POS0251 TRANSCRIPTOMIC CHANGES INDUCED BY MAVRILIMUMAB VERSUS TOCILIZUMAB IN EX-VIVO CULTURED ARTERIES FROM PATIENTS WITH GIANT-CELL ARTERITIS

Background

Giant cell arteritis (GCA) is a chronic disease, and affected patients suffer from relapses and glucocorticoid (GC)-related toxicity. Targeted therapies are emerging with the aim of achieving better disease control and reducing GC exposure. Blocking IL-6 receptor with tocilizumab has been a major advance in the treatment of GCA. However, approximately 40% of patients treated with tocilizumab in combination with GCs experience a flare or tocilizumab-related adverse event. Blocking GM-CSF receptor α with mavrilimumab significantly reduced risk of relapse and improved sustained remission at week 26 vs placebo in a Phase 2 trial. Not all patients satisfactorily respond to any therapy, indicating heterogeneity in leading pathogenic pathways among patients. For these reasons, it is crucial to understand the specific impact of targeted therapies on vascular lesions.

Objectives

In this study we investigated transcriptomic changes induced by tocilizumab or mavrilimumab in ex-vivo cultured arteries from patients with GCA.

Methods

Temporal artery sections obtained for diagnostic purposes from 11 patients with histopathologically-confirmed GCA and 3 controls were cultured ex-vivo and exposed to placebo, mavrilimumab, or tocilizumab (both at 20 µg/mL) for 5 days. Of 11 GCA donors, 2 had received no treatment prior to biopsy, 2 had received a single prednisone (60 mg) dose, 1 had received 2 daily doses, and the remaining 6 had extended treatment; in prednisone-treated patients, mean (SEM) treatment duration was 17.9 ±8.7 days. A separate cohort of patients (consisting of five newly diagnosed patients with GCA, age- and sex-matched with the previous cohort) was used to validate 7 transcripts by real time PCR. Genes were selected for validation based on high level of expression and differential expression with each treatment. All samples were homogenized, and total RNA was extracted with TRIzol reagent. 100 ng of RNA per sample were processed with Nanostring Inflammation gene expression assay (256 transcripts) and hybridized using nCounter Prep Station. Barcode counts from nCounter Digital Analyzer were processed with nSolver 4.0 Software. Normalised data were analyzed using R Studio 4.0.5 and IBM SPSS 22.0, and paired Wilcoxon tests were applied individually to each treatment comparison group for each analysed gene. One µg of RNA per sample from the validation cohort was retrotranscribed; subsequent real time PCRs were normalised against endogenous control GUSb and analysed using SDS 2.3 software.

Results

67 out of 250 transcripts were differentially expressed between arteries from GCA patients and arteries from control patients (all placebo-treated). Of those, only 9 transcripts remained significant after correction for multiple comparisons, with a false discovery rate ≤0.05. 81 transcripts were differentially expressed in at least one comparison across groups (Figure 1A). 15 transcripts were lower, and 6 were higher in the mavrilimumab group vs placebo; 3 transcripts were lower, and 2 were higher in the tocilizumab group vs placebo. Most changes elicited between treatments were unique, but CXCL-1 was common (Figure 1B). None remained significant after correction for multiple comparisons. The effects of mavrilimumab and tocilizumab on GNAS, CXCL1, IL8, IL2, IRF3, MRC1 and BCL6 expression by Nanostring were consistent with the effect assessed using real time PCR in the separate validation cohort (Figure 1C).

Conclusion

Mavrilimumab and tocilizumab have a different transcriptomic impact on cultured arteries from patients with GCA, with some overlapping effects, although differential effects may have been attenuated by prior GC use. A better understanding of the impact of targeted therapies on vascular inflammation is needed to improve treatment options for patients with GCA.

Acknowledgements

The authors would like to thank: the Genomics core facility of the Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) and Emily Plummer, PhD, Kiniksa Pharmaceuticals, for her invaluable contribution.

The study was funded by Kiniksa Pharmaceuticals, Ltd. With support from: Fundació Clínic Barcelona, Fundació Privada Cellex, IDIBAPS, Universitat de Barcelona, Vasculitis Foundation, Marie Curie Actions, and Gobierno de España, Ministerio de Economía, Industria, y Competitividad.

Disclosure of Interests

Marc Corbera-Bellalta: None declared, Farah Kamberovic: None declared, Ferran Araujo: None declared, Roser Alba-Rovira: None declared, Georgina Espigol-Frigole Consultant of: Consulting for Janssen and Hoffmann-La Roche;, Grant/research support from: Meeting attendance support from Boehringer Ingelheim, Marco Alba: None declared, Sergio Prieto-González Speakers bureau: Lecturing for Roche, Grant/research support from: Meeting attendance support from Italfarmo and CSL Behring, José Hernández-Rodríguez Speakers bureau: Lecturing for Novartis, Consultant of: Consulting for Sobi, Grant/research support from: Meeting attendance support from Sobi and Novartis, Patricia Pérez-Galán: None declared, Kent Bondensgaard Shareholder of: Kiniksa Pharmaceuticals Corp., Employee of: Kiniksa Pharmaceuticals Corp., John F. Paolini Shareholder of: Kiniksa Pharmaceuticals Corp., Employee of: Kiniksa Pharmaceuticals Corp., Maria C. Cid Speakers bureau: Educational from GSK and Vifor, Consultant of: Consulting for Janssen, GSK, and Abbvie, Grant/research support from: Research grant from Kiniksa; meeting attendance support from Roche and Kiniksa

AB1011 FACTORS RELATED TO GLUCOCORTICOID-INDUCED OSTEOPOROSIS AND FRAGILITY FRACTURES IN YOUNG SUBJECTS

Background

Glucocorticoid (GC) treatment is the most frequent cause of osteoporosis (OP) in young subjects. However, the factors related to the development of glucocorticoid-induced osteoporosis (GIOP) and fragility fractures (FF), and consequently, the therapeutic approach to GIOP in young populations is not well established.

Objectives

Analyze the prevalence of GIOP and FF in GC-treated patients and compare the risk factors related to their development according to age (< and ≥50 years).

Methods

127 patients (62±18 years) receiving chronic GC treatment were included (≥5 mg/day of prednisone, >3 months). The clinical data collected included: dose and duration of GC treatment, disease activity, previous FF, anthropometric data, bone metabolism parameters (including bone turnover markers and the presence of hypogonadism), bone mineral density (by DXA; defining densitometric OP: T-score ≤-2.5 or Z-score ≤-2, depending on the age of the patient), trabecular bone score (by DXA), and vertebral fractures (X-ray). GIOP was defined as densitometric OP and/or FF. Results were compared between subjects < and ≥50 years old.

Results

The prevalence of GIOP was similar in both age groups: <50 (n=36) 44.4% vs. 46.1% ≥50 years (n=91). Five subjects <50 (13.8%) and 30 ≥50 years (33%) presented FF (p=0.05). Young subjects with FF tended to be >40 years, have a higher body mass index (BMI) (25.4 vs. 23.3, p=n.s.), and inflammatory disease activity (CRP 0.90 vs. 0.06mg/dL, p=0.06). When analyzing the differential risk factors related to FF depending on age, a higher body mass index (BMI) (29.63 vs. 26.95, p=0.048) and inflammatory disease activity (PCR -0.87 vs. -2.51 [log scale], p=0.03) were observed in young subjects, while low lumbar T-scores (-1.08 vs.-0.06 DE, p=0.003) and higher cumulative GC-doses (9.11 vs. 8.56 g, p=0.03) were differential factors in subjects over 50. Hypogonadism was a risk factor independent of age (OR 4.89; 95%CI 1.36-17.59), being associated with the presence of FF in both age groups.

Conclusion

More than 40% of the patients receiving GC developed GIOP, with a similar prevalence in both age groups (< and ≥50 years); however, FF are less common in young subjects. Hypogonadism is a determining risk factor for FF independent of age. In addition, young subjects with FF tend to be older, with a higher BMI and disease activity, and, thus, evaluation of these risk factors can improve the identification of subjects at increased risk of fracture.

Disclosure of Interests

None declared

POS0270 DEVELOPMENT OF AORTIC ANEURYSM/DILATATION IN A PROSPECTIVE COHORT OF PATIENTS WITH BIOPSY-PROVEN GIANT-CELL ARTERITIS: EARLY IDENTIFICATION OF PATIENTS AT RISK

Background

Up to 10-33% of patients with giant-cell arteritis (GCA) develop aortic structural damage (ASD) (aneurysm or dilatation), typically involving the ascending aorta (1,2). Systematic use of imaging reveals radiological features of aortitis in 45-65% of patients at diagnosis (3). This finding has been associated with future aortic dilatation in retrospective studies (4).

Objectives

To investigate the prevalence of thoracic ASD in a large prospective cohort of patients with GCA subjected to periodic imaging. To evaluate the association between features at diagnosis with ASD development.

Methods

Patients were included in the study if consented, had biopsy-proven GCA and met the 1990 ACR criteria for GCA classification. Patients were prospectively followed and treated according to uniform criteria. Since 1995 patients were subjected to systematic imaging screening aimed to detect thoracic ASD. Until November 2006 it consisted of a chest X-ray that was performed at least 4 years after diagnosis and repeated every 4 years. When aortic dilatation was minimally suspected, patients underwent contrast-enhanced computed tomography (CT) scan. Since November 2006, most of patients were prospectively studied with CT angiography at diagnosis, after 1 year and every 4 years.

The diagnosis of ASD was confirmed by CT, defined as an aortic diameter > 4 cm at the ascending aorta or ≥4 cm at the aortic arch or the descending aorta.

Data regarding demographic characteristics, cardiovascular risk factors, GCA symptoms, laboratory tests, chronic medication at time of GCA diagnosis and corticosteroid tapering were recorded.

Kaplan-Meier survival plot was used to present the cumulated incidence of thoracic ASD over time and patients were censored at the time of ASD diagnosis or at the time of the last screening in those without ASD.

We also investigated which variables present at the time of GCA-diagnosis were associated with future development of ASD. Patients were classified in two groups according to whether they developed ASD or not during a follow-up period of 8 ± 1 years from the time of diagnosis.

Results

Thoracic ASD was confirmed by CT in 58 patients (21.6% of the patients with systematic screening diagnosed from 1994 to 2018) after a median follow-up of 4.7 years (0.05-7.5). Ascending aorta was involved in 56 patients (96.5%), followed by the aortic arch in 11 patients (18.9%), and descending aorta in 5 (8.6%). 14 patients (24.1%) had more than 1 aortic segment involved. Figure 1 shows the number of patients with thoracic ASD detected during follow-up.

Figure 1.

Thoracic ASD was detected within the first 4 years from GCA-diagnosis in 19 out of the 58 patients who developed ASD (32.7%) but was severe (≥ 50 mm) in only 3 (15.8% out of those 19 patients). Most ASD was detected between 5 and 9 years after GCA-diagnosis.

Patients who developed ASD during follow-up experienced less often cranial ischemic symptoms (14.8% vs 41.1%; p=0.003) or polymyalgia (33.3% vs 51.8%; p=0.057), and less frequently had a previous diagnosis of hypertension (66.7% vs 82.1%; p=0.081). Age, sex, clinical or laboratory findings or chronic therapies used at time of GCA-diagnosis were not significantly different between groups.

