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Verhoeven MMA, Tekstra J, Welsing PMJ, Pethö-Schramm A, Borm MEA, Bruyn GAW, Bos R, Griep EN, Klaasen R, van Laar JM, Lafeber FPJG, Bijlsma JWJ, de Hair MJH, Jacobs JWG. Effectiveness and safety over 3 years after the 2-year U-Act-Early trial of the strategies initiating tocilizumab and/or methotrexate. Rheumatology (Oxford) 2021; 59:2325-2333. [PMID: 31859346 PMCID: PMC7449801 DOI: 10.1093/rheumatology/kez602] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Revised: 11/15/2019] [Indexed: 11/25/2022] Open
Abstract
Objectives U-Act-Early was a 2-year, randomized placebo controlled, double-blind trial, in which DMARD-naïve early RA patients were treated to the target of sustained remission (SR). Two strategies initiating tocilizumab (TCZ), with and without methotrexate (MTX), were more effective than a strategy initiating MTX. The aim of the current study was to determine longer-term effectiveness in daily clinical practice. Methods At the end of U-Act-Early, patients were included in a 3-year post-trial follow-up (PTFU), in which treatment was according to standard care and data were collected every 3 months during the first year and every 6 months thereafter. Primary end point was disease activity score assessing 28 joints (DAS28) over time. Mixed effects models were used to compare effectiveness between initial strategy groups, correcting for relevant confounders. Between the groups as randomized, proportions of patients were tested for DMARD use, SR and radiographic progression of joint damage. Results Of patients starting U-Act-Early, 226/317 (71%) participated in the PTFU. Over the total 5 years, mean DAS28 was similar between groups (P > 0.20). During U-Act-Early, biologic DMARD use decreased in both TCZ initiation groups and increased in the MTX initiation group, but during follow-up this trend did not continue. SR was achieved at least once in 99% of patients. Of the 226 patients, only 30% had any radiographic progression over 5 years, without significant differences between the groups. Conclusion Although in the short-term the strategies initiating TCZ yielded the most clinical benefit, in the longer-term differences in important clinical outcomes between the strategies disappeared, probably due to continuation of the treat-to-target principle.
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Affiliation(s)
- Maxime M A Verhoeven
- Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Janneke Tekstra
- Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Paco M J Welsing
- Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | | | | | - Reinhard Bos
- Department of Rheumatology, Medical Center Leeuwarden, Leeuwarden
| | - Ed N Griep
- Department of Rheumatology, Antonius Hospital, Sneek
| | - Ruth Klaasen
- Department of Rheumatology, Meander Medical Center, Amersfoort, The Netherlands
| | - Jacob M van Laar
- Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Floris P J G Lafeber
- Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Johannes W J Bijlsma
- Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Marjolein J H de Hair
- Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Johannes W G Jacobs
- Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, Utrecht, The Netherlands
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Teitsma XM, Devenport J, Jacobs JWG, Pethö-Schramm A, Borm MEA, Budde P, Bijlsma JWJ, Lafeber FPJG. Comprehensive exploratory autoantibody profiling in patients with early rheumatoid arthritis treated with methotrexate or tocilizumab. PLoS One 2020; 15:e0241189. [PMID: 33301475 PMCID: PMC7728181 DOI: 10.1371/journal.pone.0241189] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 09/14/2020] [Indexed: 12/18/2022] Open
Abstract
Background We sought to identify immunoglobin G autoantibodies predictive of early treatment response to methotrexate, the recommended first-line therapy for patients with newly diagnosed rheumatoid arthritis, and to the interleukin-6 receptor inhibitor biologic tocilizumab, initiated as the first disease-modifying anti-rheumatic drug. Materials and methods In baseline sera of a subset of patients with newly diagnosed rheumatoid arthritis in the U-Act-Early study, selected based on specific responder/non-responder criteria using the Disease Activity Score assessing 28 joints (DAS28) within the first 20 weeks, we measured immunoglobin G antibody reactivity against 463 protein antigens and performed supervised cluster analysis to identify predictive autoantibodies for treatment response. The analysis subset comprised 56 patients in the methotrexate arm (22 responders, 34 non-responders) and 50 patients in the tocilizumab arm (34 responders, 16 non-responders). For comparison, these analyses were also performed in 50 age- and gender-matched healthy controls. Results Increased reactivity in responders versus non-responders was found in the methotrexate arm against two antigens—DOT1-like histone lysine methyltransferase (p = 0.009) and tropomyosin (p = 0.003)—and in the tocilizumab arm against one antigen—neuro-oncological ventral antigen 2 (p = 0.039). Decreased reactivity was detected against two antigens in the methotrexate arm—G1 to S phase transition 2 (p = 0.023) and the zinc finger protein ZPR1 (p = 0.021). Reactivity against the identified antigens was not statistically significant in either treatment arm for patients with rheumatoid factor–positive versus–negative or anti-cyclic citrullinated test–positive versus test–negative rheumatoid arthritis (p ≥ 0.06). Conclusions Comprehensive profiling of baseline sera revealed several novel immunoglobin G autoantibodies associated with early treatment response to methotrexate and to tocilizumab in disease-modifying anti-rheumatic drug-naive patients with rheumatoid arthritis. These findings could eventually yield clinically relevant predictive markers, if corroborated in different patient cohorts, and may facilitate future benefit in personalised healthcare.
