Interleukin 6 as a therapeutic target in systemic-onset juvenile idiopathic arthritis

Integrative Analysis of Transcriptome-Wide Association Study and Gene-Based Association Analysis Identifies In Silico Candidate Genes Associated with Juvenile Idiopathic Arthritis

Genome-wide association study (GWAS) of Juvenile idiopathic arthritis (JIA) suffers from low power due to limited sample size and the interpretation challenge due to most signals located in non-coding regions. Gene-level analysis could alleviate these issues. Using GWAS summary statistics, we performed two typical gene-level analysis of JIA, transcriptome-wide association studies (TWAS) using FUnctional Summary-based ImputatiON (FUSION) and gene-based analysis using eQTL Multi-marker Analysis of GenoMic Annotation (eMAGMA), followed by comprehensive enrichment analysis. Among 33 overlapped significant genes from these two methods, 11 were previously reported, including TYK2 (PFUSION = 5.12 × 10-6, PeMAGMA = 1.94 × 10-7 for whole blood), IL-6R (PFUSION = 8.63 × 10-7, PeMAGMA = 2.74 × 10-6 for cells EBV-transformed lymphocytes), and Fas (PFUSION = 5.21 × 10-5, PeMAGMA = 1.08 × 10-6 for muscle skeletal). Some newly plausible JIA-associated genes are also reported, including IL-27 (PFUSION = 2.10 × 10-7, PeMAGMA = 3.93 × 10-8 for Liver), LAT (PFUSION = 1.53 × 10-4, PeMAGMA = 4.62 × 10-7 for Artery Aorta), and MAGI3 (PFUSION = 1.30 × 10-5, PeMAGMA = 1.73 × 10-7 for Muscle Skeletal). Enrichment analysis further highlighted 4 Kyoto Encyclopedia of Genes and Genomes (KEGG) pathways and 10 Gene Ontology (GO) terms. Our findings can benefit the understanding of genetic determinants and potential therapeutic targets for JIA.

Correlations between serum interleukin 6, serum soluble interleukin 6 receptor, and disease activity in systemic juvenile idiopathic arthritis patients treated with or without tocilizumab

Introduction

Interleukin (IL)-6 is a proinflammatory cytokine involved in systemic juvenile idiopathic arthritis (SJIA). Since these patients are often treated with tocilizumab (TCZ), anti-IL-6 receptor (IL-6R) antibody, we investigated correlations between serum IL-6 and soluble IL-6R-levels and disease activity in SJIA patients treated with or without TCZ.

Material and methods

164 serum samples were taken from 42 SJIA patients treated with or without TCZ (69 and 95 samples, respectively). Patients were assigned to three groups according to disease status: 1) systemic (patients with systemic features and/or arthritis), 2) arthritis (patients with arthritis but no systemic features), and 3) inactive (clinically inactive disease). Disease activity was assessed using the Juvenile Arthritis Disease Activity Score-27 (JADAS-27) at the time of blood collection.

Results

IL-6 levels were highest in SJIA patients with predominant systemic features, while serum sIL-6R levels were highest in patients with persistent arthritis. Serum IL-6 correlated with JADAS-27 in patients treated with and without TCZ (r = 0.38 and r = 0.65, respectively), whereas serum sIL-6R levels correlated with JADAS-27 in patients treated without (r = 0.30) but not with (r = −0.14) TCZ. The sIL-6R/IL-6 ratio negatively correlated with JADAS-27 in patients treated with and without TCZ (r = –0.49 and r = –0.56, respectively).

Conclusions

Serum IL-6 levels correlated more strongly with disease activity parameters than did sIL-6R levels and could be useful for monitoring disease activity in SJIA patients. The sIL-6R/IL-6 ratio might be a promising disease activity marker in both SJIA patients treated with and without TCZ.

Treatment of patients with systemic-onset juvenile idiopathic arthritis with tacrolimus

Previously, few studies have reported treatment with tacrolimus (TAC) for patients with systemic-onset juvenile idiopathic arthritis (SOJIA). The aim of the current study was to investigate the effect of TAC on patients with SOJIA. Data were collected from the beginning of treatment with TAC to the 12-month endpoint, which was defined as the last follow-up. Clinical characteristics included sex, age, duration of the disease, TAC dose, erythrocyte sedimentation rate (ESR), C reactive protein (CRP), hemoglobin (Hb), platelet (PLT) and white blood cell (WB) levels, prednisolone (PDN) dose and interleukin-6 (IL-6) expression. The baseline characteristics of the patients were: ESR, 67.8±18.7 mm/h; CRP, 128.0±38.9 mg/l; Hb, 108.7±13.7 g/l; PLT, 416.8±90.1×10⁹/l; WB, 26.0±10.2×10⁹/l; PDN dose, 49.0±17.1 mg/day. Following 12 months of treatment with TAC, ESR, CRP, PLT and WB levels, and the dose of PDN required for the treatment of patients with SOIJA were all decreased compared with the baseline values. No serious adverse reactions were reported. Therefore, TAC could be an effective treatment for SOJIA.

