BIOMARKERS TO GUIDE

TREATMENT IN RA

The 1rst Kuwait-North American Update in Internal Medicine Conference

8-9 February 2014

Henri A. Ménard, MD, FRCP (C)

Professor of Medicine

McGill University

McGill University Health Center

Rheumatoid Arthritis (circa 1987) Chronic progressively deforming

polyarthritis

Extra-articular involvement (lung fibrosis, serositis, scleritis, nodules, vasculitis, sicca)

X-Ray joint damage in the 1st year in 30-50% of patients.

Permanent inability to work within 5 yrs in 40%.

Life expectancy shortened by 3-14 yrsdepending on the severity of the disease

Textbook

RATEXTBOOK

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Prognosis

Early Intervention

RA Biomarkers Clinical 2010 AutoAbs 2010 Genetic Imaging

EA/ERA Office

CLINICAL PROGRES

The ACR-EULAR 2010 Classification Criteria

A probabilistic approach to early diagnosis

1987 CRITERIAMean Disease Duration: 8 Years

Arthritis and Rheumatism 31:315-24,1988

Goals 2010In patients with undifferentiated arthritis :

•Identify those at high risk of chronicity and erosive damage

•candidates for DMARD therapy

•Not exclude patients later in the disease course

2010 ACR/EULAR RA CRITERIA

Target population 1) at least 1 joint with definite clinical synovitis (swelling)* 2) the synovitis is not better explained by another disease†

Classification: add score of categories A–D (6/10 is needed for a definite RA)‡

A. Joint involvement§ Score1 large joint 02-10 large joints 11-3 small joints (with or without involvement of large joints)# 24-10 small joints (with or without involvement of large joints) 3>10 joints (at least 1 small joint)** 5

B. Serology (at least 1 test result is needed for classification)††Negative RF and negative ACPA 0Low-positive RF or low-positive ACPA 2High-positive RF or high-positive ACPA 3

C. Acute-phase reactants (at least 1 test result is needed for classification)‡‡Normal CRP and normal ESR 0Abnormal CRP or abnormal ESR 1

D. Duration of symptoms§§ < 6 weeks 0 > 6 weeks 1

HYPOTHETICAL COURSE of RA

Inflammation

clinical

threshold

2010 Early RA

1987 Established RA

Time

Pre-RAAuto-Ab

POST-2010 PERSPECTIVES

• Extrapolation

• Validation

• Stratification

• No erosions

• New treatment approaches

• New remission criteria

• Aggressive Tx for less active

disease

• Societal cost of early Tx with

biologicals

• Need for local reference

values for APR and Auto-Abs.

EXPERT PANEL

1212

KUWAIT

Biomarkers For Early Disease

1. Clinical : ACR-EULAR 2010 Criteria

2. Serological : Citrullinated Immune Systems

Studying Auto-Immune Systems

DIAGNOSIS

PHYSIOPATHOLOGY

MONITORING

CLUES TO ETIOLOGY

TOOLS FOR BIOLOGY

PROGNOSISAuto-AbsClinician

Auto-AgsBiologist

Roadmap to Personalized Medicine

Rheumatoid Arthritis An In Vivo ELISA

Anti-IgGs(RFs)

Agn

(Many)

Abn

(Many)

Primary Systems

Specificity

Secondary Systems

Amplification

RA-Associated Auto-Immune Systems

Nucleus: DNP/ssDNA/histones/macro-histone, LMG and HMG

proteins, Ro (SS-A), hnRNP(s) A2/B1, etc…

Cytoplasm: intermediary filaments (vimentin, filaggrin, reticulin,

fodrin), endoplasmic reticulum, chaperone(s), cytokeratin(s), etc…

Extracellular Matrix Proteins: collagen(s), GAGs, link protein(s),

elastin, fibulin, keratin, etc…

Enzymes and Inhibitors: G6PI, PDI, calpastatin(s), follistatin-related

protein, hyaluran synthase, enolase, aldolase, PADI4, MPO, etc…

Others: lactoferin, phospholipids, advance glycation endproducts

(AGE), etc…

Rheumatoid Factors: poly-, oligo-, monoclonal Ig isotypes targeting

Fc, Fab, idiotopes, paratopes, etc….

RA-Specific Immune Systems

A C P A s

• Anti-Citrullinated PEPTIDE Antibodies.