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Affiliation(s)
- Xavier M. Teitsma
- Department of Rheumatology and Clinical Immunology, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
- Department of Rheumatology & Clinical Immunology, Utrecht University, Utrecht, Netherlands
- * E-mail:
| | - Jenny Devenport
- Pharmaceuticals Division, F. Hoffmann-La Roche, Basel, Switzerland
| | - Johannes W. G. Jacobs
- Department of Rheumatology and Clinical Immunology, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
- Department of Rheumatology & Clinical Immunology, Utrecht University, Utrecht, Netherlands
| | | | | | - Petra Budde
- Department of Medical Research, Oncimmune Germany GmbH, Dortmund, Germany
| | - Johannes W. J. Bijlsma
- Department of Rheumatology and Clinical Immunology, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
- Department of Rheumatology & Clinical Immunology, Utrecht University, Utrecht, Netherlands
| | - Floris P. J. G. Lafeber
- Department of Rheumatology and Clinical Immunology, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
- Department of Rheumatology & Clinical Immunology, Utrecht University, Utrecht, Netherlands
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Verhoeven MMA, Tekstra J, Jacobs JWG, Bijlsma JWJ, van Laar JM, Pethö-Schramm A, Borm MEA, Lafeber FPJ, Welsing PMJ. Is tocilizumab monotherapy as effective in preventing radiographic progression in rheumatoid arthritis as its combination with methotrexate? Arthritis Care Res (Hoboken) 2020; 74:889-895. [PMID: 33253497 PMCID: PMC9313860 DOI: 10.1002/acr.24524] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 10/23/2020] [Accepted: 11/24/2020] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To compare the effect of preventing radiographic progression (in its 3 components) of tocilizumab (TCZ) monotherapy with those of TCZ combined with methotrexate (TCZ+MTX), and to evaluate possible effect modifiers. METHODS Randomized trials comparing TCZ-monotherapy with TCZ+MTX combination therapy regarding radiographic progression were analyzed on individual patient (n=820) data level for early as well as established RA patients using mixed-effects models. Outcomes were: not having radiographic progression after 2 years (i.e., preventing radiographic progression), respectively in total Sharp van der Heijde (SvdH) score, in erosion score and in joint space narrowing (JSN) score. Effect modification by baseline joint damage, disease duration and DAS28 was studied. RESULTS Overall, TCZ+MTX was more effective in preventing radiographic progression regarding total SvdH scores compared to TCZ-monotherapy. However, in early RA patients with more joint damage (RR 1.02 vs. 0.91 for the less damage group), or a lower DAS28 (RR 1.04 vs. 0.92) at baseline, this advantage disappeared. In established RA, the advantage of TCZ+MTX over TCZ in preventing radiographic progression disappeared with a longer disease duration at baseline (RR 1.04 vs. 0.83). Results for erosion scores as outcome were in line, but were less clear for JSN. CONCLUSION Combination therapy with TCZ+MTX is more effective in preventing radiographic progression compared to TCZ-monotherapy, but the effectiveness of TCZ-monotherapy may approximate the effectiveness of TCZ+MTX in early RA patients with more joint damage and/or a lower DAS28 at baseline, and in established RA patients with longer disease duration.
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Verhoeven MMA, Tekstra J, van Laar JM, Pethö-Schramm A, Borm MEA, Bijlsma JWJ, Jacobs JWG, Lafeber FPJG, Welsing PMJ. Effect on Costs and Quality-adjusted Life-years of Treat-to-target Treatment Strategies Initiating Methotrexate, or Tocilizumab, or Their Combination in Early Rheumatoid Arthritis. J Rheumatol 2020; 48:495-503. [PMID: 32739893 DOI: 10.3899/jrheum.200067] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/15/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Our study aimed to evaluate the cost effectiveness of initiating tocilizumab (TCZ) ± methotrexate (MTX) versus initiating MTX as treat-to-target treatment strategies over 5 years in early disease-modifying antirheumatic drug (DMARD)-naïve rheumatoid arthritis (RA). METHODS Data on resource use were collected with questionnaires at baseline, 3, 6, 12, and 24 months, and yearly thereafter, and were converted to costs using Dutch reference prices. Quality-adjusted life-years (QALY) were calculated using the EQ5D5L, with utility based on Dutch tariff or estimated by the Health Assessment Questionnaire. To account for missing cost data and QALY data and for sample uncertainty, first bootstraps (10,000 samples) were obtained. Second, single imputation using chained equations nested within these bootstrap samples was performed. An economic evaluation was performed for TCZ + MTX and TCZ, compared to MTX, as initial treatment in a treat-to-target strategy from a healthcare and societal perspective over 5 years. Several sensitivity analyses were performed. RESULTS Mean differences in QALY were small and not significant (TCZ + MTX vs MTX: 0.06, 95% CI -0.02 to 0.13; TCZ vs. MTX: -0.03, 95% CI -0.05 to 0.11). Limited savings in indirect nonhealthcare costs and productivity loss costs (for TCZ only) were observed, but these did not compensate for the higher medication costs. Sensitivity analyses did not materially change these findings, although lower-priced TCZ, or reserving TCZ as initial therapy for prognostically unfavorable RA patients, improved cost effectiveness considerably but did not individually lead to a strategy being cost effective. CONCLUSION Based on our analyses, early initiation of TCZ + MTX is not cost effective compared to MTX initiation in a step-up treat-to-target treatment strategy over 5 years in early RA patients.
