SLE – An Overview and UpdateSLE – An Overview and Update

Pathobiology Course – JAN 24, 2014Pathobiology Course – JAN 24, 2014

Emilio B. GonzEmilio B. Gonzáález, MDlez, MDProfessor and Director, RheumatologyProfessor and Director, Rheumatology

UTMBUTMB

Systemic Lupus Erythematosus (SLE)Systemic Lupus Erythematosus (SLE) • Definition: a chronic inflammatory systemic Definition: a chronic inflammatory systemic

autoimmune disease of unknown etiology autoimmune disease of unknown etiology characterized by polyclonal B-cell activation and characterized by polyclonal B-cell activation and abnormal autoantibodies abnormal autoantibodies

• Not one disease but several clinical subsets, some Not one disease but several clinical subsets, some mild, e.g., “skin and joint” lupus, and others more mild, e.g., “skin and joint” lupus, and others more severe, with profound thrombocytopenia, severe, with profound thrombocytopenia, thrombosis from APS (antiphospholipid syndrome), thrombosis from APS (antiphospholipid syndrome), and severe renal, lung, and CNS involvementand severe renal, lung, and CNS involvement

1982 ACR (Revised 1997) SLE 1982 ACR (Revised 1997) SLE Classification CriteriaClassification Criteria

1.1. Malar (butterfly) rashMalar (butterfly) rash2.2. Discoid lesionsDiscoid lesions3.3. PhotosensitivityPhotosensitivity4.4. Oral ulcersOral ulcers5.5. Non-deforming arthritis (non-erosive for the most part)Non-deforming arthritis (non-erosive for the most part)6.6. Serositis: pleuropericarditis, aseptic peritonitisSerositis: pleuropericarditis, aseptic peritonitis7.7. Renal: persistent proteinuria › 0.5 g/d or ›3+ or cellular castsRenal: persistent proteinuria › 0.5 g/d or ›3+ or cellular casts8.8. Neurologic disorders: seizures, psychosisNeurologic disorders: seizures, psychosis9.9. Heme: hemolytic anemia; leukopenia, thrombocytopeniaHeme: hemolytic anemia; leukopenia, thrombocytopenia10.10. Immune: anti-DNA, or anti-Sm, or APS (ACA IgG, IgM), or lupus Immune: anti-DNA, or anti-Sm, or APS (ACA IgG, IgM), or lupus

anticoagulant (standard) or false + RPRanticoagulant (standard) or false + RPR11.11. Positive FANA (fluorescent antinuclear antibody)Positive FANA (fluorescent antinuclear antibody)

Definite SLE = 4 or more positive criteriaDefinite SLE = 4 or more positive criteria

New SLICC* Revision of the ACRNew SLICC* Revision of the ACRClassification Criteria - ClinicalClassification Criteria - Clinical

1. Acute/subacute cutaneous lupusAcute/subacute cutaneous lupus2. Chronic cutaneous lupus2. Chronic cutaneous lupus3. Oral/Nasal ulcers3. Oral/Nasal ulcers4. Nonscarring alopecia4. Nonscarring alopecia5. Inflammatory synovitis with physician-observed swelling of two or more 5. Inflammatory synovitis with physician-observed swelling of two or more

joints OR tender joints with morning stiffnessjoints OR tender joints with morning stiffness6. Serositis6. Serositis7. Renal: Urine protein/creatinine (or 24 hr urine protein) representing at 7. Renal: Urine protein/creatinine (or 24 hr urine protein) representing at least 500 mg of protein/24 hours or red blood cell castsleast 500 mg of protein/24 hours or red blood cell casts8. Neurologic: seizures, psychosis, mononeuritis multiplex, myelitis, 8. Neurologic: seizures, psychosis, mononeuritis multiplex, myelitis,

peripheral or cranial neuropathy, cerebritis (acute confusional state)peripheral or cranial neuropathy, cerebritis (acute confusional state)9. Hemolytic anemia9. Hemolytic anemia10. Leukopenia (< 4000/mm3 at least once) OR Lymphopenia (< 10. Leukopenia (< 4000/mm3 at least once) OR Lymphopenia (<

1000/mm3 at least once)1000/mm3 at least once)11. Thrombocytopenia (<100,000/mm3) at least once 11. Thrombocytopenia (<100,000/mm3) at least once *Systemic Lupus International Collaborating Clinics (SLICC)*Systemic Lupus International Collaborating Clinics (SLICC)

SLICC Revision of the ACRSLICC Revision of the ACRClassification Criteria – ImmunologicClassification Criteria – Immunologic

1. 1. ANA (antinuclear antibody) above laboratory reference rangeANA (antinuclear antibody) above laboratory reference range

2. Anti-dsDNA above laboratory reference range (except 2. Anti-dsDNA above laboratory reference range (except ELISA: twice above laboratory reference range)ELISA: twice above laboratory reference range)

3. Anti-Sm (anti-Smith) antibody3. Anti-Sm (anti-Smith) antibody

4. APS abs: LAC, false-positive test for syphilis, anticardiolipin 4. APS abs: LAC, false-positive test for syphilis, anticardiolipin IgG, IgM, or IgA Abs, at least twice normal or medium-high IgG, IgM, or IgA Abs, at least twice normal or medium-high titer, same for anti-B2 glycoprotein 1titer, same for anti-B2 glycoprotein 1

