Exploring the perspective of patients with immune-mediated inflammatory diseases and care providers on the use of immunomodulatory drugs in infections: an interview study

Objectives

Immunomodulatory agents are safe and effective as treatment for various immune-mediated inflammatory diseases (IMIDs), but are associated with a slightly increased infection risk. It is uncertain whether, in the event of an infection, continuation or temporary interruption of immunomodulatory agents leads to better outcomes. Owing to this uncertainty, it is of importance to explore the perspectives of health-care providers (HCPs) and patients on this topic. In this study, we set out to identify and provide an overview of reasons for both treatment strategies.

Methods

Semi-structured interviews were conducted with HCPs involved in the pharmacological treatment of IMIDs and with IMID patients using one or more immunomodulatory agent. Purposive sampling was used to enrich data variation. Interviews were conducted until data saturation was reached and subsequently analysed using qualitative content analysis.

Results

In total, 13 HCPs and 19 IMID patients were interviewed. A wide range of reasons for both treatment strategies were identified, categorized into 10 overarching themes, including IMID characteristics, infection characteristics and the patient-HCP relationship.

Conclusion

In this interview study, we identified various reasons for continuation or temporary interruption of immunomodulatory agents during infections for both IMID patients and HCPs. We found overlapping themes, such as IMID characteristics; however, the content and interpretation of these themes might differ between HCPs and patients. Both HCPs and patients mentioned that the decision for a treatment strategy is often about weighing benefits against risks (e.g. infection severity vs disease flare).

POS0680 PHYSICIANS’ REASONS FOR PRESCRIBING JANUS KINASE INHIBITORS (JAKi) IN PATIENTS WITH RHEUMATOID ARTHRITIS (RA), AND ASSOCIATED ALIGNMENT BETWEEN PHYSICIANS AND PATIENTS IN A REAL-WORLD CLINICAL SETTING

Background

Shared decision making, a cornerstone of RA management1, allows physicians and their patients to make informed decisions about their treatment goals and choice of care. As new treatments become available, it is important to understand rheumatologists’ reasons for choosing JAKi.

Objectives

This survey evaluated rheumatologists’ clinical and patient centric reasons for choosing JAKi, in addition to exploring alignment between rheumatologists and RA patients in terms of treatment choice and satisfaction.

Methods

The Adelphi RA Disease Specific Programme™2 is a large, multinational, point-in-time survey conducted amongst rheumatologists and their consulting patients with RA in Europe (Belgium, France, Germany, Italy, Spain, UK) between January and October 2020. Physicians completed record forms for up to 10 consecutive RA patients, collecting demographic, clinical and treatment data, and reasons for current treatment choice. Patients were invited to complete a patient questionnaire to assess their satisfaction with ongoing treatment (5-point scale), and perceptions of shared decision making for the current treatment.

Results

316 rheumatologists provided data for 3121 patients, of whom 1130 (36.2%) completed patient reported questionnaires. Overall, 67% were female, mean age was 53 years (SD 14), 23% had moderate-high disease activity score (DAS28: >3.2). 68% of patients were currently receiving either a biologic or targeted synthetic disease-modifying antirheumatic drug (DMARD; defined here as advanced therapy, AT), 72% were on first line AT. Overall, physicians and their patients were aligned that a conversation took place about a treatment decision (n=855, 79% net alignment), and this was a shared treatment decision (n=814, 75% net alignment). 15% of patients not taking an AT were reported to have a clinical condition warranting one; reasons for not taking AT included patients’ concerns about infection (24%), conventional synthetic DMARDs were tolerable and safe in the patient (18%), and patient dislike of infusions/injections (17%). Of 2143 patients receiving AT, 19% were prescribed JAKi; 57% as monotherapy, 43% as combination therapy. For physician stated reasons for choice of JAKi, factors were driven by both perceptions of clinical efficacy and onset of action, as well as factors relating to patient acceptability such as method of delivery and ease of use (Table 1). With respect to JAKi treatment (n=135 patient-physician pairs), 62% of physicians and their patients were aligned on satisfaction, however 30% of patients reported less satisfaction than their consulting physician (Figure 1).

Table 1.