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Affiliation(s)
- Maxime M A Verhoeven
- M.M. Verhoeven, PhD student, J. Tekstra, MD, PhD, J.M. van Laar, MD, PhD, J.W. Bijlsma, MD, PhD, J.W. Jacobs, MD, PhD, F.P. Lafeber, PhD, P.M. Welsing, PhD, Rheumatology & Clinical Immunology, University Medical Center Utrecht, Utrecht, the Netherlands;
| | - Janneke Tekstra
- M.M. Verhoeven, PhD student, J. Tekstra, MD, PhD, J.M. van Laar, MD, PhD, J.W. Bijlsma, MD, PhD, J.W. Jacobs, MD, PhD, F.P. Lafeber, PhD, P.M. Welsing, PhD, Rheumatology & Clinical Immunology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Jacob M van Laar
- M.M. Verhoeven, PhD student, J. Tekstra, MD, PhD, J.M. van Laar, MD, PhD, J.W. Bijlsma, MD, PhD, J.W. Jacobs, MD, PhD, F.P. Lafeber, PhD, P.M. Welsing, PhD, Rheumatology & Clinical Immunology, University Medical Center Utrecht, Utrecht, the Netherlands
| | | | | | - Johannes W J Bijlsma
- M.M. Verhoeven, PhD student, J. Tekstra, MD, PhD, J.M. van Laar, MD, PhD, J.W. Bijlsma, MD, PhD, J.W. Jacobs, MD, PhD, F.P. Lafeber, PhD, P.M. Welsing, PhD, Rheumatology & Clinical Immunology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Johannes W G Jacobs
- M.M. Verhoeven, PhD student, J. Tekstra, MD, PhD, J.M. van Laar, MD, PhD, J.W. Bijlsma, MD, PhD, J.W. Jacobs, MD, PhD, F.P. Lafeber, PhD, P.M. Welsing, PhD, Rheumatology & Clinical Immunology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Floris P J G Lafeber
- M.M. Verhoeven, PhD student, J. Tekstra, MD, PhD, J.M. van Laar, MD, PhD, J.W. Bijlsma, MD, PhD, J.W. Jacobs, MD, PhD, F.P. Lafeber, PhD, P.M. Welsing, PhD, Rheumatology & Clinical Immunology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Paco M J Welsing
- M.M. Verhoeven, PhD student, J. Tekstra, MD, PhD, J.M. van Laar, MD, PhD, J.W. Bijlsma, MD, PhD, J.W. Jacobs, MD, PhD, F.P. Lafeber, PhD, P.M. Welsing, PhD, Rheumatology & Clinical Immunology, University Medical Center Utrecht, Utrecht, the Netherlands
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Teitsma XM, Jacobs JWG, Concepcion AN, Pethö-Schramm A, Borm MEA, van Laar JM, Bijlsma JWJ, Lafeber FPJG. Explorative analyses of protein biomarkers in patients with early rheumatoid arthritis achieving sustained drug-free remission after treatment with tocilizumab- or methotrexate-based strategies: from transcriptomics to proteomics. Clin Exp Rheumatol 2018; 36:976-983. [PMID: 29745885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Accepted: 02/26/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVES Previously, we identified networks of co-expressed genes related to achieving sustained drug-free remission (sDFR). The aim of the present exploratory analysis was to identify inflammatory proteins associated with achieving sDFR and their enriched biological pathways, and compare these pathways with those found in the previous transcriptomic analyses. METHODS Serum samples were used from 60 patients who participated in the U-Act-Early trial and were treated-to-target with tocilizumab plus methotrexate, or tocilizumab or methotrexate; 37 achieved sDFR (≥3 months drug-free) and 23 did not (controls). Luminex® multi-analyte profiling (xMAP)® was used to measure 85 proteins. Partial least square discriminant analyses (PLSDA) identified proteins associated with achieving sDFR within each strategy arm, which were thereafter used for pathway analyses. RESULTS PLSDA identified 9, 14 and 13 relevant proteins in the tocilizumab plus methotrexate, tocilizumab and methotrexate arm, respectively and pathway analyses thereafter identified respectively 49, 88 and 117 significantly enriched gene ontology (GO) terms. When comparing these terms with those previously found in the transcriptomic analyses, corresponding pathways were related in the tocilizumab arm to activity of leukocytes; in the methotrexate arm to response of stimuli and regulation of the Janus kinase signal transducer and activator of transcription (JAK-STAT) pathway. In the tocilizumab plus methotrexate arm, no corresponding enriched pathways were found. CONCLUSIONS Multiple proteins were associated with achieving sDFR and several biological pathways corresponded, mainly in the methotrexate arm, with our previous transcriptomic findings potentially providing further insights into gene expression and protein translation in newly diagnosed RA patients.
