIA) is the most common chronic rheumatic disease in childhood. More therapeutic options are available for the treatment of JIA with more children achieving minimal active disease or inactive disease status.

AREAS COVERED

This review summarizes the major novel treatment options for children with non-systemic JIA, including current evidence supporting the safety and efficacy of biologic treatments.

EXPERT OPINION

With all the advances in treatment targets, the disease trajectory of patients with JIA have changed significantly and remission is the goal of today's treatment. New treatment trials show the pharmacokinetic, immunogenicity, efficacy and safety for these medications in children with JIA. Future studies will need to incorporate patient and family preferences, in addition to novel biomarkers and artificial intelligence-based diagnostic systems into head-to-head international multicenter trials to better assess the treatment algorithm for individual patients.

Efficacy of Janus kinase inhibitors in immune-mediated inflammatory diseases a systematic literature review informing the 2024 update of an international consensus statement

OBJECTIVE

This systematic literature review (SLR) on efficacy outcomes was performed to inform the 2024 update of the expert consensus statement on the treatment of immune-mediated inflammatory diseases (IMIDs) with Janus kinase inhibitors (JAKi).

METHODS

An update of the 2019 SLR was performed in MEDLINE, Embase, and the Cochrane Library. For efficacy, randomised, placebo (PLC)- or active-controlled trials on all JAKi investigated in IMIDs, as well as cohort and claims data for conditions where such studies were not available, were included.

RESULTS

In total, 10,556 records were screened, and 182 articles were included in the final analysis, investigating 21 JAKi in 51 IMIDs. Forty-three phase 2 and 59 phase 3 trials as well as 9 strategic trials and 72 pilot or cohort studies and case series were considered. JAKi demonstrated efficacy both in PLC-controlled trials as well as in head-to-head comparisons against active comparators, with 93 of 102 randomised controlled trials (RCTs) meeting their primary endpoints. Since 2019, 8 JAKi have received approval by the Federal Drug Agency and the European Medicine Agency for treatment of 11 IMIDs; of these, for 2, no approved disease-modifying antirheumatic drug (DMARD) therapy had previously been available.

CONCLUSIONS

JAKi are effective for treating IMIDs, and various compounds have recently been approved. The impact of Janus kinase (JAK) selectivity for distinct JAK-STAT pathways needs further investigation, and few data are also available on sustained disease control upon tapering or withdrawal or on the optimal strategic placement of JAKi in international treatment algorithms.

The Safety and Efficacy of JAK Inhibitors: Have We Found the Right Pathway?

Elderly patients with autoimmune diseases require long-term medication and physiotherapy, which also involves lifestyle modification. Ongoing follow-up and treatment lead to frequent consumption of healthcare resources, including outpatient visits, hospitalization, examinations, and medicines, putting financial pressure on patients and families. At the same time, the loss of patients' labor force has socioeconomic implications. Among drug therapies, Janus kinase (JAK) inhibitors are an important class of drugs that have shown significant efficacy in the treatment of autoimmune and inflammatory diseases. However, the issue of selectivity of these drugs has been a challenge in clinical application. Nonselective JAK inhibitors may lead to adverse events, including infections, hematologic alterations, cardiovascular and thrombotic risks, and possible malignancy risks, limiting their use. Nevertheless, the significance of selectivity in achieving effective treatment responses and minimizing adverse events remains uncertain.

Biomarkers of Immune Dysregulation and What They Tell Us: Gene Sequencing Is Not the Answer to Every Question

Primary immune regulatory disorders (PIRDs) are inborn errors of immunity, with autoimmune, hyperinflammatory, and lymphoproliferative manifestations as presenting features rather than recurrent infections. Genetic testing remains the primary tool for diagnosing patients with immune defects. Not all suspected PIRDs have a known genetic cause. Many hyperinflammatory disorders require urgent intervention, limiting the usefulness of gene sequencing in some cases. Current clinically approved immunology tests can detect immune dysregulation even without apparent immune deficiency. This review presents commonly known patterns of immune dysregulation that can be detected with currently available immune testing and additional testing in the clinical immunology laboratories' pipeline.

Navigating the Complexities of Common Variable Immunodeficiency Enteropathy: From Established Therapies to Emerging Interventions

Common Variable Immunodeficiency (CVID) is a prevalent primary immunodeficiency in adults, marked by low immunoglobulin levels and recurrent infections. This review examines the gastrointestinal complications of CVID, including both infectious and non-infectious manifestations. It highlights therapeutic strategies, from antimicrobials to novel biologics, and the role of immune modulation. The review also explores the impact of gut microbiota dysbiosis on CVID pathogenesis and emphasizes the need for personalized treatment approaches and routine cancer screening due to the elevated risk of gastrointestinal malignancy in CVID patients.

Malignant JAK-signaling: at the interface of inflammation and malignant transformation

The JAK pathway is central to mammalian cell communication, characterized by rapid responses, receptor versatility, and fine-tuned regulation. It involves Janus kinases (JAK1, JAK2, JAK3, TYK2), which are activated when natural ligands bind to receptors, leading to autophosphorylation and activation of STAT transcription factors [1, 2]. JAK-dependent signaling plays a pivotal role in coordinating cell communication networks across a broad spectrum of biological systems including development, immune responses, cell growth, and differentiation. JAKs are frequently mutated in the aging hematopoietic system [3, 4] and in hematopoietic cancers [5]. Thus, dysregulation of the pathway results in various diseases, including cancers and immune disorders. The binding of extracellular ligands to class I and II cytokine receptors initiates a critical signaling cascade through the activation of Janus kinases (JAKs). Upon ligand engagement, JAKs become activated and phosphorylate specific tyrosine residues on the receptor, creating docking sites for signal transducer and activator of transcription (STAT) proteins. Subsequent JAK-mediated phosphorylation of STATs enables their dimerization and nuclear translocation, where they function as transcription factors to modulate gene expression. Under physiological conditions, JAK-signaling is a tightly regulated mechanism that governs cellular responses to external cues, such as cytokines and growth factors, ensuring homeostasis and maintaining the functional integrity of tissues and organs. Highly defined regulation of JAK-signaling is essential for balancing cellular responses to inflammatory stimuli and growth signals, thus safeguarding tissue health. In contrast, dysregulated JAK-signaling results in chronic inflammation and unrestrained cellular proliferation associated with various diseases. Understanding the qualitative and quantitative differences at the interface of physiologic JAK-signaling and its aberrant activation in disease is crucial for the development of targeted therapies that precisely tune this pathway to target pathologic activation patterns while leaving homeostatic processes largely unaffected. Consequently, pharmaceutical research has targeted this pathway for drug development leading to the approval of several substances with different selectivity profiles towards individual JAKs. Yet, the precise impact of inhibitor selectivity and the complex interplay of different functional modules within normal and malignant cells remains incompletely understood. In this review, we summarize the current knowledge on JAK-signaling in health and disease and highlight recent advances and future directions in the field.

Clinical outcomes of baricitinib in patients with systemic lupus erythematosus: Pooled analysis of SLE-BRAVE-I and SLE-BRAVE-II trials

BACKGROUND

Baricitinib is an oral selective inhibitor of Janus kinase 1/2 that has achieved clinically meaningful outcomes for systemic lupus erythematosus (SLE). Only two phase 3 randomized clinical trials (SLE-BRAVE-I and SLE-BRAVE-II) have been completed, but their conclusions were inconsistent. We aimed to determine the efficacy and safety of once-daily oral baricitinib 4 mg or 2 mg treatment versus placebo in participants with active SLE.

METHODS

SLE-BRAVE-I and SLE-BRAVE-II are two multicenter, placebo-controlled, double-blind, phase 3 randomized clinical trials with follow-up to 52 weeks. At baseline, 1535 patients (aged ≥18 years) with active SLE (excluding those with central nervous system and severe active renal disease) receiving stable background therapy were randomly assigned 1:1:1 to baricitinib 4 mg, baricitinib 2 mg, or placebo once daily for 52 weeks. The primary endpoint was the proportion of patients with an SLE Responder Index (SRI)-4 response at week 52 in the baricitinib 4 mg treatment group compared with placebo.

