- Email: [email protected]
Autoimmunity induced by adalimumab during rheumatoid arthritis treatment
622
From the 4th International Congress of Autoimmunity Budapest 3–8 November 2004
blocked by CNQX, a specific glutamate/AMPA receptor-antagonist. When repetitively applied, the anti-GluR3B Ab and glutamate displayed neither inhibitory nor synergistic effects, and pre-incubation with anti-GluR3 Ab did not affect the subsequent response to the glutamatergic agonist. Conclusions: Anti-GluR3B Ab can by themselves activate both homomeric and heteromeric GluR3containing channels. If present chronically in vivo, especially in brain fluids, such anti-GluR3B Abs may possibly lead to chronic and detrimental activation of GluR3, because of the extra energetic load imposed on depolarized neurons, and because such depolarization may cause an easier release of the magnesium block on NMDA receptors. These findings call for further investigation. STUDY NO. 3: AUTOANTIBODIES IN SOME EPILEPSY PATIENTS ARE PRESENT ON BOTH SIDES OF THE BLOOD–BRAIN BARRIER, DECREASE IN BRAIN FLUIDS AFTER HEMISPHEROTOMY, KILL NEURONS AND BIND SEVERAL AUTOANTIGENS Purpose: To elucidate the potential contribution of Ab to the etiology and/or pathology of Rasmussen’s encephalitis (RE) and possibly other epilepsies. Methods: Six RE patients were studied for the presence of various Ab in serum and cerebrospinal fluid (CSF) and for the ability of their serum/CSF to kill neurons.
Results: Elevated anti-GluR3B Ab were found in serum and CSF of the RE patients studied. In two patients, anti-GluR3B Ab decreased drastically in CSF following functional hemispherotomy, in association with seizure cessation and neurological improvement. Anti-GluR3B Ab-positive sera and CSF of some RE patients killed cultured hipppocampal neurons. Serum and CSF of two RE patients contained also significantly elevated levels of anti-dsDNA Ab. The sera (but not the CSF) of some RE patients harbored clinically elevated levels of dclassicalT autoimmune Ab, directed against glutamic acid decarboxylase, cardiolipin, h2glycoprotein I and nuclear antigens. Conclusions: Patients with RE may harbor Ab to GluR3 and DNA on both sides of the blood–brain barrier, and additional autoimmune Ab only in serum. Since all these Ab may be detrimental to the nervous system and/or peripheral organs, we recommend testing for their presence in severe epilepsies, and silencing their activity in Ab-positive patients [2]. References [1] Levite M. Autoimmune epilepsy. Nat Immunol 2003;3:6. [2] Levite M, Fleidervitch I, Schwartz A, Pelled D, Futerman A. Antibodies to the glutamate receptor kill neurons via activation of the receptor ion channel. J Autoimmun 1999;13:61 – 72. doi:10.1016/j.autrev.2004.08.033
Autoimmunity induced by adalimumab during rheumatoid arthritis treatment Piercarlo Sarzi-Puttini*, Fabiola Atzeni Rheumatology Unit, L.Sacco Hospital, Milan, Italy Available online 11 September 2004
Tumor necrosis factor-a (TNF-a) blocking represents an important advance in the clinical treatment of rheumatoid arthritis (RA). Adalimumab (HUMIRA) is a recombinant human immunoglobulin G1 monoclonal antibody that is specific for human tumor necrosis factor (TNF), approved by
the U.S. Food and Drug Administration in 2002 for the treatment of moderate to severe RA. Adalimumab binds specifically to circulating and cell surface TNF-a and blocks its interaction with the p55 and p75 cell surface TNF receptors. Adalimumab also modulates biologic responses that
From the 4th International Congress of Autoimmunity Budapest 3–8 November 2004
are induced or regulated by TNF, including changes in the levels of adhesion molecules responsible for leukocyte migration (ELAM-1, VCAM-1, and ICAM-1). The recommended dose of adalimumab in adults with RA is 40 mg administered every other week (eow) as a single dose by subcutaneous (sc) injection. Adalimumab acted rapidly to reduce the signs and symptoms of disease and demonstrated a significant inhibition of disease progression [1]. The drug is generally safe and well tolerated according to the data from the clinical safety database in nearly 2500 patients. Adalimumab has also been shown to substantially improve physical function as measured by the HAQ score and in quality