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Affiliation(s)
- Xavier M Teitsma
- Department of Rheumatology and Clinical Immunology, University Medical Centre Utrecht, The Netherlands.
| | - Johannes W G Jacobs
- Department of Rheumatology and Clinical Immunology, University Medical Centre Utrecht, The Netherlands
| | - Arno N Concepcion
- Department of Rheumatology and Clinical Immunology, University Medical Centre Utrecht, The Netherlands
| | | | | | - Jacob M van Laar
- Department of Rheumatology and Clinical Immunology, University Medical Centre Utrecht, The Netherlands
| | - Johannes W J Bijlsma
- Department of Rheumatology and Clinical Immunology, University Medical Centre Utrecht, The Netherlands
| | - Floris P J G Lafeber
- Department of Rheumatology and Clinical Immunology, University Medical Centre Utrecht, The Netherlands
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Teitsma XM, Yang W, Jacobs JWG, Pethö-Schramm A, Borm MEA, Harms AC, Hankemeier T, van Laar JM, Bijlsma JWJ, Lafeber FPJG. Baseline metabolic profiles of early rheumatoid arthritis patients achieving sustained drug-free remission after initiating treat-to-target tocilizumab, methotrexate, or the combination: insights from systems biology. Arthritis Res Ther 2018; 20:230. [PMID: 30322408 PMCID: PMC6235217 DOI: 10.1186/s13075-018-1729-2] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Accepted: 09/20/2018] [Indexed: 12/26/2022] Open
Abstract
Background We previously identified, in newly diagnosed rheumatoid arthritis (RA) patients, networks of co-expressed genes and proteomic biomarkers associated with achieving sustained drug-free remission (sDFR) after treatment with tocilizumab- or methotrexate-based strategies. The aim of this study was to identify, within the same patients, metabolic pathways important for achieving sDFR and to subsequently study the complex interactions between different components of the biological system and how these interactions might affect the therapeutic response in early RA. Methods Serum samples were analyzed of 60 patients who participated in the U-Act-Early trial (ClinicalTrials.gov number NCT01034137) and initiated treatment with methotrexate, tocilizumab, or the combination and who were thereafter able to achieve sDFR (n = 37); as controls, patients were selected who never achieved a drug-free status (n = 23). Metabolomic measurements were performed using mass spectrometry on oxidative stress, amine, and oxylipin platforms covering various compounds. Partial least square discriminant analyses (PLSDA) were performed to identify, per strategy arm, relevant metabolites of which the biological pathways were studied. In addition, integrative analyses were performed correlating the previously identified transcripts and proteins with the relevant metabolites. Results In the tocilizumab plus methotrexate, tocilizumab, and methotrexate strategy, respectively, 19, 13, and 12 relevant metabolites were found, which were subsequently used for pathway analyses. The most significant pathway in the tocilizumab plus methotrexate strategy was “histidine metabolism” (p < 0.001); in the tocilizumab strategy it was “arachidonic acid metabolism” (p = 0.018); and in the methotrexate strategy it was “arginine and proline metabolism” (p = 0.022). These pathways have treatment-specific drug interactions with metabolites affecting either the signaling of interleukin-6, which is inhibited by tocilizumab, or affecting protein synthesis from amino acids, which is inhibited by methotrexate. Conclusion In early RA patients treated-to-target with a tocilizumab- or methotrexate-based strategy, several metabolites were found to be associated with achieving sDFR. In line with our previous observations, by analyzing relevant transcripts and proteins within the same patients, the metabolic profiles were found to be different between the strategy arms. Our metabolic analysis further supports the hypothesis that achieving sDFR is not only dependent on predisposing biomarkers, but also on the specific treatment that has been initiated. Trial registration ClinicalTrials.gov, NCT01034137. Registered on January 2010 Electronic supplementary material The online version of this article (10.1186/s13075-018-1729-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Xavier M Teitsma
- Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, Netherlands.
