TREATMENT OF RA 2014

The 1rst Kuwait-North American Update in Internal Medicine Conference

8-9 February 2014

Henri A. Ménard, MD, FRCP (C)

Professor of Medicine

McGill University

McGill University Health Center

Sequence of Events in RA

Immune response Pathologic inflammatory response

T100

LymphomaCVD

Destruction AmyloidosisVasculitis

T0

Pre- Early- Established- RA

GenesEnvironment

Anti-CCPRF

Break of tolerance RA Onset

Anti-Sa

Smoking Habit

Ulnar Drift

Rheumatoid Hand

Oral health: Parodontitis

• Chronic Inflammatory condition.

• Erosive disease

• Associated with RF, HLA DR4 and Coronary Artery Disease.

• Intriguing because associated with Porphyromonas gingivalis. The

bacterial PADI and its products are very different from that of the

mammalian PADIs’. Break of tolerance???

• Circumstantial evidence only. No hard data available.

(Ménard HA Dresden Symposium on Autoimmunity 2007)

Principles of Patient Centered RA Treatment in 2014

• DO MORE THAN LESS clinical observation and biological documentation of the disease to pinpoint the particular context of your patient where N=1.

• EXPLAIN AND REASSURE the patient and the family;• INSIST ON LIFESTYLE ISSUES: smoking, oral hygiene (flossing)

and beware of the associated obesity and metabolic syndrome: PREHABILITATION is better than REHABILITATION;

• TREAT EARLY AND AGGRESSIVELY with full DMARDs combos and use biologicals when needed;

• USE TOOLS BORROWED FROM THE BUSINESS WORLD to contract with the patient short term and long term objectives with periodic timely deliverables (Treat-to-Target approach);

• ADAPT AND ADJUST as the disease evolves and changes.

To treat moving targets in vivo we need to develop HUMAN BIOMARKER(S)

Clinical : intra vs extra-articular featuresSerologic : anti-Sa For Prognosis and Monitoring Genomic

immune response genes (SE and non-SE),pharmacogenomics (drug metabolism),innate immunity genes (cytokine SNPs)

Immunopathologic : Cell mediated vs humoralEvolutive disease = Δ physiopathical pattern

Personalizing Is Challenging

To chose the best drug for the right patient at the right time, we need to STOP EMPIRICISM i.e.

Stop making real world medical decisions and using guidelines based on trial data;

Start dissecting each individual patient as a N=1 trial, not as a member of poorly characterized cohorts of N=1000.

Know why & when one starts & stops a drug Know why & when one needs to change/switch Know why & when to reassess.

Personalizing Is Challenging

Contribution of Cytokines to RA Clinical Manifestations

IL-6LiverAPR, anemia

TNF, IL-17, IL-6, IL-1Bone Erosion

Joint

IL-1, IL-17Cartilage Degradation MMP

TNF, IL-17, IL-6, IL-1Leukocyte Chemotaxis

TNF, IL-6Angiogenesis

Colmegna et al. Clin Pharmacol Ther 2012;91:607-20

Do Our Treatments Regulate Citrullinated Ags – ACPAs?

Anti-CP Abs

Effect Of MTX On CitrullinationIn UMR 106 Cells

Dose-response curve of in vitro MTX treatment of UMR 106 cells at 10 µg of total proteins/lane at in vivo therapeutic concentrations.

0

10

20

30

40

50

60

70

80

90

100

0 1 10 50 100

MTX (nM)

% In

hibi

tion

PAD

2CM

C

0 1 10 50 100

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11392

MTX (nM)

Lora M et al (Ménard HA) ACR 2005

Henri-André Ménard MD & Maximilien Lora PhDMSK Research Axis 0f The McGill University Health Center At The Royal Victoria Hospital, Montreal (QC), CANADA H3A 1A1

A Scientific Basis For A Century Of Empiricism In Treating RA: All DMARDs Downregulate The Production

Of Citrullinated Proteins/Antigens In Vitro.

INTRODUCTION

MATERIALS AND METHODS

RATIONALE AND HYPOTHESIS

CONCLUSIONS

ACKNOWLEDGEMENT

RESULTS

RA patients have IgG auto-antibodies against citrullinated (cit-)epitopes.