RESULTS

There was no difference in the primary efficacy outcome of the proportion of SRI-4 responders at week 52 between participants who received baricitinib 4mg (263 [52%]; odds ratio (OR) 1.27 [95% CI 0.99, 1.63]), 2 mg (246 [48%]; 1.09 [0.85, 1.39]) and placebo (232 [46%]). However, based on SLE-BRAVE-I and SLE-BRAVE-II studies, baricitinib 4 mg and baricitinib 2 mg were more effective in reducing the disease activity in participants who treated with a glucocorticoid dose at baseline of 10 mg per day or higher of prednisone or equivalent, and baricitinib 4 mg was more effective in reducing the disease activity in participants with highly active disease (SLEDAI-2K score at baseline >10). None of the major secondary endpoints, including time to first severe flare and glucocorticoid tapering, were met. Compared with placebo, baricitinib 4 mg and baricitinib 2 mg in the treatment of SLE did not increase the incidence of treatment-emergent adverse events (TEAEs).

CONCLUSIONS

Pooled analysis showed that once-daily oral baricitinib 4 mg or baricitinib 2 mg in addition to SOC did not reduce the overall disease activity compared with placebo although they were safe for SLE. However, baricitinib might be a potential treatment option for SLE in certain subpopulation, such as in participants who received a glucocorticoid dose at baseline of 10 mg per day or higher of prednisone or equivalent (baricitinib 4 mg and baricitinib 2 mg) and in participants with highly active disease (SLEDAI-2K score at baseline >10) (baricitinib 4 mg).

TRIAL REGISTRATION NUMBER

ClinicalTrials. gov Registry (NCT03616912 and NCT03616964).

Personalised treatment of rheumatoid arthritis based on cytokine profiles and synovial tissue signatures: potentials and challenges

BACKGROUND

Rheumatoid arthritis (RA) is an autoimmune, chronic inflammatory disease that mainly affects the joints and periarticular soft tissues. Although there have been significant advances in RA treatment over the past two decades, approximately 40% of patients do not respond to first-line biological disease-modifying antirheumatic drugs (bDMARDs). Physicians often use an empirical, trial-and-error approach to select bDMARDs to treat patients with RA. This is inefficient and can be costly for healthcare systems which have limited resources. Unlike in oncology, where molecular pathology helps guide targeted therapies, reliable, predictive biomarkers for drug response in RA are yet to be identified. This narrative review aims to summarise current knowledge on novel biomarkers of disease activity and drug response in RA, with a particular focus on serum cytokine profiles and macrophage and fibroblast subsets in synovial tissue. We also highlight key areas of further research that could advance the development of targeted therapies for patients with RA.

METHODS

We searched PubMed to identify studies pertaining to biomarkers of disease activity and drug response in the treatment of RA.

RESULTS

We present a detailed overview of the key studies that have identified serum cytokine profiles and synovial macrophage and fibroblast subsets as novel biomarkers of disease activity and drug response in RA.

CONCLUSION

A novel, evidence-based approach to precision medicine in RA, which involves tailoring treatment based on cytokine profiles and synovial tissue signatures, shows promise for improving patient care. However, more research is needed to identify biomarkers that predict drug response.

PD1+ innate lymphoid cells 3 predict JAK-dependent inflammation in rheumatoid arthritis

Innate lymphoid cells (ILCs) play a key role in maintaining immune homeostasis and are linked to inflammation and autoimmunity. This study investigates the role of ILCs in the pathogenesis of rheumatoid arthritis (RA) and their response to two targeted therapies - JAK inhibitors (JAKi), which block critical signaling pathways required for their activation, and TNF inhibitors (TNFi), which target a key inflammatory mediator - offering insights into how these interventions shape ILC-driven inflammation. ILC distribution correlated with RA activity, as indicated by the DAS28 score, and this imbalance was improved significantly within four weeks of JAKi, underscoring its early therapeutic impact on ILC-mediated inflammation. While levels of ILC3-activating cytokines such as IL-1β and IL-23 declined under JAKi therapy, they remained unchanged with TNFi. Although JAKi and TNFi showed similar treatment efficacy, multivariate regression analysis showed that improvement in DAS28 score was strongly associated with increase in CTLA-4+ILC3 and reduction in both PD1+ILC3 frequency and systemic IL12p40/IL-23 levels only with JAKi. Notably, this two ILC3 subtypes determined the DAS28 score after 50 d of JAKi. In contrast, patients showing limited response to JAKi (ΔDAS28 < 1.2) maintained high systemic IL-18 levels, a cytokine that induces signaling independent of the JAK pathway, suggesting a potential resistance mechanism. These findings highlight that monitoring PD1+ILC3s or IL-12p40/IL-23 may serve as an indicator of JAKi responsiveness, while elevated IL-18 may identify patients benefiting from alternative therapies. These results also emphasize the clinical relevance of targeting innate immunity for more personalized, pathway-focused RA therapies.

Biomarker identification for rheumatoid arthritis with inadequate response to DMARD and TNF therapies using multidimensional analyses

PURPOSE

Rheumatoid arthritis (RA) is an immune system disorder disease accompanied with severe joint damage. However, the molecular mechanism of RA with insensitive to medicine remains insufficient. Thus, this study aims to identify the biomarkers of RA patients with inadequate responses (IR) toward disease-modifying antirheumatic drug (DMARD) and antitumor necrosis factor (TNF) therapies, using multidimensional analyses.

METHODS

Gene expression data GSE45291 originating from clinics were downloaded from the Gene Expression Omnibus public database (GEO). Differentially expressed genes (DEGs) closely associated with DMARD&TNF-IR RA were identified using the Limma R package. Weighted gene co-expression network analysis (WGCNA) was carried out to identify critical genes. The CIBERSORT algorithm and single sample Gene Set Enrichment Analysis (ssGSEA) were employed for immune infiltration analysis and functional enrichment analysis, respectively. Lastly, mRNA expression levels of the identified hub genes in inflammatory conditions of collagen-induced arthritis (CIA) rats and lipopolysaccharide (LPS)-induced RAW264.7 cells were further observed using RT-qPCR.

RESULTS

In this work, a total of 17 genes were identified as hub genes. Of these, the expression levels of UHMK1, ELK4, APOC2, and SFT2D1 were significantly lowered in inflammatory conditions. GSEA indicated B cells with the immune-related genes play an essential role in the course of DMARD&TNF-IR RA. Notable differences in immune cell proportions (activated. Dendritic. cell, CD56 bright. Natural. killer. Cell, gamma. Delta. T. cell, MDSC, macrophage) were observed between normal and disease groups, suggesting immune involvement.

CONCLUSION

The findings of this study provide additional understanding of the detection of DMARD&TNF-IR RA.

Severe infection risk in triple and quadruple therapy for anti-MDA5 antibody-positive dermatomyositis

INTRODUCTION

Anti-melanoma differentiation-associated gene 5 (MDA5) antibody-positive dermatomyositis (MDA5-DM) can be refractory to treatment, and a triple combination therapy (TCT) consisting of a glucocorticoid, cyclophosphamide, and a calcineurin inhibitor is widely used in induction therapy. For progressive or severe disease despite TCT, another immunosuppressive agent, such as a Janus kinase (JAK) inhibitor, may be added to the induction regimen.

METHOD

A retrospective cohort study across two centers in Japan was undertaken between January 2016 and December 2024 evaluating patients with MDA5-DM receiving TCT or quadruple combination therapy (QCT) determining the presence of severe infection. The latter therapy consisted of the addition of a JAK inhibitor to the TCT. A severe infection was defined as Grade 3 or higher according to the Common Terminology Criteria for Adverse Events (CTCAE), version 5.0.