Physician stated clinical and patient centric reasons for prescribing a JAKi in their patients with RA (data are percentage of patients; n=397)

Reasons for prescribing JAKiPatients (%)Top 5 clinical reasonsStrong overall efficacy74Fast onset of action49Inhibition of disease progression42Strong efficacy as monotherapy39Achievement of clinical remission37Top 5 patient centric reasonsAcceptability of method of delivery for the patient39Enabling patient to perform everyday tasks/activities36Ease of product use (for the patient)33Improvement or maintenance of quality of life30Improving patient’s mood/state of mind14

Conclusion

Communicating the choice of pharmacological therapy to patients with RA has become increasingly complex for physicians with expansion of approved treatments. In this subgroup of patients on JAKi, the drug attributes considered as reasons for prescribing were driven by clinical factors as well as by patient centric attributes. Although communications between patients and physicians were largely aligned, better understanding of patient expectations might serve to improve messaging about treatment options and resulting satisfaction.

References

[1]Smolen JS et al. Ann Rheum Dis 2017;76.

[2]Anderson P et al. Curr Med Res Opin 2008;24(11):3063–72.

Acknowledgements

The study was funded by Galapagos NV (Mechelen, Belgium). We thank the physicians and patients who participated in this survey. Medical writing support was provided by Gary Sidgwick, PhD (Adelphi Real World, Bollington, UK) and publications management was provided by Aspire Scientific Ltd, (Bollington, UK), funded by Galapagos NV.

Disclosure of Interests

Peter C. Taylor Consultant of: AbbVie, Biogen, Bristol Myers Squibb, Fresenius, Galapagos, Gilead, GlaxoSmithKline, Janssen, Lilly, Nordic Pharma, Pfizer, Roche, Sanofi, and UCB, Grant/research support from: Celgene and Galapagos, Bruno Fautrel Consultant of: AbbVie, Amgen, Biogen, Bristol Myers Squibb, Celgene, Celltrion, Fresenius Kabi, Gilead, Janssen, Lilly, Medac, MSD, Mylan, NORDIC Pharma, Novartis, Pfizer, Roche, Sandoz, Sanofi-Genzyme, Sobi, and UCB, Grant/research support from: AbbVie, Lilly, MSD, and Pfizer, Yves Piette Consultant of: AbbVie, Galapagos, Grünenthal, Novartis, Janssen, and Sandoz, Susana Romero-Yuste Speakers bureau: AbbVie, Amgen, Bristol Myers Squibb, Grunenthal, Janssen, Kern Pharma, Lilly, Roche, Sandoz, Sanofi, and UCB, Consultant of: AbbVie, Bristol, Biogen, Fresenius, Galapagos, Gebro, Janssen, and Lilly, Grant/research support from: Bristol Myers Squibb, MSD, Novartis, and Pfizer, Jasper Broen Consultant of: Galapagos, Gilead, UCB, and Novartis, Martin Welcker Speakers bureau: AbbVie, Aescu, Amgen, Biogen, BMS, Berlin Chemie, GSK, Hexal, Janssen, Medac, MSD, Mundipharma, Mylan, Novartis, Pfizer, Riemser, Sanofi, and UCB, Consultant of: AbbVie, Boehringer, BMS, Celgene, Galapagos, Gilead, GSK, Medac, Mylan, Novartis, Pfizer, Sanofi, and UCB, Grant/research support from: AbbVie, Actelion, Boehringer, Galapagos, Gilead, GSK, Hexal, Novartis, and UCB, Elizabeth Holdsworth Employee of: Adelphi Real World, Monia Zignani Employee of: Galapagos NV, Katrien Van Beneden Shareholder of: Galapagos NV, Employee of: Galapagos NV, Roberto Caporali Speakers bureau: AbbVie, Amgen, Bristol Myers Squibb, Celltrion, Fresenius Kabi, Galapagos, Gilead, Lilly, MSD, Pfizer, Roche, Samsung Bioepis, Sanofi, and UCB, Consultant of: Galapagos, Gilead, Janssen, Lilly, and MSD, Rieke Alten Consultant of: AbbVie, Amgen, Biogen, BMS, Celltrion, Galapagos, Gilead, Janssen, Lilly, Novartis, Pfizer, and Roche

POS0305 PHYSICIAN AND PATIENT ATTITUDES TOWARDS TREAT-TO-TARGET, ITS IMPLEMENTATION AND STATED TREATMENT GOALS IN PATIENTS WITH RHEUMATOID ARTHRITIS IN A REAL-WORLD SETTING ACROSS EUROPE

Background:

The principles of treat to target (T2T) include defining an appropriate treatment target, assessed at pre-defined intervals, with a commitment to changing therapeutic approach if the target is not met (1). T2T is recommended as a key strategy for the treatment of rheumatoid arthritis (RA).