Potential Effects of Interleukins on the Pathogenesis of Systemic Onset Juvenile Idiopathic Arthritis

BACKGROUND

To analyze the correlation of cytokines with clinical inflammatory indexes in systemic onset juvenile idiopathic arthritis (SOJIA).

METHODS

A total of 30 active SOJIAs, 30 remission SOJIAs, and 20 normal controls were enrolled. The clinical inflammatory indexes such as tender joints counts, swelling joints counts, C-reactive protein, erythrocyte sedimentation rate, visual analogue scale (VAS), and disease activity score 28 (DAS28) were detected. The serum cytokines interleukin (IL)-17, IL-6, IL-21, interferon (IFN)-γ, and IL-4 levels were determined with enzyme-linked immunosorbent assay method. The correlation coefficients between these cytokines and two clinical indexes (VAS and DAS28) in the active SOJIA group were calculated with the Spearman's method.

RESULTS

The serum IL-17 and IL-6 levels in active SOJIA group were significantly increased compared with those in the remission SOJIA group and control group (p < 0.05), and the serum IL-21, IFN-γ, and IL-4 levels showed no obvious difference. In the active SOJIA group, the Spearman coefficients between IL-17 and DAS28, IL-17 and IL-6, IL-6 and DAS28, and between IL-17 and VAS were 0.686 (p = 0.000), 0.833 (p = 0.000), 0.633 (p = 0.000), and 0.524 (p = 0.003), respectively. There was no correlation between cytokines of IL-21, IFN-γ, and IL-4 and the clinical indexes of DAS28 and VAS. Furthermore, in the other two groups, none of the five cytokines exhibited an association with DAS28 or VAS.

CONCLUSION

IL-6 and IL-17 were significantly correlated with DAS28 and VAS, and they might be considered as therapeutic targets for the treatment of SOJIA.

Increased C-reactive protein and fever in Japanese infants with food protein-induced enterocolitis syndrome

BACKGROUND

Increased C-reactive protein (CRP) and fever are observed in some infants with food protein-induced enterocolitis syndrome (FPIES) in Japan, but the reproducibility of these findings has not yet been confirmed on oral food challenge (OFC).

METHODS

Fourteen infants with FPIES induced by cow's milk (CM) formula were enrolled. OFC using CM formula was performed on each infant once or repeatedly (total 18 tests), with a stepwise incremental protocol in an infection-controlled setting. CRP was measured 24 h after the last ingestion of the CM formula.

RESULTS

Increased CRP was observed in 11 of the 18 OFC conducted (median, 2.60 mg/dL; range, 0.22-4.84 mg/dL). Fever was induced in six occasions during OFC. Serum CRP in the patients with fever increased to median 3.76 mg/dL (range, <0.7-4.84 mg/dL), which was significantly higher than that of the patients without fever (median <0.1 mg/dL; range, <0.1-2.6 mg/dL; P < 0.001). CRP during OFC significantly correlated with that at disease onset (rs = 0.62, P < 0.02). Three of the four patients with fever at disease onset also had fever during OFC.

CONCLUSIONS

Increased CRP and fever are reproducible during OFC in some infants with FPIES, suggesting that these are not accidental phenomena, but instead are associated with FPIES itself in Japanese patients.

A comprehensive review and update on the biologic treatment of adult noninfectious uveitis: part II

INTRODUCTION

Treatment of adult, noninfectious uveitis remains a major challenge for ophthalmologists around the world, especially in regard to recalcitrant cases. It is reported to comprise approximately 10% of preventable blindness in the USA. The cause of uveitis can be idiopathic or associated with infectious and systemic disorders. The era of biologic medical therapies provides new options for patients with otherwise treatment-resistant inflammatory eye disease.

AREAS COVERED

This two-part review gives a comprehensive overview of the existing medical treatment options for patients with adult, noninfectious uveitis, as well as important advances for the treatment ocular inflammation. Part I covers classic immunomodulation and latest information on corticosteroid therapy. In part II, emerging therapies are discussed, including biologic response modifiers, experimental treatments and ongoing clinical studies for uveitis.

EXPERT OPINION

The hazard of chronic corticosteroid use in the treatment of adult, noninfectious uveitis is well documented. Corticosteroid-sparing therapies, which offer a very favorable risk-benefit profile when administered properly, should be substituted. Although nothing is currently approved for on-label use in this indication, many therapies, through either translation or novel basic science research, have the potential to fill the currently exposed gaps.