RESULTS

There were 24 patients were included; TCT: n = 19 and QCT: n = 5. In the former, three (3/19, 16%), two (2/19, 11%), and three (3/19, 16%) patients had a severe bacterial infection, invasive fungal infection, and a CMV infection, respectively. In the QCT group, two (2/5, 40%), two (2/5, 40%), and four (4/5: 80%) patients had a severe bacterial infection, invasive fungal infection, and a CMV infection, respectively. CMV infections were significantly more frequent in the QCT group (p = 0.014). Both TCT and QCT groups had five patients each with a severe infection (5/19, 26% and 5/5, 100%, respectively) (p = 0.006).

CONCLUSION

While both TCT and QCT have infection, the QCT group may be at a higher risk, hence highlighting the need for vigilance and adequate prophylaxis.

Nicotinamide mononucleotide supplementation ameliorates testicular damage induced by ischemia-reperfusion through reshaping macrophage and neutrophil inflammatory properties

BACKGROUND

Ischemia-reperfusion (I/R) injury is the main pathophysiology of testicular torsion-detorsion (T/D). However, there is no safe and effective treatment for testicular I/R injury.

METHODS

The levels of NAD+ related genes were measured in the sham group, I/R + saline-treated group, and I/R + NMN-treated group by quantitative reverse transcription PCR (qRT-PCR). Testicular NAD+, Malondialdehyde (MDA), and superoxide dismutase (SOD) were evaluated. The markers of testicular function, including sperm quality, testosterone secretion, and the number of germ cells, were compared between groups. The reactive oxygen species (ROS), apoptosis, and immune cells were analyzed by flow cytometry. The expression of inflammatory genes, germ cell markers, and the phosphorylation of p65 and STAT3 were assessed by qRT-PCR, immunofluorescence, and western blot, respectively.

RESULTS

In this study, we analyzed the therapeutic potentials of NMN supplementation in testicular injury induced by torsion-detorsion in mice. NMN supplementation could increase testicular NAD+ content, increase serum testosterone levels, prevent Leydig cell and germ cell injury, and improve sperm quantity. Mechanistically, NMN supplementation relieved the sharply hostile immune microenvironment. Specifically, NMN supplementation could mitigate the oxidative stress and cell apoptosis in the I/R injured testes, downregulate the protein expression of p-p65 and p-STAT3 in inflammatory pathways, limit the excessive activation of inflammatory responses in testicular tissues, and reshape the inflammatory properties of macrophages and neutrophils.

CONCLUSIONS

The beneficial effects of NMN supplementation indicated that boosting NAD+ may be a promising and safe strategy to improve clinical outcomes in I/R-induced testicular damage.

Achievement of treatment targets and maintenance of response with upadacitinib in patients with moderate-to-severe rheumatoid arthritis in real-world practice: 1-year outcomes from the UPHOLD observational study

BACKGROUND

Upadacitinib (UPA), an oral Janus kinase inhibitor, has shown efficacy with an acceptable safety profile in rheumatoid arthritis (RA) clinical trials.

OBJECTIVE

To assess the real-world effectiveness and safety of UPA in adults with moderate-to-severe RA in the UPHOLD observational study.

METHODS

Co-primary endpoints were: (i) proportion of patients achieving disease activity score in 28 joints using C-reactive protein (DAS28[CRP]) remission (< 2.6) at 6 months; and (ii) proportion of those patients maintaining remission at 12 months. Additional analyses included proportions of patients achieving and maintaining DAS28(CRP) low disease activity (LDA; ≤ 3.2), other composite measures of disease activity, and subgroup analyses by therapy strategy and prior treatment. Treatment-emergent adverse events (TEAEs) in the full analysis set (FAS; patients receiving ≥ 1 UPA dose) were reported through August 10, 2023. Co-primary and selected secondary endpoints were analyzed by modified non-responder imputation (mNRI) in modified (m)FAS1 (FAS patients who completed 6 months of treatment and had DAS28[CRP] data available, and those who discontinued before 6 months) and mFAS2 (mFAS1 patients who achieved remission at 6 months, completed 12 months of treatment, and had DAS28[CRP] data available, and those who discontinued between 6 and 12 months); and as observed (AO) in patients with non-missing data.

RESULTS

Of 1719 participants, 1717 were enrolled; 1701 comprised the FAS. Overall, 400/1719 (23.3%) patients discontinued before 12 months. Of mFAS1 patients, 499 (mNRI: 499/1074 [46.5%]; AO: 499/902 [55.3%]) achieved DAS28(CRP) remission at 6 months; of mFAS2 patients, 269 (mNRI: 269/340 [79.1%]; AO: 269/317 [84.9%]) maintained remission at 12 months. DAS28(CRP) remission or LDA rates were consistent regardless of whether UPA was initiated and maintained as monotherapy or combination therapy. Similar responses were observed across prior treatment subgroups. Among selected TEAEs of special interest, herpes zoster and serious infection occurred at 3.12 and 2.62 events/100 patient-years, respectively. No new safety signals were identified.

CONCLUSIONS

UPA demonstrated real-world effectiveness in moderate-to-severe RA, with approximately half of patients achieving DAS28(CRP) remission at 6 months and most maintaining remission through 12 months. The real-world benefit-risk profile of UPA remains favorable and is consistent with phase 3 clinical trial data.

TRIAL REGISTRATION

NCT04497597.

Laboratory markers predicting tofacitinib efficacy in Japanese patients with rheumatoid arthritis: A pooled analysis of Phase 2/3 randomised controlled clinical trials

OBJECTIVES

We characterised early changes in laboratory parameters in Japanese patients with rheumatoid arthritis and assessed whether these changes at Month (M)1 were predictive of tofacitinib efficacy at M3.

METHODS

This post hoc analysis included pooled data from Japanese patients receiving tofacitinib or placebo in three Phase 2/Phase 3 studies (NCT00603512; NCT00687193; NCT00847613). Outcomes included changes from baseline in laboratory parameters (Week 2 and M1/3); efficacy end points were Disease Activity Score in 28 joints, based on C-reactive protein; Disease Activity Score in 28 joints, based on erythrocyte sedimentation rate; and American College of Rheumatology-N index at M3. Univariate/multivariable analyses assessed whether changes at M1 were predictive of efficacy at M3.

RESULTS

Overall, 467 patients receiving tofacitinib and 104 receiving placebo were included. Tofacitinib treatment was associated with decreases from baseline in C-reactive protein, erythrocyte sedimentation rate, neutrophils, and platelets and increases in lymphocytes, haemoglobin, and lipids up to M3. Decreased platelet count and increased low-density lipoprotein cholesterol and haemoglobin at M1 were predictive of changes in efficacy outcomes at M3.

CONCLUSIONS

Changes in laboratory parameters at M1 could potentially be used to assess whether tofacitinib therapy will be effective at M3; however, further investigation is needed.

JAK-STAT pathway, type I/II cytokines, and new potential therapeutic strategy for autoimmune bullous diseases: update on pemphigus vulgaris and bullous pemphigoid

Autoimmune Bullous Diseases (AIBDs), characterized by the formation of blisters due to autoantibodies targeting structural proteins, pose significant therapeutic challenges. Current treatments, often involving glucocorticoids or traditional immunosuppressants, are limited by their non-specificity and side effects. Cytokines play a pivotal role in AIBDs pathogenesis by driving inflammation and immune responses. The JAK-STAT pathway is central to the biological effects of various type I and II cytokines, making it an attractive therapeutic target. Preliminary reports suggest that JAK inhibitors may be a promising approach in PV and BP, but further clinical validation is required. In AIBDs, particularly bullous pemphigoid (BP) and pemphigus vulgaris (PV), JAK inhibitors have shown promise in modulating pathogenic cytokine signaling. However, the safety and selectivity of JAK inhibitors remain critical considerations, with the potential for adverse effects and the need for tailored treatment strategies. This review explores the role of cytokines and the JAK-STAT pathway in BP and PV, evaluating the therapeutic potential and challenges associated with JAK inhibitors in managing these complex disorders.

