The 1rst Kuwait-North American Update in Internal Medicine Conference 8-9 February 2014 TREATMENT OF RA 2014 Henri A. Ménard, MD, FRCP (C) Professor of Medicine McGill University McGill University Health Center Sequence of Events in RA Pre- Early- Immune response Anti-CCP RF Established- RA Pathologic inflammatory response Anti-Sa Destruction Amyloidosis Vasculitis T0 T100 Break of tolerance RA Onset CVD Environment Genes Lymphoma Rheumatoid Hand Smoking Habit Ulnar Drift Oral health: Parodontitis • Chronic Inflammatory condition. • Erosive disease • Associated with RF, HLA DR4 and Coronary Artery Disease. • Intriguing because associated with Porphyromonas gingivalis. The bacterial PADI and its products are very different from that of the mammalian PADIs’. Break of tolerance??? • Circumstantial evidence only. No hard data available. (Ménard HA Dresden Symposium on Autoimmunity 2007) Principles of Patient Centered RA Treatment in 2014 • DO MORE THAN LESS clinical observation and biological documentation of the disease to pinpoint the particular context of your patient where N=1. • EXPLAIN AND REASSURE the patient and the family; • INSIST ON LIFESTYLE ISSUES: smoking, oral hygiene (flossing) and beware of the associated obesity and metabolic syndrome: PREHABILITATION is better than REHABILITATION; • TREAT EARLY AND AGGRESSIVELY with full DMARDs combos and use biologicals when needed; • USE TOOLS BORROWED FROM THE BUSINESS WORLD to contract with the patient short term and long term objectives with periodic timely deliverables (Treat-to-Target approach); • ADAPT AND ADJUST as the disease evolves and changes. Personalizing Is Challenging To treat moving targets in vivo we need to develop HUMAN BIOMARKER(S) Clinical : intra vs extra-articular features Serologic : anti-Sa For Prognosis and Monitoring Genomic immune response genes (SE and non-SE), pharmacogenomics (drug metabolism), innate immunity genes (cytokine SNPs) Immunopathologic : Cell mediated vs humoral Evolutive disease = Δ physiopathical pattern Personalizing Is Challenging To chose the best drug for the right patient at the right time, we need to STOP EMPIRICISM i.e. Stop making real world medical decisions and using guidelines based on trial data; Start dissecting each individual patient as a N=1 trial, not as a member of poorly characterized cohorts of N=1000. Know why & when one starts & stops a drug Know why & when one needs to change/switch Know why & when to reassess. Contribution of Cytokines to RA Clinical Manifestations APR, anemia Liver IL-6 Leukocyte Chemotaxis TNF, IL-17, IL-6, IL-1 Angiogenesis TNF, IL-6 Cartilage Degradation MMP Bone Erosion IL-1, IL-17 TNF, IL-17, IL-6, IL-1 Joint Colmegna et al. Clin Pharmacol Ther 2012;91:607-20 Do Our Treatments Regulate Citrullinated Ags – ACPAs? Anti-CP Abs Effect Of MTX On Citrullination In UMR 106 Cells MTX (nM) MTX (nM) 113 92 PAD2 53 % Inhibition 113 92 CMC 100 90 80 70 60 50 40 30 20 10 0 0 1 10 50 100 Dose-response curve of in vitro MTX treatment of UMR 106 cells at 10 µg of total proteins/lane at in vivo therapeutic concentrations. Lora M et al (Ménard HA) ACR 2005 A Scientific Basis For A Century Of Empiricism In Treating RA: All DMARDs Downregulate The Production Of Citrullinated Proteins/Antigens In Vitro. Henri-André Ménard MD & Maximilien Lora PhD MSK Research Axis 0f The McGill University Health Center At The Royal Victoria Hospital, Montreal (QC), CANADA H3A 1A1 INTRODUCTION RESULTS RESULTS CRA Kanaskis 2009 and ACR Philadelphia 2009 H N H O Azathioprine (AZA) Clinical concentration 0.5 to 10µM Methotrexate (MTX) Clinical concentration: 25 nM CITRULLINATION is the conversion of an arginine within a peptidic link to a citrulline in an enzymatic process carried out by PeptidylArginine Deiminases. CTRL 193 WB with anti-Sa MTX (100 nM) treatment of UMR106 at subconfluence showed a decrease in PAD activity. This MTX effect was prevented by folinic acid (20 µM). O N 115 97 10 50 100 200 Prednisone (Pred) Clinical concentration 0.1 µM µM UMR106 CTRL 0.1 1.0 193 WB with anti-CMC AZA treated subconfluent UMR106 cells. AZA at 50 µM to 200 µM significantly decreased PAD activity. RESULTS 10 µM ECV304 CTRL 0.1 1.0 10 µM 193 115 97 115 97 WB with anti-CMC Pred. treated subconfluent UMR106 & ECV304 cells. Pred. had no effect on PAD activity. 