• Anti-Citrullinated PROTEINS Antibodies

Citrullination isthe Enzymatic Conversion of

Arginine To Citrulline

The Antigen(s)

Citrullination: A MechanismTo Recycle Aminoacids

1 2

3

4 5

CitrullinationAn Intracellular Agonic Event

1. PADIs are present in most cells: epithelial,

fibroblast, osteoblast, endothelial, myeloid and

dentritic cells but NOT IN LYMPHOID CELLS.

2. Citrullination occurs during the calcium influx

of early apoptosis. Vimentin is the first protein

to be citrullinated in macrophages (Senshu).

Cit-Vimentin = the Sa antigen.

3. Citrullination is thus a cellular agonic event, a

NORMAL feature of inflammation and repair.

Citrullination Is Also A Secondary Extracellular Event

Fibrin,Collagen,

ANY PROTEIN

Exocytosis / Apoptosis

No known natural inhibitor

Five Points To Remember About Cit-Proteins/ACPAs In Joints

1. Cit-proteins are found in all inflammed tissues and fluids, not CCP.

2. The PANNUS CITRULLINOME is mostly made of the Sa Ag (Ménard

1988) i.e. neo-Ags on Cit-VIMENTIN (Ménard 2004, Bang 2007, Tilleman

2008) generated during apoptosis and present in ACPA-containing

immune complexes (Van Steendam 2008).

3. The SYNOVIAL FLUID CITRULLINOME is mostly made of cit-FIBRIN

(Serre 2006, Pruijn 2006) generated extracellularly and present in

ACPA-containing immune complexes (Zhao 2008).

4. The pannus is an ectopic lymphoid tissue producing RF, anti-AgN

including ACPAs (Smiley 1970, Serre 2000).

5. ACPAs are IgGs typical of a mature/ongoing polyclonal Ag-driven

response (Ménard 1984, Schellekens 1998 and Ioan-Facsinay 2008, 10) .

Anti-CCP2 ELISA : Designed For Screening Populations

Anti-CCP2 Titer

O.D.

Ceiling effect

Low Threshold

ULT

ULN

van Venrooij W 2003

Cumulative percentage of patients with one or more positive test results before symptoms

49%

41%

28%

0

10

20

30

40

50

60

15 14 13 12 11 10 9 8 7 6 5 4 3 2 1 0

Years before start of symptoms

Per

cen

tag

e o

f p

osi

tive

pat

ien

ts

IgM-RF or anti-CCP

anti-CCP

IgM-RF

Retrospective Study Scandinavian Blood Donors

SR Dahlqvist et al. A&R 2003

Hypothetical Course of RA

Inflammation

clinical

threshold

2010 Early RA

1987 Established RA

Time

Pre-RAAuto-Ab

Prospective StudyNorth American Natives

• highest rates of RA in the world (2-4%)

• high rates of multicase families

• predisposing HLA-DRB1 alleles very common

• high levels of antibodies (RF, ACPA)

Ideal population to identify individuals at risk…

PI : H El-Gabalawy,Winnipeg, Manitoba

Co-PI : HA MénardMontreal, Quebec

Anti-Sa ELISA (2004) : Design For Prognosis and Monitoring

Individual RA Patients

Anti-Sa titerAnti-CCP Titer

O.D.

ULN

ULT

ULN

ULT

Anti-Sa / anti-CCP2 In NANA Prospective Study

Anti-CCP2ELISA

Anti-SaELISA

RA FDR UNRELATED

0%0%

9%20%79%

51%

Ioan-Facsinay A et al. (El Gabalawy H, Ménard H) A&R 2008

Baseline AutoAbs And Erosions After 3 years Prospective Early RA Sherbrooke Cohort

Guzian C et al. (Boire G, Ménard H) AR&T 2010

29.2 (57)

51.7 (30) p<0.005 33.3 (6)

60.0 (24) p<0.0005

41.0 (80) 74.1 (43) p<0.0001

66.7 (12) 77.5 (31) p<0.0001

Anti-Sa (n=253) Neg (195) Pos (58) Low (18) Moderate/High (40)

31.4 (49) 39.2 (38) 36,4 (4)

39.5 (34)

42.9 (67) 57.7 (56)

54.5 (6) 58.1 (50) p<0.05

Anti-CCP2 (n=253) Neg (156) Pos (97) Low (11) Moderate/High (86)

29.3 (41) 40.7 (46) 38.1 (8)

32.6 (38)

42.9 (60) 55.8 (63)

42.9 (9) 58.7 (54) p<0.05

RF (n=253) Neg (140) Pos (113) Low (21) Moderate/High (92)

Very Erosive (≥14) % (n)Erosive (≥ 5) % (n)Titers at Inclusion (n)

Examples of Anti-CCP2 in Non-Rheumatoid Patients

• Idiopathic inflammatory myopathy (Rheumatology (Oxford) 2009) from a Tertiary Care Center in Barcelona. 13% positive anti-CCP (75% mod-high titers). No arthritis, no AKA.