Comparison of anti-IL-6 receptor and JAK inhibitors in patients with rheumatoid arthritis from the real-world practice FIRST registry

OBJECTIVES

A molecular-targeted drug that is suitable as the second choice for patients with rheumatoid arthritis (RA) who show an inadequate response to the first biological disease-modifying antirheumatic drug (bDMARD) is unknown. This study aimed to analyse the efficacy and safety of interleukin-6 receptor (IL-6Ri) and Janus kinase inhibitors (JAKis), often selected as molecular-targeted drugs for second or subsequent treatments.

METHODS

The efficacy and safety of JAKis and IL-6Ri were compared using propensity score-based inverse probability of treatment weighting (PS-IPTW) using propensity scores after 26 weeks of therapy in patients with RA.

RESULTS

The remission rate at week 26, determined by the clinical disease activity index (CDAI), and the incidence of infection were higher in the JAKis than in the IL-6Ri group. The CDAI trajectories were divided into four according to the growth mixture modeling. IL-6Ri demonstrated greater efficacy in RA patients with ineffective to single bDMARD therapy compared with those with multiple ineffective bDMARDs. In patients who failed to respond to one bDMARD, there was no significant difference in the CDAI remission rate at week 26 between the JAKis (29.1%) and IL-6Ri (21.8%) groups (P = 0.21). However, for patients who did not respond to at least two bDMARDs, the CDAI remission rate at week 26 was higher in the JAKis than in the IL-6Ri group.

CONCLUSIONS

IL-6Ri offers a superior balance of efficacy and safety compared with JAKis for RA patients unresponsive to one bDMARD. However, JAKis may suit patients who do not respond to multiple bDMARDs.

Modulating IL-21-driven B cell responses in idiopathic inflammatory myopathies via inhibition of the JAK/STAT pathway

BACKGROUND

Idiopathic inflammatory myopathies (IIM) are autoimmune disorders characterized by muscle inflammation and autoreactive B cell responses. The Janus kinase (JAK)-signal transducer and activator of transcription (STAT) signaling pathway is essential for B cell functions, making it a promising therapeutic target. This study explores the potential of tofacitinib, a JAK1/JAK3 inhibitor, to modulate B cell activity in IIM.

METHODS

Peripheral B cell populations from dermatomyositis (DM), anti-synthetase syndrome (ASyS) and overlap myositis (OM) patients were analyzed by flow cytometry. Peripheral blood mononuclear cells (PBMC) or sorted memory B cells were cultured with tofacitinib and stimulated with combinations of CD40, IL-21, IL-2, BAFF and CpG. B cell proliferation, differentiation and (auto)antibody, cytokine/chemokine production were assessed by flow cytometry, Luminex, and ELISA/ELiA assays.

RESULTS

The IIM peripheral B cell compartment had elevated transitional and naive B cells, with reduced Bmem frequencies compared to healthy donors. Tofacitinib significantly inhibited CD40/IL-21-induced B cell proliferation, plasmablast formation and function in PBMC and B cell-only cultures across all IIM subgroups, predominantly affecting the IL-21-induced differentiation and antibody production. Remarkably, tofacitinib reduced the levels of anti-Jo1 autoantibodies, as well as of CXCL10 and CXCL13 in ASyS memory B cell cultures.

CONCLUSIONS

These findings highlight the B cell involvement in IIM, evidenced by altered peripheral B cell composition in active disease and the effective inhibition of essential B cell responses, including proliferation, differentiation, and (auto)antibody production, by tofacitinib in vitro. This positions the JAK/STAT pathway as a promising new therapeutic target to modulate B cell activity in IIM.

Effective Second-Line b/tsDMARDs for Patients with Rheumatoid Arthritis Unresponsive to First-Line b/tsDMARDs from the FIRST Registry

INTRODUCTION

For patients with rheumatoid arthritis (RA) unresponsive to first-line biologic/targeted synthetic disease-modifying antirheumatic drugs (b/tsDMARDs), the selection of second-line b/tsDMARDs is crucial to prevent progression to difficult-to-treat rheumatoid arthritis (D2TRA). However, indicators for selection are lacking. This study aimed to identify optimal second-line b/tsDMARDs among the phase III treatment strategies based on European League Against Rheumatism (EULAR) RA management recommendations.

METHODS

A total of 687 RA patients treated with second-line b/tsDMARDs (tumor necrosis factor inhibitor (n = 246), interleukin-6 receptor inhibitor [n = 195], cytotoxic T-lymphocyte-associated protein 4 immunoglobulin [n = 119], and Janus kinase inhibitor [n = 127]) were enrolled between October 2013 and April 2023. Rates of patients achieving Clinical Disease Activity Index (CDAI) remission and CDAI low disease activity (LDA), changes in CDAI, persistence rates, and adverse events within 24 weeks after treatment initiation were compared among the four groups. Propensity score-based inverse probability of treatment weighting (PS-IPTW) was used to minimize selection bias.

RESULTS

After PS-IPTW adjustment, the Janus kinase inhibitor (JAKi) group had the highest persistence rate among the four groups. At 24 weeks, the JAKi group showed the greatest improvement in CDAI and the highest CDAI remission rate. Among patients treated with JAKi as second-line b/tsDMARDs, upadacitinib (UPA) was most likely to achieve CDAI remission at 24 weeks. The comparison between the UPA group (n = 32) and the non-UPA JAKi group (tofacitinib and baricitinib [n = 95]) showed comparable persistence rates but significantly lower CDAI scores and higher CDAI remission rate at 24 weeks in the UPA group. No significant difference was noted in the overall incidence of adverse events among the four groups treated with b/tsDMARDs or between the groups treated with JAKi.

CONCLUSIONS

Selecting JAKi, especially UPA, may effectively improve the disease activity for RA patients unresponsive to first-line b/tsDMARDs. Further large-scale studies are needed to clarify the efficacy and safety of UPA.

TRIAL REGISTRATION

FIRST registry (approval number#04-23): October 2013, retrospectively registered.

Future Directions and Pipeline Therapies for Hidradenitis Suppurativa

Hidradenitis suppurativa (HS) is a painful, autoinflammatory condition with dramaticimpact on quality of life. As of January 1, 2024, there are 25 phase I-III clinical trials for topical and systematic medications in the management of HS. Only three medications, adalimumab, secukinumab and bemikizumab, are currently approved by the United States Food and Drug Administration for the treatment of moderate to severe HS. In addition, 15 nonmedication-based studies are ongoing, including those for various surgical techniques, botulinum toxin, laser and light-based therapies, differing wound care methods, and a variety of complementary and alternative medicine practices for HS.

Pharmacotherapy of type 1 diabetes - part 3: tomorrow

INTRODUCTION

The last 100 years have seen type 1 diabetes, a previously fatal disease, transformed by the administration of exogenous insulin.

AREAS COVERED

A standard literature search using the Google and Microsoft search engines and PubMed was performed. The development of synthetic insulins with varying onsets and duration of action improved glucose control, essential to mitigate the microvascular and macrovascular consequences of diabetes. Today insulin pumps guided by continuous glucose monitors are approaching the objective of normalized glucose levels. The area of greatest development is now in attempting to suppress the immune process which results in progressive destruction of the beta cell. It is possible to identify family members of patients with type 1 diabetes who may eventually develop the disease by measuring several beta cell antibodies. Very recently teplizumab, a CD3 inhibitor, has been approved to delay the onset of hyperglycemia in these individuals.

EXPERT OPINION

The future will see progress in immunosuppression, possibly using specific CAR-Treg cells directed at the beta cell antigens which trigger the immune process. In parallel, stem cell-derived beta cells may eventually make it possible to replace lost beta cells, resulting in a true cure for type 1 diabetes.