Tocilizumab in pediatric rheumatology: the clinical experience

During the last two decades, clinical use of novel biological therapy has led to increased mechanistic understanding of complex rheumatological diseases. Conversely, basic and translational studies have led to development of new and varied therapeutic agents. These new medications which "target" specific steps in one or more immune pathways have the potential to control disease symptoms, improve quality of life and long-term prognosis, and perhaps in some, restore immunological tolerance. Use of these agents in clinical trials, combined with post-marketing surveillance, has revealed both the benefits and the undesirable side-effects of biological disease-modifying anti-rheumatic drugs (DMARDs). In this review we focus on the use of tocilizumab, a monoclonal antibody directed against the IL6 receptor (IL6R), which potently inhibits IL-6/IL6R signaling.

IL-6 receptor is a possible target against growth of metastasized lung tumor cells in the brain

In the animal model of brain metastasis using human lung squamous cell carcinoma-derived cells (HARA-B) inoculated into the left ventricle of the heart of nude mice, metastasized tumor cells and brain resident cells interact with each other. Among them, tumor cells and astrocytes have been reported to stimulate each other, releasing soluble factors from both sides, subsequently promoting tumor growth significantly. Among the receptors for soluble factors released from astrocytes, only IL-6 receptor (IL-6R) on tumor cells was up-regulated during the activation with astrocytes. Application of monoclonal antibody against human IL-6R (tocilizumab) to the activated HARA-B cells, the growth of HARA-B cells stimulated by the conditioned medium of HARA-B/astrocytes was significantly inhibited. Injecting tocilizumab to animal models of brain metastasis starting at three weeks of inoculation of HARA-B cells, two times a week for three weeks, significantly inhibited the size of the metastasized tumor foci. The up-regulated expression of IL-6R on metastasized lung tumor cells was also observed in the tissue from postmortem patients. These results suggest that IL-6R on metastasized lung tumor cells would be a therapeutic target to inhibit the growth of the metastasized lung tumor cells in the brain.

Tocilizumab for the Treatment of Juvenile Idiopathic Arthritis

OBJECTIVE:

To evaluate the pharmacology, clinical efficacy, safety, and role of tocilizumab for the treatment of juvenile idiopathic arthritis.

DATA SOURCES:

A literature search via MEDLINE through PubMed (1970-December 2011) and International Pharmaceutical Abstracts (1970-December 2011) was performed to identify clinical trials and review articles. The key search terms tocilizumab, anti-interleukin 6, and juvenile idiopathic arthritis were used, with several combinations of terms. Bibliographies of selected articles were examined to identify additional references, and ongoing trials were identified through a review of www.clinicaltrials.gov .

STUDY SELECTION AND DATA EXTRACTION:

Articles were limited to those published in English and studies in humans. Studies included in the review examined pediatric data in systemic and polyarticular juvenile idiopathic arthritis. Background information was obtained through reviews of literature on a wide variety of autoimmune disease states in both adult and pediatric populations.

DATA SYNTHESIS:

Tocilizumab is Food and Drug Administration–approved for use in patients aged 2 years and older with systemic juvenile idiopathic arthritis. Tocilizumab was superior to placebo in triggering a symptomatic response during Phase 2 and 3 clinical trials. Tocilizumab was determined to be safe, with only a small number of serious adverse drug events occurring within studies.

CONCLUSIONS:

Tocilizumab provides expansion of the available options for the treatment of systemic juvenile idiopathic arthritis, specifically in patients who have not responded to conventional therapies. Tocilizumab is relatively well tolerated and has proven efficacy for up to 52 weeks. Further studies are warranted to determine its utility as a first-line option for systemic juvenile idiopathic arthritis as well as its role within the treatment of polyarticular juvenile idiopathic arthritis.

Systemic arthritis in children: a review of clinical presentation and treatment

Systemic juvenile idiopathic arthritis (sJIA) constitutes a small part of juvenile idiopathic arthritis (JIA), yet has a disproportionally higher rate of mortality. Despite being grouped under JIA, it is considered to be a multifactorial autoinflammatory disease. The objective of this paper is to review the epidemiology, pathogenesis, genetics, clinical manifestations, complications, therapy, prognosis, and outcome of sJIA. The presentation and clinical manifestations of sJIA have not changed much in the past several decades, but the collective understanding of the pathogenesis and the development of new targeted therapies (particularly the biologic agents) have transformed and improved the disease outcome for children with sJIA.

Anti-inflammatory treatment of uveitis with biologicals: new treatment options that reflect pathogenetic knowledge of the disease

BACKGROUND

Endogenous uveitis is a sight-threatening disease. In addition to corticosteroids, immunosuppressive agents are commonly used to treat patients with severe course. Immunosuppressive drugs act nonspecifically, rather than providing a specific interaction with the critical pathogenetic pathways of uveitis. Better knowledge of the basic mechanisms underlying uveitis and of the molecules that are important for regulating inflammation has helped to create new and more specific treatment approaches. Biological therapy for inflammatory diseases employs substances that interfere with specific molecules or pathways induced in the body during the inflammatory process.