• 25% positive anti-CCP in SLE from low to high titers. (Unpublished Ménard and Van Venroij). No arthritis, no anti-Sa.

• Chronic infections like HIV (South Africa), Tb (India) No arthritis. Anti-CCP positive, anti-Sa status unknown,

• RA-like conditions: HVB or HVC with cryo, CPPD with hemochromatosis, Psoriatic Arthritis, IBD Arthritis. Some anti-CCP pos but anti-Sa always negative.

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

3500

3700

3900

4100

4300

4500

4700

1 28 29 36 41

An

ti-S

a

Cit

rulli

ne

(nm

ol/m

L)

Week

Lazina H.Citrulline

Anti-Sa

Jasmine C.

4000

5000

6000

7000

1 136 185 211

Week

Cit

rull

ine

(nm

ol/

mL

)

0

0.5

1

1.5

2

An

ti-S

a

Citrulline

Anti-Sa

Aghda D.

2500

3000

3500

4000

4500

5000

1 11 17 43

Week

Cit

rull

ine

(nm

ol/

mL

)

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

1.8

An

ti-S

a

Citrulline

Anti-Sa

CSR

SR

CR

ERA

MonoA

ERA

RA

Lili R-L.

3500

4000

4500

5000

5500

6000

6500

1 10 20 24 40 56 76

Week

Cit

rull

ine

(nm

ol/

mL

)

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

An

ti-S

a

Citrulline

Anti-Sa

Suzanne C.

3500

4000

4500

5000

5500

6000

6500

1 3 11 56 56 93 93 105 133 152 180

Week

Cit

rull

ine (

nm

ol/

mL

)

0

0.5

1

1.5

2

2.5

3

An

ti-S

a

Citrulline

Anti-Sa

CR

RA VASC

RA VASCRTX

MONITORING RA WITH ANTI-Sa

CSR = Clinical Serological RemissionAnti-CCP2 never changed significantly

Dieter R.

2500

2700

2900

3100

3300

3500

3700

1 1 36 56 80 99

Week

Cit

rull

ine (

nm

ol/

mL

)

-0.05

0

0.05

0.1

0.15

0.2

0.25

0.3

0.35

0.4

0.45

An

ti-S

a

Citrulline

Anti-Sa

Clotilde Z.

3000

3500

4000

4500

1 1 2 30 53 79

Week

Cit

rull

ine (

nm

ol/

mL

)

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

An

ti -

Sa

Citrulline

Anti-Sa

CSR

CSR

NHL-RA

Palindrome

RTX

Rotman J (Ménard HA) European Workshop Rheum Res Toulouse 2008

- Anti-CCP and RF are present up to 15 years before disease onset;

- The higher the anti-CCP titres the shorter the time to disease onset (retrospective data).

- Anti-Sa Abs define a sub-group of RA patients

with higher titres of anti-CCP and higher Ig isotype usage = MORE SEVERE

- Anti-Sa Abs are strictly RA disease-associated, not anti-CCP.

Summary Of ACPA in Pre-RA

Clinical Summary of ACPA LiteratureIn Early and Established RA

1. SPECIFICITY (85-100%)

anti-Sa >> CCP > MCV

2. SENSITIVITY 40% to 80%

depending on test and patients

i.e. phase of disease, age at

onset, treatment.

anti-CCP = MCV > anti-Sa

3. For SCREENING

anti-CCP > MCV >> Sa

more sensitive, less specific.

4. for DIAGNOSIS

anti-Sa>> CCP > MCV

5. for MONITORING

anti-Sa >> MCV >> CCP = 0

6. ACPA are highly correlated with RF

– 80-90% ACPA also have RF

– 50-85% RF also have ACPA

– 25-30% RF(-) have ACPA

– Same in children with adult form

Interpretation Of The Clinical Data

“It is not one or the other, it is one and the other”.Ménard HA. Nature Clin Practice Rheumatol 2007.

ARTHRITIS

Anti-CCP Anti-Sa

RASLE

ANA Anti-dsDNA

NEPHRITIS

SHUKRAN

ALA ALDAWAH