T-bet+ CXCR3+ B cells drive hyperreactive B-T cell interactions in multiple sclerosis

Multiple sclerosis (MS) is an autoimmune disease of the central nervous system (CNS). Self-peptide-dependent autoproliferation (AP) of B and T cells is a key mechanism in MS. Here, we show that pro-inflammatory B-T cell-enriched cell clusters (BTECs) form during AP and mirror features of a germinal center reaction. T-bet+CXCR3+ B cells are the main cell subset amplifying and sustaining their counterpart Th1 cells via interferon (IFN)-γ and are present in highly inflamed meningeal tissue. The underlying B cell activation signature is reflected by epigenetic modifications and receptor-ligand interactions with self-reactive T cells. AP+ CXCR3+ B cells show marked clonal evolution from memory to somatically hypermutated plasmablasts and upregulation of IFN-γ-related genes. Our data underscore a key role of T-bet+CXCR3+ B cells in the pathogenesis of MS in both the peripheral immune system and the CNS compartment, and thus they appear to be involved in both early relapsing-remitting disease and the chronic stage.

IL-6/IL-12 superfamily of cytokines and regulatory lymphocytes play critical roles in the etiology and suppression of CNS autoimmune diseases

Cytokines influence cell-fate decisions of naïve lymphocytes and determine outcome of immune responses by transducing signals that regulate the initiation, intensity and duration of immune responses. However, aberrant regulation of physiological levels of cytokines contribute to the development of autoimmune and other inflammatory diseases. The Interleukin 6 (IL-6)/IL-12 superfamily of cytokines have a profound influence on all aspects of host immunity and our focus in this review is on the signaling pathways that mediate their functions, with emphasis on how this enigmatic family of cytokines promote or suppress inflammation depending on the physiological context. We also describe regulatory lymphocyte populations that suppress neuroinflammatory diseases by producing cytokines, such as IL-27 (i27-Breg) or IL-35 (i35-Breg and iTR35). We conclude with emerging immunotherapies like STAT-specific Nanobodies, Exosomes and Breg therapy that ameliorate CNS autoimmune diseases in preclinical studies.

Neuroinflammatory pathways and potential therapeutic targets in neonatal post-hemorrhagic hydrocephalus

BACKGROUND

Post-hemorrhagic hydrocephalus (PHH) is a severe complication in premature infants following intraventricular hemorrhage (IVH). It is characterized by abnormal cerebrospinal fluid (CSF) accumulation, disrupted CSF dynamics, and elevated intracranial pressure (ICP), leading to significant neurological impairments.

OBJECTIVE

This review provides an overview of recent molecular insights into the pathophysiology of PHH and evaluates emerging therapeutic approaches aimed at addressing its underlying mechanisms.

METHODS

Recent studies were reviewed, focusing on molecular and cellular mechanisms implicated in PHH, including neuroinflammatory pathways, immune mediators, and regulatory genes. The potential of advanced technologies such as whole genome/exome sequencing, proteomics, epigenetics, and single-cell transcriptomics to identify key molecular targets was also analyzed.

RESULTS

PHH has been strongly linked to neuroinflammatory processes triggered by the degradation of blood byproducts. These processes involve cytokines, chemokines, the complement system, and other immune mediators, as well as regulatory genes and epigenetic mechanisms. Current treatments, primarily surgical CSF diversion, do not address the underlying molecular pathology. Emerging therapies, such as mesenchymal stem cell-based interventions, show promise in modulating immune responses and mitigating neurological damage. However, concerns about the safety of these novel approaches in neonatal populations and their potential effects on brain development remain unresolved.

CONCLUSIONS

Advanced molecular tools and emerging therapies have the potential to transform the treatment of PHH by targeting its underlying pathophysiology. Further research is needed to validate these approaches, enhance their safety profiles, and improve outcomes for infants with PHH.

IMPACT STATEMENT

1. This review elucidates the molecular complexities of post-hemorrhagic hydrocephalus (PHH) by examining specific immune pathways and their impact on disease pathogenesis and progression. 2. It outlines the application of genomic, epigenomic, and proteomic technologies to identify critical molecular targets in PHH, setting the stage for innovative, targeted therapeutic approaches that could improve the outcomes of neonates affected by PHH. 3. It discusses the potential of gene and stem cell therapies in treating PHH, offering non-surgical alternatives and focusing on the underlying neuroinflammatory mechanisms.

JAK Inhibitors and B Cell Function: A Comparative Study of Their Impact on Plasma Cell Differentiation, Cytokine Production, and Naïve B Cell Activation

B cells play a crucial role in autoimmune diseases, as evidenced by autoantibody responses and the effectiveness of B cell-targeted therapies. Janus kinase inhibitors (JAKi), which target downstream signaling of cytokine receptors, are potent rheumatic disease-modifying drugs. However, besides reducing inflammation, JAKi may impact the adaptive immune system. In this study, we examined the effects of JAKi on B-cell function using in vitro cultures and multiparameter flow cytometry. The results show a JAKi-mediated reduction in plasma cell differentiation, primarily by inhibition of memory B-cell stimulation and proliferation. JAKi exposure resulted in stalling R848, IL-2, and IL-21 stimulated B cells in an intermediate activated state with elevated naïve cells displaying increased expression of CXCR5, CD71, CD22, and CD20. In addition, the data demonstrate a moderate JAKi-mediated reduction of B cell TNF and IL-8 cytokine expression following stimulation. Importantly, the efficacy varied greatly between drugs; tofacitinib and upadacitinib (pan JAKi; JAK1i) exhibited the strongest impact, while baricitinib (JAK1/JAK2i) showed donor-dependent variation, and filgotinib (JAK1i) had no effect. All JAKi, except filgotinib, inhibited IL-2 or IL-21-induced STAT3 phosphorylation. Still, filgotinib demonstrated similar inhibition of phospho-STAT5 as other JAKi following IL-21. These findings underscore the therapeutic impact of JAKi through the modulation of B-cell functions.

Pineal cyst in bipolar patient with normolithiaemia and positive fibromyalgic tender points

Pineal cysts are benign, nonneoplastic lesions of the pineal gland, often identified incidentally on MRI scans. Although these cysts are usually asymptomatic, they can occasionally enlarge and compress adjacent structures, leading to neurological complications such as obstructive hydrocephalus and Parinaud's syndrome. The underlying mechanisms of pineal cyst development remain largely unclear, although inflammation - common in rheumatological conditions such as fibromyalgia - and mechanical stress have been suggested as contributing factors. In addition, the incomplete blood-brain barrier of the pineal gland raises the possibility that chronic lithium therapy, commonly used for psychiatric disorders and also known for its hyperplastic effects, could facilitate cysts formation through lithium accumulation and epithelial stimulation. We report the case of a 49-year-old woman with bipolar disorder on long-term lithium treatment who presented with a pineal cyst and clinical symptoms consistent with fibromyalgia. A review of the literature highlights possible links between pineal cyst formation, systemic inflammation associated with rheumatological disorders and prolonged lithium exposure. Although the hyperplastic properties of lithium in glandular tissue are well documented, there is no conclusive evidence directly linking lithium use to the development of pineal cysts in humans. The possibility of cystic growth driven by the pro-inflammatory environment of fibromyalgia remains plausible and warrants further investigation of the complex interactions between lithium therapy, systemic inflammation and pineal cystogenesis, particularly in patients with coexisting rheumatological and psychiatric disorders.

Janus-kinase inhibitor use in immune-mediated inflammatory diseases beyond licensed indications: A scoping review

INTRODUCTION

The use of Janus kinase inhibitors (JAKis) in immune-mediated inflammatory diseases (IMIDs) beyond licence is expanding rapidly. The aim of this scoping review was to identify and present the available evidence on the efficacy of JAKis in all conditions without marketing authorisation.

METHODS

Through a systematic literature search we identified studies including 5 or more patients that assessed the use of any JAKi for any efficacy outcome. Quantitative analyses in the form of pairwise meta-analyses were performed for eligible data from randomised controlled trials (RCTs) only.