of life measures as determined by the SF 36 scores when given alone or with concomitant MTX. When necessary, Adalimumab can be temporarily discontinued and restarted without loss of clinical response or increased risk of anaphylaxis or immunologic reaction. As with all current TNF antagonists, safety issues under consideration include infection including Mycobacterium tuberculosis and other opportunistic infections, demyelinating disorders, autoimmune syndromes (i.e., systemic lupus erythematous), congestive failure, and injection site reactions. The most common side effects reported in the 705 patients treated with 40 mg eow relative to 690 patients treated with placebo (with or without MTX) include injection site reactions, upper respiratory tract infections, rash, headache, and sinusitis. As with other TNF antagonists, M. tuberculosis has been observed with adalimumab. Thirteen cases have been documented—10 in Europe and 3 in the United States [1]. All but 1 of the 13 cases was treated with higher than the standard 40 mg eow dose. Eight cases were seen before screening for M. tuberculosis in early dose-finding studies. Other opportunistic infections have been observed with adalimumab, including histoplasmosis (n=3; in endemic areas of the United States), aspergillosis (n=2; one of which had a preexisting aspergilloma), nocardia (n=1), and atypical mycobacteria (n=1). Four cases of demyelination have been observed with adalimumab therapy, including optic neuritis (n=1) and parasthesias (n=3). One case was observed after a single adalimumab dose, and another patient’s symptoms were consistent with the prior diagnosis of multiple sclerosis. Three of
623
the four cases resolved within discontinuation of therapy. Clinical studies on the effect of adalimumab on rheumatoid arthritis have reported the appearance of autoantibodies, including antinuclear antibodies (12.9%) and antidouble stranded DNA (5.3%). One case of a lupus-like syndrome presenting with serositis and arthritis was seen and resolved upon discontinuation of therapy [1]. However, limited data exist on the autoantibodies induction on a long-term treatment. Recently, our group has described the appearance of autoantibodies in a group of 49 patients with active RA, treated with adalimumab at a dosage of 40 mg subcutaneously (sc) administered every 15 days for 36 weeks. At baseline, four patients (8.1%) were ANA positive [2]. No patients was anti-DNA positive. After 36 weeks of treatment, 20/49 (44%) patients were ANA positive, and only two (4%) developed anti-ds-DNA antibodies. Anti-ENA were negative in all patients at baseline and remained unchanged during the study. None of our patients developed a lupus-like syndrome. The authors have concluded that the increase and the appearance of autoantibodies during adalimumab treatment is common but it has no clinical relevance. As would be expected with infusion of any immunoglobulin into humans, a proportion of patients develop human anti-idiotypic antibodies specific for adalimumab. In clinical trials, these anti-idiotypic antibodies have been observed in 12% of patients who received monotherapy and 1% of patients who received combination therapy with MTX [1]. These antibodies likely account for the somewhat lower ACR responses observed in the monotherapy study. A significantly improved response was observed in this study with adalimumab given in a dose of 40 mg weekly. It is estimated that 5–15% of patients may require weekly doses while receiving monotherapy. There is no evidence that weekly adalimumab dosing in patients receiving concomitant MTX therapy will be beneficial. There is no evidence to suggest that the anti-idiotype antibodies affect the safety profile of adalimumab. Conclusion: Adalimumab eow administration makes it a significant advancement in the therapeutic armamentarium for patients who have RA but no conclusive data at present can be drawn
624
From the 4th International Congress of Autoimmunity Budapest 3–8 November 2004
for the autoantibodies in adalimumab-treated patients.
[2] Atzeni F, Sarzi-Puttini P, Capsoni F, et al. Autoantibodies profile of rheumatoid arthritis patients during a 6-month treatment with adalimumab [abstract FRI 0163]. Ann Rheum Dis 2004;63(Suppl. 1):298.