METHODS

This review gives an overview on molecules that play a critical role in the pathogenetic process of uveitis, as has been observed in patients or the respective animal models, and summarizes the current experience with biologicals for the treatment of uveitis refractive to conventional immunosuppressives.

Clinical value of blocking IL-6 receptor

PURPOSE OF REVIEW

Interleukin-6 (IL-6) is a multifunctional cytokine that regulates inflammatory response and immune reaction. Overproduction of IL-6 is pathologically involved in inflammatory autoimmune diseases such as rheumatoid arthritis (RA) and juvenile idiopathic arthritis, and therefore, blocking IL-6 activity is one of therapeutic options for these diseases. Tocilizumab is a humanized anti-IL-6 receptor (IL-6R) antibody and inhibits IL-6 activity. There is now accumulating evidence that tocilizumab is therapeutically effective for patients with RA and other inflammatory autoimmune diseases. This article reviews the clinical value of blocking IL-6R.

RECENT FINDINGS

Tocilizumab, as monotherapy and in combination with methotrexate, has been shown to be effective for RA patients with insufficient efficacy to methotrexate or other disease-modifying antirheumatic drugs. These findings of tocilizumab have been expanded to patients refractory to tumor necrosis factor inhibitors. Tocilizumab also retards the progression of structural joint damage. Furthermore, a 5-year long-term safety and efficacy has been shown. Tocilizumab is also a promising therapeutic option for other rheumatic diseases such as systemic-onset juvenile idiopathic arthritis, adult-onset Still's disease, and Takayasu arteritis.

SUMMARY

Blocking IL-6R with tocilizumab represents a promising new treatment for RA and other inflammatory diseases. Large registry data will warrant the safety profile of tocilizumab.

Cytokine signal regulation and autoimmune disorders

Understanding of biological activities of cytokines and exquisite mechanism to regulate their functions has facilitated the therapeutic concept to restore the disequilibrium between pro-inflammatory cytokines and anti-inflammatory cytokines or cytokine inhibitors in some autoimmune inflammatory diseases such as rheumatoid arthritis (RA) and Crohn's disease. The application of molecular biology techniques to design monoclonal antibodies, soluble receptors, or receptor antagonists as therapeutic biologic agents made it possible to regulate the cytokine signals for the treatment of the diseases refractory to conventional therapies. Japanese researchers have contributed considerably to the establishment of cytokine signal regulation in autoimmune diseases. In this article, Japanese studies of cytokine signal regulation, particularly for Interleukin-6 (IL-6) in autoimmune diseases are reviewed.

The role of heme oxygenase-1 in systemic-onset juvenile idiopathic arthritis

We have determined the serum levels of heme oxygenase-1 (HO-1) in 56 patients with systemic-onset juvenile idiopathic arthritis (s-JIA) and compared these with serum HO-1 levels in healthy controls and patients with other pediatric rheumatic diseases. Serum HO-1 levels were measured by the sandwich enzyme-linked immunosorbent assay. The mean serum HO-1 level in s-JIA patients during the active phase was 123.6 +/- 13.83 ng/ml, which was significantly higher than that in patients with polyarticular juvenile idiopathic arthritis (p-JIA), Kawasaki disease, systemic lupus erythematosus or mixed connective tissue disease (P < 0.0005). The serum levels of HO-1, cytokines and cytokine receptors in patients with s-JIA were also assessed at both the active and inactive phases. The serum HO-1 level in patients with s-JIA in the active phase was found to be significantly greater than that in patients with the disease in the inactive phase (P < 0.0001). An assessment of the relationships between serum HO-1 levels and other laboratory parameters or cytokines in patients with s-JIA did not reveal any strong correlations. These results suggest that the serum level of HO-1 may be a useful marker for the differential diagnosis of s-JIA. Further study will be necessary to elucidate the mechanism of HO-1 production and to clarify the role of HO-1 in the disease process.