After multivariate analysis, the presence of cranial ischemic symptoms (HR 0.180, 95% CI 0.065-0.495, p=0.001) and polymyalgia rheumatica (HR 0.329, 95% CI 0.136-0.793, p=0.013) remained inversely associated with thoracic ASD development.

Conclusion

ASD is frequent and probably an underdiagnosed complication of GCA. There is no consensus yet regarding the optimal screening protocol during follow-up and early identification of patients at risk is crucial for this purpose. The presence of cranial ischemic symptoms or polymyalgia rheumatica were inversely associated with thoracic ASD development in our prospective cohort.

References

[1]García-Martínez A et al. Ann Rheum Dis 2014.

[2]Evans JM et al. Ann Intern Med 1995.

[3]Prieto-González S et al. Ann Rheum Dis 2012.

[4]Blockmans D et al. Rheumatology (Oxford) 2008.

Acknowledgements

Both first co-authors contributted equally to this work.

The research was supported MTV3 2014/20150730

Disclosure of Interests

None declared

POS0252 MYOFIBROBLASTS MAINTAIN Th1 and Tc1 POLARIZATIONS IN GIANT CELL ARTERITIS

Background

Giant cell arteritis (GCA) is a large-vessel vasculitis mainly involving the aorta and cranial arteries. It is the most frequent vasculitis in adults over 50 years. When they are stimulated by interferon-gamma (IFN-γ), vascular smooth muscle cells (VSMC) contribute to GCA pathogenesis by producing chemokines triggering the recruitment of pro-inflammatory T cells and monocytes (1).

Objectives

Current knowledge about the interaction between resident cells of the vascular wall (VSMC, myofibroblasts [MF]) and immune cells is limited. The aim of our research was to better characterize the interactions between VSMC, MF and T cells in GCA.

Methods

Fresh fragments of temporal artery biopsies (TAB) performed at Dijon university hospital (France) were prospectively sent to our research unit. Fresh sections of positive and negative TAB were fixed and embedded in optimal cutting temperature OCT and stored at -80°C. Then, cryostat sections were fixed, permeabilized, blocked and incubated with primary antibodies (anti-alpha smooth muscle actin [α-SMA], anti-myosin heavy chain 11 [MHC11], anti-Desmin, anti CD90, anti-CD45, anti-HLA-DR, anti-phospho STAT1 [pSTAT1] and anti-pSTAT3) and secondary antibodies for confocal microscopy analyses. Fresh sections of healthy TAB were embedded in MATRIGEL and covered by DMEM to obtain vascular cells in culture. Cells were treated with trypsina-EDTA between each passage. Vascular cells were used after 4-7 doubling passages. Cells were analyzed by immunofluorescence, flow cytometry and RT-PCR and their proliferation was evaluated by impedancemetry (iCELLigence system). Peripheral blood mononuclear cells (PBMC) and vascular cells thus obtained were co-cultured for 7 days in different conditions. Vascular cells were cultured in the presence or absence of IFN-γ and tumor necrosis factor alpha (TNF-α) or interleukin-6 (IL-6) and soluble receptor of IL-6 for 72 hours. When cells reached confluence, they were cultured alone or with allogenic PBMC activated with anti-CD3/CD28 microbeads. After 7 days of culture, cells were separated with a treatment with EDTA and studied by flow cytometry.

Results

Confocal microscopy analyses of GCA arteries showed that neointima was mainly composed of myofibroblasts (MF) (α-SMA+Desmin+MHC11lowCD90+) in contact with CD45+ cells and that MF expressed HLA-DR, the phosphorylated form of STAT1 (pSTAT1) and in a lesser extent pSTAT3, strongly suggesting the activation of the IFN-γ signaling pathway rather than the IL-6 pathway. The phenotype of cultured vascular cells isolated from fresh TAB was consistent with MF. When MF were exposed to IFN-γ and TNF-α in vitro, their proliferation capacity decreased and their levels of expression of HLA-DR and CD86 increased (median fluorescence intensity [MFI] from 0 to 57 [p=0.03] and from 34 to 103 [p=0.03], respectively). In addition, co-cultures of MF and activated PBMC revealed that MF maintained the polarization of T cells into Th1 and Tc1 cells (p≤0.001) and to a lesser extent into Th17 and Tc17 cells (p=0.03). This effect was even more significant when MF were previously exposed to IFN-γ and TNF-α but not when they were exposed to IL-6.

Conclusion

Our results show that myofibroblasts are present in the neointima of GCA patients and that these MF activate signaling pathways indicative of IFN-γ exposure. Moreover, these MF, especially when exposed to IFN-γ, maintain the polarization of T cells into Th1 and Tc1 cells, which contributes to amplify the production of IFN-γ and thus initiate a pro-inflammatory amplification loop that likely participates in vascular inflammation and remodelling.

References

[1]Corbera-Bellalta M, Planas-Rigol E, Lozano E, Terrades-Garcia N, Alba MA, Prieto-Gonzalez S, et al. Blocking interferon gamma reduces expression of chemokines CXCL9, CXCL10 and CXCL11 and decreases macrophage infiltration in ex vivo cultured arteries from patients with giant cell arteritis. Ann Rheum Dis 2016;75:1177-86.

Disclosure of Interests

None declared

POS0121 RESPONSE OF EOSINOPHILIC GRANULOMATOSIS WITH POLYANGIITIS TO MEPOLIZUMAB ACCORDING TO DISEASE MANIFESTATIONS. A SINGLE CENTRE EXPERIENCE

Background:

Eosinophilic granulomatosis with polyangiitis (EGPA) is a relapsing disease with frequent glucocorticoid (GC) dependence. Mepolizumab (MEPO) has been demonstrated to reduce flares and spare GC. However, EGPA is a heterogeneous disease and the effects of MEPO on specific disease manifestations has not been completely delimitated.

Objectives:

To analyze the impact of MEPO on manifestations derived from small-vessel vasculitis, ENT symptoms, asthma, eosinophilic tissue infiltration and ANCA status in a single-centre cohort of EGPA patients.

Methods:

Medical chart of EGPA patients treated with MEPO were reviewed to describe demographics, clinical characteristics, steroid dose at the initiation of MEPO and during follow-up, flares, disease activity, damage accrual and laboratory results.

Results:

Among 52 EGPA patients regularly controlled in our department, 11 patients were treated with MEPO. MEPO was prescribed when a) patients required prednisone (PDN) at ≥ 7.5 mg/d to maintain stability, or b) when maintained with < 7.5mg/d, presented at least 4 exacerbations/year requiring an increase in PDN dose. 6 were males and 5 females, with a mean age of 54 years at MEPO initiation. Baseline characteristics of the patients and course under treatment are presented in Table 1. ENT involvement, followed by asthma and eosinophil-related tissue-infiltration (ETI) were the most common symptoms when prescribing MEPO. Regarding treatment, patients received MEPO at 100-300mg SC monthly. The definition of flare was the same used in the MIRRA trial1. The mean time of treatment with MEPO was 34 months. All patients achieved a BVAS score of 0 points at 12 months or earlier. In general, patients reduced the number of flares, which tended to be milder, and all related to asthma or ENT manifestations. All improved their asthma control, but 3 of them persisted with recurrent ENT symptoms in spite of treatment with MEPO. None of them had vasculitic manifestations (cutaneous, neurological, gastrointestinal, renal) manifestations during treatment. All patients were able to tapper their PDN dose to ≤5 mg/day or less, except 3 patients. Of the 3 patients who required ≥5mg/d, 1 had severe asthma, but diminished the previous PDN dose (22.5 mg/d pre-MEPO, 10 mg/d currently) and the yearly rate of flares (8.2 pre-MEPO, 0.64 under-MEPO). The other one notably improved his asthma, but had ENT symptoms that responded unsatisfactorily to MEPO and required a maintenance PDN dose of 7.5 mg/d. The last one, improved her asthma control and was able to begin PDN tapering, but persisted with ENT symptoms. Regarding damage accrual, 6 patients remained stable during treatment, and 5 worsened. Two of three ANCA positive patients remained positive in spite of treatment.

Table 1.Baseline characteristics at diagnosisAt mepolizumab initiationAfter mepolizumab (last follow-up)Age, median (range) years49 (23-67)54 (35-69)-Male/Female, n (%)6/5 (54.5%/45.5%)--BVAS, median (range)11 (2-20)2 (0-6)0FFS, value (n, %)1 (1, 9.1%)--VDI, mean (range)-1.7 (0-5)2.3 (0-5)Asthma, n (%)11 (100%)3 (27.3%)0 (0%)ENT, n (%)10 (90%)4 (36.4%)3 (27.3%)SVV, n (%)4 (36.4%)0 (0%)0 (0%)ETI signs/symptoms, n (%)7 (63.6%)2 (18.2%)0 (0%)Constitutional symptoms, n (%)4 (36.4%)0 (0%)0 (0%)Eosinophils, mean (range) cells x1095500 (600-8850)240 (0-600)55 (0-200)ANCA positivity (IIF)7 (77.8%)32Anti-MPO titers, mean (range)286 (93-740)88 (3-739)7 (3-37)Yearly rate of flares-1,750.51Immunosuppressants, n-31Prednisone dose, mg/d (range)8 (7.5-25)11.4 (5-22.5)5.125 (0-10)

Conclusion:

MEPO was effective for the treatment of patients with EGPA, with a reduction in the number and severity of flares and a decrease in PDN doses. A worse response of ENT involvement was observed. No vasculitic flares were observed in spite of GC reduction. Mepolizumab did not prevent damage accrual during the treatment period.

References:

[1]Wechsler ME et al. MEPO or Placebo for Eosinophilic Granulomatosis with Polyangiitis. N Engl J Med. 2017.

Acknowledgements:

Funding: Plan Estatal de Investigación Científica y Técnica y de Innovación 2013-2016 (PI18/00461), co-funded by Instituto de Salud Carlos III (ISCIII) and Fondo Europeo de Desarrollo Regional (FEDER) and by Río Hortega program (ISCIII, CM19/00032).

Disclosure of Interests:

Roberto Ríos-Garcés: None declared, Sergio Prieto-González: None declared, José Hernández-Rodríguez: None declared, Maria C. Cid Paid instructor for: GSK and Vifor, Consultant of: GSK, Abbvie and Janssen, Grant/research support from: Kiniksa and Roche, Georgina Espígol-Frigolé Consultant of: Janssen, Grant/research support from: Roche

AB0370 UTILITY OF CRP AND ESR IN THE DIAGNOSIS OF GIANT CELL ARTERITIS RELAPSE IN A PHASE 2 TRIAL OF MAVRILIMUMAB

Background:

No universally accepted definition of flare currently exists in giant cell arteritis (GCA). Although relapses are defined mostly on clinical grounds (recurrence of GCA-related signs/symptoms), C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) help clinicians assess disease activity. In fact, >70% of patients on glucocorticoids (GCs) alone have increased CRP or ESR when the disease is active. In contrast, tocilizumab, given its IL-6-blockade effect in the liver, rapidly reduces CRP and ESR levels, rendering them unreliable for disease activity monitoring. Mavrilimumab – a GM-CSF receptor α inhibitor with demonstrated efficacy in a Phase 2 GCA trial1 – downregulates inflammation upstream of IL-6. We hypothesized that mavrilimumab would not interfere with the utility of CRP and ESR in monitoring disease activity and in identifying GCA relapse.