RESULTS

Eighty-three (n = 83) studies in total were included in our review, assessing efficacy of JAKis in 34 IMIDs. In most conditions, JAKis exhibited generally positive effects, though the majority of evidence came from observational, non-comparative studies. Pairwise meta-analyses were possible for hidradenitis suppurativa and systemic lupus erythematosus (SLE). For hidradenitis suppurativa, we found a clear benefit of treatment with JAKis compared with placebo in achieving clinical response [OR 2.35, 95 % CI (1.24 to 4.46)]. For treatment-resistant SLE, the results were equivocal; JAKi showed some benefit over placebo but statistical significance was only reached for one of the two meta-analysed outcome measures [SLE Responder Index 4, OR 1.41, 95 % CI (1.01 to 1.98); SLE Disease Activity Index 2000; OR 1.36, 95 % CI (0.99 to 1.88)].

CONCLUSIONS

There is a rapidly increasing use of JAKis beyond current licencing in most IMIDs. Large comparative trials are necessary to confirm efficacy and guide future licencing decisions.

Safety of baricitinib in Japanese patients with rheumatoid arthritis in clinical use: 3-year data of all-case postmarketing surveillance study

OBJECTIVES

To assess safety of baricitinib in Japanese patients with rheumatoid arthritis (RA) in real-world clinical practice.

METHODS

This all-case postmarketing surveillance study included patients initiating baricitinib for RA from September 2017 to April 2019. Treatment duration was recorded. Safety data were collected for up to 3 years from initiation (up to 4 weeks postdiscontinuation in discontinuing patients).

RESULTS

Safety analyses included 4720 patients; 2580 (54.7%) were ≥65 years old. Baricitinib persistence rate was 45.4% (3-year Kaplan-Meier analysis); the most common discontinuation reason was insufficient effectiveness (n = 1005, 21.3%). Serious adverse events occurred in 600 patients [incidence rate (IR) 10.42/100 patient-years (PY); 95% confidence interval, 9.76-11.09]. There were 39 deaths [IR 0.43 (0.30-0.57)/100 PY]. Adverse events of special interest IRs per 100 PY were herpes zoster 4.68 (4.22-5.14), serious infection 3.05 (2.68-3.41), malignancy 1.09 (0.87-1.30), major adverse cardiovascular events 0.35 (0.23-0.48), and venous thromboembolism 0.25 (0.15-0.36). IRs did not increase with prolonged exposure.

CONCLUSIONS

No new safety concerns were identified during this 3-year postmarketing surveillance study of baricitinib in Japanese patients with RA. Patients and clinicians should be cognizant of herpes zoster and other serious infection risks during baricitinib treatment, especially in the first 6 months.

Hyaluronic-Acid-Functionalized Tofacitinib Loaded Transethosomes for Targeted Drug Delivery in Rheumatoid Arthritis

The Janus kinase inhibitor tofacitinib (TOF) is an FDA-approved drug for rheumatoid arthritis (RA) treatment, but its long-term oral use leads to significant systemic side effects. The present research aimed to conquer these challenges by formulating hyaluronic-acid-coated transethosomes (HA-TOF-TE), a novel system for targeted, topical delivery of TOF to reduce systemic toxicity and improve therapeutic efficacy. Transethosomes were synthesized via the cold sonication technique with HA functionalization enabling CD44 receptor-mediated targeting of inflamed synovial tissue. Optimized TOF-TE and HA-TOF-TE formulations showed particle sizes of 199.08 ± 4.2 and 151.5 ± 5.4 nm, zeta potentials of -27.1 ± 0.75 and -34.10 ± 0.89 mV, and entrapment efficiencies of 81.16 ± 0.84% and 79.19 ± 2.65%, respectively. The gels were assessed through in vitro drug release, ex vivo permeability, and in vivo effectiveness experiments using Freund's complete adjuvant (CFA) model. Ex vivo studies showed 2.02-fold and 1.61-fold increments in flux for TOF-TE and HA-TOF-TE, respectively, with superior skin retention for HA-TOF-TE. In vivo efficacy confirmed HA-TOF-TE's significant (P < 0.001) anti-inflammatory effect on arthritic rat paws, outperforming TOF-TE and FD gels. Cytokine analysis showed notable reductions in serum IL-1, IL-6, and PGE-2 levels after HA-TOF-TE treatment, closely approximating control values. Additionally, mRNA analysis demonstrated marked decreases in IL-6, CD44, and collagen II expression, indicating HA-TOF-TE's potential as an effective, targeted RA treatment, addressing the challenges of conventional TOF therapy and minimizing systemic side effects.

Methylglyoxal Formation-Metabolic Routes and Consequences

Methylglyoxal (MGO), a by-product of glycolysis, plays a significant role in cellular metabolism, particularly under stress conditions. However, MGO is a potent glycotoxin, and its accumulation has been linked to the development of several pathological conditions due to oxidative stress, including diabetes mellitus and neurodegenerative diseases. This paper focuses on the biochemical mechanisms by which MGO contributes to oxidative stress, particularly through the formation of advanced glycation end products (AGEs), its interactions with antioxidant systems, and its involvement in chronic diseases like diabetes, neurodegeneration, and cardiovascular disorders. MGO exerts its effects through multiple signaling pathways, including NF-κB, MAPK, and Nrf2, which induce oxidative stress. Additionally, MGO triggers apoptosis primarily via intrinsic and extrinsic pathways, while endoplasmic reticulum (ER) stress is mediated through PERK-eIF2α and IRE1-JNK signaling. Moreover, the activation of inflammatory pathways, particularly through RAGE and NF-κB, plays a crucial role in the pathogenesis of these conditions. This study points out the connection between oxidative and carbonyl stress due to increased MGO formation, and it should be an incentive to search for a marker that could have prognostic significance or could be a targeted therapeutic intervention in various diseases.

Recent Issues in the Development and Application of Targeted Therapies with Respect to Individual Animal Variability

This literature review explores the impact of molecular, genetic, and environmental factors on the efficacy of targeted therapies in veterinary medicine. Relevant studies were identified through systematic searches of PubMed, Web of Science, Scopus, and ScienceDirect using keywords such as "species-specific treatment strategies", "signalling pathways", "epigenetic and paragenetic influences", "targeted therapies", "veterinary medicine", "genetic variation", and "free radicals and oxidative stress". Inclusion criteria included studies focusing on species-specific therapeutic responses, genetic influences, and oxidative stress. To ensure that only the most recent and relevant evidence was included, only peer-reviewed publications from the last two decades were considered. Each study selected for analysis was critically appraised, with a particular emphasis on methodological quality, experimental design, and scientific contribution to the understanding of how environmental and biological factors influence therapeutic outcomes. A special emphasis was placed on studies that used a comparative, cross-species approach to assess variability in therapeutic responses and potential adverse effects. The review synthesises evidence on the role of epigenetic and paragenetic factors and highlights the importance of cross-species studies to understand how environmental and biological factors influence treatment outcomes. By highlighting genetic variation, oxidative stress, and individual species differences, the review argues for personalised and species-specific therapeutic approaches. The review emphasises that such an approach would improve veterinary care and inform future research aimed at optimising targeted therapies, ultimately leading to better animal health and treatment efficacy. A key contribution of the review is its emphasis on the need for more personalised treatment protocols that take into account individual genetic profiles and environmental factors; it also calls for a greater integration of cross-species studies.

Tyrosine kinase 2 inhibitors: Synthesis and applications in the treatment of autoimmune diseases

Janus kinase (JAK), a class of non-receptor tyrosine kinases, are essential in modulating the cytokine signaling cascade of cytokines associated with immune responses. Despite their potential in the treatment of autoimmune diseases, JAK inhibitors are associated with safety concerns, regarding cytokine suppression and significant side effects. Tyrosine kinase 2 (TYK2), a prominent member of the JAK family, is central to the signaling of interleukins (ILs) and interferons (IFNs), such as IL-12, IL-23 and IFNs. Targeted TYK2 inhibitors that specifically target the Janus Homology 1 (JH1) and pseudokinase (JH2) domains show enhanced specificity. JH1 acts as an ATP-competitive inhibitor, while JH2 acts as an allosteric regulator, contributing to reduced systemic side effects and improved therapeutic outcomes in clinical settings. This review summarizes the recent advances on the synthetic strategies of TYK2 inhibitors and their applications in the treatment of autoimmune diseases.