Objectives:

To explore attitudes towards T2T, its implementation and stated treatment goals among physicians and their patients with RA.

Methods:

The Adelphi RA Disease Specific Programme™ was a large, quantitative, point-in-time survey conducted amongst rheumatologists (n=296) and their consulting patients with RA (n=3042) in Europe (France, Germany, Italy, Spain, UK) between Q4 2019–Q3 2020. Physicians were recruited via publicly available lists, completing an online survey and medical record extraction for their next 10–12 consecutive patients. The same patients were invited to voluntarily complete a self-report questionnaire (n=1098, 36% response), collecting data on attitudes towards T2T and treatment goals.

Results:

Physicians reported that 76% of patients were in remission (DAS28: <2.6) or had low disease activity (DAS28: 2.6 – 3.2), and 24% had moderate-high disease activity (DAS28: >3.2). Patient mean age was 53.0 years (SD 14.0), mean time since diagnosis was 7.2 years (SD 7.2). The proportion of patients currently receiving an advanced therapy (AT; defined as biologic or targeted synthetic DMARD) was 68%, of whom 70% were on a first line AT. No difference was observed between disease activity groups.

In the physician survey, 86% of physicians stated they followed T2T principals in at least some of their RA patients, and would utilize a T2T approach in RA patients with moderate-high disease activity (61%), the most uncontrolled patients (37%) and those who do not respond well to initial therapy (34%). In this sample of real-world RA patients, 66% were reported by physicians to be on a T2T plan at the time of data collection. The most common physician-reported targets were remission (DAS28: <2.6) (75%), improvement of quality of life (QoL) (41%) and reduction of pain (31%), with 85% of physicians perceiving these treatment goals were fully or partially met. The most stated reasons for not implementing T2T was physician preference not to adjust current treatment (34%), patient preference not to adjust current treatment (23%), and there are no achievable goals for this patient (16%).

Overall, 29% of patients reported they were involved in setting their T2T goals, while 34% stated their T2T goals were set by their physicians only, and 29% perceived no T2T goal had been set (n=620). The most common overall T2T goals from the patient perspective were remission (61%), controlling symptoms (41%), and reducing impact on QoL (34%). Of those patients who acknowledged a T2T goal had been set (n=407), 77% reported their T2T goal was fully or partially achieved.

Of 719 patients who had moderate-high disease activity, 57% were on a T2T plan, with 46% of physicians perceiving these treatment goals were fully or partially met. The most common physician-stated reason for not implementing T2T was a lack of achievable targets (29%).

Conclusion:

Rheumatologists in this study reported a strong belief in T2T. The most common physician-set T2T goals were remission, improvement of QoL and reduction of pain, corresponding with T2T goals as reported by patients. However, a third of patients in this cohort were not aware of a defined T2T objective in their management, which may be a result of a perceived lack of achievable goals by physicians. It may be desirable to promote more patient involvement in defining achievable targets amongst those with moderate-high disease activity who despite best efforts may not reach a clinical state of remission. Further research is needed to identify and understand goals important to RA patients.

References:

[1]van Vollenhoven R. Treat-to-target in rheumatoid arthritis - are we there yet? Nat Rev Rheumatol. 2019;15(3):180-6.

Acknowledgements:

This study was funded by Galapagos NV, Belgium.

Medical writing support was provided by Gary Sidgwick, PhD (Adelphi Real World, Bollington, UK) and editorial support was provided by Debbie Sherwood, BSc, CMPP (Aspire Scientific, Bollington, UK), both funded by Galapagos NV.