Objectives:

To analyze the relationship between CRP/ESR and clinical disease activity in GCA patients treated with mavrilimumab.

Methods:

New-onset and relapsing GCA patients with active disease were recruited. GC-induced remission (no GCA symptoms and CRP <1 mg/dL or ESR <20 mm/hr) was required by baseline. Patients were randomized 3:2 to mavrilimumab 150 mg or placebo subcutaneously every 2 weeks plus a protocol-defined 26-week prednisone taper. The primary efficacy endpoint was time to relapse by Week 26. Relapse (adjudicated) was defined as recurrent GCA-related signs/symptoms, including new/worsening vasculitis on imaging, concurrent with CRP ≥1 mg/dL and/or ESR ≥30 mm/hr. CRP and ESR were also measured periodically during the trial.

This post hoc analysis assessed the association of recurrent GCA-related signs/symptoms with concurrent CRP or ESR elevation post-randomization by treatment arm. We also assessed the proportion of patients with CRP or ESR elevation without GCA-related signs/symptoms up to Week 26.

Results:

Seventy patients were enrolled (mavrilimumab, N=42; placebo, N=28). The association of CRP or ESR elevation with unequivocal GCA-related signs/symptoms post-randomization was consistent regardless of treatment arm: 8/8 in the mavrilimumab group and 13/13 in the placebo group (Table 1). During relapse, median (range) CRP was 1.8 (1.4 – 8.4) mg/dL (mavrilimumab group) and 1.8 (1.1 – 9.0) mg/dL (placebo group). Corresponding ESR values were 39.5 (30 – 102) mm/hr (mavrilimumab group) and 49 (31 – 101) mm/hr (placebo group). Four mavrilimumab recipients had self-limited, equivocal GCA-related signs/symptoms without concurrent CRP or ESR elevation; all 4 completed the prespecified GC taper by Week 26 without need for rescue GCs, so relapse was not confirmed. At least 1 elevated CRP or ESR value in the absence of GCA-related signs/symptoms was observed in 58.8% of mavrilimumab recipients and 93.3% of placebo recipients by Week 26.

Conclusion:

The observed association of CRP or ESR elevation with GCA-related signs/symptoms is consistent with the upstream mechanism and supports the utility of the stringent protocol definition of relapse. The frequency and magnitude of CRP and ESR elevations at relapse were similar in both treatment groups, suggesting that CRP and ESR remain useful in assessments of disease activity in mavrilimumab-treated patients. CRP and ESR elevations without GCA-related signs/symptoms occurred more often in placebo recipients.

References:

[1]Cid, Unizony et al. Arthritis Rheumatol. 2020; 72 (suppl 10)

Table 1.

CRP and ESR levels in patients with or without GCA relapse

Assessment§MavrilimumabPlaceboMavrilimumabPlaceboN=42N=28N=42N=28With RelapseWithout Relapse# of patients8 (19.1)13 (46.4)34 (81.0)15 (53.6) Elevated CRP* or ESR†8 (100.0)13 (100.0)20 (58.8)14 (93.3)  Elevated CRP*7 (87.5)10 (76.9)10 (29.4)11 (73.3)   Median (range) mg/dL1.8 (1.4 - 8.4)1.8 (1.1 - 9.0)2.6 (1.3 – 7.0)2.0 (1.0 – 6.6) Elevated ESR†6 (75.0)9 (69.2)16 (47.1)10 (66.7)  Median (range) mm/hr39.5 (30 - 102)49.0 (31 - 101)41.5 (30 - 110)53.5 (30 - 82)

§# (%), except where indicated otherwise.

*CRP ≥ 1 mg/dL

†ESR ≥ 30 mm/hr

Disclosure of Interests:

Sebastian Unizony Consultant of: Janssen and Kiniksa, Grant/research support from: Genentech, Maria C. Cid Speakers bureau: Roche and Kiniksa, Paid instructor for: GSK and Vifor, Consultant of: Janssen, GSK, and Abbvie, Grant/research support from: Kiniksa, Elisabeth Brouwer Speakers bureau: Dr. E.Brouwer as an employee of the UMCG received speaker fees and consulting fees from Roche in 2017 2018 which were paid to the UMCG., Consultant of: Dr. E.Brouwer as an employee of the UMCG received speaker fees and consulting fees from Roche in 2017 2018 which were paid to the UMCG., Lorenzo Dagna Speakers bureau: Abbvie, Amgen, Biogen, BMS, Celltrion, Galapagos, Glaxo SmithKline, Novartis, Pfizer, Roche, Sanofi-Genzyme, SOBI, Consultant of: Abbvie, Amgen, Biogen, BMS, Celltrion, Galapagos, Glaxo SmithKline, Novartis, Pfizer, Roche, Sanofi-Genzyme, SOBI; clinical trial for Kiniksa, Grant/research support from: Abbvie, Amgen, BMS, Celltrion, Galapagos, Novartis, Pfizer, Roche, Sanofi-Genzyme, SOBI, Merk Sharp &Dohme, Janssen, Kiniksa, Bhaskar Dasgupta Paid instructor for: Educational grant symposium/workshop for Roche-chugai, Sanofi, and Abbvie, Consultant of: CI UK for the Kiniksa trial, Grant/research support from: Educational grant symposium/workshop for Roche-chugai, Sanofi, and Abbvie, Bernhard Hellmich Consultant of: Honoraria paid to the institution for participation in the clinical trial, Eamonn Molloy: None declared, Carlo Salvarani: None declared, Bruce C. Trapnell Consultant of: Consultant member of DSMB for Kiniksa., Kenneth J Warrington Consultant of: Clinical trial support from Eli Lilly and Kiniksa, Ian Wicks: None declared, Manoj Samant Shareholder of: Kiniksa Pharmaceuticals, Employee of: Kiniksa Pharmaceuticals, Teresa Zhou Shareholder of: Kiniksa Pharmaceuticals, Employee of: Kiniksa Pharmaceuticals, Lara Pupim Shareholder of: Kiniksa Pharmaceuticals, Employee of: Kiniksa Pharmaceuticals, John F. Paolini Shareholder of: Kiniksa Pharmaceuticals, Employee of: Kiniksa Pharmaceuticals

OP0059 MAVRILIMUMAB (ANTI GM-CSF RECEPTOR Α MONOCLONAL ANTIBODY) REDUCES RISK OF FLARE AND INCREASES SUSTAINED REMISSION IN A PHASE 2 TRIAL OF PATIENTS WITH GIANT CELL ARTERITIS

Background:

T helper (Th)1 and Th17 lymphocytes play a role in the pathogenesis of giant cell arteritis (GCA). Current treatments primarily target the Th17 axis, possibly leaving residual Th1 activity. Granulocyte macrophage colony stimulating factor (GM-CSF), a mediator of Th1 and Th17 cells, is a pathogenic factor in GCA.

Objectives:

To evaluate the efficacy and safety of the GM-CSF inhibitor mavrilimumab in patients with GCA.

Methods:

Randomized, double-blind, placebo-controlled phase 2 trial enrolling patients with active, biopsy- or imaging-proven new onset (N/O) or relapsing refractory (R/R) GCA. Active disease: GCA symptoms and erythrocyte sedimentation rate (ESR) (>30 mm/hr) and/or C-reactive protein (CRP) (≥1 mg/dL) elevation within 6 weeks from randomization. Corticosteroid-induced remission (resolution of GCA symptoms and CRP <1 mg/dL or ESR <20 mm/hr) was required by baseline. 3:2 randomization to mavrilimumab 150 mg or placebo subcutaneously every 2 weeks and protocol-defined 26-week prednisone taper starting at 20-60 mg/day.

Primary efficacy endpoint: time to first adjudicated flare (ESR ≥30 mm/hr and/or CRP ≥1 mg/dL and GCA symptoms or new/worsening vasculitis on imaging) by Week 26 in all treated patients. Key secondary endpoint: sustained remission through Week 26. Safety up to Week 38 was assessed.

Results:

70 patients (35 N/O, 35 R/R) were enrolled (mavrilimumab [N=42] or placebo [N=28]). Mean (SD) age was 69.7 (7.48) years and 71.4% were female. Flare by Week 26 occurred in 8 (19%) and 13 (46.4%) patients receiving mavrilimumab and placebo, respectively (27.4 percentage points reduction). Median time to flare by Week 26 could not be estimated in the mavrilimumab group due to too few events (Not Estimable) and was 25.1 weeks [95% CI: (16.0, NE)] in the placebo group (HR [95% CI] 0.38 [0.15, 0.92]; p=0.0263) (Figure). Sustained remission at Week 26 occurred in 83.2% of patients receiving mavrilimumab and 49.9% of those receiving placebo (33.4 percentage points increase; p=0.0038). Results were consistent across disease type subgroups (HR for flare: N/O 0.29 [95% CI: 0.06, 1.31; nominal p= 0.0873]; R/R 0.43 [95% CI: 0.14, 1.30]; nominal p=0.1231), although not powered for significance (Table). Adverse events (AEs), mostly mild to moderate, were comparable between groups. There were 5 serious AEs (mavrilimumab 2 [4.8%], placebo 3 [10.7%]), none drug-related. No deaths or vision loss occurred. No adjudicated cases of pulmonary alveolar proteinosis were observed.

Table 1.

Efficacy at Week 26

All Patients [1]SubgroupsN/OR/RMavrilimu-mab (N=42)Placebo (N=28)Mavrilimu-mab (N=24)Placebo (N=11)Mavrilimu-mab (N=18)Placebo (N=17)Patients with Flare, n (%)8 (19.0)13 (46.4)3 (12.5)4 (36.4)5 (27.8)9 (52.9)Time to Flare (weeks) [2]Median, 95% CINE (NE, NE)25.1 (16.0, NE)NE (NE, NE)NE (11.7, NE)NE (16.4, NE)22.6 (16.0, NE)HR (Mavrilimumab vs Placebo), 95% CI [3]0.38 (0.15, 0.92)0.29 (0.06, 1.31)0.43 (0.14, 1.30)P-value [4] [5]0.02630.08730.1231Sustained Remission (%), 95% CI [6]83.2 (67.9, 91.6)49.9 (29.6, 67.3)91.3 (69.3, 97.7)62.3 (27.7, 84.0)72.2 (45.6, 87.4)41.7 (17.4, 64.5)Difference in Proportions (95% CI) [7]33.3 (10.7, 55.8)28.9 (-2.7, 60.5)30.6 (-2.1, 63.2)P-value [5] [7]0.00380.07270.0668

NE = Not estimable. [1] Total mITT population. Stratified by randomization strata. [2] Kaplan-Meier. [3] Cox proportional-hazards model; treatment as covariate. [4] Log-rank test. [5] N/O and R/R subgroups not powered for significance; nominal p values reported. [6] Kaplan-Meier Survival Estimates with standard error. [7] Two-sided p-value for the difference in sustained remission between 2 arms using normal approximation. Placebo arm is reference.