Fracture-Related Safety Reporting of JAK Inhibitors: An Analysis from the WHO Global VigiBase

INTRODUCTION

The Janus kinase (JAK) inhibitors are treatment options for autoimmune diseases. Numerous safety concerns have been raised. The European Medicines Agency updated the product information of tofacitinib to include the risk of fractures-but not for other JAK inhibitors. We conducted a global pharmacovigilance analysis of previously investigated JAK inhibitors to investigate a potential class effect.

METHODS

Individual case safety reports (ICSRs) for all licensed JAK inhibitors were identified from the global WHO pharmacovigilance database. The primary outcome of interest was a bone fracture. Disproportionality analyses using reporting odds ratios (RORs) were conducted.

RESULTS

We identified 122,037 ICSRs for tofacitinib, 27,786 ICSRs for upadacitinib, 14,616 ICSRs for baricitinib, 830 for filgotinib, and 350 for abrocitinib. Among the ICSRs, we identified 2198 (1.8%), 634 (2.3%), and 144 (1.0%) reports, where a bone fracture was reported for tofacitinib, upadacitinib, and baricitinib, respectively. Few reports were available for the newest drugs filgotinib (10) and abrocitinib (1). JAK inhibitors were associated with increased reporting for fracture: tofacitinib (ROR 3.34, 95% confidence interval [CI] 3.20-3.48), upadacitinib (ROR 4.23, 95% CI 3.80-4.48), baricitinib (ROR 1.80, 95% CI 1.52-2.11) and filgotinib (ROR 2.24, 95% CI 1.11-3.94). Patients with bone fractures were more often female, older and had a higher number of co-reported medications. They were more likely to use glucocorticoids, opioids, and bisphosphonates.

CONCLUSION

The results from this pharmacovigilance analysis, based on a spontaneous reporting database associated with inherent limitations, suggest a potential risk of fractures with JAK inhibitors, indicating that a class effect cannot be ruled out.

Tofacitinib prevents depressive-like behaviors through decreased hippocampal microgliosis and increased BDNF levels in both LPS-induced and CSDS-induced mice

Depressive disorders are a global mental health challenge that is closely linked to inflammation, especially in the post-COVID-19 era. The JAK-STAT pathway, which is primarily associated with inflammatory responses, is not fully characterized in the context of depressive disorders. Recently, a phase 3 retrospective cohort analysis heightened that the marketed JAK inhibitor tofacitinib is beyond immune diseases and has potential for preventing mood disorders. Inspired by these clinical facts, we investigated the role of the JAK-STAT signaling pathway in depression and comprehensively assessed the antidepressant effect of tofacitinib. We found that aberrant activation of the JAK-STAT pathway is highly conserved in the hippocampus of classical depressive mouse models: LPS-induced and chronic social defeat stress (CSDS)-induced depressive mice. Mechanistically, the JAK-STAT pathway mediates proinflammatory cytokine production and microgliosis, leading to synaptic defects in the hippocampus of both depressive models. Remarkably, the JAK inhibitor tofacitinib effectively reverses these phenomena, contributing to its antidepressant effect. These findings indicate that the JAK/STAT pathway could be implicated in depressive disorders, and suggest that the JAK inhibitor tofacitinib has a potential translational implication for preventing mood disorders far beyond its current indications.

Long-term safety and sustained efficacy of bimekizumab in patients with ankylosing spondylitis (radiographic axial spondyloarthritis): 5-year results from BE AGILE (phase 2b) and its open-label extension

OBJECTIVE

Assess long-term safety, tolerability and efficacy of bimekizumab in ankylosing spondylitis (radiographic axial spondyloarthritis (r-axSpA)).

METHODS

Patients with active r-axSpA completing the dose-ranging 48-week randomised controlled trial could enrol in the open-label extension, where patients received bimekizumab 160 mg every 4 weeks. Safety (exposure-adjusted incidence rates/100 patient-years (EAIRs)) and efficacy outcomes (binary: non-responder imputation (NRI) and observed case (OC); continuous: multiple imputation (MI)) are presented through 256 weeks.

RESULTS

From Weeks 0-256, 289/303 (95.4%) patients had ≥1 treatment-emergent adverse event (TEAE); most frequent were nasopharyngitis (21.8%) and upper respiratory tract infection (14.5%). The EAIR of fungal infections was 7.4 (Candida infections: 2.6; oral candidiasis: 2.2); none systemic. EAIR of serious infections was 1.4; no active tuberculosis was reported. Active inflammatory bowel disease and anterior uveitis EAIRs were 0.8 and 0.7, respectively. 202/303 (66.7%) patients completed Week 256. 42 (13.9%) patients discontinued treatment due to TEAEs.Efficacy at Week 48 was maintained for 5 years. At Week 256, NRI analysis showed 49.7% (OC: 73.1%) and 41.6% (OC: 71.1%) of patients achieved Assessment of SpondyloArthritis International Society 40% (ASAS40) response and Axial Spondyloarthritis Disease Activity Score (ASDAS) low disease activity, respectively. Mean (SE; MI) ASDAS improved from 3.9 (0.1) at baseline to 2.1 (0.1) at Week 48, which was maintained to Week 256. Improvements in pain, fatigue, physical function and health-related quality of life were sustained.

CONCLUSIONS

The safety profile of bimekizumab after 5 years of treatment remained consistent with previous reports, with no new safety signals identified. 5-year efficacy was sustained in this r-axSpA population following robust disease control achieved at Week 48.

TRIAL REGISTRATION NUMBERS

NCT02963506; NCT03355573.

Safety and efficacy of filgotinib in patients with rheumatoid arthritis: final results of the DARWIN 3 long-term extension study

OBJECTIVES

DARWIN 3 (ClinicalTrials.gov: NCT02065700) assessed the safety and efficacy of filgotinib in a long-term extension (LTE) of two phase II randomised controlled rheumatoid arthritis (RA) trials.

METHODS

Eligible patients completing the 24-week DARWIN 1 (filgotinib plus methotrexate) and DARWIN 2 (filgotinib monotherapy) trials could enrol. Patients received filgotinib 200 mg/day, except 15 men who received filgotinib 100 mg/day. The primary endpoints were safety and tolerability, which were assessed by the incidence of treatment-emergent adverse events (TEAEs). Safety and efficacy analyses included all enrolled patients who received ≥1 dose of filgotinib in DARWIN 3.

RESULTS

739 patients entered the LTE. The total patient-years of exposure (PYE) to filgotinib was 3706.3 years; the mean exposure duration was 259.8 weeks. 497 patients (67.3%) discontinued prematurely (including 266 TEAEs and 172 withdrawals due to the patient's decision or 'sponsor request'). Overall exposure-adjusted incidence rate (EAIR) was 67 (95% CI 62 to 72.2)/100 PYE for TEAEs and 3.8 (95% CI 3.2 to 4.5)/100 PYE for serious TEAEs. EAIR of infections was 23.3 (95% CI 21.2 to 25.6)/100 PYE, 1.3 (95% CI 0.9 to 1.7)/100 PYE for serious infections and 1.3 (95% CI 0.9 to 1.7)/100 PYE for herpes zoster. EAIRs of major adverse cardiovascular events (0.19 (95% CI 0.8 to 0.39)/100 PYE) and malignancies (0.6 (95% CI 0.4 to 0.9)/100 PYE) were low. Disease response assessed using non-responder imputation plateaued at LTE week 12 before slowly declining over time, with overall American College of Rheumatology (ACR)20/50/70 response rates of 26.9%/20.2%/14.7% at week 396.

CONCLUSION

Filgotinib was well tolerated in patients with RA for up to 8 years. Safety and efficacy profiles were maintained in patients previously receiving either filgotinib plus methotrexate or filgotinib monotherapy.