Disclosure of Interests:

Bruno Fautrel Consultant of: AbbVie, Amgen, Biogen, BMS, Celgene, Celltrion, Fresenius Kabi, Gilead, Janssen, Lilly, Medac, MSD, Mylan, NORDIC Pharma, Novartis, Pfizer, Roche, Sandoz, Sanofi-Genzyme, SOBI, UCB, Grant/research support from: AbbVie, Lilly, MSD, Pfizer, Roberto Caporali Speakers bureau: AbbVie, Amgen, Bristol Myers Squibb, Celltrion, Galapagos, Gilead, Lilly, Pfizer, Roche, UCB, Sanofi, Fresenius Kabi, Samsung Bioepis, MSD, Consultant of: Galapagos, Gilead, Lilly, Janssen, MSD, Elizabeth Holdsworth Employee of: Adelphi Real World, Bethany Donaghy Employee of: Adelphi Real World, Mona Khalid Shareholder of: Galapagos, Employee of: Galapagos, Mark Moore Shareholder of: Gilead Sciences, Speakers bureau: Gilead Sciences (only as employee), Paid instructor for: Gilead Sciences (only as employee), Consultant of: Gilead Sciences (only as employee), Grant/research support from: Gilead Sciences (only as employee), Employee of: Gilead Sciences, and previously Sanofi and AstraZeneca, Katrien Van Beneden Shareholder of: Galapagos, Employee of: Galapagos, Yves Piette Consultant of: AbbVie, Amgen, Galapagos, Grünenthal and Sandoz, Grant/research support from: Amgen, Mylan and UCB, Susana Romero-Yuste Speakers bureau: AbbVie, Amgen, Bristol Myers Squibb, Grunenthal, Kern Pharma, Lilly, Roche, Sandoz, Sanofi, UCB, Janssen, Consultant of: AbbVie, Biogen, Fresenius, Galapagos, Gebro, Janssen, Lilly, Grant/research support from: Bristol Myers Squibb, MSD, Novartis, Pfizer, Jasper Broen Shareholder of: Pharming Group, Consultant of: Galapagos, Gilead, Novartis, Peter C. Taylor Consultant of: AbbVie, Biogen, Galapagos, Gilead, GlaxoSmithKline, Janssen, Lilly, Pfizer, Roche, Sanofi, Nordic Pharma, Fresenius, UCB, Grant/research support from: Celgene, Galapagos, Gilead, Lilly

POS1197 IN DEPTH IDENTIFICATION OF RISK FACTORS FOR SEVERE COVID-19, REQUIRING HOSPITALIZATION, IN PATIENTS WITH INFLAMMATORY RHEUMATIC DISEASES: RESULTS OF A DUTCH NESTED CASE CONTROL STUDY (PRELIMINARY RESULTS)

Background:

Several risk factors for severe COVID-19 have been identified1. An important question is whether in addition to these generic risk factors, patients with a potentially altered immune response, either by disease (inflammatory rheumatic diseases (IRDs)) or use of immunomodulatory agents (IA), carry a higher or lower risk of severe COVID-19. In addition, several other potential risk factors for severe COVID-19 have been suggested, such as vitamin D status and specific medication (NSAIDs, ACE-inhibitors)2.

Objectives:

To identify risk factors for severe COVID-19, requiring hospitalization, in patients with IRDs.

Methods:

Multicenter, unmatched nested case control study in four rheumatology centers in the Netherlands. Cases are IRD patients requiring hospitalization for COVID-19 between March 1st 2020 and May 31st 2020. Control patients are IRD patients not hospitalized for COVID-19 within this period and were included in a 1:4 ratio. Patient-, disease- and treatment characteristics were extracted (still ongoing) from electronic patient files, and a questionnaire was used to collect additional data (e.g. on behavioral aspects). Potential risk factors for severe COVID-19 were analyzed using unconditional logistic regression, corrected for confounders.

Results:

77 cases and 198 controls were included. 26 case patients died as a result of COVID-19, 14 were admitted to the ICU. Crude ORs for female sex, age, BMI and presence of one or more comorbidities were 0.46 (95% CI 0.27-0.29), 1.1 (95%CI 1.0-1.1), 1.0 (95%CI 0.98-1.1) and 3.0 (95%CI 1.7-5.2) respectively. Table 1 displays corrected OR, highlighted when OR <0.5/>2.0. Corrected ORs were not significantly increased for any IRD, but a trend for gout was present. Use of hydroxychloroquine (HCQ) shows a protective effect, while use of other csDMARDs than methotrexate or HCQ leads to a higher risk of severe COVID-19. Trends were present for increased risk for rituximab (RTX), glucocorticoids and ACE inhibitors, and protective effect for IL-6R blockers.