| | - Wei Yang
- Leiden Academic Center for Drug Research, Leiden University, 2300 RA, Leiden, Netherlands
| | - Johannes W G Jacobs
- Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, Netherlands
| | | | | | - Amy C Harms
- Leiden Academic Center for Drug Research, Leiden University, 2300 RA, Leiden, Netherlands.,Netherlands Metabolomic Centre, Einsteinweg 55, 2333 CC, Leiden, Netherlands
| | - Thomas Hankemeier
- Leiden Academic Center for Drug Research, Leiden University, 2300 RA, Leiden, Netherlands.,Netherlands Metabolomic Centre, Einsteinweg 55, 2333 CC, Leiden, Netherlands
| | - Jacob M van Laar
- Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, Netherlands
| | - Johannes W J Bijlsma
- Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, Netherlands
| | - Floris P J G Lafeber
- Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, Netherlands
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Teitsma XM, Jacobs JWG, de Jong PHP, Hazes JMW, Weel AEAM, Welsing PMJ, Pethö-Schramm A, Borm MEA, van Laar JM, Bijlsma JWJ, Lafeber FPJG. Adding baseline protein biomarkers to clinical predictors does not enhance prediction of treatment response to a methotrexate strategy in early rheumatoid arthritis. Ann Rheum Dis 2018; 78:142-144. [DOI: 10.1136/annrheumdis-2018-213767] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Revised: 06/20/2018] [Accepted: 08/08/2018] [Indexed: 11/03/2022]
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Teitsma XM, Jacobs JWG, Welsing PMJ, de Jong PHP, Hazes JMW, Weel AEAM, Pethö-Schramm A, Borm MEA, van Laar JM, Lafeber FPJG, Bijlsma JWJ. Inadequate response to treat-to-target methotrexate therapy in patients with new-onset rheumatoid arthritis: development and validation of clinical predictors. Ann Rheum Dis 2018; 77:1261-1267. [PMID: 29760159 DOI: 10.1136/annrheumdis-2018-213035] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Revised: 03/30/2018] [Accepted: 04/23/2018] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To identify and validate clinical baseline predictors associated with inadequate response (IR) to methotrexate (MTX) therapy in newly diagnosed patients with rheumatoid arthritis (RA). METHODS In U-Act-Early, 108 disease-modifying antirheumatic drug (DMARD)-naive patients with RA were randomised to initiate MTX therapy and treated to target until sustained remission (disease activity score assessing 28 joints (DAS28) <2.6 with four or less swollen joints for ≥24 weeks) was achieved. If no remission, hydroxychloroquine was added to the treatment regimen (ie, 'MTX+') and replaced by tocilizumab if the target still was not reached thereafter. Regression analyses were performed to identify clinical predictors for IR, defined as needing addition of a biological DMARD, to 'MTX+'. Data from the treatment in the Rotterdam Early Arthritis Cohort were used for external validation of the prediction model. RESULTS Within 1 year, 56/108 (52%) patients in U-Act-Early showed IR to 'MTX+'. DAS28 (adjusted OR (ORadj) 2.1, 95% CI 1.4 to 3.2), current smoking (ORadj 3.02, 95% CI 1.1 to 8.0) and alcohol consumption (ORadj 0.4, 95% CI 0.1 to 0.9) were identified as baseline predictors. The area under the receiver operator characteristic curve (AUROC) of the prediction model was 0.75 (95% CI 0.66 to 0.84); the positive (PPV) and negative predictive value (NPV) were 65% and 80%, respectively. When applying the model to the validation cohort, the AUROC slightly decreased to 0.67 (95% CI 0.55 to 0.79) and the PPV and NPV to 54% and 80%, respectively. CONCLUSION Higher DAS28, current smoking and no alcohol consumption are predictive factors for IR to step-up 'MTX+' in DMARD-naive patients with new-onset RA. TRIAL REGISTRATION NCT01034137; Post-results, ISRCTN26791028; Post-results.
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Affiliation(s)
- Xavier M Teitsma
- Department of Rheumatology and Clinical Immunology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Johannes W G Jacobs
- Department of Rheumatology and Clinical Immunology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Paco M J Welsing
- Department of Rheumatology and Clinical Immunology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Pascal H P de Jong
- Department of Rheumatology, Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands.,Department of Rheumatology, Maasstad Hospital, Rotterdam, The Netherlands
| | - Johanna M W Hazes
- Department of Rheumatology, Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Angelique E A M Weel
- Department of Rheumatology, Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands.,Department of Rheumatology, Maasstad Hospital, Rotterdam, The Netherlands
| | | | | | - Jacob M van Laar
- Department of Rheumatology and Clinical Immunology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Floris P J G Lafeber
- Department of Rheumatology and Clinical Immunology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Johannes W J Bijlsma
- Department of Rheumatology and Clinical Immunology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
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Teitsma XM, Jacobs JWG, Welsing PMJ, Pethö-Schramm A, Borm MEA, van Laar JM, Lafeber FPJG, Bijlsma JWJ. Radiographic joint damage in early rheumatoid arthritis patients: comparing tocilizumab- and methotrexate-based treat-to-target strategies. Rheumatology (Oxford) 2017; 57:309-317. [DOI: 10.1093/rheumatology/kex386] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2017] [Indexed: 11/14/2022] Open
