OP0100 IL-17A BLOCKADE MODULATES DISEASE SPECIFIC IMMUNE AND STROMAL PATHWAYS IN PERIPHERAL SPONDYLOARTHRITIS SYNOVITIS

Background

The cellular and molecular mechanisms driving inflammation and structural remodelling in spondyloarthritis (SpA) remain largely unknown, though the IL-23/IL-17 pathway can contribute to synovial inflammation and radiographic progression.

Objectives

To investigate the molecular pathways affected by IL-17A blockade (IL-17Ai) with secukinumab in SpA synovitis, and assess if this response is tissue- and/or treatment-specific.

Methods

Synovial biopsies were obtained from peripheral SpA patients by needle arthroscopy before and after 12 weeks of IL-17Ai with secukinumab (n=12), and analyzed by RNA-sequencing and qPCR. We performed pathway enrichment analysis of the differentially expressed genes (DEGs) to identify pathways modulated after treatment. We compared the synovial tissue response in patients with psoriatic arthritis (PsA) in our cohort (n=7) with open source gene expression data of skin biopsies of psoriasis patients receiving secukinumab (n=22)[1] and of synovial biopsies of PsA patients receiving IL-12p40/IL-23p40 blockade (n=7)[2].

Results

IL-17Ai significantly modulated the expression of 1255 genes (549 up- and 706 down-regulated, FDR 0.1) in the synovium at week 12 compared to baseline (Figure 1). Genes downregulated upon IL-17Ai were significantly enriched in GO terms and KEGG pathways related to immune and inflammatory responses, including neutrophil and monocyte chemotaxis, TNF-mediated, NF-κB-, Wnt-, and JAK-STAT signalling pathways, and, importantly, bone-remodelling responses, such as osteoblast and osteoclast differentiation. Upregulated genes are enriched in JNK-, MAPK-, Wnt-, and PI3K-Akt signalling and negative regulation of osteoblast differentiation. We validated differential expression of selected genes from several pathways by qPCR, including: IL1B, p=0.027; CXCL6, p=0.020; ADAMTS4, p=0.002; MMP3, p=0.020; and CHRDL2, p= 0.039.

Figure 1.

Heatmap of differentially expressed genes (DEGs) and pathway enrichment analyses of changes in peripheral SpA synovium 12 weeks after anti-IL-17A treatment (IL-17Ai). A. Hierarchical cluster analysis of the top 100 most significant DEGs (FDR < 0.1) modulated by IL-17Ai separates pre- and post-treated groups. Normalized and scaled log2 gene expression levels are shown. B. Pathway enrichment analysis through DAVID. Enriched (p < 0.05) gene ontology terms from IL-17Ai-induced up- and down-regulated DEGs in peripheral SpA synovium are shown.

To assess if this response is tissue- and/or treatment-specific, we compared changes in gene expression by IL-17Ai in PsA synovium versus psoriatic skin, and in the PsA synovium after IL-17Ai versus IL-12p40/IL-23p40 blockade. While many inflammation-related GO terms and KEGG pathways were over-represented in both tissues and treatments, NF-κB-, JAK-STAT-, and PI3K-Akt-signaling were enriched in DEGs in both skin and synovium after IL-17Ai, whereas JNK cascade, IL-17 signalling pathway and Th17 cell differentiation were overrepresented in DEGs after IL-17Ai in the synovium specifically. Remarkably, IL-17Ai, but not IL-12p40/IL-23p40 blockade, modulated multiple bone-remodelling related pathways. Also, IL-17Ai modulated ossification and collagen catabolic process terms in PsA synovium and psoriatic skin in the opposite direction: these terms were over-represented in downregulated genes in synovium, but in upregulated genes in skin. Accordingly, genes upregulated after IL-17Ai were enriched in negative regulation of osteoblast differentiation in the synovium, but in positive regulation of osteoblast differentiation in the skin.

Conclusion

These first in vivo human data provide molecular confirmation of previously reported animal data[3] that demonstrated down-modulation of disease-relevant immune and stromal pathways in the synovium in response to IL-17Ai.