Conclusion:

Mavrilimumab was superior to placebo on the primary and secondary efficacy endpoints of time to flare and sustained remission at week 26 in patients with GCA. Mavrilimumab was well tolerated, and no new safety signals were observed.

Disclosure of Interests:

Maria C. Cid Speakers bureau: meeting attendance support from Roche and Kiniksa, Paid instructor for: educational from GSK and Vifor, Consultant of: consulting for Janssen, GSK, and Abbvie, Grant/research support from: research grant from Kiniksa, Sebastian Unizony Consultant of: consulting for Janssen and Kiniksa, Grant/research support from: research support from Genentech, Lara Pupim Shareholder of: Kiniksa Pharmaceuticals, Employee of: Kiniksa Pharmaceuticals, Fang Fang Shareholder of: Kiniksa Pharmaceuticals, Employee of: Kiniksa Pharmaceuticals, Joseph Pirrello Shareholder of: Kiniksa Pharmaceuticals, Employee of: Kiniksa Pharmaceuticals, Ai Ren Shareholder of: Kiniksa Pharmaceuticals, Employee of: Kiniksa Pharmaceuticals, Manoj Samant Shareholder of: Kiniksa Pharmaceuticals, Employee of: Kiniksa Pharmaceuticals, Teresa Zhou Shareholder of: Kiniksa Pharmaceuticals, Employee of: Kiniksa Pharmaceuticals, John F. Paolini Shareholder of: Kiniksa Pharmaceuticals, Employee of: Kiniksa Pharmaceuticals

FRI0010 GM-CSFR PATHWAY IS IMPLICATED IN PATHOGENIC INFLAMMATORY MECHANISMS IN GIANT CELL ARTERITIS

Background:

Giant Cell Arteritis (GCA) is characterized by inflammation of large and medium arteries. Classic symptoms include headaches, malaise and, in severe cases, blindness and aortic aneurysms. Corticosteroids (CS) are the first line of treatment. Relapsing disease patients undergo multiple courses of CS therapy increasing their CS exposure and toxicity. A significant unmet need for disease-modifying CS-sparing therapy remains in GCA as the efficacy of current treatment options, including tocilizumab have limitations.

We have previously reported elevated expression of granulocyte-macrophage colony stimulating factor (GM-CSF) pathway transcriptomic signature in GCA vessels. GM-CSF may contribute to underlying disease mechanisms by regulating inflammatory macrophages, dendritic cells (DCs) and T helper (TH1/TH17) cells which are involved in GCA pathogenesis. GM-CSF produced by T cells1can promote polarization of inflammatory macrophages2and recruitment and differentiation of monocytes into inflammatory DCs2that can in turn recruit T cells and stimulate TH1/TH17 differentiation creating a feedback loop. GM-CSF may also exert direct effects on angiogenesis3and vessel wall remodeling4.

Objectives:

To demonstrate the contributing role of GM-CSF pathway to inflammation in GCA arteries.

Methods:

Immunostaining was used to examine expression of GM-CSF and GM-CSF-Rα proteins in temporal artery biopsies (TABs) from GCA and controls (patients with suspected but not confirmed GCA and a negative TAB). Costaining with cell markers such as CD31, CD3, and CD68 allowed visualization of cells expressing GM-CSF and GM-CSF-Rα. Expression of GM-CSF pathway molecules such as phospho-JAK2 and PU.1 proteins was detected by immunohistochemical staining of GCA and control TABs.Ex vivocultured GCA arteries treated (10 each) with mavrilimumab (anti-GM-CSF-Rα) or placebo for 5 days were assayed for gene expression by qPCR, and culture supernatants were analyzed by ELISA.

Results:

Endothelial cells and macrophages were the main cell types expressing GM-CSF and GM-CSF-Rα. Increased expression of phospho-JAK2 (activated signaling molecule) and nuclear-localized PU.1 (transcription factor) in GCA TABs compared to controls indicated the presence of active GM-CSF signaling pathway in GCA.

Inhibition of PU.1 mRNA expression inex vivocultures of GCA arteries treated with mavrilimumab indicated blockade of GM-CSFR signaling pathway. Mavrilimumab induced decrease in mRNA expression of key cell type markers including DC and macrophage activation markers CD83 and HLA-DRA, monocyte markers CD14 and CD16, T cell marker CD3ε, and B cell marker CD20 in these GCA artery cultures. Expression of inflammatory TH1/TH17 factors IFNγ (mRNA), TNFα, CXCL10 (IFNγ-stimulated chemokine) and IL-6 (mRNA and protein) was also inhibited by mavrilimumab in GCA artery cultures.

Conclusion:

Increased GM-CSF, GM-CSF-Rα, and downstream pathway-associated protein levels in GCA biopsies were consistent with previously-observed increased transcriptome signature. Expression of genes associated with inflammatory cells was suppressed by mavrilimumab in cultured GCA arteries. These data implicate the GM-CSF pathway in GCA pathophysiology and increase confidence in rationale for targeting the GM-CSF pathway in GCA.

References:

[1]GM-CSF and T-cell responses: what we do and don’t know. Shiet al., Cell Res 2006

[2]GM-CSF-Dependent Inflammatory Pathways. Hamilton, Front Immunol 2019

[3]GM-CSF increases tumor growth and angiogenesis. Zhenget al., Tumour Biol 2017

[4]GM-CSF deficiency affects vascular elastin production and integrity of elastic lamellae. Weissen-Plenzet al., J Vasc Res 2008

Disclosure of Interests:

Maria C. Cid Grant/research support from: Kiniksa Pharmaceuticals, Consultant of: Janssen, Abbvie, Roche, GSK, Speakers bureau: Vifor, Sujatha Muralidharan Shareholder of: Kiniksa, Employee of: Kiniksa, Marc Corbera-Bellalta: None declared, Georgina Espigol-Frigole Consultant of: Roche and Janssen, Javier Marco Hernandez: None declared, Amanda Denuc: None declared, Roberto Rios-Garces: None declared, Nekane Terrades-Garcia: None declared, John F. Paolini Shareholder of: Kiniksa, Employee of: Kiniksa, Annalisa D’Andrea Shareholder of: Kiniksa, Employee of: Kiniksa

THU0305 PREVALENCE AND CLINICAL OUTCOME OF INTERSTITIAL LUNG DISEASE IN ANCA ASSOCIATED VASCULITIS

Background:

Lung involvement is frequent in ANCA-associated vasculitis (AAV). Classical lung manifestations consist of capillaritis with lung haemorrhage, inflammatory infiltrates and nodules. Interstitial lung disease (ILD) is increasingly recognized among patients with AAV. However, little is known concerning risk factors and clinical course of these patients.

Objectives:

The aim of our study was to characterize the prevalence and clinical course of ILD in patients with AAV.

Methods:

We have performed a clinical retrospective single-centre observational analysis (1990-2019) of all patients with the diagnosis of microscopic polyangiitis (MPA) and granulomatosis with polyangiitis (GPA) diagnosed according to 2018 Draft Classification Criteria for GPA and MPA1. Demographic, clinical and immunologic data were reviewed. Radiologic pattern of ILD were assessed by high-resolution-CT. Main outcome evaluated was overall-all survival.

Results:

The study population consisted of 123 patients, 56% female, aged 59.3±18.2 years old at the time of diagnosis. Clinical diagnosis was of MPA in 54% of patients and GPA in 46%. While 108 (88%) ANCA positive patients had PR3 (n=25) or MPO (n=83), 15 (12%) patients had negative or atypical ANCA. Any lung involvement was present in 82 (71%) and ILD was identified in 24 (20%) of all patients. ILD pattern was of usual interstitial pneumonia (UIP) in 12 patients, non-specified interstitial pneumonia (NSIP) in 9 and chronic organizing pneumonia (OP) in 3. There was an association between the presence of ILD and ANCA specificity: MPO were present in 100% of patients with UIP and in 75% of patients with NSIP/OP (p=0.017). Bronchiectasis were more prevalent among patients with ILD (19/24; p<0.001). During the median follow-up time period of 68 (23-126) months, mortality was of 42% among patients with ILD-AAV compared with 11% in no ILD-AAV (log-rank p=0.0001). On the multivariate Cox regression model, ILD was an independent predictor of mortality HR 2.95 (95%CI 1.09-7.96; p=0.033).

Conclusion:

ILD is a frequent manifestation of MPA and GPA patients. The presence of ILD, particularly UIP, is associated with ANCA-MPO and is a predictor of mortality. Therefore, a better management of fibrotic lung involvement in AAV is warranted.

References:

[1]Robson JC, Grayson PC, Ponte C, et al. Draft classification criteria for the ANCA associated vasculitides. Ann Rheum Dis 2018;77 (suppl 2):60-1.

Disclosure of Interests:

João Fernandes Serodio: None declared, José Hernández-Rodríguez: None declared, Georgina Espígol-Frigolé: None declared, Marco Alba: None declared, Javier Marco-Hernández: None declared, Marcelo Sánchez: None declared, Fernanda Hernández-González: None declared, Jacobo Sellarés: None declared, Maria C. Cid Grant/research support from: Kiniksa Pharmaceuticals, Consultant of: Janssen, Abbvie, Roche, GSK, Speakers bureau: Vifor, Sergio Prieto-González: None declared

SAT0275 MAINTAINED BENEFIT IN HEALTH-RELATED QUALITY OF LIFE OF PATIENTS WITH GIANT CELL ARTERITIS TREATED WITH TOCILIZUMAB PLUS PREDNISONE TAPERING: RESULTS FROM THE OPEN-LABEL, LONG-TERM EXTENSION OF A PHASE 3 RANDOMIZED CONTROLLED TRIAL

Background:

In part 1 of the 52-week, double-blind GiACTA trial, patients with giant cell arteritis (GCA) who received weekly tocilizumab (TCZ) plus prednisone tapering reported improvement in the 36-item Short-Form Health Survey (SF-36) Mental Component Summary (MCS) and Physical Component Summary scores and FACIT-Fatigue scores that were statistically significant and clinically meaningful compared with patients who received prednisone alone.1

Objectives:

To analyze whether benefit in SF-36 MCS was maintained in patients originally assigned to TCZ compared with those originally assigned to placebo (PBO) plus a 26- or 52-week prednisone taper among patients who achieved clinical remission at week 52 and maintained treatment-free clinical remission in the 2-year, long-term extension of GiACTA.

Methods:

At the end of part 1, patients entered open-label part 2, in which GCA therapy (including initiation/termination of open-label TCZ and/or GCs) was given at the investigator’s discretion according to disease status. Change from baseline in SF-36 MCS score was compared for combined original TCZ (n = 33) and PBO (n = 17) patients who achieved clinical remission at week 52 and maintained treatment-free (no TCZ or GCs) clinical remission in part 2 using a repeated-measures model. The minimal clinically important difference (MCID) for SF-36 MCS is >2.5.2

Results:

During treatment, SF-36 MCS scores in all 50 patients who maintained treatment-free clinical remission in part 2 had diverged between the TCZ and PBO groups as early as 36 weeks after baseline, with greater improvements evident in the TCZ group (Figure). The difference in least square means (LSM) change between TCZ and PBO was statistically significant at week 52 (p= 0.016) and maintained at weeks 100 (p= 0.023) and 156 (p= 0.002). The LSM difference (95% CI) between TCZ and PBO at weeks 52, 100, and 156 was 5.6 (1.1-10.2), 6.5 (0.9-12.1), and 7.4 (2.9-11.9), respectively, exceeding the MCID.