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Teitsma XM, Jacobs JWG, Welsing PMJ, Pethö-Schramm A, Borm MEA, Hendriks L, Denissen NHAM, van Laar JM, Lafeber FPJG, Bijlsma JWJ. Patient-reported outcomes in newly diagnosed early rheumatoid arthritis patients treated to target with a tocilizumab- or methotrexate-based strategy. Rheumatology (Oxford) 2017; 56:2179-2189. [DOI: 10.1093/rheumatology/kex319] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Indexed: 01/01/2023] Open
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Teitsma XM, Jacobs JWG, Mokry M, Borm MEA, Pethö-Schramm A, van Laar JM, Bijlsma JWJ, Lafeber FPJ. Identification of differential co-expressed gene networks in early rheumatoid arthritis achieving sustained drug-free remission after treatment with a tocilizumab-based or methotrexate-based strategy. Arthritis Res Ther 2017; 19:170. [PMID: 28728565 PMCID: PMC5520225 DOI: 10.1186/s13075-017-1378-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Accepted: 06/30/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Methotrexate is endorsed to be used as first-line treatment in rheumatoid arthritis (RA). However, a large proportion of patients need additional treatment with a biological disease-modifying anti-rheumatic drug (DMARD) to adequately suppress their disease activity. A better understanding of genotypes could help to distinguish between patients with different pathogenic mechanisms. The aim of this study was therefore to identify networks of genes within DMARD-naive early RA patients associated with achieving sustained drug-free remission (sDFR) after initiating tocilizumab plus methotrexate, tocilizumab, or methotrexate therapy. METHODS Samples were used from 60 patients from the U-Act-Early study who received tocilizumab plus methotrexate, tocilizumab, or methotrexate therapy, and who achieved sDFR (≥3 months in drug-free remission until the end of the study, n = 37) after therapy was tapered and subsequently stopped, or who were not able to discontinue the therapy as controls (n = 23). Whole blood samples were collected and ribonucleic acid (RNA) was isolated from positive cluster of differentiation 4 (CD4+) and CD14+ cells and analysed using high-throughput sequencing. Weighted gene co-expression network analyses were performed to identify clusters (i.e. modules) of differently expressed genes associated with achieving sDFR and which were subsequently used for pathway analyses. RESULTS Network analyses within CD4+ cells identified two significant modules in the tocilizumab plus methotrexate arm and four modules in the tocilizumab and methotrexate arms, respectively (p ≤ 0.039). Important pathways in the module best correlating with achieving sDFR were in the tocilizumab plus methotrexate arm related to processes involved with transcription and translation; in the tocilizumab arm, pathways were related to migration of white blood cells and G-protein coupled receptors, and in the methotrexate arm pathways were involved with the response to a bacterial or biotic (i.e. biological material)-related stimulus. No relevant networks could be identified in the sequenced CD14+ cells. CONCLUSIONS Within networks of co-expressed genes, several pathways were found related to achieving sDFR after initiating therapy with tocilizumab, methotrexate, or the combination. Between the three strategy arms, we identified different networks of predisposing genes which indicates that specific gene expression profiles, depending on the treatment strategy chosen, are associated with a higher chance of achieving sDFR. TRIAL REGISTRATION Clinicaltrials.gov, NCT01034137 . Registered on 16 December 2009.
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Affiliation(s)
- Xavier M Teitsma
- Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, Heidelberglaan 100, 3584, CX, Utrecht, Netherlands.
| | - Johannes W G Jacobs
- Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, Heidelberglaan 100, 3584, CX, Utrecht, Netherlands
| | - Michal Mokry
- Epigenomics Facility, University Medical Center Utrecht, Heidelberglaan 100, 3584, CX, Utrecht, Netherlands.,Division of Paediatrics, University Medical Center Utrecht, Heidelberglaan 100, 3584, CX, Utrecht, Netherlands
| | | | | | - Jacob M van Laar
- Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, Heidelberglaan 100, 3584, CX, Utrecht, Netherlands
| | - Johannes W J Bijlsma
- Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, Heidelberglaan 100, 3584, CX, Utrecht, Netherlands
| | - Floris P J Lafeber
- Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, Heidelberglaan 100, 3584, CX, Utrecht, Netherlands