RESULTS RESULTS

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Anti-CMC Anti-Sa

Sa

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- + Ca2+ - +

Sa

UMR106 and ECV304 cell lines were treated for 4 days with increasing doses of methotrexate (MTX), sulphasalazine (SSZ), azathioprine (AZT), hydroxychloroquine (HCQ) or Prednisone (Pred) at doses corresponding to those obtained in vivo during RA treatment. We estimated semi-quantitatively by western blot (WB) on cell extracts, their effect on the production of all cit-proteins (detected by a rabbit anti-CMC serum) and cit-antigens (detected by anti-Sa RA sera).

Factual commonality 1: pharmacologically unrelated drugs, the DMARDs have survived empirically as good treatment for RA;Factual commonality 2: cit-proteins (non-specific products of inflammation), have a central role in RA as they induce a specific autoimmune response that drives the disease;Factual commonality 3: biologicals target effector mechanisms, downstream from the immunological synapse with little effect on auto-Abs and they all work most efficiently when combined with DMARDs ;Hypothetical commonality 4: DMARDs have a common mode of action complementary to biologicals via inhibition of citrullination, an event upstream from the immunological synapse.

All DMARDs downregulate the productionof cit-proteins/antigens in vitro.

- MTX blocks PAD-activity in proliferating cells via a folate dependent pathway. The effect is independent of adenosine receptors (not shown) and the quantity of PAD-protein is unchanged. - AZT, SSZ and HCQ decrease the quantity of PADs in various conditions either in resting or dividing cells. - Prednisone has no effect on citrullination in dividing cells but has an unexpected upregulating effect at high dose in resting cells.

Those data support our hypothesis that DMARDs all work by decreasing the cit-Ag load in vivo. In patients with autoAbs to a cit-protein Ag like cit-vimentin/Sa, DMARDs may influence the putative ongoing auto-Ab response to cit-vimentin (anti-Sa), thus acting on the two major elements of the autoimmune amplification loop responsible for chronicity.

UMR106 cells have PAD activity at

confluence only.

ECV304 cells have PAD activity at both subconfluence and

confluence.

WB with anti-SaMTX (100 nM) treatment of UMR106 at subconfluence showed a decrease in

PAD activity. This MTX effect was prevented by folinic acid (20 µM).

At the same dosage, MTX had no effect on PAD activity of confluent UMR106 or subconfluent and confluent ECV304

Methotrexate (MTX)Clinical concentration: 25 nM

Sulphasalazine (SSZ)Clinical concentration 50 µM

Azathioprine (AZA)Clinical concentration 0.5 to 10µM

Hydroxychloroquine (HCQ)Clinical concentration 1 µM

Prednisone (Pred)Clinical concentration 0.1 µM

WB with anti-PAD2MTX treatment showed no decrease in

PAD-2 protein

H

NOH

NH

H2N+ NH2

+ H2O

NO

NH

O NH2

+ NH3 + H+

PeptidylArginine PeptidylCitrulline

PADsCa++

CITRULLINATION

is the conversion of an arginine within a peptidic link to a citrulline in an enzymatic process carried out by

PeptidylArginine Deiminases.

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CTRL 25 125 250 µM

WB with anti-CMCSSZ treated subconfluent UMR 106 cells.

SSZ at 250 µM significantly decreased PAD activity.

WB with anti-CMCSSZ treated confluent UMR 106 cells.SSZ at 500 and 1000 µM significantly

decreased PAD activity.

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CTRL 500 1000 µM

WB with anti-CMC SSZ treated subconfluent ECV304 cells.

SSZ at 1000 µM significantly decreased PAD activity.

At the same dosage, SSZ had no effect on ECV304 confluent assays.

The Abs are present before or at disease onset at40-80% sensitivity with >95% specificity.

WB with anti-PAD2 SSZ treated subconfluent ECV304 cells.

SSZ at 750 µM significantly decreased PAD2 protein.

CTRL 10 50 200 µM100

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53

WB with anti-CMCAZA treated confluent UMR106

cells.AZA at 200 µM decreased PAD

activity.

WB with anti-CMCAZA treated subconfluent

UMR106 cells.AZA at 50 µM to 200 µM

significantly decreased PAD activity.