Conclusion:

Among patients who maintained treatment-free clinical remission during part 2 of GiACTA, those originally assigned to receive TCZ plus a prednisone taper during part 1 maintained statistically significant and clinically meaningful improvements in SF-36 MCS up to week 156 compared with those originally assigned to receive PBO plus a prednisone taper in part 1. This was true even though neither of the patient groups received TCZ or GC treatment after they achieved clinical remission at week 52.

References:

[1]Strand V et al.Arthritis Res Ther2019;21:64.

[2]Lubeck DP.Pharmacoeconomics2004;22:27-38.

Disclosure of Interests:

John H. Stone Grant/research support from: Roche, Consultant of: Roche, Jian Han Shareholder of: Genentech, Inc., Employee of: Genentech, Inc., Sebastian Unizony Grant/research support from: Genentech, Inc., Martin Aringer Consultant of: Boehringer Ingelheim, Roche, Speakers bureau: Boehringer Ingelheim, Roche, Daniel Blockmans Consultant of: yes, Speakers bureau: yes, Elisabeth Brouwer Consultant of: Roche (consultancy fee 2017 and 2018 paid to the UMCG), Speakers bureau: Roche (2017 and 2018 paid to the UMCG), Maria C. Cid Speakers bureau: Roche, Bhaskar Dasgupta Grant/research support from: Roche, Consultant of: Roche, Sanofi, GSK, BMS, AbbVie, Speakers bureau: Roche, Jürgen Rech Consultant of: BMS, Celgene, Novartis, Roche, Chugai, Speakers bureau: AbbVie, Biogen, BMS, Celgene, MSD, Novartis, Roche, Chugai, Pfizer, Lilly, Carlo Salvarani: None declared, Robert Spiera Grant/research support from: Roche-Genetech, GSK, Boehringer Ingelheim, Chemocentryx, Corbus, Forbius, Sanofi, Inflarx, Consultant of: Roche-Genetech, GSK, CSL Behring, Sanofi, Janssen, Chemocentryx, Forbius, Mistubishi Tanabe, Min Bao Shareholder of: Roche, Employee of: Genentech

OP0027 TIME TO FLARE AND GLUCOCORTICOID EXPOSURE IN PATIENTS WITH NEW-ONSET VERSUS RELAPSING GIANT CELL ARTERITIS TREATED WITH TOCILIZUMAB OR PLACEBO PLUS PREDNISONE TAPERING: 3-YEAR RESULTS FROM A RANDOMIZED CONTROLLED PHASE 3 TRIAL

Background:

In part 1 of the 52-week, double-blind GiACTA trial, tocilizumab (TCZ) every week (QW) or every other week (Q2W) + prednisone tapering reduced the risk for flare versus placebo (PBO) + 26-week prednisone tapering among patients with new-onset giant cell arteritis (GCA) at baseline. Among patients with relapsing GCA, TCZ QW but not Q2W + prednisone reduced the risk for flare versus both PBO groups, and there was separation in the time to flare between the TCZ QW and Q2W groups.1

Objectives:

To report time to first flare and potential cumulative glucocorticoid (GC) sparing over 3 years of the GiACTA trial (part 1 + 2-year open-label part 2) among patients with new-onset or relapsing GCA.

Methods:

At the end of part 1, patients entered open-label part 2, in which GCA therapy (including initiation/termination of open-label TCZ and/or GCs) was given at the investigator’s discretion according to disease status. Time to first GCA flare during the 3-year study period was assessed using Kaplan-Meier analysis for patients in the intention-to-treat population according to disease onset status at baseline (new-onset/relapsing) based on their originally assigned treatment groups: TCZ QW, TCZ Q2W, or pooled PBO (PBO+26-week and PBO+52-week prednisone taper).

Results:

Among patients randomly assigned in part 1, 47 of 100 (47%) in the TCZ QW group, 26 of 49 (53%) in the TCZ Q2W group, and 46 of 101 (46%) in the pooled PBO group had new-onset GCA at baseline; the rest had relapsing GCA. Median time to first flare over 3 years was longer for patients assigned to TCZ treatment in part 1 than for patients assigned to PBO; Kaplan-Meier analysis showed a clear separation between the TCZ QW and the pooled PBO groups over 3 years for patients with new-onset and relapsing GCA (Figure 1A). Separation between the TCZ QW and TCZ Q2W groups was also observed over 3 years in patients with new-onset and relapsing GCA, although this was more evident in patients with relapsing GCA (Figure 1B). Higher proportions of patients in the TCZ QW group (new-onset, 49%; relapsing, 47%) than the pooled PBO group (new-onset, 28%; relapsing, 31%) and the TCZ Q2W group (new-onset, 27%; relapsing, 35%) remained flare-free during their entire treatment period. Cumulative prednisone dose over 3 years was lower for patients originally assigned to TCZ QW versus those originally assigned to PBO for patients with new-onset GCA and those with relapsing GCA at baseline (Figure 2).

Conclusion:

In this 3-year analysis of GiACTA parts 1 and 2, time to first flare favored TCZ QW over TCZ Q2W in patients with new-onset and relapsing GCA. TCZ QW delayed time to first flare and resulted in lower cumulative GC exposure compared with PBO in patients with new-onset and relapsing GCA, supporting TCZ QW dosing in patients with GCA regardless of disease onset.

References:

[1]Stone JH et al. N Engl J Med 2017;377:317-28.

Disclosure of Interests:

John H. Stone Grant/research support from: Roche, Consultant of: Roche, Helen Spotswood Shareholder of: Roche Products Ltd, Employee of: Roche Products Ltd, Sebastian Unizony Grant/research support from: Genentech, Inc., Martin Aringer Consultant of: Boehringer Ingelheim, Roche, Speakers bureau: Boehringer Ingelheim, Roche, Daniel Blockmans Consultant of: yes, Speakers bureau: yes, Elisabeth Brouwer Consultant of: Roche (consultancy fee 2017 and 2018 paid to the UMCG), Speakers bureau: Roche (2017 and 2018 paid to the UMCG), Maria C. Cid Speakers bureau: Roche, Bhaskar Dasgupta Grant/research support from: Roche, Consultant of: Roche, Sanofi, GSK, BMS, AbbVie, Speakers bureau: Roche, Jürgen Rech Consultant of: BMS, Celgene, Novartis, Roche, Chugai, Speakers bureau: AbbVie, Biogen, BMS, Celgene, MSD, Novartis, Roche, Chugai, Pfizer, Lilly, Carlo Salvarani: None declared, Robert Spiera Grant/research support from: Roche-Genetech, GSK, Boehringer Ingelheim, Chemocentryx, Corbus, Forbius, Sanofi, Inflarx, Consultant of: Roche-Genetech, GSK, CSL Behring, Sanofi, Janssen, Chemocentryx, Forbius, Mistubishi Tanabe, Min Bao Shareholder of: Roche, Employee of: Genentech

AB0475 CLINICAL RELEVANCE OF CLINICOPATHOLOGICAL PHENOTYPE AND ANTIBODY SPECIFICITY IN ANCA-ASSOCIATED VASCULITIS

Background:

Classification of ANCA-associated vasculitis (AAV) has emerged in order to identify more homogenous subgroups of patients with granulomatosis with polyangiitis (GPA) or microscopic polyangiitis (MPA). However, the exact value of classifying patients according to antibody specificity (proteinase 3 [PR3] or myeloperoxidase [MPO]) is still unclear.

Objectives:

To assess demographic, clinical and prognostic differences among subgroups of AAV patients, according to clinicopathological classification (GPAvs. MPA) and antibody specificity (PR3vs. MPO) in a single-centre cohort.

Methods:

A clinical retrospective (1990-2019) observational analysis was performed. Among all patients with ANCA positivity, we analysed patients with GPA and MPA diagnosed according to 2018 Draft Classification Criteria for AAV1, who were homogeneously treated and followed by the authors. Demographic, clinical and laboratory data, as well as disease outcomes, particularly BVAS, disease relapses and survival, were reviewed.

Results:

Among a total 140 patients with any form of AAV, 32 were excluded for a diagnosis of isolated interstitial lung disease (n=10), cocaine-induced AAV (n=3), ANCA negative or undetermined disease (n=16), atypical ANCA or double PR3/MPO positivity (n=3). Finally, 108 patients with MPA (n=66) or GPA (n=42) were included (83 MPO, 25 PR3). GPA was associated with PR3 in 55% and MPO 45% of patients. MPA was associated with MPO in 97% and PR3 in 3% of patients. GPA patients with PR3 or MPO presented with similar clinical features, disease extent and BVAS. However, compared with GPA/PR3, GPA/MPO were more frequently women (p=0.002). MPA patients presented more frequent with renal involvement (p=0.008) and GPA patients with ENT/ocular involvement (p<0.001). Patients with MPO were older (p=0.028) and more frequently women (p=0.001) than PR3 patients. When antibody specificity was compared, differences on organ-specific manifestations were less clear than between clinical phenotypes (GPA vs. MPA), and were only seen in ENT/ocular involvement (more frequent in PR3 than in MPO patients) and in muscle biopsies disclosing vasculitis (more frequent in MPO than in PR3 patients). GPA and PR3 patients presented more frequent relapsing disease than MPA and MPO patients, respectively (GPA 60% vs. MPA 36%; p=0.018 / PR3 60% vs. MPO 41%; p=0.094). While GPA tended to have a better survival rate than MPA patients (p=0.066) (Graph1), the MPO-associated disease (GPA or MPA) had clearly worse survival prognosis than PR3-AAV (p=0.008) (Graph2), similarly to what occurred in GPA-MPO (compared with GPA-PR3).

Conclusion:

A high proportion of GPA patients with MPO-ANCA (45%) is observed in our series. GPA is associated with a more frequent relapsing disease than MPA. MPA and presence of MPO were more frequent in females and older patients. Clinical features were similar in GPA patients with PR3 or MPO. The presence of MPO (in GPA or MPA) seems to be the main factor associated with mortality in AAV.

Table 1.

Symptomatology and ultrasound findings in the patients examined. PMR: Polymyalgia Rheumatica

UltrasoundSymptomsCranial(n=17)PMR only(n=17)Non-specific symptoms (n=18)PMR (+) (n=7)PMR (-) (n=10)Temporal (+)7301Facial (+)2100Axilliary (+)0031

References:

[1]Robson JC, Grayson PC, Ponte C, et al.Draft classification criteria for the ANCA associated vasculitides. Ann Rheum Dis 2018;77 (suppl 2):60-1.