Mechanisms and pathologic significances in increase in serum interleukin-6 (IL-6) and soluble IL-6 receptor after administration of an anti-IL-6 receptor antibody, tocilizumab, in patients with rheumatoid arthritis and Castleman disease

Interleukin-6 (IL-6) plays pathologic roles in immune-inflammatory diseases such as rheumatoid arthritis (RA) and Castleman disease. By inhibiting IL-6 receptors (IL-6Rs), tocilizumab (a humanized anti-IL-6R antibody) ameliorates the symptoms of these diseases and normalizes acute-phase proteins, including C-reactive protein (CRP). We found that tocilizumab treatment increased serum levels of IL-6 and soluble IL-6R (sIL-6R). To investigate the pathologic significance of these increases, we analyzed the kinetics of serum IL-6 and sIL-6R and the proportion of sIL-6R saturated with tocilizumab after tocilizumab administration in patients with RA and Castleman disease and then compared the results with the CRP values. Serum IL-6 and sIL-6R markedly increased after tocilizumab administration in both RA and Castleman disease. As long as free tocilizumab was detectable, sIL-6R was saturated with tocilizumab and IL-6 signaling was completely inhibited. We concluded that it is likely that sIL-6R increased because its elimination half-life was prolonged by the formation of tocilizumab/sIL-6R immune complex, and that free serum IL-6 increased because IL-6R-mediated consumption of IL-6 was inhibited by the unavailability of tocilizumab-free IL-6R. We also concluded that the increased level of free IL-6 during tocilizumab treatment closely reflects the actual endogenous IL-6 production and true disease activity.

Juvenile idiopathic arthritis

Juvenile idiopathic arthritis (JIA), a term referring to a group of disorders characterized by chronic arthritis, is the most common chronic rheumatic illness in children and is a significant cause of short- and long-term disability. This article discusses the classification, differential diagnosis, and treatment of JIA.

Proposal for juvenile idiopathic arthritis guidance on diagnosis and treatment for primary care pediatricians and nonpediatric rheumatologists (2007)

The Pediatric Standing Committee of the Japan College of Rheumatology, in collaboration with the Pediatric Rheumatology Association of Japan, produced guidance on the diagnosis and treatment for juvenile idiopathic arthritis (JIA) for primary care pediatricians and nonpediatric rheumatologists in Japan. This guidance aims to achieve early diagnosis and treatment for JIA, which is similar to adult rheumatoid arthritis (RA), based on recent progress in rheumatology, and to resolve arthritis at an early stage and improve the prognosis of the affected inflammatory joints. It describes clinical symptoms and laboratory findings characteristic to JIA in order to make early diagnosis and treatment possible, and also serves as a triage of patients who are refractory to the treatment protocol described here and need more aggressive interventions. However, because JIA is a complicated and heterogeneous disease and the optimal treatment approach can be diverse and different patient by patient, these guidelines should be viewed as recommendations and be individualized according to the condition of the patient. Finally, we hope that this guidance will trigger exploration for further information by referring to the textbooks and literature listed at the end of these guidelines.

Auranofin blocks interleukin-6 signalling by inhibiting phosphorylation of JAK1 and STAT3

Auranofin (AF) is a sulphur-containing gold compound. Because of its anti-inflammatory and immunosuppressive activities, AF has been widely used for the therapeutic treatment of rheumatoid arthritis. However, little is known about its mechanism of action. To elucidate the molecular mechanism underlying the anti-inflammatory effect of AF, we studied the effects of AF on cellular responses to interleukin-6 (IL-6). In HepG2 human hepatoma cells, AF markedly inhibited IL-6-induced phosphorylation of janus kinase 1 (JAK1) and signal transducer and activator of transcription 3 (STAT3) and STAT3 translocation into the nucleus. Consistent with this, AF diminished IL-6-induced production of the acute-phase proteins, haptoglobin, fibrinogen, C3 complement and alpha(1)-acid glycoprotein, and gene expression of vascular endothelial growth factor, all of whose transcriptional activities are regulated by STAT3. The inhibitory activity of AF on STAT3 phosphorylation was also demonstrated in primary cells, i.e. fibroblast-like synoviocytes from rheumatoid arthritis patients, human umbilical vein endothelial cells and rat astrocytes. Auranofin-mediated inhibition of STAT3 phosphorylation was recovered by pretreatment with antioxidants containing thiol groups. These findings suggest that the anti-inflammatory action of AF is associated with a blockade of JAK1/STAT3 signalling. Thiol-group-reactive proteins may be involved in AF-induced suppression of JAK1/STAT3 phosphorylation.

Interleukin 6: from bench to bedside

Interleukin (IL)-6 is a pleiotropic cytokine that has important roles in the regulation of the immune response, inflammation, and hematopoiesis. Disruption of IL-6 regulation might, however, affect the immune response and consequently induce immune-mediated inflammatory diseases such as rheumatoid arthritis, systemic juvenile idiopathic arthritis, Castleman disease, and Crohn's disease. Overproduction of IL-6 also contributes, through its roles as a growth factor or an antiapoptotic factor, to the development of malignant diseases such as multiple myeloma and renal cancer. Progress in the study of IL-6 has increased our understanding of the pathological roles of this cytokine in these diseases and provided key evidence that antagonizing its activities can be used as a therapeutic strategy. The application of molecular biology techniques to design monoclonal antibodies as therapeutic agents has made it possible to regulate the IL-6 signal to successfully treat diseases that have so far proved refractory to conventional therapies. Blocking IL-6 actions by use of a humanized antibody, tocilizumab, which targets the IL-6 receptor, has been proven to be therapeutically effective for rheumatoid arthritis, systemic juvenile idiopathic arthritis, Castleman disease and Crohn's disease. In this review, we discuss a paradigm of IL-6 from basic science to clinical use.