193

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53

CTRL 10 50 200 µM100

WB with anti-CMCAZA treated subconfluent ECV304

cells.AZA decreased PAD activity at all

concentrations tested.At the same dosage, AZA had little

effect on ECV304 confluent assays.

CTRL 50 200 µM100

193

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53

10

WB with anti-CMCHCQ treated subconfluent &

confluent UMR106 cells.HCQ at 50 µM to 100 µM

significantly decreased PAD activity.

193

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53

CTRL 50 µM100Sub-confluent Confluent

10 CTRL 50 10010

µMCTRL 50 10010

WB with anti-CMCHCQ treated subconfluent

ECV304 cells.HCQ at 50 and 100 µM decreased PAD activity.

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97

53

115

193

µMCTRL 50 10010

WB with anti-CMCHCQ treated confluent

ECV304 cells.HCQ at 50 and 100 µM decreased PAD activity.

CTRL 100 µMWB with anti-PAD2

HCQ treated subconfluent

ECV304 cells.

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193

37

CTRL 1.0 µM10UMR106 ECV3040.1 CTRL 1.0 100.1 µM

WB with anti-CMCPred. treated

subconfluent UMR106 & ECV304 cells.

Pred. had no effect on PAD activity.

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193

CTRL 1.0 100.1 µM

WB with anti-CMCPred. treated confluent UMR106 cells.

Pred. at 10µM might be increasing PAD activity.

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53

193

37

WB with anti-CMCPred. treated confluent ECV304 cells.

Pred. at 10 µM may actually increase PAD activity.

CTRL 1.0 100.1 µM

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37

CTRL 250 500 1000 µM

CTRL 750 µM

PAD2

CTRL MTXMTX

Folinic Folinic

NS

19311597

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11597

PAD2

CRA Kanaskis 2009 and ACR Philadelphia 2009

1. MTX, blocks PADI-2 activity in proliferating cells without affecting the quantity of enzyme. It does so via folate-dependent and adenosine receptor-independent pathways. The induction of a PAD Inhibitor is a possibility.

2. HCQ, AZT and, SSZ decrease the quantity of PADIs in resting and proliferating cells in vitro.

3. Corticosteroids have no direct effect on citrullination .

4. DMARDs decrease the afferent antigenic input while Prednisone and the Biologicals suppress the efferent mechanisms of the immune synapse involving citrullinated epitopes.

Conclusions on Citrullination in RAThose in vitro data provide an explanation for why the pharmacologically diverse DMARDs are successful in RA : they are PADIBs

1. Individually, with MTX being the best at it;

2. In combination with each other, providing a variety of not mutually exclusive inhibition modalities;

3. Essential to use with biologicals as they are unique in decreasing the afferent arm of the immune process;

4. Especially relevant when ACPAs (anti-Sa) drive the disease.

Take Home Message On Anti-CCP• They relate to immune response genes specifically

predisposing to RA but are not always associated with severe or even actual disease. In the context of N = 1,

• most useful when negative to rule out RA;• low titers may lead to circular clinical reasoning;• high titres most useful to rule in RA.

• Their prognostic value is based on longitudinal and transversal testing of RA COHORTS. They are less reliable at disease onset in personalized N=1 medicine.

• Normalization is unusual and, as currently tested for, unchanging titers do not allow immune monitoring.

Ménard HA, Editorial. J Rheumatology 2009

Take Home Message On Anti-Sa

• strictly linked to RA disease: DIAGNOSIS• closely linked with the more severe erosive long term

phenotype: PROGNOSIS

• titers vary with activity as pathogenic antibodies do:

MONITORING• normalization is achievable and may turn out to be a

robust marker of remission maintenance at T0/S0:

REMISSION

Ménard HA, Editorial J Rheumatology 2009

TREATMENT IMPLICATIONS

MTX, HCQ, SSZ,AZT= PADIBs ABATACEPT

RITUXIMAB

ACPAs

ANTI-CYTOKINES

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STE

ROID

S

PKIs ?

PKIs ?

PKIs ?

PKIs ?

PKIs ?

HA MÉNARD, Jan 2013

FORGET THIS OSLER’S QUOTATION

"When a patient with arthritis comes through the front door,

I want to leave by the back door".

Times are changing

SHUKRANALA ALDAWAH

QUESTIONS?COMMENTS?