1. MTX, blocks PADI-2 activity in proliferating cells without affecting the quantity of enzyme. It does so via folate-dependent and adenosine receptor-independent pathways. The induction of a PAD Inhibitor is a Sulphasalazine (SSZ) Clinical concentration 50 µM possibility. RATIONALE AND HYPOTHESIS + H2O NH H2N+ PADs + NH3 + H+ Ca++ O NH2 PeptidylArginine 53 53 NH CTRL NS NH2 RA patients have IgG auto-antibodies PAD2 At the same dosage, MTX had no effect on PAD activity of confluent UMR106 or subconfluent and confluent ECV304 against citrullinated (cit-)epitopes. 100 200 µM WB with anti-CMC AZA treated confluent UMR106 cells. AZA at 200 µM decreased PAD activity. 25 125 250 µM WB with anti-CMC SSZ treated subconfluent UMR 106 cells. SSZ at 250 µM significantly decreased PAD activity. 37 115 97 CTRL 0.1 1.0 10 µM 193 53 CTRL CTRL 53 193 The Abs are present before or at disease onset at 40-80% sensitivity with >95% specificity. Factual commonality 1: pharmacologically unrelated drugs, the 50 115 97 WB with anti-PAD2 MTX treatment showed no decrease in PAD-2 protein PeptidylCitrulline 10 10 50 100 WB with anti-CMC Pred. treated confluent UMR106 cells. Pred. at 10µM might be increasing PAD activity. 200 µM 115 97 193 WB with anti-CMC AZA treated subconfluent ECV304 cells. AZA decreased PAD activity at all concentrations tested. At the same dosage, AZA had little effect on ECV304 confluent assays. 53 115 97 CTRL 0.1 1.0 10 µM 193 2. HCQ, AZT and, SSZ decrease the quantity of PADIs in resting and Hydroxychloroquine (HCQ) Clinical concentration 1 µM proliferating cells in vitro. DMARDs have survived empirically as good treatment for RA; Factual commonality 2: cit-proteins (non-specific products of inflammation), have a central role in RA as they induce a specific autoimmune response that drives the disease; Factual commonality 3: biologicals target effector mechanisms, downstream from the immunological synapse with little effect on autoAbs and they all work most efficiently when combined with DMARDs ; Hypothetical commonality 4: DMARDs have a common mode of action complementary to biologicals via inhibition of citrullination, an event upstream from the immunological synapse. 115 96 53 WB with anti-CMC Pred. treated confluent ECV304 cells. Pred. at 10 µM may actually increase PAD activity. 51 CTRL 500 1000 µM Sub-confluent CTRL 10 50 100 115 96 WB with anti-CMC SSZ treated confluent UMR 106 cells. SSZ at 500 and 1000 µM significantly decreased PAD activity. Confluent CTRL 10 50 100 µM 193 WB with anti-CMC HCQ treated subconfluent & confluent UMR106 cells. HCQ at 50 µM to 100 µM significantly decreased PAD activity. 115 97 53 CTRL UMR106 cells have PAD activity at confluence only. 113 92 53 CTRL 250 500 1000 µM 115 WB with anti-CMC SSZ treated subconfluent ECV304 cells. SSZ at 1000 µM significantly decreased PAD activity. At the same dosage, SSZ had no effect on ECV304 confluent assays. Anti-Sa Ca2+ 10 50 100 µM 115 97 51 53 WB with anti-PAD2 HCQ treated CTRL subconfluent ECV304 cells. All DMARDs downregulate the production of cit-proteins/antigens in vitro. - MTX blocks PAD-activity in proliferating cells via a folate dependent pathway. The effect is independent of adenosine receptors (not shown) and the quantity of PAD-protein is unchanged. - AZT, SSZ and HCQ decrease the quantity of PADs in various conditions either in resting or dividing cells. - Prednisone has no effect on citrullination in dividing cells but has an unexpected upregulating effect at high dose in resting cells. 