Conclusion:

The outcomes of this study are in agreement with other research regarding risk of severe COVID-19 related to IRDs and use of IA1. The suggested increased risk of severe COVID-19 in RTX use is of concern and should be monitored closely. Strengths of this study include low bias due to behavioral effects as only cases early in the pandemic were included, completeness of the determinants of interest and ultimately, it provides answers to a relevant and urgent question.

References:

[1]Williamson, Elizabeth J et al. “Factors associated with COVID-19-related death using OpenSAFELY.” Nature vol. 584,7821 (2020): 430-436.

[2]Rizk, John G et al. “Pharmaco-Immunomodulatory Therapy in COVID-19.” Drugs vol. 80,13 (2020): 1267-1292.

[3]Rentsch, Christopher T et al. “Effect of pre-exposure use of hydroxychloroquine on COVID-19 mortality: a population-based cohort study in patients with rheumatoid arthritis or systemic lupus erythematosus using the OpenSAFELY platform.” The Lancet Rheumatology vol. 3,1 (2021): e19-e27.

Table 1.

Corrected ORs for several potential risk factors

Potential risk factorCorrected OR (95% CI)IRDRA*1.38 (0.68 – 2.8)Spondylarthritis0.60 (0.25-1.5)Gout2.8 (0.80-9.8)Polymyalgia0.54 (0.18-1.6)Systemic diseases1.6 (0.49-5.0)DMARDscsDMARDs (any)0.39 (0.17-0.88) Methotrexate0.90 (0.46-1.7)HCQ0.40 (0.16-0.98)Other2.0 (0.99-4.1)bDMARDs (any)0.96 (0.43-2.2) TNF-inhibitors1.0 (0.43-2.6) IL6R-blockers0.43 (0.044 – 4.2)RTX4.5 (0.25-79)tsDMARDs0.89 (0.08-9.8)OtherGlucocorticoids > 10 mg/day2.5 (0.70-9.0)NSAIDs0.82 (0.37-1.8)ACE-inhibitors3.4 (1.6-7.1)Vitamin D sufficient0.77 (0.40-1.5)

*incl. unspecified arthritis

Disclosure of Interests:

Merel Opdam Grant/research support from: has received research grants (to the institution) from Gilead, S Benoy: None declared, L.M. Verhoef: None declared, Sandra van Bijnen: None declared, Femke Lamers-Karnebeek: None declared, R.A.M. Traksel: None declared, Petra Vos: None declared, Alfons den Broeder Grant/research support from: has received consultancy honoraria, congress invitations and research grants (to the institution) from Abbvie, Amgen, Cellgene, Roche, Biogen, Lilly, Novartis, Celltrion Sanofi, Gilead. Is coinventor on a rituximab related patent (pending)., Jasper Broen Consultant of: has received consultancy fees from Gilead and Galapagos.

Analysis of the influence of PTPN22 gene polymorphisms in systemic sclerosis

OBJECTIVE

Two functional single nucleotide polymorphisms (SNP) in the PTPN22 gene (rs24746601 and rs33996649) have been associated with autoimmunity. The aim of this study was to investigate the role of the R263Q SNP for the first time and to re-evaluate the role of the R620W SNP in the genetic predisposition to systemic sclerosis (SSc) susceptibility and clinical phenotypes.

METHODS

3422 SSc patients (2020 with limited cutaneous SSc and 1208 with diffuse cutaneous SSc) and 3638 healthy controls of Caucasian ancestry from an initial case--control set of Spain and seven additional independent replication cohorts were included in our study. Both rs33996649 and rs2476601 PTPN22 polymorphisms were genotyped by TaqMan allelic discrimination assay. A meta-analysis was performed to test the overall effect of these PTPN22 polymorphisms in SSc.

RESULTS

The meta-analysis revealed evidence of association of the rs2476601 T allele with SSc susceptibility (p(FDRcorrected)=0.03 pooled, OR 1.15, 95% CI 1.03 to 1.28). In addition, the rs2476601 T allele was significantly associated with anticentromere-positive status (p(FDRcorrected)=0.02 pooled, OR 1.22, 95% CI 1.05 to 1.42). Although the rs33996649 A allele was significantly associated with SSc in the Spanish population (p(FDRcorrected)=0.04, OR 0.58, 95% CI 0.36 to 0.92), this association was not confirmed in the meta-analysis (p=0.36 pooled, OR 0.89, 95% CI 0.72 to 1.1).