Effectiveness and Safety of Dupilumab and Tralokinumab for Treating Atopic Dermatitis and Pruritic Skin Disorders in Oncological Patients: A Narrative Review

Introduction

Atopic dermatitis (AD) and pruritic skin disorders are increasingly recognized in cancer patients. The management of these conditions in patients with a history or with concomitant cancer presents unique challenges, as traditional systemic therapies may pose risks due to their immunosuppressive effects. In recent years, biologic agents such as dupilumab and tralokinumab have emerged as promising treatments for AD, offering targeted modulation of the immune response with potentially fewer systemic side effects. This article aims to review the current evidence on the safety and efficacy of dupilumab and tralokinumab in treating AD and pruritus among cancer survivors, addressing the potential benefits and considerations for this unique patient population.

Methods

A comprehensive analysis of the current medical literature was performed on the PubMed, Ovid, Scopus, Embase, and Cochrane Library databases until December 15, 2024. In conducting this narrative review, Medical Subject Headings (MeSH) terms and medical terminology related to clinical trials and real-life studies were employed, focusing on the pharmacological agents dupilumab, and tralokinumab.

Discussion

Patients with active or past cancer are typically excluded from clinical trials of new medications, complicating the evaluation of cancer progression or recurrence risks in these patients setting. The potential use of biologic drugs like dupilumab and tralokinumab in oncological patients marks a significant breakthrough for treating conditions such as eczema and pruritus, which are common in this patient group. Although there are no explicit contraindications for using dupilumab and tralokinumab in patients with active cancer or a history of malignancy, there is no definitive guidance on their use in such cases. Real-world data is emerging, facilitated by collaboration between dermatologists and oncologists, supporting the effectiveness and safety of dupilumab and tralokinumab for managing AD in cancer patients. Nonetheless, larger studies with longer follow-up periods and dedicated pharmacovigilance programs are needed to substantiate these findings.

MAPK4 inhibits the early aberrant activation of B cells in rheumatoid arthritis by promoting the IRF4-SHIP1 signaling pathway

The involvement of B lymphocytes in the pathogenesis of rheumatoid arthritis (RA) is well-established, with their early and aberrant activation being a crucial factor. However, the mechanisms underlying this abnormal activation in RA remain incompletely understood. In this study, we identified a significant reduction in MAPK4 expression in both RA patients and collagen-induced arthritis (CIA) mouse models, which correlates with disrupted B cell activation. Using MAPK4 knockout (KO) mice, we demonstrated that MAPK4 intrinsically promotes the differentiation of marginal zone (MZ) B cells. Loss of MAPK4 in KO mice enhances proximal BCR signaling and activates the PI3K-AKT-mTOR pathway, leading to heightened B cell proliferation. Notably, B cells from MAPK4 KO mice produce significantly higher levels of IL-6, a key pro-inflammatory cytokine in RA. Furthermore, MAPK4 KO mice exhibit impaired T cell-independent humoral immune responses. Mechanistically, MAPK4 inhibits the activation of the PI3K signaling pathway in B cells by activating the IRF4-SHIP1 pathway. Treatment with the MAPK4 agonist Vacquinol-1 enhances MZ B cell differentiation in WT mice and reduces IL-6 secretion in CIA mouse models. In summary, this study reveals the diverse roles of MAPK4 in regulating of B cell functions, with potential implications for developing therapeutic strategies for RA and related autoimmune diseases.

STAT3 phosphorylation in the rheumatoid arthritis immunological synapse

Targeting the JAK/STAT pathway has emerged as a key therapeutic strategy for managing Rheumatoid Arthritis (RA). JAK inhibitors suppress cytokine-mediated signaling, including the critical IL-6/STAT3 axis, thereby effectively targeting different aspects of the pathological process. However, despite their clinical efficacy, a subset of RA patients remains refractory to JAK inhibition, underscoring the need for alternative approaches. Here, we identify a novel JAK-independent mechanism of STAT3 activation, which is triggered by the formation of the immunological synapse (IS) in naïve CD4+ T cells. Our data demonstrates that Lck mediates the TCR-dependent phosphorylation of STAT3 at the IS, highlighting this pathway as a previously unrecognized hallmark of early T cell activation. Furthermore, we show that the synaptic Lck/TCR-STAT3 pathway is compromised in RA. This discovery highlights a new therapeutic target for RA beyond JAK inhibitors, offering potential avenues for treating patients resistant to current therapies.

Switching to biological DMARDs versus cycling among JAK inhibitors in patients with rheumatoid arthritis and with inadequate response to JAK inhibitors: from FIRST registry

OBJECTIVES

This study aimed to identify characteristics of patients with rheumatoid arthritis (RA) with an inadequate response to Janus kinase inhibitors (JAKi-IR) and evaluate the efficacy and safety of subsequent treatments.

METHODS

This study included 434 patients with RA who started JAKi treatment. JAKi-IR patients were those who switched to another drug due to inadequate response or did not reach low disease activity within 26 weeks of beginning JAKi. The efficacy and safety of switched biological disease-modifying anti-rheumatic drugs (bDMARDs) or cycled targeted synthetic disease-modifying anti-rheumatic drugs were analysed 26 weeks after switching treatment in JAKi-IR patients.

RESULTS

Patients with JAKi-IR RA accounted for 31.8% (n=138/434). Multiple logistic regression identified factors contributing to JAKi-IR, such as the prior use of multiple ineffective bDMARDs and suboptimal JAKi dosing. There were no differences in patient background when comparing patients with RA with JAKi-IR who cycled to another JAKi (n=31) versus those who switched to bDMARDs (n=45). Among those cycling to another JAKi, the Clinical Disease Activity Index (CDAI) scores improved by week 26, with higher remission rates, while retention and adverse events remained similar. Trajectory analysis identified three CDAI response patterns, with the 'treatment response' group showing rapid and sustained improvement when cycling to another JAKi. Multiple logistic regression in this group identified another JAKi cycle as the critical factor for the treatment response.

CONCLUSIONS

Cycling JAKis is more effective than switching to bDMARDs in JAKi-IR RA, with no differences in safety or retention. This study suggests that cycling to another JAKi may be appropriate for patients with RA with JAKi-IR.

Upregulation of interferon-γ response genes in monocytes and T cells identified by single-cell transcriptomics in patients with anti-citrullinated peptide antibody-positive early rheumatoid arthritis

Introduction

Our aim was to investigate the insufficiently understood differences in the immune system between anti-citrullinated peptide antibody (ACPA)-positive (ACPA+) and ACPA-negative (ACPA-) early rheumatoid arthritis (eRA) patients.

Methods

We performed multiple cytokine assays using sera from drug-naïve ACPA+ and ACPA- eRA patients. Additionally, we conducted single-cell RNA sequencing of CD45+ cells from peripheral blood samples to analyze and compare the distribution and functional characteristics of the cell subsets based on the ACPA status.

Results

Serum concentrations of interferon-γ (IFN-γ) and interleukin (IL)-12 were higher in ACPA+ eRA than in ACPA- eRA. Single-cell transcriptome analysis of 37,318 cells identified 17 distinct cell types and revealed the expansion of IL1B+ proinflammatory monocytes, IL7R+ T cells, and CD8+ CCL4+ T cells in ACPA+ eRA. Furthermore, we observed an enrichment of IFN-γ response genes in nearly all monocytes and T cells of ACPA+ eRA subsets. Heightened interactions between IFN-γ and IFN-γ receptors were observed in ACPA+ eRA, particularly between monocytes and T cells. We examined IFITM2 and IFITM3 as potential key markers in ACPA+ eRA given their pronounced upregulation and association with the IFN response. Specifically, the expression of these genes was elevated in IL1B+ proinflammatory monocytes (likely M1 monocytes), correlating with serum IFN-γ levels.

Discussion

Compared to ACPA- eRA, ACPA+ eRA showed higher serum IFN-γ and IL-12 levels, upregulated IFN-γ response genes, and enhanced IFN-γ-driven monocyte-T cell interactions. These distinct immune features of the peripheral circulation in ACPA+ eRA suggest a role for type 1 helper T cell-related immunity in its pathogenesis.