Immunoprofiling of active and inactive systemic juvenile idiopathic arthritis reveals distinct biomarkers: a single-center study

BACKGROUND

This study aimed to perform an immunoprofiling of systemic juvenile idiopathic arthritis (sJIA) in order to define biomarkers of clinical use as well as reveal new immune mechanisms.

METHODS

Immunoprofiling of plasma samples from a clinically well-described cohort consisting of 21 sJIA patients as well as 60 age and sex matched healthy controls, was performed by a highly sensitive proteomic immunoassay. Based on the biomarkers being significantly up- or down-regulated in cross-sectional and paired analysis, related canonical pathways and cellular functions were explored by Ingenuity Pathway Analysis (IPA).

RESULTS

The well-studied sJIA biomarkers, IL6, IL18 and S100A12, were confirmed to be increased during active sJIA as compared to healthy controls. IL18 was the only factor found to be increased during inactive sJIA as compared to healthy controls. Novel factors, including CASP8, CCL23, CD6, CXCL1, CXCL11, CXCL5, EIF4EBP1, KITLG, MMP1, OSM, SIRT2, SULT1A1 and TNFSF11, were found to be differentially expressed in active and/or inactive sJIA and healthy controls. No significant pathway activation could be predicted based on the limited factor input to the IPA. High Mobility Group Box 1 (HMGB1), a damage associated molecular pattern being involved in a series of inflammatory diseases, was determined to be higher in active sJIA than inactive sJIA.

CONCLUSIONS

We could identify a novel set of biomarkers distinguishing active sJIA from inactive sJIA or healthy controls. Our findings enable a better understanding of the immune mechanisms active in sJIA and aid the development of future diagnostic and therapeutic strategies.

T helper cells expressing fractalkine receptor and bearing T follicular helper 1-like cell functions in patients with IgG4-related disease

OBJECTIVE

Since the pathological features of IgG4-related disease (IgG4-RD) include lymphocyte infiltration and fibrotic changes in the lesions, we investigated the significance of fractalkine (CX3CL1) and lymphocyte subsets in patients with IgG4-RD.

METHODS

Peripheral blood and biopsied samples were obtained from healthy controls (HCs, n = 10), rheumatoid arthritis (RA, n = 10), and IgG4-RD patients (n = 16) and were analyzed by flow cytometry, immunohistology and costimulation assays.

RESULTS

Peripheral CX3CR1+ CD4+ T cells had an approximately threefold increase in the IgG4-RD patients (15.4%), compared with the HCs (5.0%). In addition, CX3CR1+ CD4+ T cells were localized in the salivary glands of the IgG4-RD patients but not in those with Sicca syndrome. CX3CR1 was induced on 20% of CD4+ T cells after T cell receptor (TCR) simulation with IL-12 for five days-culture. CX3CR1+ T cells showed high expression of both CXCR5 and CXCR3. Moreover, they co-expressed Bcl-6 and T-bet, the master transcription factors for T helper 1 (Th1) and T follicular helper (Tfh) cells. After secondary stimulation, CX3CR1+ T cells produced both interferon-gamma (IFN-γ) and IL-21. Compared with their CX3CR1- counterparts, CX3CR1+ CD4+ T cells induced plasmablast differentiation from naïve B cells more efficiently (15.0 vs 5.0%) and increased the production of IgG2, IgG3, and IgG4 by B cells.

CONCLUSION

CX3CR1+ CD4+ T cells characteristically increased in the peripheral blood and the affected tissues and were associated with an increase in the serum IgG4 levels of patients with IgG4-RD. This CD4 subset has a Th1/Tfh-like phenotype and a B cell helper function.

Association and predictive value of biomarkers with severe outcomes in hospitalized patients with SARS-CoV-2 infection

This study analyzed the levels at admission of biomarkers for their association with and ability to predict risk of severe outcomes, including admission to the ICU, need for invasive mechanical ventilation (IMV), need for vasopressor use (VU), and in-hospital mortality (IHM) in 700 patients hospitalized with COVID-19. Biomarker data split by outcomes was compared using Mann-Whitney U tests; frequencies of biomarker values were compared using Chi-square tests and multivariable logistic regression analysis was performed to look at the impact of biomarkers by outcome. Patients that suffered IHM were more likely to have reduced platelet numbers and high blood urea nitrogen (BUN) levels among patients admitted to the ICU. Risk factors for mortality were related to hyper-coagulability (low platelet count and increased D-dimer) and decreased respiratory (PaO₂/FiO₂ ratio) and kidney function (BUN). Association with risks of other severe outcomes were as follows: ICU with hyper-inflammation (IL-6) and decreased respiratory function; IMV with low platelet count, abnormal neutrophil–lymphocyte ratio with reduced respiratory function, VU with inflammatory markers (IL-6), and low platelet count with respiratory function. Our studies confirmed the association of biomarkers of hematological, inflammatory, coagulation, pulmonary and kidney functions with disease severity. Whether these biomarkers have any mechanistic or causal role in the disease progress requires further investigation.

Filgotinib or Lanraplenib in Moderate to Severe Cutaneous Lupus Erythematosus: A Phase 2, Randomised, Double-Blind, Placebo-Controlled Study

OBJECTIVES

To explore the safety and efficacy of filgotinib (FIL), a Janus kinase 1 inhibitor, and lanraplenib (LANRA), a spleen kinase inhibitor in cutaneous lupus erythematosus (CLE).