References

[1]Krueger JG et al. J Allergy Clin Immunol. 2019. Sep;144(3):750-763

[2]Fiechter RH et al. Front Immunol. 2021. Mar 4;12:611656

[3]Van Tok MN et al. Arthritis Rheumatol. 2019. Apr;71(4):612-625

Disclosure of Interests

Renée Fiechter: None declared, Leonieke van Mens: None declared, Ihsan Hammoura: None declared, Henriëtte de Jong: None declared, Desire Pots: None declared, Inka Fluri: None declared, Sander Tas: None declared, Dominique Baeten Employee of: Current employee of UCB Pharma, Marleen G.H. van de Sande Consultant of: Novartis and AbbVie, Grant/research support from: Janssen, Novartis and Eli Lilly, Nataliya Yeremenko: None declared.

Bimekizumab for the treatment of moderate-to-severe plaque psoriasis: efficacy, safety, pharmacokinetics, pharmacodynamics and transcriptomics from a phase IIa, randomized, double-blind multicentre study

BACKGROUND

Bimekizumab is a monoclonal antibody that selectively inhibits both interleukin (IL)-17A and IL-17F, which is currently under investigation for treatment of moderate-to-severe plaque psoriasis. Maintenance dosing every 4 weeks is well established with IL-17 inhibitors for psoriasis.

OBJECTIVES

To investigate the possible dosing interval during bimekizumab maintenance therapy to maintain clear skin, to inform phase III studies.

METHODS

Forty-nine patients with moderate-to-severe plaque psoriasis received bimekizumab 320 mg at weeks 0/4, followed at week 16 by bimekizumab 320 mg (n = 17) or placebo (n = 32). Efficacy, safety, pharmacokinetics, immunogenicity and biopsy transcriptomic analyses were assessed to week 28.

RESULTS

At week 8, 47% of patients achieved a 100% improvement from baseline in Psoriasis Area and Severity Index (PASI 100), increasing to 57% at week 12 (8 weeks after the second dose) before decreasing. In those who received bimekizumab at week 16, PASI 100 rate increased to comparable peak levels at week 20, but reduced by week 28 to 41% (12 weeks after the third dose). The week 8 transcriptional signature observed in lesional psoriatic skin rapidly normalized to levels consistent with nonlesional skin, resulting in molecular remission. Keratinocyte-related gene products such as CXCL1 (C-X-C motif chemokine ligand 1), IL-8 (encoded by the CXCL8 gene), CCL20 (C-C motif chemokine 20), IL-36γ and IL-17C were profoundly normalized to levels associated with nonlesional skin.

CONCLUSIONS

Here, inhibition of IL-17F in addition to IL-17A resulted in rapid, deep clinical responses. Additionally, profound normalization of keratinocyte biology and the psoriatic transcriptome was observed, including normalization of both IL17 and IL23 gene expression by week 8. These data provide evidence to support evaluation of bimekizumab maintenance dosing both every 8 and every 4 weeks in phase III clinical trials.

AB0114 IL12P40/IL23P40 BLOCKADE WITH USTEKINUMAB DECREASES THE INFLAMMATORY INFILTRATE AND MODULATES MOLECULAR PATHWAYS IN THE SYNOVIUM OF PSORIATIC ARTHRITIS PATIENTS

Background:

Psoriatic arthritis (PsA) is a chronic inflammatory joint disease within the spondyloarthritis (SpA) spectrum. TNF and IL17/IL23 pathways play a key role in SpA pathogenesis. Blocking of IL12p40/IL23p40 has been shown to effectively reduce disease activity in PsA [1,2]. It is however incompletely understood how IL12p40/IL23p40 blockade affects local inflammatory processes.

Objectives:

To investigate the cellular and molecular pathways affected by IL12p40/IL23p40 blockade with ustekinumab in PsA patients (pts).