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Bijlsma JWJ, Welsing PMJ, Woodworth TG, Middelink LM, Pethö-Schramm A, Bernasconi C, Borm MEA, Wortel CH, Ter Borg EJ, Jahangier ZN, van der Laan WH, Bruyn GAW, Baudoin P, Wijngaarden S, Vos PAJM, Bos R, Starmans MJF, Griep EN, Griep-Wentink JRM, Allaart CF, Heurkens AHM, Teitsma XM, Tekstra J, Marijnissen ACA, Lafeber FPJ, Jacobs JWG. Early rheumatoid arthritis treated with tocilizumab, methotrexate, or their combination (U-Act-Early): a multicentre, randomised, double-blind, double-dummy, strategy trial. Lancet 2016; 388:343-355. [PMID: 27287832 DOI: 10.1016/s0140-6736(16)30363-4] [Citation(s) in RCA: 168] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND For patients with newly diagnosed rheumatoid arthritis, treatment aim is early, rapid, and sustained remission. We compared the efficacy and safety of strategies initiating the interleukin-6 receptor-blocking monoclonal antibody tocilizumab with or without methotrexate (a conventional synthetic disease-modifying antirheumatic drug [DMARD]), versus initiation of methotrexate monotherapy in line with international guidelines. METHODS We did a 2-year, multicentre, randomised, double-blind, double-dummy, strategy study at 21 rheumatology outpatient departments in the Netherlands. We included patients who had been diagnosed with rheumatoid arthritis within 1 year before inclusion, were DMARD-naive, aged 18 years or older, met current rheumatoid arthritis classification criteria, and had a disease activity score assessing 28 joints (DAS28) of at least 2·6. We randomly assigned patients (1:1:1) to start tocilizumab plus methotrexate (the tocilizumab plus methotrexate arm), or tocilizumab plus placebo-methotrexate (the tocilizumab arm), or methotrexate plus placebo-tocilizumab (the methotrexate arm). Tocilizumab was given at 8 mg/kg intravenously every 4 weeks with a maximum of 800 mg per dose. Methotrexate was started at 10 mg per week orally and increased stepwise every 4 weeks by 5 mg to a maximum of 30 mg per week, until remission or dose-limiting toxicity. We did the randomisation using an interactive web response system. Masking was achieved with placebos that were similar in appearance to the active drug; the study physicians, pharmacists, monitors, and patients remained masked during the study, and all assessments were done by masked assessors. Patients not achieving remission on their initial regimen switched from placebo to active treatments; patients in the tocilizumab plus methotrexate arm switched to standard of care therapy (typically methotrexate combined with a tumour necrosis factor inhibitor). When sustained remission was achieved, methotrexate (and placebo-methotrexate) was tapered and stopped, then tocilizumab (and placebo-tocilizumab) was also tapered and stopped. The primary endpoint was the proportion of patients achieving sustained remission (defined as DAS28 <2·6 with a swollen joint count ≤four, persisting for at least 24 weeks) on the initial regimen and during the entire study duration, compared between groups with a two-sided Cochran-Mantel-Haenszel test. Analysis was based on an intention-to-treat method. This trial was registered at ClinicalTrials.gov, number NCT01034137. FINDINGS Between Jan 13, 2010, and July 30, 2012, we recruited and assigned 317 eligible patients to treatment (106 to the tocilizumab plus methotrexate arm, 103 to the tocilizumab arm, and 108 to the methotrexate arm). The study was completed by a similar proportion of patients in the three groups (range 72-78%). The most frequent reasons for dropout were adverse events or intercurrent illness: 27 (34%) of dropouts, and insufficient response: 26 (33%) of dropouts. 91 (86%) of 106 patients in the tocilizumab plus methotrexate arm achieved sustained remission on the initial regimen, compared with 86 (84%) of 103 in the tocilizumab arm, and 48 (44%) of 108 in the methotrexate arm (relative risk [RR] 2·00, 95% CI 1·59-2·51 for tocilizumab plus methotrexate vs methotrexate, and 1·86, 1·48-2·32 for tocilizumab vs methotrexate, p<0·0001 for both comparisons). For the entire study, 91 (86%) of 106 patients in the tocilizumab plus methotrexate arm, 91 (88%) of 103 in the tocilizumab arm, and 83 (77%) of 108 in the methotrexate arm achieved sustained remission (RR 1·13, 95% CI 1·00-1·29, p=0·06 for tocilizumab plus methotrexate vs methotrexate, 1·14, 1·01-1·29, p=0·0356 for tocilizumab vs methotrexate, and p=0·59 for tocilizumab plus methotrexate vs tocilizumab). Nasopharyngitis was the most common adverse event in all three treatment groups, occurring in 38 (36%) of 106 patients in the tocilizumab plus methotrexate arm, 40 (39%) of 103 in the tocilizumab arm, and 37 (34%) of 108 in the methotrexate arm. The occurrence of serious adverse events did not differ between the treatment groups (17 [16%] of 106 patients in the tocilizumab plus methotrexate arm vs 19 [18%] of 103 in the tocilizumab arm and 13 [12%] of 108 in the methotrexate arm), and no deaths occurred during the study. INTERPRETATION For patients with newly diagnosed rheumatoid arthritis, strategies aimed at sustained remission by immediate initiation of tocilizumab with or without methotrexate are more effective, and with a similar safety profile, compared with initiation of methotrexate in line with current standards. FUNDING Roche Nederland BV.
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Affiliation(s)
- Johannes W J Bijlsma
- Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Paco M J Welsing
- Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Thasia G Woodworth
- Division of Rheumatology, UCLA David Geffen School of Medicine, Los Angeles, CA, USA
| | | | | | | | | | | | | | | | | | | | | | | | | | - Reinhard Bos
- Medical Center Leeuwarden, Leeuwarden, Netherlands
| | | | | | | | | | | | - Xavier M Teitsma
- Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Janneke Tekstra
- Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Anne Carien A Marijnissen
- Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Floris P J Lafeber
- Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Johannes W G Jacobs
- Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, Utrecht, Netherlands.