CONCLUSION

The study suggests that the PTPN22 R620W polymorphism influences SSc genetic susceptibility but the novel R263Q genetic variant does not. These data strengthen evidence that the R620W mutation is a common risk factor in autoimmune diseases.

The FAS -670A>G polymorphism influences susceptibility to systemic sclerosis phenotypes

OBJECTIVE

To investigate the possible role of the FAS -670A>G functional polymorphism in the genetic predisposition to systemic sclerosis (SSc) susceptibility or clinical phenotype.

METHODS

A total of 2,900 SSc patients and 3,186 healthy controls were included in this study. We analyzed the genotype and allele frequencies of the FAS -670A>G polymorphism in 9 distinct ethnic cohorts, including 6 cohorts of European ancestry (a Spanish cohort of 228 SSc patients and 265 controls, a Dutch cohort of 203 SSc patients and 277 controls, a German cohort of 313 SSc patients and 247 controls, an Italian cohort of 323 SSc cases and 89 controls, a British cohort of 269 SSc patients, and a Swedish cohort of 182 patients) and 3 distinct ethnic cohorts from the US (a cohort of 1,047 white patients and 692 controls, a cohort of 159 Hispanic patients and 137 controls, and a cohort of 176 black SSc patients and 194 controls). Genotyping was performed using a TaqMan 5' allelic discrimination assay.

RESULTS

In the British, Italian, and American white cohorts we observed an association of the FAS -670G allele with limited cutaneous SSc (lcSSc) (odds ratios [ORs] 1.25, 1.43, and 1.18, respectively). A meta-analysis comprising all 9 cohorts revealed an association of both the FAS -670G allele (OR 1.10) and the FAS -670GG genotype (OR 1.13) with the lcSSc phenotype. In a meta-analysis including only white subjects, both the FAS -670G allele and the FAS -670GG genotype remained associated with lcSSc (allele OR 1.12; genotype OR 1.16). In addition, a recessive model of the -670GG genotype exhibited a strong association with SSc, lcSSc, and anticentromere antibody-positive lcSSc (OR 1.23, OR 1.33, and OR 1.45, respectively).

CONCLUSION

Our data show that the FAS -670A>G polymorphism plays a role in lcSSc susceptibility. A similar trend has been observed in other autoimmune diseases.

BANK1 functional variants are associated with susceptibility to diffuse systemic sclerosis in Caucasians

OBJECTIVE

To investigate the possible association of the BANK1 gene with genetic susceptibility to systemic sclerosis (SSc) and its subphenotypes.

METHODS

A large multicentre case-control association study including 2380 patients with SSc and 3270 healthy controls from six independent case-control sets of Caucasian ancestry (American, Spanish, Dutch, German, Swedish and Italian) was conducted. Three putative functional BANK1 polymorphisms (rs17266594 T/C, rs10516487 G/A, rs3733197 G/A) were selected as genetic markers and genotyped by Taqman 5 allelic discrimination assay.

RESULTS

A significant association of the rs10516487 G and rs17266594 T alleles with SSc susceptibility was observed (pooled OR=1.12, 95% CI 1.03 to 1.22; p=0.01 and pooled OR=1.14, 95% CI 1.05 to 1.25; p=0.003, respectively), whereas the rs3733197 genetic variant showed no statistically significant deviation. Stratification for cutaneous SSc phenotype showed that the BANK1 rs10516487 G, rs17266594 T and rs3733197 G alleles were strongly associated with susceptibility to diffuse SSc (dcSSc) (pooled OR=1.20, 95% CI 1.05 to 1.37, p=0.005; pooled OR=1.23, 95% CI 1.08 to 1.41, p=0.001; pooled OR=1.15, 95% CI 1.02 to 1.31, p=0.02, respectively). Similarly, stratification for specific SSc autoantibodies showed that the association of BANK1 rs10516487, rs17266594 and rs3733197 polymorphisms was restricted to the subgroup of patients carrying anti-topoisomerase I antibodies (pooled OR=1.20, 95% CI 1.02 to 1.41, p=0.03; pooled OR=1.24, 95% CI 1.05 to 1.46, p=0.01; pooled OR=1.26, 95% CI 1.07 to 1.47, p=0.004, respectively).