Methods:

Eleven male PsA pts with at least 1 inflamed knee or ankle joint, who were scheduled to start ustekinumab treatment, were included in a 24-week single-center open-label study. All pts received ustekinumab 45 mg/sc according to standard care at week (W) 0, 4 and 16. Besides clinical outcomes, needle arthroscopic synovial tissue (ST) biopsy samples were obtained from an inflamed knee or ankle joint at baseline (BL), W12 and W24. ST samples were analyzed by immunohistochemistry (IHC), RNA sequencing and real-time quantitative polymerase chain reaction (qPCR) analysis.

Results:

Paired BL and W12, and paired BL, W12 and W24 ST samples were available of 9 and 6 pts, respectively. Two pts only underwent BL ST sampling (pt refusal; withdrawal after the W12 clinical visit). Two pts were excluded after W12 because of treatment adjustments. Of 1 pt no ST was obtained at W24 due to technical difficulties. Eight pts finished 24 weeks of clinical follow-up. No serious adverse events were observed. At W12 6/11 pts met ACR20, 2/11 met ACR50 and 1/11 met ACR70 improvement criteria, at W24 this was 3/8, 2/8 and 1/8 pts, respectively. Significant improvements between BL and W12 and/or W24 were seen in clinical (TJC, PASI, BASDAI) and serological markers (CRP and ESR), Table 1. IHC showed a significant decrease in sublining macrophages, a sensitive biomarker of an inflammatory response in peripheral SpA, of BL 2[1-3] vs W12 1.5[0-2]p=0.020, but not W24 1[0.5-2.5]ns. Other synovial infiltrating cells were not significantly decreased. Significant downregulation of MMP3 (p=0.047) and IL-23p19 (p=0.046), but not IL6, TNF or IL12p40 were seen with qPCR analysis at W12. RNA seq analysis showed 178 significantly differentially expressed genes between BL and W12 (FDR 0.1). Gene ontology and KEGG terms enrichment analyses identified overrepresentation of MAPK and PI3K-Akt signalling pathways among the down-regulated genes and WNT signalling pathway among the up-regulated genes. Gene expression was confirmed by qPCR analysis.

Table 1.Baseline(n=11)Week 12(n=11)Week 24(n=8)p-value*p-value**TJC1 (0-5)1 (1-2)0 (0-0.75)0.1680.034SJC2 (1-3)2 (1-3)1.5 (1-2)0.3940.715VAS patient global28 (16-55)22 (12-46)45 (2.8-50.5)0.4230.779PASI3.2 (1.2-7.4)0.8 (0-1.8)0 (0-2.4)0.0280.046BASDAI3.2 (2.4-4.7)1.9 (1-3.8)2.1 (0.4-4.2)0.0080.161CRP (mg/L)8.5 (1.7-16.4)1.6 (0.6-3)1.0 (0.6-7.0)0.0080.012ESR (mm/hr)20 (8-35)6 (2-17)8 (2-20.5)0.0080.017

TJC/SJC tender/swollen joint count; VAS visual analogue scale; PASI psoriasis area severity index; BASDAI Bath Ankylosing Spondylitis Disease Activity Index; CRP C-reactive protein; ESR erythrocyte sedimentation rate;

All values are presented as median (IQR) p-value for the comparison of baseline and week 12 (*) or week 24 (**)

Conclusion:

Ustekinumab treatment reduced synovial inflammation and modulated specific molecular pathways, however inflammation was not completely resolved. Future studies comparing histological and gene expression data between different treatments targeting IL17/IL23 axis will show which changes are treatment-specific and which reflect downregulation of local inflammation.

References:

[1]McInnes et al. Lancet. 2013;382:780–789.

[2]Kavanaugh et al. Ann Rheum Dis. 2014;73:990–999.