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Abstract
Nuclear factor kappaB (NF-kappaB) designates a group of critical transcription factors involved in a variety of immunologic and/or inflammatory processes. Conceivably, genes involved in the NF-kappaB pathway make interesting candidate genes for chronic inflammatory disorders, including the inflammatory bowel diseases (IBD), Crohn's disease (CD) and ulcerative colitis (UC). In two mouse models of colitis, strong linkage has been observed with a locus on chromosome 3 that harbours the Nfkb1 gene. In addition, a polymorphism in the promoter region of the human NFKB1 gene was found to be associated with susceptibility to UC. In this study, we searched to confirm this previously found association in IBD in a different population. Allele and genotype frequencies of the -94 ins/delATTG polymorphism were determined in 266 unrelated Dutch Caucasian IBD patients (127 UC, 139 CD), and 155 matched healthy controls. The allele frequency of the deletion was significantly higher in UC patients (P = 0.019), but not in CD patients, compared to healthy controls, and the UC patients homozygous for the -94 ATTG deletion had a younger age of onset. Our findings confirm the previously found association between this polymorphism and susceptibility to UC in an independent study population and adds further evidence for the role of this gene in disease susceptibility.
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Affiliation(s)
- M E A Borm
- Department of Molecular Cell Biology and Immunology, Vrije Universiteit Medical Center, Amsterdam, The Netherlands
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Borm MEA, He J, Kelsall B, Peña AS, Strober W, Bouma G. A major quantitative trait locus on mouse chromosome 3 is involved in disease susceptibility in different colitis models. Gastroenterology 2005; 128:74-85. [PMID: 15633125 DOI: 10.1053/j.gastro.2004.10.044] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
BACKGROUND & AIMS Mice with a disrupted gene for the G-protein alpha inhibitory 2 chain ( Gnai2 -/- ) develop a spontaneous colitis resembling human inflammatory bowel disease. Disease expression differs markedly between inbred strains of mice, indicating genetic control of disease susceptibility. We performed a genome-wide screen to localize the chromosomal regions regulating disease expression. METHODS A total of 284 F2 mice derived from resistant C57BL/6J Gnai2 -/- mice and susceptible C3H/HeN Gnai2 -/- mice were analyzed in a genome-wide screen for colitis susceptibility and severity. RESULTS A highly significant locus on chromosome 3 (Gpdc1) contributed to colitis susceptibility and severity (likelihood ratio statistics [LRS] = 32.4; LOD score = 7; P < 1.0 x 10(-5)). The peak linkage of this locus at 62 cM colocalizes exactly with a previously identified locus controlling colitis susceptibility in interleukin-10-deficient mice. In addition, evidence for linkage with a locus on chromosome 1 (Gpdc2 ; LRS = 19.7; LOD = 4.3) was found, and the 2 loci interacted epistatically (combined LRS = 68.2). A third locus (Gpdc3) was found on chromosome 9 and this locus interacted epistatically with a locus on chromosome 7, which by itself did not have an effect on the trait. CONCLUSIONS The identification of a major locus on chromosome 3 that controls susceptibility to spontaneous colitis in 2 different gene-knockout models indicates that this locus harbors a gene(s) that plays a key role in maintaining mucosal homeostasis. Identification of this gene(s) may contribute to further understanding of the mechanisms underlying human inflammatory bowel disease.
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Affiliation(s)
- Michelle E A Borm
- Department of Immunogenetics, Vrije Universiteit Medical Center, Van der Boechorststraat 7, 1081 BT Amsterdam, The Netherlands
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Seegers D, Borm MEA, van Belzen MJ, Mulder CJJ, Bailing J, Crusius JBA, Meijer JWR, Wijmenga C, Peña AS, Bouma G. IL12B
and IRF1
gene polymorphisms and susceptibility to celiac disease. ACTA ACUST UNITED AC 2003; 30:421-5. [PMID: 14675396 DOI: 10.1111/j.1365-2370.2003.00428.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Celiac disease (CD) is a common gastro-intestinal disorder resulting from permanent intolerance to wheat gliadins and related proteins in rye and barley. In addition to the strong genetic association with HLA-DQ2 and HLA-DQ8, a genetic region on chromosomes 5 (CELIAC2) has been identified that harbours a susceptibility gene for CD. The gene(s) responsible for this association, however, remains to be identified. In the present study we evaluated polymorphisms in the genes encoding interleukin-12 p40 (IL12B) and interferon regulatory factor 1 (IRF1). Both genes are located in the celiac2 region, and have key roles in inducing interferon (IFN)-gamma secreting T helper 1 (Th1) cells, one of the immunological hallmarks of CD. The frequencies of a TaqI gene polymorphism in the 3' UTR of IL12B and a HinfI gene polymorphism in the 3' UTR of IRF1 were studied in 258 Dutch CD patients and 237 ethnically matched healthy controls. The transmission of the polymorphic variants from parents to affected child was determined in 123 families with at least one affected child. The frequencies of the IL12B TaqI gene polymorphism and the IRF1 HinfI gene polymorphism did not differ significantly between patients and controls. In addition, in the family study, no deviation from the expected transmission from parents to affected child of any of the polymorphic variants was found. The IL12B TaqI and the IRF1 HinfI gene polymorphisms do not appear to be involved in susceptibility to CD. Further studies on the factors that drive the Th1 immunopathology in CD are required.
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Affiliation(s)
- D Seegers
- Department of Immunogenetics, Vrije Universiteit Medical Center, Amsterdam, The Netherlands
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