Blood and synovial fluid cytokine signatures in patients with juvenile idiopathic arthritis: a cross-sectional study

BACKGROUND

Juvenile idiopathic arthritis (JIA) consists of a heterogeneous group of disorders with, for the most part, an unknown immunopathogenesis. Although onset and disease course differ, the subtypes of JIA share the occurrence of chronic inflammation of the joints, with infiltrations of immunocompetent cells that secrete inflammatory mediators.

OBJECTIVE

To identify a panel of cytokines specifically related to the inflammatory process in JIA.

METHODS

Using a new technology, the multiplex immunoassay, 30 cytokines were measured in plasma of 65 patients with JIA, of which 34 were paired with synovial fluid. These data were compared with plasma of 20 healthy controls and 9 patients with type I diabetes, a chronic inflammatory disease.

RESULTS

Patients with JIA had, irrespective of their subclassification, significantly higher levels of tumour necrosis factor alpha, macrophage inhibitory factor (MIF), CCL2, CCL3, CCL11, CCL22 and CXCL9 in plasma than controls. In paired plasma and synovial fluid samples of patients with JIA, significantly higher levels of interleukin (IL)6, IL15, CCL2, CCL3, CXCL8, CXCL9 and CXCL10 were present in synovial fluid. Cluster analysis in all patients with JIA revealed a predominant pro-inflammatory cytokine cluster during active disease and a regulatory/anti-inflammatory-related cytokine cluster during remission. Whether a discrimination profile of various cytokines could help in the determination of disease classification was tested.

CONCLUSION

It is suggested that several cytokines (IL18, MIF, CCL2, CCL3, CCL11, CXCL9 and CXCL10) may correspond to the activation status during inflammation in JIA and could be instrumental in monitoring disease activity and outcomes of (new) immunotherapies.

Biologic therapies for inflammatory eye disease

The era of biologic medical therapies provides new options for patients with treatment-resistant inflammatory eye disease. In this review, the authors summarize current published experience in a rapidly progressing clinical field, including the use of biologics, such as the tumour necrosis factor blockers, daclizumab and rituximab, and related agents, interferons and intravenous immunoglobulin, for the treatment of uveitis, scleritis and orbital inflammation. Reports of dramatic recoveries in patients with recalcitrant ocular inflammation who have received such therapies must be balanced against the high cost of biologics and the potential for serious, and at times unanticipated, complications of this treatment.

Anakinra Therapy in a Child With Systemic-Onset Juvenile Rheumatoid Arthritis After Human Herpesvirus 6 Encephalitis

A 3-year-old patient with biopsy-proven herpesvirus 6 (HHV-6) encephalitis developed a clinical condition consistent with systemic-onset juvenile idiopathic rheumatoid arthritis (SoJIA) and responsive to synthetic interleukin-1 (IL-1) receptor therapy. This suggested both a temporal relationship between HHV-6 infection and the development of SoJIA and the likely involvement of IL-1 in his disease. This case adds to the current experience of IL-1 receptor antagonist therapy in SoJIA. In addition, it suggests that future prospective studies in new-onset SoJIA should include an evaluation for HHV-6 infection.

Leukocytapheresis for the treatment of refractory systemic-onset juvenile idiopathic arthritis

Although leukocytapheresis (LCAP) has been reported to be effective for the treatment of various autoimmune disorders, little information has been published yet on the efficacy and safety of LCAP for the treatment of systemic-onset juvenile idiopathic arthritis (SOJIA). A pilot trial of LCAP was therefore conducted on two children with refractory SOJIA using a granulocyte apheresis filter packed with cellulose acetate beads in an attempt to control the disease flares. Following three to eight sessions of LCAP, the joint symptoms gradually resolved without any increase in the dose of corticosteroids. The procedure was associated with a decrease in the serum interleukin-6. No severe adverse effects were observed except for mild nausea. However, efficacy of LCAP sustained in a short time since both patients subsequently developed flares after 3 months of the treatment.

Targeting cytokines beyond tumor necrosis factor-α and interleukin-1 in rheumatoid arthritis

Targeting tumor necrosis factor-a has proven of considerable value in treatment for rheumatoid arthritis, with substantial benefits achieved in a proportion of treated patients. However, a significant number of patients do not achieve sufficient improvement and as a result there remains considerable unmet clinical need. A number of cytokines have recently been described with proinflammatory activity in rheumatoid arthritis synovitis, including interleukin (IL)-6, IL-12, IL-15, and IL-18. We review recent data that support the notion that some or all of these moieties offer therapeutic potential. The possibility that some may be useful in partial responders to tumor necrosis factor blocking agents or in synergy with the latter is discussed.