Work was financially supported by an unrestricted grand of Janssen Pharmaceutica

Disclosure of Interests:

Renée Fiechter: None declared, Henriëtte de Jong: None declared, Leonieke van Mens: None declared, Inka Fluri: None declared, Sander Tas: None declared, Dominique Baeten Employee of: UCB Pharma, Nataliya Yeremenko: None declared, Marleen G.H. van de Sande Grant/research support from: Novartis, Eli lily, UCB, Jansen, Consultant of: Abbvie, Novartis, Eli lily, MSD

OP0105 EFFICACY AND SAFETY OF BIMEKIZUMAB IN ANKYLOSING SPONDYLITIS: 48-WEEK PATIENT-REPORTED OUTCOMES FROM A PHASE 2B, RANDOMISED, DOUBLE-BLIND, PLACEBO-CONTROLLED, DOSE-RANGING STUDY

Background:

Bimekizumab (BKZ), a monoclonal antibody that selectively neutralises interleukin (IL)-17A and IL-17F, is a potential therapeutic option in ankylosing spondylitis (AS).

Objectives:

To report 48-week (wk) patient-reported outcomes (PROs) in patients (pts) with AS treated with BKZ in a phase 2b dose-ranging study (BE-AGILE;NCT02963506).

Methods:

Pts with active AS (Bath AS Disease Activity Index [BASDAI] ≥4; spinal pain ≥4 [0–10]), fulfilling modified New York criteria (central reading), and inadequate response/intolerance to NSAIDs were randomised according to the study design (Figure 1). PROs included spinal pain, fatigue (BASDAI Q1), morning stiffness (mean of BASDAI Q5 + 6), Bath AS Functional Index (BASFI), Medical Outcomes Study (MOS) Sleep Problems Index II and AS Quality of Life questionnaire (ASQoL). Efficacy is reported for pts initially randomised to placebo (PBO) or BKZ 160/320 mg every 4 weeks (Q4W); treatment-emergent adverse events (TEAEs) are reported for pts who received ≥1 dose of study drug (Safety Set).

Results:

Of 303 pts, 181 were randomised to PBO or BKZ 160/320 Q4W mg at Wk 0; 179/181 completed Wk 12 and 161/181 completed Wk 48. At Wk 12, improvements in pain, fatigue, morning stiffness, BASFI, sleep and ASQoL were greater in BKZ pts vs PBO pts. Responses were further improved or maintained to Wk 48, with no meaningful differences between BKZ 160 mg and 320 mg (Table 1). Serious TEAEs occurred in 13/303 (4.3%) pts (Table 2), which included 2 major adverse cardiac events considered not related to study drug. Oral candidiasis occurred in 16 (5.3%) pts.

Table 1.

PRO efficacy endpoints to Week 48 (multiple imputation)

Mean (SD)WkPBO – BKZ 160 mg(n=24)PBO – BKZ 320 mg(n=36)BKZ 160 mg(n=58)BKZ 320 mg(n=61)Spinal pain06.9 (1.4)7.0 (1.9)6.6 (2.0)7.3 (1.5)CfB12-1.5 (1.6)-0.7 (1.7)-2.6 (2.2)-3.6 (2.4)48-3.7 (2.0)-3.7 (2.6)-3.8 (2.4)-4.7 (2.1)Fatigue06.4 (1.7)6.8 (1.6)6.4 (1.7)6.4 (1.9)CfB12-0.7 (2.5)-1.0 (1.7)-2.1 (2.2)-2.1 (2.5)48-2.7 (2.2)-2.8 (2.4)-3.1 (2.1)-3.3 (2.4)Morning stiffness06.9 (1.7)6.7 (2.0)6.5 (1.8)6.6 (2.1)CfB12-1.5 (1.7)-1.1 (1.5)-2.8 (2.0)-3.4 (2.7)48-3.9 (2.2)-3.6 (2.4)-3.9 (2.2)-4.4 (2.4)BASFI05.8 (1.8)5.5 (2.2)5.5 (2.2)5.9 (2.0)CfB12-1.0 (2.1)-0.3 (1.7)-1.7 (1.8)-2.2 (2.0)48-2.9 (2.2)-2.4 (2.2)-2.5 (2.0)-2.9 (2.2)MOS Sleep Problems Index II045.5 (8.1)45.3 (7.9)46.9 (7.5)47.2 (9.4)CfB122.1 (8.3)1.8 (6.8)5.6 (6.7)6.8 (7.5)487.6 (8.7)8.0 (9.1)6.5 (6.1)8.0 (7.9)ASQoL08.4 (4.7)9.2 (4.7)8.4 (4.3)8.7 (4.3)CfB12-1.3 (5.5)-1.3 (3.7)-3.5 (4.3)-4.6 (4.8)48-4.2 (5.6)-5.3 (5.6)-4.9 (4.1)-5.4 (4.8)

CfB: change from baseline

Table 2.