References [1] Keystone E, Haraoui B. Adalimumab therapy in rheumatoid arthritis. Rheum Dis Clin North Am 2004;30:349 – 64.
doi:10.1016/j.autrev.2004.08.021
Regulation of B-cell activation by complement receptors CR1 (CD35) and CR2 (CD21)—possible involvement in the pathogenesis of autoimmune diseases Anna Erdeia,b,*, Jo´zsef Prechlb, Andrea Isaa´ka, Miha´ly Jo´zsia, Zsuzsa Bajtaya, Eszter Molna´ra, Pe´ter Gergely Jr.c, Gyula Poo´rc, Ja´nos Gergelya,b a
Department of Immunology, Eo¨tvo¨s Lora´nd University, Pa´zma´ny P.s. 1/c, H-1117 Budapest, Hungary b Research Group of the Hungarian Academy of Sciences, Budapest, Hungary c Institute of Rheumatology and Physiotherapy, Budapest, Hungary Available online 21 August 2004
1. Introduction In recent years, the complement system—particularly component C3 and its receptors—have been demonstrated to be a key link between innate and adaptive immunity. The trimolecular complex of CR2/ CD19 and TAPA is known to promote B cell activation when co-ligated with the B cell antigen receptor (BCR) via C3d fragments deposited onto the antigen, while the exact role of human CR1 is not clarified yet [1]. Here, we summarize our recent findings revealing further functions of CR1 and CR2 of B-cells.
2. Studies in murine system To target antigens to CR1/2 on B-cells, we have developed recombinant antibody fragments (7G6scFv, 8C12scFv) which recognize murine type 1 (CR1) and type 2 (CR2) complement receptors and carry influenza virus-derived epitopes. CR1/CR2-specific scFvs were generated from the genetic material of the hybridomas 7G6 and 8C12 and expressed in E. coli.
Sequences coding for the peptides of influenza hemagglutinin regions were created by RT-PCR from the respective virus, and cloned to the 5’ termini of the constructs. Recognition of the complement receptors by the constructs was tested by cytofluorometry, and their ability to deliver the viral epitopes was confirmed in antigen presentation assays. Uptake of antigen via CR1/CR2 enhanced the efficiency of presentation but was not improved by independent cross-linkage of the BCR. Coligation of the BCR to construct loaded CR1/2 did enhance the effectiveness of antigen presentation, indicating that unless physically joined, CR1/CR2 ligands follow distinct intracellular trafficking pathways. To test the in vivo targeting capability of 7G6scFv, we determined the presence of the molecule in various organs after intraperitoneal injection. 7G6scFv could be readily detected on CR1/CR2-bearing cells in blood, mesenteric lymph nodes, and spleen. The construct was rapidly cleared from the mice and was not detectable after 16 h. In spite of the in vitro effectiveness however, in vivo administration of the constructs containing a subdominant T cell epitope (IP-7G6scFv) could not
From the 4th International Congress of Autoimmunity Budapest 3–8 November 2004
blocked by CNQX, a specific glutamate/AMPA receptor-antagonist. When repetitively applied, the anti-GluR3B Ab and glutamate displayed neither inhibitory nor synergistic effects, and pre-incubation with anti-GluR3 Ab did not affect the subsequent response to the glutamatergic agonist. Conclusions: Anti-GluR3B Ab can by themselves activate both homomeric and heteromeric GluR3containing channels. If present chronically in vivo, especially in brain fluids, such anti-GluR3B Abs may possibly lead to chronic and detrimental activation of GluR3, because of the extra energetic load imposed on depolarized neurons, and because such depolarization may cause an easier release of the magnesium block on NMDA receptors. These findings call for further investigation. STUDY NO. 3: AUTOANTIBODIES IN SOME EPILEPSY PATIENTS ARE PRESENT ON BOTH SIDES OF THE BLOOD–BRAIN BARRIER, DECREASE IN BRAIN FLUIDS AFTER HEMISPHEROTOMY, KILL NEURONS AND BIND SEVERAL AUTOANTIGENS Purpose: To elucidate the potential contribution of Ab to the etiology and/or pathology of Rasmussen’s encephalitis (RE) and possibly other epilepsies. Methods: Six RE patients were studied for the presence of various Ab in serum and cerebrospinal fluid (CSF) and for the ability of their serum/CSF to kill neurons.