Update on the pathogenesis and treatment of systemic onset juvenile rheumatoid arthritis

PURPOSE OF REVIEW

Although systemic onset juvenile rheumatoid arthritis accounts for only about 20% of most reported series, children with systemic onset juvenile rheumatoid arthritis are often the most difficult to treat. Many children with persistent systemic onset juvenile rheumatoid arthritis have marked physical and emotional disability as a result of both disease and treatment-related morbidities. This review highlights recent studies that better elucidate the etiopathogenesis of systemic onset juvenile rheumatoid arthritis. New therapies derived from better understanding of cytokines, cytokine gene expression, and their complex interactions, which result in inflammation, are improving our ability to control active disease while reducing or reliance on corticosteroids.

RECENT FINDINGS

Recent advances in our understanding of the etiopathogenesis of systemic onset juvenile rheumatoid arthritis have led to therapies that specifically target the cytokines found in abnormal quantities in children with active disease. Biologic agents that directly target interleukin-1a, interleukin-6, and tumor necrosis factor alpha are currently in use, and additional agents that modulate interleukin-18, myeloid-related proteins 8 and 14, natural killer cell function, and macrophage migration inhibitory factor production are under investigation.

SUMMARY

Anakinra, monoclonal antibody to interleukin-6 receptor, and thalidomide each have led to significant clinical improvement with fewer side effects than resulted when corticosteroids were the mainstay of therapy.

Coronary artery dilation among patients presenting with systemic-onset juvenile idiopathic arthritis

OBJECTIVE

To evaluate coronary artery diameters among patients presenting with systemic-onset juvenile idiopathic arthritis (SoJIA).

METHODS

Fifty cases of SoJIA were reviewed. At the time of initial presentation with fever, 12 patients had echocardiograms that included a complete evaluation of the coronary arteries. A single reviewer measured the diameters of the left main, proximal left anterior descending, and proximal right coronary arteries. Body surface area-adjusted z scores were calculated with respect to a normative population.

RESULTS

Coronary artery dilation (z score: >2) was observed for 5 of the 12 patients with SoJIA who had echocardiograms performed at the time of presentation with fever. No patient developed a coronary artery aneurysm, and all of the coronary artery z scores normalized within 4 months. Only 2 of the 5 patients with coronary artery z scores of >2 fulfilled the clinical criteria for Kawasaki disease, the most commonly recognized cause of coronary artery dilation among children.

CONCLUSIONS

Children presenting with SoJIA may have coronary artery dilation similar to that observed for children with Kawasaki disease. These data suggest that the presence of coronary artery dilation on initial echocardiograms for patients with fever does not exclude the diagnosis of SoJIA.

Treatment of refractory autoimmune diseases with autologous stem cell transplantation: focus on juvenile idiopathic arthritis

Autologous stem cell transplantation (ASCT) can be performed in a variety of refractory autoimmune diseases. A retrospective multicenter analysis is presented to evaluate safety and efficacy of ASCT for refractory juvenile idiopathic arthritis. In all, 18 of the 34 patients (53%) with a follow-up of 12 to 60 months achieved a drug-free complete remission. There were three cases (9%) of transplant-related mortality and two cases of disease-related mortality (6%). Infectious complications were seen frequently. We propose adjustments in future protocols to reduce this mortality in this high-risk patient group.

Inflammation in juvenile idiopathic arthritis

Inflammation evolved to aid in the clearance of microorganisms. In pediatric arthritides, the inflammation persists and causes damage to the joint. The contribution of the innate immune system to inflammation is significant and can be exploited therapeutically. Although cells of the adaptive immune system such as T cells and B cells participate in the disease process, many of the features of arthritis are directly attributable to inflammatory mediators. Recent advances in the understanding of these processes have led to dramatic improvements in treatment.

Juvenile idiopathic arthritis

Juvenile idiopathic arthritis (JIA), a term referring to a group of disorders characterized by chronic arthritis, is the most common chronic rheumatic illness in children and is a significant cause of short- and long-term disability. This article discusses the classification, differential diagnosis, and treatment of JIA.