Overview of TEAEs to Week 48 (Safety Set; N=303)

n (%)BKZ 160 mg(n=149)BKZ 320 mg(n=150)All BKZ [a](N=303)Any TEAE103 (69.1)122 (81.3)235 (77.6)Drug-related TEAEs48 (32.2)54 (36.0)110 (36.3)Serious TEAEs5 (3.4)6 (4.0)13 (4.3)Discontinuations due to TEAEs7 (4.7)10 (6.7)20 (6.6)

[a] Includes TEAEs for 16 and 64 mg BKZ

Conclusion:

Pts with active AS demonstrated rapid and sustained improvements in PROs, sleep and quality of life over 48 wks of BKZ treatment. BKZ was generally well tolerated with no unexpected safety findings versus previous studies.

Acknowledgments:

This study was funded by UCB Pharma. Editorial services were provided by Costello Medical.

Disclosure of Interests:

Désirée van der Heijde Consultant of: AbbVie, Amgen, Astellas, AstraZeneca, BMS, Boehringer Ingelheim, Celgene, Cyxone, Daiichi, Eisai, Eli-Lilly, Galapagos, Gilead Sciences, Inc., Glaxo-Smith-Kline, Janssen, Merck, Novartis, Pfizer, Regeneron, Roche, Sanofi, Takeda, UCB Pharma; Director of Imaging Rheumatology BV, Lianne S. Gensler Grant/research support from: Pfizer, Novartis, UCB, Consultant of: AbbVie, Eli Lilly, GSK, Novartis, UCB, Atul Deodhar Grant/research support from: AbbVie, Eli Lilly, GSK, Novartis, Pfizer, UCB, Consultant of: AbbVie, Amgen, Boehringer Ingelheim, Bristol Myer Squibb (BMS), Eli Lilly, GSK, Janssen, Novartis, Pfizer, UCB, Speakers bureau: AbbVie, Amgen, Boehringer Ingelheim, Bristol Myer Squibb (BMS), Eli Lilly, GSK, Janssen, Novartis, Pfizer, UCB, Xenofon Baraliakos Grant/research support from: Grant/research support from: AbbVie, BMS, Celgene, Chugai, Merck, Novartis, Pfizer, UCB and Werfen, Consultant of: AbbVie, BMS, Celgene, Chugai, Merck, Novartis, Pfizer, UCB and Werfen, Speakers bureau: AbbVie, BMS, Celgene, Chugai, Merck, Novartis, Pfizer, UCB and Werfen, Denis Poddubnyy Grant/research support from: AbbVie, MSD, Novartis, and Pfizer, Consultant of: AbbVie, Bristol-Myers Squibb, Eli Lilly, MSD, Novartis, Pfizer, Roche, UCB, Speakers bureau: AbbVie, Bristol-Myers Squibb, Eli Lilly, MSD, Novartis, Pfizer, Roche, UCB, Alan Kivitz Shareholder of: AbbVie, Amgen, Gilead, GSK, Pfizer Inc, Sanofi, Consultant of: AbbVie, Boehringer Ingelheim, Flexion, Genzyme, Gilead, Janssen, Novartis, Pfizer Inc, Regeneron, Sanofi, SUN Pharma Advanced Research, UCB, Paid instructor for: Celgene, Genzyme, Horizon, Merck, Novartis, Pfizer, Regeneron, Sanofi, Speakers bureau: AbbVie, Celgene, Flexion, Genzyme, Horizon, Merck, Novartis, Pfizer Inc, Regeneron, Sanofi, Mary Katherine Farmer Employee of: UCB Pharma, Dominique Baeten Employee of: UCB Pharma, Nadine Goldammer Employee of: UCB Pharma, Jason Coarse Employee of: UCB Pharma, Marga Oortgiesen Employee of: UCB Pharma, Maxime Dougados Grant/research support from: AbbVie, Eli Lilly, Merck, Novartis, Pfizer and UCB Pharma, Consultant of: AbbVie, Eli Lilly, Merck, Novartis, Pfizer and UCB Pharma, Speakers bureau: AbbVie, Eli Lilly, Merck, Novartis, Pfizer and UCB Pharma