Results: Elevated anti-GluR3B Ab were found in serum and CSF of the RE patients studied. In two patients, anti-GluR3B Ab decreased drastically in CSF following functional hemispherotomy, in association with seizure cessation and neurological improvement. Anti-GluR3B Ab-positive sera and CSF of some RE patients killed cultured hipppocampal neurons. Serum and CSF of two RE patients contained also significantly elevated levels of anti-dsDNA Ab. The sera (but not the CSF) of some RE patients harbored clinically elevated levels of dclassicalT autoimmune Ab, directed against glutamic acid decarboxylase, cardiolipin, h2glycoprotein I and nuclear antigens. Conclusions: Patients with RE may harbor Ab to GluR3 and DNA on both sides of the blood–brain barrier, and additional autoimmune Ab only in serum. Since all these Ab may be detrimental to the nervous system and/or peripheral organs, we recommend testing for their presence in severe epilepsies, and silencing their activity in Ab-positive patients [2]. References [1] Levite M. Autoimmune epilepsy. Nat Immunol 2003;3:6. [2] Levite M, Fleidervitch I, Schwartz A, Pelled D, Futerman A. Antibodies to the glutamate receptor kill neurons via activation of the receptor ion channel. J Autoimmun 1999;13:61 – 72. doi:10.1016/j.autrev.2004.08.033
Autoimmunity induced by adalimumab during rheumatoid arthritis treatment Piercarlo Sarzi-Puttini*, Fabiola Atzeni Rheumatology Unit, L.Sacco Hospital, Milan, Italy Available online 11 September 2004
Tumor necrosis factor-a (TNF-a) blocking represents an important advance in the clinical treatment of rheumatoid arthritis (RA). Adalimumab (HUMIRA) is a recombinant human immunoglobulin G1 monoclonal antibody that is specific for human tumor necrosis factor (TNF), approved by
the U.S. Food and Drug Administration in 2002 for the treatment of moderate to severe RA. Adalimumab binds specifically to circulating and cell surface TNF-a and blocks its interaction with the p55 and p75 cell surface TNF receptors. Adalimumab also modulates biologic responses that
From the 4th International Congress of Autoimmunity Budapest 3–8 November 2004
are induced or regulated by TNF, including changes in the levels of adhesion molecules responsible for leukocyte migration (ELAM-1, VCAM-1, and ICAM-1). The recommended dose of adalimumab in adults with RA is 40 mg administered every other week (eow) as a single dose by subcutaneous (sc) injection. Adalimumab acted rapidly to reduce the signs and symptoms of disease and demonstrated a significant inhibition of disease progression [1]. The drug is generally safe and well tolerated according to the data from the clinical safety database in nearly 2500 patients. Adalimumab has also been shown to substantially improve physical function as measured by the HAQ score and in quality of life measures as determined by the SF 36 scores when given alone or with concomitant MTX. When necessary, Adalimumab can be temporarily discontinued and restarted without loss of clinical response or increased risk of anaphylaxis or immunologic reaction. As with all current TNF antagonists, safety issues under consideration include infection including Mycobacterium tuberculosis and other opportunistic infections, demyelinating disorders, autoimmune syndromes (i.e., systemic lupus erythematous), congestive failure, and injection site reactions. The most common side effects reported in the 705 patients treated with 40 mg eow relative to 690 patients treated with placebo (with or without MTX) include injection site reactions, upper respiratory tract infections, rash, headache, and sinusitis. As with other TNF antagonists, M. tuberculosis has been observed with adalimumab. Thirteen cases have been documented—10 in Europe and 3 in the United States [1]. All but 1 of the 13 cases was treated with higher than the standard 40 mg eow dose. Eight cases were seen before screening for M. tuberculosis in early dose-finding studies. Other opportunistic infections have been observed with adalimumab, including histoplasmosis (n=3; in endemic areas of the United States), aspergillosis (n=2; one of which had a preexisting aspergilloma), nocardia (n=1), and atypical mycobacteria (n=1). Four cases of demyelination have been observed with adalimumab therapy, including optic neuritis (n=1) and parasthesias (n=3). One case was observed after a single adalimumab dose, and another patient’s symptoms were consistent with the prior diagnosis of multiple sclerosis. Three of
623
the four cases resolved within discontinuation of therapy. Clinical studies on the effect of adalimumab on rheumatoid arthritis have reported the appearance of autoantibodies, including antinuclear antibodies (12.9%) and antidouble stranded DNA (5.3%). One case of a lupus-like syndrome presenting with serositis and arthritis was seen and resolved upon discontinuation of therapy [1]. However, limited data exist on the autoantibodies induction on a long-term treatment. Recently, our group has described the appearance of autoantibodies in a group of 49 patients with active RA, treated with adalimumab at a dosage of 40 mg subcutaneously (sc) administered every 15 days for 36 weeks. At baseline, four patients (8.1%) were ANA positive [2]. No patients was anti-DNA positive. After 36 weeks of treatment, 20/49 (44%) patients were ANA positive, and only two (4%) developed anti-ds-DNA antibodies. Anti-ENA were negative in all patients at baseline and remained unchanged during the study. None of our patients developed a lupus-like syndrome. The authors have concluded that the increase and the appearance of autoantibodies during adalimumab treatment is common but it has no clinical relevance. As would be expected with infusion of any immunoglobulin into humans, a proportion of patients develop human anti-idiotypic antibodies specific for adalimumab. In clinical trials, these anti-idiotypic antibodies have been observed in 12% of patients who received monotherapy and 1% of patients who received combination therapy with MTX [1]. These antibodies likely account for the somewhat lower ACR responses observed in the monotherapy study. A significantly improved response was observed in this study with adalimumab given in a dose of 40 mg weekly. It is estimated that 5–15% of patients may require weekly doses while receiving monotherapy. There is no evidence that weekly adalimumab dosing in patients receiving concomitant MTX therapy will be beneficial. There is no evidence to suggest that the anti-idiotype antibodies affect the safety profile of adalimumab. Conclusion: Adalimumab eow administration makes it a significant advancement in the therapeutic armamentarium for patients who have RA but no conclusive data at present can be drawn
624
From the 4th International Congress of Autoimmunity Budapest 3–8 November 2004
for the autoantibodies in adalimumab-treated patients.