100 µM CTRL Sa 113 92 53 WB with anti-CMC HCQ treated subconfluent ECV304 cells. HCQ at 50 and 100 µM decreased PAD activity. 96 37 CTRL ECV304 cells have PAD activity at both subconfluence and confluence. Sa 37 51 4. DMARDs decrease the afferent antigenic input while Prednisone and - + - + the Biologicals suppress the efferent mechanisms of the immune synapse involving citrullinated epitopes. Anti-CMC 53 CONCLUSIONS 3. Corticosteroids have no direct effect on citrullination . MATERIALS AND METHODS UMR106 and ECV304 cell lines were treated for 4 days with increasing doses of methotrexate (MTX), sulphasalazine (SSZ), azathioprine (AZT), hydroxychloroquine (HCQ) or Prednisone (Pred) at doses corresponding to those obtained in vivo during RA treatment. We estimated semi-quantitatively by western blot (WB) on cell extracts, their effect on the production of all cit-proteins (detected by a rabbit anti-CMC serum) and cit-antigens (detected by anti-Sa RA sera). 115 97 WB with anti-PAD2 SSZ treated subconfluent ECV304 cells. SSZ at 750 µM significantly decreased PAD2 protein. 750 µM PAD2 10 50 100 µM 193 WB with anti-CMC HCQ treated confluent ECV304 cells. HCQ at 50 and 100 µM decreased PAD activity. 115 97 53 Those data support our hypothesis that DMARDs all work by decreasing the cit-Ag load in vivo. In patients with autoAbs to a cit-protein Ag like cit-vimentin/Sa, DMARDs may influence the putative ongoing auto-Ab response to cit-vimentin (anti-Sa), thus acting on the two major elements of the autoimmune amplification loop responsible for chronicity. ACKNOWLEDGEMEN T Conclusions on Citrullination in RA Those in vitro data provide an explanation for why the pharmacologically diverse DMARDs are successful in RA : they are PADIBs 1. Individually, with MTX being the best at it; 2. In combination with each other, providing a variety of not mutually exclusive inhibition modalities; 3. Essential to use with biologicals as they are unique in decreasing the afferent arm of the immune process; 4. Especially relevant when ACPAs (anti-Sa) drive the disease. Take Home Message On Anti-CCP • They relate to immune response genes specifically predisposing to RA but are not always associated with severe or even actual disease. In the context of N = 1, • most useful when negative to rule out RA; • low titers may lead to circular clinical reasoning; • high titres most useful to rule in RA. • Their prognostic value is based on longitudinal and transversal testing of RA COHORTS. They are less reliable at disease onset in personalized N=1 medicine. • Normalization is unusual and, as currently tested for, unchanging titers do not allow immune monitoring. Ménard HA, Editorial. J Rheumatology 2009 Take Home Message On Anti-Sa • strictly linked to RA disease: DIAGNOSIS • closely linked with the more severe erosive long term phenotype: PROGNOSIS • titers vary with activity as pathogenic antibodies do: MONITORING • normalization is achievable and may turn out to be a robust marker of remission maintenance at T0/S0: REMISSION Ménard HA, Editorial J Rheumatology 2009 TREATMENT IMPLICATIONS PKIs ? S T E R O I D S MTX, HCQ, SSZ,AZT= PADIBs ABATACEPT PKIs ? PKIs ? ACPAs PKIs ? PKIs ? ANTI-CYTOKINES RITUXIMAB FORGET THIS OSLER’S QUOTATION "When a patient with arthritis comes through the front door, I want to leave by the back door". Times are changing HA MÉNARD, Jan 2013 SHUKRAN ALA ALDAWAH QUESTIONS? COMMENTS?