CONCLUSION

The results suggest that the BANK1 gene confers susceptibility to SSc in general, and specifically to the dcSSc and anti-topoisomerase I antibody subsets.

The STAT4 gene influences the genetic predisposition to systemic sclerosis phenotype

The aim of this study was to investigate the possible role of STAT4 gene in the genetic predisposition to systemic sclerosis (SSc) susceptibility or clinical phenotype. A total of 1317 SSc patients [896 with limited cutaneous SSc (lcSSc) and 421 with diffuse cutaneous SSc (dcSSc)] and 3113 healthy controls, from an initial case-control set of Spanish Caucasian ancestry and five independent cohorts of European ancestry (The Netherlands, Germany, Sweden, Italy and USA), were included in the study. The rs7574865 polymorphism was selected as STAT4 genetic marker. We observed that the rs7574865 T allele was significantly associated with susceptibility to lcSSc in the Spanish population [P = 1.9 x 10(-5) odds ratio (OR) 1.61 95% confidence intervals (CI) 1.29-1.99], but not with dcSSc (P = 0.41 OR 0.84 95% CI 0.59-1.21). Additionally, a dosage effect was observed showing individuals with rs7574865 TT genotype higher risk for lcSSc (OR 3.34, P = 1.02 x 10(-7) 95% CI 2.11-5.31). The association of the rs7574865 T allele with lcSSc was confirmed in all the replication cohorts with different effect sizes (OR ranging between 1.15 and 1.86), as well as the lack of association of STAT4 with dcSSc. A meta-analysis to test the overall effect of the rs7574865 polymorphism showed a strong risk effect of the T allele for lcSSc susceptibility (pooled OR 1.54 95% CI 1.36-1.74; P < 0.0001). Our data show a strong and reproducible association of the STAT4 gene with the genetic predisposition to lcSSc suggesting that this gene seems to be one of the genetic markers influencing SSc phenotype.

The interleukin 23 receptor gene does not confer risk to systemic sclerosis and is not associated with systemic sclerosis disease phenotype

Objectives:

Multiple studies indicate the role of the interleukin (IL)-17/IL-23 axis in autoimmune diseases, including systemic sclerosis (SSc). The aim of the current study was to investigate the possible implication of the IL23R gene in SSc susceptibility and/or clinical phenotype.

Methods:

An initial case–control study in 143 Dutch patients with SSc and geographically matched healthy individuals (n = 246) was carried out and followed by a replication study in a cohort of 365 Spanish patients with SSc and 515 healthy individuals. Seven single nucleotide polymorphisms (SNPs) spanning the IL23R gene were selected and genotyped using a Taqman assay.

Results:

Using a Dutch cohort of patients with SSc and controls we observed an association between two (rs11209032, rs1495965) of the seven tested SNPs and disease susceptibility (allelic p values: p = 0.02 and p = 0.01 respectively). However, a replication study in an independent Spanish cohort did not confirm these findings and reveal no association of any of the IL23R-tested SNP with disease susceptibility or clinical phenotype. Similarly, a meta-analysis considering both populations did not reveal any significant association. In addition, no association was observed between IL23R genetic variants and SSc clinical phenotypes.

Conclusions:

Our results suggest that the IL23R gene is not associated with SSc susceptibility or clinical phenotype.

The pathway for processing leader-derived peptides that regulate the maturation and expression of Qa-1b

Qa-1b and its human homolog, HLA-E, predominantly bind leader peptides derived from other class I molecules. Their presentation is TAP-dependent and proteasome-independent. We demonstrate that Dd targeted to the cytosol does not generate the Qa-1b peptide epitope even in the presence of lactacystin. Cells expressing herpes virus ICP-47 block the generation of this epitope, demonstrating that TAP functions in the transport of the peptide from cytosol to ER. This reveals a pathway for antigen presentation of leader peptides that involves translocation of a protein to the ER where its leader is cleaved followed by its release into the cytosol and transport back into the ER. Further, it ensures that Qa-1b expression mirrors the normal expression of class Ia molecules.