[2] Atzeni F, Sarzi-Puttini P, Capsoni F, et al. Autoantibodies profile of rheumatoid arthritis patients during a 6-month treatment with adalimumab [abstract FRI 0163]. Ann Rheum Dis 2004;63(Suppl. 1):298.
References [1] Keystone E, Haraoui B. Adalimumab therapy in rheumatoid arthritis. Rheum Dis Clin North Am 2004;30:349 – 64.
doi:10.1016/j.autrev.2004.08.021
Regulation of B-cell activation by complement receptors CR1 (CD35) and CR2 (CD21)—possible involvement in the pathogenesis of autoimmune diseases Anna Erdeia,b,*, Jo´zsef Prechlb, Andrea Isaa´ka, Miha´ly Jo´zsia, Zsuzsa Bajtaya, Eszter Molna´ra, Pe´ter Gergely Jr.c, Gyula Poo´rc, Ja´nos Gergelya,b a
Department of Immunology, Eo¨tvo¨s Lora´nd University, Pa´zma´ny P.s. 1/c, H-1117 Budapest, Hungary b Research Group of the Hungarian Academy of Sciences, Budapest, Hungary c Institute of Rheumatology and Physiotherapy, Budapest, Hungary Available online 21 August 2004
1. Introduction In recent years, the complement system—particularly component C3 and its receptors—have been demonstrated to be a key link between innate and adaptive immunity. The trimolecular complex of CR2/ CD19 and TAPA is known to promote B cell activation when co-ligated with the B cell antigen receptor (BCR) via C3d fragments deposited onto the antigen, while the exact role of human CR1 is not clarified yet [1]. Here, we summarize our recent findings revealing further functions of CR1 and CR2 of B-cells.
2. Studies in murine system To target antigens to CR1/2 on B-cells, we have developed recombinant antibody fragments (7G6scFv, 8C12scFv) which recognize murine type 1 (CR1) and type 2 (CR2) complement receptors and carry influenza virus-derived epitopes. CR1/CR2-specific scFvs were generated from the genetic material of the hybridomas 7G6 and 8C12 and expressed in E. coli.
Sequences coding for the peptides of influenza hemagglutinin regions were created by RT-PCR from the respective virus, and cloned to the 5’ termini of the constructs. Recognition of the complement receptors by the constructs was tested by cytofluorometry, and their ability to deliver the viral epitopes was confirmed in antigen presentation assays. Uptake of antigen via CR1/CR2 enhanced the efficiency of presentation but was not improved by independent cross-linkage of the BCR. Coligation of the BCR to construct loaded CR1/2 did enhance the effectiveness of antigen presentation, indicating that unless physically joined, CR1/CR2 ligands follow distinct intracellular trafficking pathways. To test the in vivo targeting capability of 7G6scFv, we determined the presence of the molecule in various organs after intraperitoneal injection. 7G6scFv could be readily detected on CR1/CR2-bearing cells in blood, mesenteric lymph nodes, and spleen. The construct was rapidly cleared from the mice and was not detectable after 16 h. In spite of the in vitro effectiveness however, in vivo administration of the constructs containing a subdominant T cell epitope (IP-7G6scFv) could not