METHODS

This was a phase 2, randomised, double-blind, placebo-controlled, exploratory, proof-of-concept study of LANRA (30 mg), FIL (200 mg), or placebo (PBO) once daily for 12 weeks in patients with active CLE. At week 12, PBO patients were rerandomised 1:1 to receive LANRA or FIL for up to 36 additional weeks.

RESULTS

Of 47 randomised patients, 45 were treated (N = 9 PBO, N = 19 LANRA, N = 17 FIL). The primary end point (change from baseline in Cutaneous Lupus Erythematosus Disease Area and Severity Index Activity [CLASI-A] score at week 12) was not met. Least squares mean (standard error) CLASI-A score change from baseline was -5.5 (2.56) with PBO, -4.5 (1.91) with LANRA, and -8.7 (1.85) with FIL. Numerical differences between FIL and PBO were greater in select subgroups. A ≥ 5-point improvement in CLASI-A score at week 12 was achieved by 50.0%, 56.3%, and 68.8% in the PBO, LANRA, and FIL arms, respectively. A numerically greater proportion of patients in the FIL arm (50%) also achieved ≥50% improvement in CLASI-A score at week 12 (37.5% PBO, 31.3% LANRA). Most adverse events (AEs) were mild or moderate in severity. Two serious AEs were reported with LANRA and 1 with FIL.

CONCLUSION

The primary end point was not met. Select subgroups displayed a numerically greater treatment response to FIL relative to PBO. LANRA and FIL were generally well tolerated.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT03134222.

Apremilast monotherapy for long-term treatment of active psoriatic arthritis in DMARD-naive patients

OBJECTIVES

Apremilast monotherapy was evaluated up to 5 years in PALACE 4 DMARD-naive patients with PsA.

METHODS

Patients with active PsA were randomized (1:1:1) to placebo, apremilast 30 mg or apremilast 20 mg twice daily. Placebo patients were rerandomized to apremilast at week 16 or 24. Double-blind apremilast continued to week 52, with a 4-year open-label extension (≤260 weeks of exposure). Analyses through week 260 were based on observed data.

RESULTS

527 patients were treated. Among patients randomized to apremilast 30 mg at baseline, 45.5% completed week 260. At study end, 24.8% reported csDMARD or steroid use for any reason. At week 260, 65.8%/39.0%/20.3% of apremilast 30 mg patients achieved ACR20/ACR50/ACR70 responses, respectively. PsA sign/symptom improvements were sustained up to week 260 with continued treatment, including reductions in swollen (84.8%) and tender (76.4%) joint counts. Among apremilast 30 mg patients with baseline enthesitis or dactylitis, 71.2% achieved a Maastricht Ankylosing Spondylitis Enthesitis Score of 0 and 95.1% achieved a dactylitis count of 0, respectively. Over 50% of patients achieved a HAQ-DI minimal clinically important difference (≥0.35). In patients with ≥3% baseline psoriasis-involved body surface area, 60.3% and 47.6% achieved ≥50% and ≥75% improvement in Psoriasis Area and Severity Index scores, respectively. Patients continuing apremilast 20 mg also demonstrated consistent, sustained improvements. The most common adverse events were diarrhoea, nausea, headache, upper respiratory tract infection and nasopharyngitis. No new safety concerns were observed long term.

CONCLUSIONS

Apremilast led to sustained PsA efficacy up to 260 weeks and was well tolerated.

TRIAL REGISTRATION

ClinicalTrials.gov (http://clinicaltrials.gov), NCT01307423.

Subcutaneous dosing regimens of tocilizumab in children with systemic or polyarticular juvenile idiopathic arthritis

Objectives

To determine s.c. tocilizumab (s.c.-TCZ) dosing regimens for systemic JIA (sJIA) and polyarticular JIA (pJIA).

Methods

In two 52-week phase 1 b trials, s.c.-TCZ (162 mg/dose) was administered to sJIA patients every week or every 2 weeks (every 10 days before interim analysis) and to pJIA patients every 2 weeks or every 3 weeks with body weight ≥30 kg or <30 kg, respectively. Primary end points were pharmacokinetics, pharmacodynamics and safety; efficacy was exploratory. Comparisons were made to data from phase 3 trials with i.v. tocilizumab (i.v.-TCZ) in sJIA and pJIA.

Results

Study participants were 51 sJIA patients and 52 pJIA patients aged 1–17 years who received s.c.-TCZ. Steady-state minimum TCZ concentration (C_trough) >5th percentile of that achieved with i.v.-TCZ was achieved by 49 (96%) sJIA and 52 (100%) pJIA patients. In both populations, pharmacodynamic markers of disease were similar between body weight groups. Improvements in Juvenile Arthritis DAS-71 were comparable between s.c.-TCZ and i.v.-TCZ. By week 52, 53% of sJIA patients and 31% of pJIA patients achieved clinical remission on treatment. Safety was consistent with that of i.v.-TCZ except for injection site reactions, reported by 41.2% and 28.8% of sJIA and pJIA patients, respectively. Infections were reported in 78.4% and 69.2% of patients, respectively. Two sJIA patients died; both deaths were considered to be related to TCZ.

Conclusion

s.c.-TCZ provides exposure and risk/benefit profiles similar to those of i.v.-TCZ. S.c. administration provides an alternative administration route that is more convenient for patients and caregivers and that has potential for in-home use.

Trial registration

ClinicalTrials.gov, http://clinicaltrials.gov, NCT01904292 and NCT01904279