Disclosure of Interests:

João Fernandes Serodio: None declared, Sergio Prieto-González: None declared, Georgina Espígol-Frigolé: None declared, Marco Alba: None declared, Javier Marco-Hernández: None declared, Maria C. Cid Grant/research support from: Kiniksa Pharmaceuticals, Consultant of: Janssen, Abbvie, Roche, GSK, Speakers bureau: Vifor, José Hernández-Rodríguez: None declared

EULAR/ERA-EDTA recommendations for the management of ANCA-associated vasculitis

In this article, the 2009 European League Against Rheumatism (EULAR) recommendations for the management of antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) have been updated. The 2009 recommendations were on the management of primary small and medium vessel vasculitis. The 2015 update has been developed by an international task force representing EULAR, the European Renal Association and the European Vasculitis Society (EUVAS). The recommendations are based upon evidence from systematic literature reviews, as well as expert opinion where appropriate. The evidence presented was discussed and summarised by the experts in the course of a consensus-finding and voting process. Levels of evidence and grades of recommendations were derived and levels of agreement (strengths of recommendations) determined. In addition to the voting by the task force members, the relevance of the recommendations was assessed by an online voting survey among members of EUVAS. Fifteen recommendations were developed, covering general aspects, such as attaining remission and the need for shared decision making between clinicians and patients. More specific items relate to starting immunosuppressive therapy in combination with glucocorticoids to induce remission, followed by a period of remission maintenance; for remission induction in life-threatening or organ-threatening AAV, cyclophosphamide and rituximab are considered to have similar efficacy; plasma exchange which is recommended, where licensed, in the setting of rapidly progressive renal failure or severe diffuse pulmonary haemorrhage. These recommendations are intended for use by healthcare professionals, doctors in specialist training, medical students, pharmaceutical industries and drug regulatory organisations.

Small-vessel vasculitis with prominent IgG4 positive plasma cell infiltrates as potential part of the spectrum of IgG4-related disease: a case report

IgG4-related disease (IgG4-RD) is a systemic entity characterised by multiorgan inflammatory lesions with abundant IgG4+ plasma cells, obliterative phlebitis, and storiform fibrosis. Involvement of several organs such as the pancreas, gastrointestinal tract, salivary glands, periorbital tissue and lymph nodes has been described. Up to now, vascular involvement by IgG4-RD has been thought to be essentially confined to large vessels. We present a patient with small-vessel systemic vasculitis involving muscle, peripheral nerve and kidney (glomerulonephritis) in the context of IgG4-RD diagnosed on the basis of elevated serum IgG4+ concentrations and histologically consistent signs in all biopsied tissues. Thoracic and abdominal aortic aneurysms in addition to aortitis, suggestive of large-vessel involvement, were also present. This observation expands the spectrum of vascular involvement in the context of IgG4-RD and supports the inclusion of IgG4-RD in the category of vasculitis associated with systemic disorder.

Identification of the PTPN22 functional variant R620W as susceptibility genetic factor for giant cell arteritis

OBJECTIVE

To analyse the role of the PTPN22 and CSK genes, previously associated with autoimmunity, in the predisposition and clinical phenotypes of giant cell arteritis (GCA).

METHODS

Our study population was composed of 911 patients diagnosed with biopsy-proven GCA and 8136 unaffected controls from a Spanish discovery cohort and three additional independent replication cohorts from Germany, Norway and the UK. Two functional PTPN22 polymorphisms (rs2476601/R620W and rs33996649/R263Q) and two variants of the CSK gene (rs1378942 and rs34933034) were genotyped using predesigned TaqMan assays.

RESULTS

The analysis of the discovery cohort provided evidence of association of PTPN22 rs2476601/R620W with GCA (PFDR=1.06E-04, OR=1.62, CI 95% 1.29 to 2.04). The association did not appear to follow a specific GCA subphenotype. No statistically significant differences between allele frequencies for the other PTPN22 and CSK genetic variants were evident either in the case/control or in stratified case analysis. To confirm the detected PTPN22 association, three replication cohorts were genotyped, and a consistent association between the PTPN22 rs2476601/R620W variant and GCA was evident in the overall meta-analysis (PMH=2.00E-06, OR=1.51, CI 95% 1.28 to 1.79).

CONCLUSIONS

Our results suggest that the PTPN22 polymorphism rs2476601/R620W plays an important role in the genetic risk to GCA.

A case-control study suggests that the CCR6 locus is not involved in the susceptibility to giant cell arteritis

OBJECTIVES

Polymorphisms of the CC chemokine receptor 6 (CCR6) gene have been recently reported to be associated with a number of autoimmune diseases. We aimed to investigate the possible influence of CCR6 rs3093024 gene variant in the susceptibility to and clinical expression of GCA.

METHODS

The CCR6 polymorphism rs3093024 was genotyped in a total of 463 Spanish patients diagnosed with biopsy-proven GCA and 920 healthy controls using a TaqMan® allelic discrimination assay. PLINK software was used for the statistical analyses.

RESULTS

No significant association between this CCR6 variant and GCA was observed (p=0.42, OR=0.94, CI95% 0.79-1.10). Similarly, when patients were stratified according to the specific clinical features of GCA such as polymyalgia rheumatica, visual ischaemic manifestations or irreversible occlusive disease, no statistical significant difference was detected either between the case subgroups and the control set or between GCA patients with and without the specific features of the disease.

CONCLUSIONS

Our results suggest that the CCR6 rs3093024 polymorphism may not play a relevant role in the GCA pathophysiology.

Increased expression of the endothelin system in arterial lesions from patients with giant-cell arteritis: association between elevated plasma endothelin levels and the development of ischaemic events

Objective:

Approximately 15–20% of patients with giant-cell arteritis (GCA) develop ischaemic complications often preceded by transient ischaemia. The expression of the endothelin (ET) system in GCA lesions was investigated to assess its relationship with the development of ischaemic complications.

Methods:

Plasma ET-1 was quantified by immunoassay in 61 patients with biopsy-confirmed GCA and 16 healthy donors. ET-1, endothelin-converting enzyme (ECE-1) and endothelin receptor (ETAR and ETBR) messenger RNA were measured by real-time quantitative reverse transcriptase–PCR in temporal arteries from 35 of these patients and 19 control arteries. Proteins were measured by immunoassay and Western blot.

Results:

ET-1 concentration was increased at the protein level in temporal artery samples from GCA patients compared with controls (0.98 (SEM 0.32) vs 0.28 (SEM 0.098) fmol/mg, p = 0.028). ECE-1, ETAR and ETBR/actin ratios (Western blot) were also significantly higher in GCA patients. Intriguingly, mRNA expression of ET-1, ECE-1 and both receptors was significantly reduced in GCA lesions compared with control arteries. When investigating mechanisms underlying these results, platelet-derived growth factor and IL-1β, present in GCA lesions, were found to downregulate ET-1 mRNA in cultured human temporal artery-derived smooth muscle cells. Glucocorticoid treatment for 8 days did not result in significantly decreased endothelin tissue concentration (0.87 (SEM 0.2) vs 0.52 (SEM 0.08); p = 0.6). Plasma endothelin concentrations were higher in patients with ischaemic complications (1.049 (SEM 0.48) vs 1.205 (SEM 0.63) pg/ml, p = 0.032).

Conclusions:

The endothelin system is increased at the protein level in GCA lesions creating a microenvironment prone to the development of ischaemic complications. Recovery induced by glucocorticoids is delayed, indicating persistent exposure to endothelin during initial treatment.

EULAR recommendations for the management of primary small and medium vessel vasculitis

OBJECTIVES

To develop European League Against Rheumatism (EULAR) recommendations for the management of small and medium vessel vasculitis.

METHODS

An expert group (consisting of 10 rheumatologists, 3 nephrologists, 2 immunologists, 2 internists representing 8 European countries and the USA, a clinical epidemiologist and a representative from a drug regulatory agency) identified 10 topics for a systematic literature search using a modified Delphi technique. In accordance with standardised EULAR operating procedures, recommendations were derived for the management of small and medium vessel vasculitis. In the absence of evidence, recommendations were formulated on the basis of a consensus opinion.

RESULTS

In all, 15 recommendations were made for the management of small and medium vessel vasculitis. The strength of recommendations was restricted by low quality of evidence and by EULAR standardised operating procedures.

CONCLUSIONS

On the basis of evidence and expert consensus, recommendations have been made for the evaluation, investigation, treatment and monitoring of patients with small and medium vessel vasculitis for use in everyday clinical practice.

EULAR recommendations for the management of large vessel vasculitis

OBJECTIVES

To develop European League Against Rheumatism (EULAR) recommendations for the management of large vessel vasculitis.

METHODS

An expert group (10 rheumatologists, 3 nephrologists, 2 immunolgists, 2 internists representing 8 European countries and the USA, a clinical epidemiologist and a representative from a drug regulatory agency) identified 10 topics for a systematic literature search through a modified Delphi technique. In accordance with standardised EULAR operating procedures, recommendations were derived for the management of large vessel vasculitis. In the absence of evidence, recommendations were formulated on the basis of a consensus opinion.

RESULTS

Seven recommendations were made relating to the assessment, investigation and treatment of patients with large vessel vasculitis. The strength of recommendations was restricted by the low level of evidence and EULAR standardised operating procedures.

CONCLUSIONS

On the basis of evidence and expert consensus, management recommendations for large vessel vasculitis have been formulated and are commended for use in everyday clinical practice.

Imatinib mesylate inhibits in vitro and ex vivo biological responses related to vascular occlusion in giant cell arteritis

OBJECTIVES

Ischaemic complications occur in 15-20% of patients with giant cell arteritis (GCA). The aim of our study was to explore the effect of mesenchymal growth factors expressed in GCA lesions on myointimal cell responses related to the development of intimal hyperplasia and vessel occlusion.

METHODS

We developed a method to obtain primary human temporal artery derived myointimal cells (HTAMCs) based on the culture of temporal artery sections on Matrigel.

RESULTS

Among the factors tested (platelet-derived growth factor (PDGF)-AB, fibroblast growth factor (FGF)-2, vascular endothelial growth factor (VEGF), epidermal growth factor (EGF), transforming growth factor (TGF)beta, chemokine (C-C motif) ligand (CCL)2, interleukin (IL)6 and IL1beta), PDGF exhibited the strongest activity in inducing HTAMC proliferation and migration. As assessed by protein array, immunoassay and quantitative real-time reverse transcriptase (RT)-PCR, PDGF stimulated matrix proteins (collagen I, collagen III and fibronectin) as well as CCL2 and angiogenin production by HTAMCs. Imatinib mesylate inhibited PDGF-mediated activation of signalling pathways (Src, extracellular signal-regulated kinase (ERK) and Akt phosphorylation) related to cell motility and survival, efficiently resulting in inhibition of PDGF-induced HTAMC responses. Myointimal cell outgrowth from cultured temporal artery sections from patients with GCA, where multiple interactions take place, was also efficiently reduced by imatinib.

CONCLUSION

Among several mediators produced in GCA, PDGF has the highest vaso-occlusive potential. PDGF may also contribute to disease perpetuation by stimulating the production of angiogenic factors (angiogenin) and chemoattractants (CCL2). Imatinib mesylate strongly inhibits PDGF-mediated responses, suggesting a therapeutic potential to limit vascular occlusion and ischaemic complications in large vessel vasculitis.

Association between increased CCL2 (MCP-1) expression in lesions and persistence of disease activity in giant-cell arteritis*

OBJECTIVE

Patients with giant-cell arteritis (GCA) usually respond dramatically to corticosteroid treatment. However, recurrences are frequent and corticosteroid requirements are highly variable among patients. The aim of our study was to identify genes potentially involved in disease persistence.