History and Diagnostic Value of Antibodies to Citrullinated Proteins in Rheumatoid Arthritis

Rheumatoid arthritis is a chronic inflammatory joint disease characterized by the presence of autoantibodies. The best known autoantibody is the rheumatoid factor. Another group of antibodies directed against citrullinated epitopes is proven to be more specific for rheumatoid arthritis. This review gives an overview of the history of the different anti-citrullinated protein antibody detection methods and their diagnostic and prognostic properties in RA.

Beneficial Immune Effects of Myeloid-Related Proteins in Kidney Transplant Rejection

Acute rejection is a risk factor for inferior long-term kidney transplant survival. Although T cell immunity is considered the main effector in clinical acute rejection, the role of myeloid cells is less clear. Expression of S100 calcium-binding protein A8 (S100A8) and S100A9 was evaluated in 303 biopsies before and after transplantation from 190 patients. In two independent cohorts of patients with acute rejection (n = 98 and n = 11; mostly cellular rejections), high expression of S100 calcium-binding protein A8 (S100A8) and A9 (S100A9) was related to improved graft outcome. Mechanisms of action of the S100 molecules were investigated. In the graft and peripheral blood cells, S100A8 and S100A9 expression correlated with myeloid-derived suppressor markers. In line with this finding, recombinant S100A8 and S100A9 proteins inhibited maturation and the allogeneic T cell stimulatory capacity of dendritic cells. S100A9 enhanced the production of reactive oxygen species by macrophages, which suppressed T cell activity at low concentrations in the form of hydrogen peroxide. Intragraft S100A8 and S100A9 expression linked to reduced expression of T cell immunity and tissue injury markers and higher expression of immune regulatory molecules. This study sheds new light on the importance of myeloid cell subsets in directing the outcome of T cell-mediated acute rejection.

Inflamed target tissue provides a specific niche for highly expanded T-cell clones in early human autoimmune disease

OBJECTIVE

To profile quantitatively the T-cell repertoire in multiple joints and peripheral blood of patients with recent onset (early) or established rheumatoid arthritis (RA) using a novel next-generation sequencing protocol to identify potential autoreactive clones.

METHODS

Synovium of patients with recent onset (early) RA (<6 months) (n=6) or established RA (>18 months) (n=6) was screened for T-cell clones by sequencing over 10 000 T-cell receptors (TCR) per sample. T cells from paired blood samples were analysed for comparison. From two patients synovial T cells were obtained from multiple inflamed joints. The degree of expansion of each individual clone was based on its unique CDR3 sequence frequency within a sample. Clones with a frequency of over 0.5% were considered to be highly expanded clones (HEC).

RESULTS

In early RA synovium, the T-cell repertoire was dominated by 35 HEC (median, range 2-70) accounting for 56% of the TCR sequenced. The clonal dominance in the synovium was patient specific and significantly greater than in established RA (median of 11 HEC (range 5-24) in established RA synovium accounting for 9.8% of T cells; p<0.01). 34% (range 28-40%) of the most expanded T-cell clones were shared between different joints in the same patients, compared with only 4% (range 0-8%) between synovium and blood (p=0.01).

CONCLUSIONS

In RA, a systemic autoimmune disease, the inflamed synovium forms a niche for specific expanded T-cell clones, especially in early disease. This suggests that, at least in RA, autoreactive T cells should be addressed specifically in the inflamed tissue, preferably in the early phase of the disease.