Effect of particulate bioactive glasses on human macrophages and monocytesin vitro

Bioactive glasses, originally developed to promote tissue adhesion, are finding an increasing array of biomedical applications. The aim of the current study was to assess the ability of silicate- and zinc phosphate-based bioactive glasses to modulate the secretion of cytokines from activated human macrophages and monocytes. Human macrophages and monocytes were isolated and cultured on surfaces coated with a range of quantities of the bioactive glasses. Nontoxic concentrations of the glasses were selected and assessed further for their ability to modulate the secretion of tumor necrosis factor (TNF)-alpha, interleukin (IL)-10 and -6, in the presence or absence of the stimulant lipopolysaccharide. 45S5 glass produced a significant reduction to the amount of TNF-alpha (p<0.05) and IL-6 (p<0.01) secreted by stimulated cells compared with cells stimulated in the absence of bioactive glass. A significant reduction in IL-6 secretion was also observed with the other silicate- and zinc phosphate-based glasses tested. IL-10 secretion was increased (but not significantly) in presence of all glasses tested. TNF-alpha and IL-6 secretion from stimulated cells was lower in presence of the silicate glasses compared with the zinc phosphate glasses, indicating that this system of bioactive glass might be of clinical use in conditions associated with inflammation.

Basic Science of Articular Cartilage and Osteoarthritis

Articular cartilage is a specialized tissue uniquely suited for load distribution with a low-friction articulating surface. Its compressive and tensile properties are determined by its matrix and fluid composition, and are maintained by chondrocytes in the homeostatic joint. Osteoarthritis (OA) is increasingly understood as a family of disorders in which the biomechanical properties of cartilage are altered and ultimately fail as the tissue is degraded by local proteases. Mechanically mediated and cytokine-mediated pathways of cartilage degeneration have been identified in the pathogenesis of OA. Further insight into the basic science of cartilage and OA is necessary to develop diagnostic and treatment strategies for this pervasive disease.

Suppression of the onset and progression of collagen-induced arthritis by chebulagic acid screened from a natural product library

OBJECTIVE

Chebulagic acid (CHE) from the immature seeds of Terminalia chebula was identified from a natural product library as a potent suppressor of T cell activity. This study examined the effectiveness of CHE against the onset and progression of collagen-induced arthritis (CIA) in mice.

METHODS

Arthritis was induced in DBA/1J mice by subcutaneous immunization with bovine type II collagen on days 0 and 21. CHE was administered intraperitoneally for 3 weeks, either as prophylaxis (10 or 20 mg/kg) before disease onset or as therapy (20 mg/kg) after disease onset. Clinical scores, serum antibody levels, and cytokines were measured, and flow cytometric analysis and real-time reverse transcription-polymerase chain reaction were performed to evaluate the knee joints of mice with CIA.

RESULTS

In both the prophylactic and therapeutic CHE dosing models, all clinical scores, serum levels of total and anticollagen IgG, and levels of interleukin-10 (IL-10) and IL-6 were reduced, while serum levels of transforming growth factor beta (TGFbeta) were markedly elevated. The number of granulocytes was reduced, but the proportion of CD4+,CD25+ T cells was greater in the knee joints of CHE-treated CIA mice. Expression of Foxp3 and TGFbeta messenger RNA was also augmented significantly in the knee joints of CHE-treated CIA mice in the therapeutic dosing model.

CONCLUSION

CHE significantly suppressed the onset and progression of CIA in mice. Immune suppression via the induction of TGFbeta and CD4+,CD25+ T cells may represent a new strategy in the development of therapies for managing rheumatoid arthritis and other inflammatory diseases.

Remittive agents in pediatric rheumatology

PURPOSE OF REVIEW

Children with rheumatic diseases frequently require therapy with disease-modifying antirheumatic drugs and/or biologic agents. Therapies that have been prospectively tested in adults are often used in children before full evaluation of their safety and efficacy. Published experience that may report "off-label" usage can be helpful in decision making, although such reports do not reduce the need for prospective clinical trials in children. The purpose of this review is to summarize the recent published evidence regarding efficacy (and safety, when available) of standard and novel agents used in pediatric rheumatic disease.

RECENT FINDINGS

Etanercept, one of three currently available tumor necrosis factor-alpha inhibitors has a juvenile idiopathic arthritis indication. Novel "off-label" uses in children for interleukin-1 receptor agonist (Anakinra), antiinterleukin-6 receptor antibody (MRA), and rituximab (anti-CD20 monoclonal antibody) are discussed.

SUMMARY

This review summarizes the published evidence that supports the use of selected disease-modifying antirheumatic drugs and novel biologic agents in children with rheumatic diseases.

Targeting cytokines beyond tumor necrosis factor-α and interleukin-1 in rheumatoid arthritis

Targeting tumor necrosis factor-a has proven of considerable value in treatment for rheumatoid arthritis, with substantial benefits achieved in a proportion of treated patients. However, a significant number of patients do not achieve sufficient improvement and as a result there remains considerable unmet clinical need. A number of cytokines have recently been described with proinflammatory activity in rheumatoid arthritis synovitis, including interleukin (IL) -6, IL-12, IL-15, and IL-18. We review recent data that support the notion that some or all of these moieties offer therapeutic potential. The possibility that some may be useful in partial responders to tumor necrosis factor blocking agents or in synergy with the latter is discussed.