METHODS

Gene expression was explored with cDNA arrays in temporal artery biopsies from six GCA patients with relapsing disease and six patients who easily achieved sustained remission. Differentially expressed genes of interest were subsequently analysed by quantitative real-time polymerase chain reaction (PCR) and immunohistochemistry in temporal artery biopsies from 35 patients with biopsy-proven GCA and nine controls.

RESULTS

CCL2 (MCP-1) was up-regulated in temporal artery samples from relapsing individuals. In the extended series of patients, CCL2 mRNA concentration in lesions was significantly higher than in controls (31 +/- 15.6 vs 0.44 +/- 0.10, P = 0.0001). In addition, CCL2 was more abundant in patients who experienced two or more relapses during the first year compared with those who endured sustained remission (127 +/- 82 vs 11 +/- 5.5, P = 0.0233) and correlated with the cumulated prednisolone dose (R = 0.533, P = 0.0024). CCL2 mRNA concentration correlated with IL-1beta (R = 0.45, P = 0.02), tumour necrosis factor-alpha (TNF-alpha) (R = 0.47, P = 0.013) and IL-6 (R = 0.52, P = 0.0053) mRNA. However, circulating CCL2 determined by ELISA was decreased in patients with strong systemic inflammatory response, suggesting that reduction in circulating CCL2 may reinforce the local gradient in lesions.

CONCLUSION

Increased CCL2 (MCP-1) expression in lesions is associated with persistence of disease activity in GCA.

[Autosomal dominant compelling helio-ophthalmic outburst syndrome (photic sneeze reflex). Clinical study of six Spanish families]

INTRODUCTION

Sneeze is an ubiquitous phenomenon that happens to everyone. In spite of this, little attention has been paid to it, among medical literature in general, and even less in neurologic texts. A curious entity, called autosomal dominant compelling helio-ophthalmic outburst syndrome, has been scarcely described in the scientific literature. This reflex appears when subjects are exposed suddenly to intense sunlight and it consists of long incoercible sneeze bursts. There are no publications on this subject among the spanish literature.and intensity increase with time.

OBJECTIVE

To study the clinical and physiological features of the reflex in Spanish families.

PATIENTS AND METHOD

Affected subjects were identified by personal interview and given a questionnaire drawn up for this study. Besides, they were instructed to give the questionnaire to their relatives.and intensity increase with time.

RESULTS

All the six families showed a high-penetrance, autosomal dominant inheritance. The reflex had a high consistency, a latency about 3 seconds, an intersneeze interval of 2 seconds and a frequency of 2-3 sneezes/ burst. Refractory period was long.and intensity increase with time.

DISCUSSION

Our study suggest a higher consistency, shorter latency and lower age of onset of the reflex in our patients than general population, and that frequency and intensity increase with time.

Tissue production of pro-inflammatory cytokines (IL-1 , TNF and IL-6) correlates with the intensity of the systemic inflammatory response and with corticosteroid requirements in giant-cell arteritis

OBJECTIVES

To investigate proinflammatory cytokine expression in temporal arteries from patients with giant-cell arteritis (GCA) and to analyse its relationship with the intensity of the initial systemic inflammatory reaction and response to corticosteroid therapy.

METHODS

Quantification of interleukin-1beta (IL-1beta), tumor necrosis factor alpha (TNFalpha), and interleukin-6 (IL-6) mRNA by real-time quantitative PCR in temporal artery samples from 36 patients with biopsy-proven GCA and 11 controls. Immunohistochemical detection of IL-1beta, TNFalpha, and IL-6 in temporal artery sections from 74 patients with GCA and 15 controls. Clinical and biochemical parameters of inflammation as well as the time (weeks) required to reach a maintenance prednisone dose <10 mg/day were recorded.

RESULTS

IL-1beta (13.8 +/- 2.5 vs 5.4 +/- 1.3 relative units, P = 0.012) and IL-6 transcripts (34 +/- 13.7 vs 7.8 +/- 4.5 relative units, P = 0.034) were significantly more abundant in patients with a strong systemic inflammatory response compared with those with no inflammatory parameters. Immunohistochemical scores for IL-1beta (2.7 +/- 0.3 vs 1.9 +/- 0.2, P = 0.018), TNFalpha (3.2 +/- 0.2 vs 2.4 +/- 0.3, P = 0.028) and IL-6 (3 +/- 0.2 vs 2.1 +/- 0.3, P = 0.023) were also significantly higher in patients with strong systemic inflammatory reaction. A significant correlation was found between the amount of tissue TNFalpha mRNA and the time required to reach a maintenance dose of prednisone <10 mg/day (r = 0.586, P = 0.001).

CONCLUSION

GCA patients with a strong systemic inflammatory response, who have been previously shown to be more resistant to corticosteroid therapy, have elevated tissue expression of proinflammatory cytokines IL-1beta, TNFalpha and IL-6. High production of TNFalpha is associated with longer corticosteroid requirements.

Estradiol enhances endothelial cell interactions with extracellular matrix proteins via an increase in integrin expression and function

Premenopausal women have a lower cardiovascular risk and a higher incidence of several autoimmune diseases involving blood vessels than men. Although the precise effects of estrogens on the cardiovascular system are largely unknown, recent data suggest that estrogens can exert direct regulatory effects on endothelial cells. In the present study, we show that 17beta-estradiol increases human umbilical vein endothelial cell attachment to the extracellular matrix proteins laminin-1, type IV collagen, type I collagen, and fibronectin. Estradiol enhanced adhesion most significantly to laminin-1 and to fibronectin-derived synthetic peptides containing an RGD sequence. Upon exposure to estradiol, an increase in beta1, alpha5 and alpha6 integrin mRNA was observed in subconfluent cells which was abrogated by treatment with cycloheximide. This increase was followed by a later enhancement in surface expression of the above integrins. In addition, integrin-mediated signaling was also enhanced by estrogens since an increase in tyrosine-phosphorylation of focal adhesion kinase induced by cell attachment was observed in estrogen-treated endothelial cells. Since integrins have an important role in mediating endothelial cell attachment, migration and differentiation, the increase in integrin expression and function induced by estradiol may be an important mechanism through which estrogens can promote neovascularization and vessel repair.

Small-vessel vasculitis surrounding a spared temporal artery: clinical and pathological findings in a series of twenty-eight patients

OBJECTIVE

Occasionally, a temporal artery biopsy reveals small-vessel vasculitis (SVV) surrounding a spared temporal artery, the significance of which is unclear. We analyzed the final diagnosis in a series of patients with this condition and tried to identify histopathologic features with potential usefulness in predicting the ultimate diagnosis.

METHODS

We performed a clinical and histopathologic review of 28 patients in whom SVV surrounding a spared temporal artery was the first histologic finding that led to the diagnosis of vasculitis. For comparison purposes, we analyzed the pattern of small vessel involvement in 30 patients with biopsy-proven giant cell arteritis (GCA).

RESULTS

GCA was considered the most likely diagnosis in 12 patients, based on the absence of clinical evidence of additional organ involvement and normal findings on muscle biopsy and electrophysiologic study. Three patients had systemic necrotizing vasculitis (SNV), based on the demonstration of typical lesions on subsequent muscle, nerve, or kidney biopsy. After extensive evaluation, 4 patients remained unclassifiable. Nine patients were incompletely studied. Fibrinoid necrosis was significantly more frequent in patients with SNV (P = 0.0022), whereas involvement of vasa vasorum was more frequent in patients classified as having GCA (P = 0.022). No differences in the pattern of small vessel involvement were found in patients with SVV surrounding a spared temporal artery who were classified as having GCA compared with patients with biopsy-proven GCA. Granulocytes were observed at similar frequency in all conditions.

CONCLUSION

SVV may be the only abnormal feature in a temporal artery biopsy and the only histologic evidence of vasculitis. The diagnosis of GCA can be reasonably established in most of these patients when there is no apparent evidence of additional organ involvement. However, when fibrinoid necrosis is observed or the temporal artery vasa vasorum are not involved, SNV must be extensively excluded.

Tissue targeting and disease patterns in systemic vasculitis

The systemic vasculitides include a group of diseases with highly heterogeneous organ distribution and disease expression patterns. The mechanisms mediating tissue targeting in systemic vasculitis are largely unknown. Mechanical forces may contribute to the distribution of lesions in immune complex-mediated vasculitis. The site at which the antigen is encountered may be crucial in determining the location of inflammatory infiltrates in some vasculitides. Co-existence of different immunopathogenic mechanisms with variable dominance may generate diversity in disease presentation patterns. Heterogeneous and incompletely understood triggering mechanisms attract inflammatory cells to the site of interest through sophisticated molecular mechanisms: interplay between leukocyte receptors and endothelial ligands, and interactions between chemokines and chemokine receptors. Even with a similar distribution of lesions, patients with vasculitis may display highly variable clinical manifestations. Variations in genes involved in immune response might determine the severity of disease, the intensity of the systemic inflammatory response, the degree of vessel occlusion and the response to therapy.

Cell adhesion molecules in the development of inflammatory infiltrates in giant cell arteritis: inflammation-induced angiogenesis as the preferential site of leukocyte-endothelial cell interactions

OBJECTIVE

To investigate the expression pattern of adhesion molecules involved in leukocyte-endothelial cell interactions in giant cell arteritis (GCA).

METHODS

Immunohistochemical analysis was performed on frozen temporal artery sections from 32 patients with biopsy-proven GCA and from 12 control patients with other diseases. Adhesion molecules identified were intercellular adhesion molecule 1 (ICAM-1), ICAM-2, ICAM-3, vascular cell adhesion molecule 1 (VCAM-1), platelet endothelial cell adhesion molecule 1 (PECAM-1), E-selectin, P-selectin, L-selectin, lymphocyte function-associated antigen 1 (LFA-1), very late activation antigen 4 (VLA-4), Mac-1 (CD18/CD11b), and gp 150,95 (CD18/CD11c). Clinical and biochemical parameters of inflammation in the patients, as well as the duration of previous corticosteroid treatment, were prospectively recorded.

RESULTS

Constitutive (PECAM-1, ICAM-1, ICAM-2, and P-selectin) and inducible (E-selectin and VCAM-1) endothelial adhesion molecules for leukocytes were mainly expressed by adventitial microvessels and neovessels within inflammatory infiltrates. Concurrent analysis of leukocyte receptors indicated a preferential use of VLA-4/VCAM-1 and LFA-1/ICAM-1 at the adventitia and Mac-1/ICAM-1 at the intima-media junction. The intensity of inducible endothelial adhesion molecule expression (E-selectin and VCAM-1) correlated with the intensity of the systemic inflammatory response. Previous corticosteroid treatment reduced, but did not completely abrogate, the expression of the inducible endothelial adhesion molecules E-selectin and VCAM-1.

CONCLUSION

Inflammation-induced angiogenesis is the main site of leukocyte-endothelial cell interactions leading to the development of inflammatory infiltrates in GCA. The distribution of leukocyte-endothelial cell ligand pairs suggests a heterogeneity in leukocyte-endothelial cell interactions used by different functional cell subsets at distinct areas of the temporal artery.

Cell adhesion molecules in the development of inflammatory infiltrates in giant cell arteritis: inflammation-induced angiogenesis as the preferential site of leukocyte-endothelial cell interactions

OBJECTIVE

To investigate the expression pattern of adhesion molecules involved in leukocyte-endothelial cell interactions in giant cell arteritis (GCA).

METHODS

Immunohistochemical analysis was performed on frozen temporal artery sections from 32 patients with biopsy-proven GCA and from 12 control patients with other diseases. Adhesion molecules identified were intercellular adhesion molecule 1 (ICAM-1), ICAM-2, ICAM-3, vascular cell adhesion molecule 1 (VCAM-1), platelet endothelial cell adhesion molecule 1 (PECAM-1), E-selectin, P-selectin, L-selectin, lymphocyte function-associated antigen 1 (LFA-1), very late activation antigen 4 (VLA-4), Mac-1 (CD18/CD11b), and gp 150,95 (CD18/CD11c). Clinical and biochemical parameters of inflammation in the patients, as well as the duration of previous corticosteroid treatment, were prospectively recorded.

RESULTS

Constitutive (PECAM-1, ICAM-1, ICAM-2, and P-selectin) and inducible (E-selectin and VCAM-1) endothelial adhesion molecules for leukocytes were mainly expressed by adventitial microvessels and neovessels within inflammatory infiltrates. Concurrent analysis of leukocyte receptors indicated a preferential use of VLA-4/VCAM-1 and LFA-1/ICAM-1 at the adventitia and Mac-1/ICAM-1 at the intima-media junction. The intensity of inducible endothelial adhesion molecule expression (E-selectin and VCAM-1) correlated with the intensity of the systemic inflammatory response. Previous corticosteroid treatment reduced, but did not completely abrogate, the expression of the inducible endothelial adhesion molecules E-selectin and VCAM-1.

CONCLUSION

Inflammation-induced angiogenesis is the main site of leukocyte-endothelial cell interactions leading to the development of inflammatory infiltrates in GCA. The distribution of leukocyte-endothelial cell ligand pairs suggests a heterogeneity in leukocyte-endothelial cell interactions used by different functional cell subsets at distinct areas of the temporal artery.

Fibronectin upregulates gelatinase B (MMP-9) and induces coordinated expression of gelatinase A (MMP-2) and its activator MT1-MMP (MMP-14) by human T lymphocyte cell lines. A process repressed through RAS/MAP kinase signaling pathways

T-lymphocyte migration into tissues requires focal degradation of the basement membrane. In this study, we show that transient adherence to fibronectin induces the production of activated forms of matrix metalloproteinase-2 (MMP-2) and MMP-9, as well as downregulation of tissue inhibitor of metalloproteinase-2 (TIMP-2) by T-cell lines. MMP-2 activation was likely achieved by inducing a coordinated expression of membrane-type matrix metalloproteinase-1 (MMP-14), a major activator of MMP-2. Blocking monoclonal antibodies against alpha4, alpha5, and alphav integrins strongly reduced MMP-2 and MMP-9 production induced by fibronectin. Disrupting actin cytoskeleton organization by cytochalasin D strongly enhanced fibronectin-induced MMP-2 and MMP-9 expression. Inhibiting Src tyrosine kinases with herbimycin A reduced MMP-2 and MMP-9 production with no effect on cell attachment. By contrast, G-protein inhibition by pertussis toxin, or transfection with a dominant negative mutant of Ha-Ras strongly increased fibronectin-induced MMP-2 and MMP-9. Inhibition of PI3 kinase, MAPkinase (MEK1), or p38 MAPkinase by wortmannin, PD 98059, or SB 202190, respectively, strongly promoted fibronectin-induced MMP2 and MMP-9. Cells at high density lost their ability to synthesize MMP-2 and MMP-9 in response to fibronectin and MMP expression was restored by transfection with a dominant-negative mutant of Ha-Ras or by treatment with wortmannin, PD 98059, or SB 202190. Our findings suggest that adhesion to fibronectin transduces both stimulatory (through Src-type tyrosin kinases) and inhibitory signals (through Ras/MAPKinase signaling pathways) for MMP-2 and MMP-9 expression by T lymphocytes and that their relative predominance is regulated by additional stimuli related to cell adhesion, motility, and growth.

Expression of beta-integrin adhesion molecules in non-Hodgkin's lymphoma: correlation with clinical and evolutive features

PURPOSE

To analyze beta-integrin expression in non-Hodgkin's lymphomas (NHLs) in order to assess its distribution among histologic subtypes and correlate with clinical features and outcome.

PATIENTS AND METHODS

The expression of alpha2 through alpha6 and beta1 common chains of very late activation antigen (VLA ) molecules and alphaL (CD11a) and beta2 common (CD18) chains of leukocyte function-associated antigen 1 molecule were studied in 137 patients with NHL. Immunostaining was performed by a streptavidin-biotin alkaline phosphatase method, and integrin expression was semiquantitatively assessed. Correlation with clinical features was analyzed in 80 patients consecutively diagnosed as having immunocytoma (five cases), follicular lymphoma (19 cases), mantle-cell lymphoma (MCL; four cases), diffuse large-cell lymphoma (DLCL; 40 cases), lymphoblastic lymphoma (LL; six cases), anaplastic Ki-1-positive lymphoma (one case), and other peripheral T-cell lymphoma (five cases).

RESULTS

MCL cells did not show alpha2 and alpha6 expression, whereas most expressed weak to moderate levels of alpha3, alpha4, and alpha5. LL mostly showed alpha2 to alpha5 expression, whereas alpha6 was observed in seven of 11 cases (higher proportion than that shown in other subgroups). Alpha chains of VLA molecules were present more frequently in T-cell than in B-cell lymphomas. Patients with moderate/strong alpha4, CD11a, and beta2 common chain expression presented more frequently with advanced stage and bone marrow infiltration. Moderate/strong alpha4, alpha5, and beta1 common chain expression correlated with extranodal involvement. In the subset of B-cell DLCL patients, negative/weak expression of alpha3 and alpha4 chains was related to a higher complete response rate. Moreover, negative or weak expression of alpha2, alpha3, alpha4, and beta1( )common chain had favorable significance for overall and failure-free survivals.

CONCLUSION

In NHL, beta-integrin expression is related to histologic subtype. The expression pattern of these molecules probably influences disease dissemination and patients' prognoses.

Interferon-alpha may exacerbate cryoblobulinemia-related ischemic manifestations: an adverse effect potentially related to its anti-angiogenic activity

The discovery of the strong association between hepatitis C virus (HCV) infection and the development of mixed cryoglobulinemia has motivated active testing of antiviral-directed alternative therapies. Several trials have demonstrated that classic cryoglobulinemia-associated manifestations improve with interferon-alpha (IFNalpha) treatment. Herein we report on 3 HCV-infected patients with severe cryoglobulinemia-related ischemic manifestations who were closely followed up during IFNalpha therapy. Clinical evaluations with special attention to ischemic lesions, liver function tests, and cryocrit determinations were serially performed. In addition to prednisone and immunosuppressive agents, the patients received IFNalpha at 3 x 10(6) units, 3 times per week for 2 months, 3 months, and 4 months, respectively. In all 3 patients, systemic features improved, liver function results returned to normal, and cryocrit values decreased. However, ischemic lesions became less vascularized and ischemia progressed, leading to transmetatarsal and subcondylar amputation, respectively, in 2 of the patients and fingertip necrosis and ulcer enlargement in the third. Skin biopsies performed before IFNalpha therapy and after 2 months of IFNalpha therapy in the third patient showed a significant decrease in subepidermal microvessels. When IFNalpha was discontinued, the lesions finally healed. Cryoglobulinemia-related ischemic lesions may worsen during IFNalpha treatment, presumably through a decrease in inflammation-induced angiogenesis. The anti-angiogenic activity of IFNalpha may delay the appropriate healing of ischemic lesions.

Interferon-alpha may exacerbate cryoblobulinemia-related ischemic manifestations: an adverse effect potentially related to its anti-angiogenic activity

The discovery of the strong association between hepatitis C virus (HCV) infection and the development of mixed cryoglobulinemia has motivated active testing of antiviral-directed alternative therapies. Several trials have demonstrated that classic cryoglobulinemia-associated manifestations improve with interferon-alpha (IFNalpha) treatment. Herein we report on 3 HCV-infected patients with severe cryoglobulinemia-related ischemic manifestations who were closely followed up during IFNalpha therapy. Clinical evaluations with special attention to ischemic lesions, liver function tests, and cryocrit determinations were serially performed. In addition to prednisone and immunosuppressive agents, the patients received IFNalpha at 3 x 10(6) units, 3 times per week for 2 months, 3 months, and 4 months, respectively. In all 3 patients, systemic features improved, liver function results returned to normal, and cryocrit values decreased. However, ischemic lesions became less vascularized and ischemia progressed, leading to transmetatarsal and subcondylar amputation, respectively, in 2 of the patients and fingertip necrosis and ulcer enlargement in the third. Skin biopsies performed before IFNalpha therapy and after 2 months of IFNalpha therapy in the third patient showed a significant decrease in subepidermal microvessels. When IFNalpha was discontinued, the lesions finally healed. Cryoglobulinemia-related ischemic lesions may worsen during IFNalpha treatment, presumably through a decrease in inflammation-induced angiogenesis. The anti-angiogenic activity of IFNalpha may delay the appropriate healing of ischemic lesions.

Circulating soluble adhesion molecules in patients with giant cell arteritis. Correlation between soluble intercellular adhesion molecule-1 (sICAM-1) concentrations and disease activity

OBJECTIVE

To evaluate whether changes in concentrations of circulating adhesion molecules are related to disease activity in patients with giant cell arteritis (GCA).

METHODS

A sandwich ELISA was used to measure soluble intercellular adhesion molecule-1 (sICAM-1), sICAM-3, vascular cell adhesion molecule-1 (sVCAM-1), E-selectin (sE-selectin), and L-selectin (sL-selectin) in serum and plasma samples from patients with GCA. A cross sectional study was performed on 64 GCA patients at different activity stages and on 35 age and sex matched healthy donors. Thirteen of these patients were evaluated at the time of diagnosis and serially during follow up.

RESULTS

At the time of diagnosis, sICAM-1 concentrations were significantly higher in active GCA patients than in controls (mean (SD) 360.55 (129.78) ng/ml versus 243.25 (47.43) ng/ml, p < 0.001). In contrast, sICAM-3, sVCAM-1, sE-selectin, and sL-selectin values did not differ from those obtained in normal donors. With corticosteroid administration, a decrease in sICAM-1 concentrations was observed, reaching normal values when clinical remission was achieved (263.18 (92.7) ng/ml globally, 293.59 (108.39) ng/ml in the group of patients in recent remission, and 236.83 (70.02) ng/ml in those in long term remission). In the 13 patients followed up longitudinally, sICAM-1 values also normalised with clinical remission (225.87 (64.25) ng/ml in patients in recent remission, and 256.29 (75.15) ng/ml in those in long term remission).

CONCLUSIONS

Circulating sICAM-1 concentrations clearly correlate with clinically apparent disease activity in GCA patients. Differences with results previously found in patients with other vasculitides may indicate that different pathogenic mechanisms contribute to vascular inflammation in different disorders.