5. Low complement: low C3, low C4, low CH505. Low complement: low C3, low C4, low CH50

6. Direct Coombs test in the absence of hemolytic anemia 6. Direct Coombs test in the absence of hemolytic anemia

Petri M, et al. A & R, 2012Petri M, et al. A & R, 2012

Lupus - SLICC* 17 New Classification Lupus - SLICC* 17 New Classification Criteria: 4 neededCriteria: 4 needed

• At least 1 clinical plus at least 1 immunologic At least 1 clinical plus at least 1 immunologic criteria (for a total of 4)criteria (for a total of 4)

oror

• Lupus nephritis by biopsy as the sole clinical Lupus nephritis by biopsy as the sole clinical criterion plus SLE autoantibodies: (+) ANA or criterion plus SLE autoantibodies: (+) ANA or (+) anti-dsDNA(+) anti-dsDNA

*Systemic Lupus International Collaborating Clinics (SLICC)*Systemic Lupus International Collaborating Clinics (SLICC)

Petri M, et al. A & R, 2012Petri M, et al. A & R, 2012

The Use of ANA for ScreeningThe Use of ANA for Screening• Anti-nuclear antibody (ANA) is considered a Anti-nuclear antibody (ANA) is considered a

screening method for diagnosis of autoimmune screening method for diagnosis of autoimmune disordersdisorders

• Immunofluorescence ANA assay (IF) remains Immunofluorescence ANA assay (IF) remains the gold standard for detection of ANA (2011 the gold standard for detection of ANA (2011 ACR position statement) ACR position statement)

• Many laboratories perform immunoassays (such Many laboratories perform immunoassays (such as the multiplexed immunobead assay), for the as the multiplexed immunobead assay), for the detection of ANA as it is less labor-intensivedetection of ANA as it is less labor-intensive

Our UTMB Data - AIMSOur UTMB Data - AIMS• To compare ANA detection by multiplex To compare ANA detection by multiplex

immunobead assay with the gold standard immunobead assay with the gold standard immunofluorescence (IF) at UTMB immunofluorescence (IF) at UTMB

• Patient samples tested for both assays: 110Patient samples tested for both assays: 110

• Multiplex immunobead assay (MIA) were Multiplex immunobead assay (MIA) were considered positive based on the manufacturerconsidered positive based on the manufacturer’’s s instructionsinstructions

• Immunofluorescence (IF)Immunofluorescence (IF) was considered was considered positive at a titer ≥ 1:160positive at a titer ≥ 1:160

MethodsMethods• Data collected prospectively on rheumatology patients from Data collected prospectively on rheumatology patients from

March 2011 to May 2012 tested for ANA by multiplex March 2011 to May 2012 tested for ANA by multiplex immunobead assay MIA (BioPlex ANA screen, Bio-Rad immunobead assay MIA (BioPlex ANA screen, Bio-Rad Laboratories, Hercules, CA, USA) and IF assay (HEp-2000 Laboratories, Hercules, CA, USA) and IF assay (HEp-2000 (Immuno Concepts, Sacramento, CA, USA) (Immuno Concepts, Sacramento, CA, USA)

• Patients were separated into 4 groups based on positive Patients were separated into 4 groups based on positive and negative ANA by MIA and IF assay and negative ANA by MIA and IF assay

• Data collected by individual chart review including age, Data collected by individual chart review including age, gender, ethnicity, and indication for ANA testing gender, ethnicity, and indication for ANA testing

• Performance characteristics of the immuno-assay were Performance characteristics of the immuno-assay were determined using the IF results as the determined using the IF results as the ““gold standardgold standard””

Baseline Demographic ComparisonBaseline Demographic Comparison  Multiplex +, IF+Multiplex +, IF+

(TP)(TP)Multiplex-, IF- Multiplex-, IF- (TN)(TN)

Multiplex+, IF-Multiplex+, IF- (FP)(FP)

Multiplex-Multiplex- IF+ (FN)IF+ (FN)

Age (mean±SD)yrsAge (mean±SD)yrs 45±1345±13 48±1548±15 47±1847±18 48±1648±16

Females n (%)Females n (%) 11 (91%)11 (91%) 59 (79%)59 (79%) 8 (89%)8 (89%) 13 (86%)13 (86%)

Ethnicity*(%)Ethnicity*(%) AA (16%)AA (16%) C (25%)C (25%) H (50%)H (50%)

AA (13%)AA (13%)C (70%)C (70%)H (9%)H (9%)

AA (33%)AA (33%)C (44%)C (44%)H (11%)H (11%)

AA (46%)AA (46%) C (46%)C (46%)

Reason for testing/Clinical Reason for testing/Clinical diagnosis (n)diagnosis (n)

           

SLESLE 55 11 11   

Sjogren’sSjogren’s 11         

RARA 11 99 11 22

Systemic sclerosis/PM/DMSystemic sclerosis/PM/DM          22

PolyarthralgiasPolyarthralgias 22 3030 22 66

Undifferentiated connective Undifferentiated connective tissue disordertissue disorder

22       33

OthersOthers 22 3232 55 11Dang N, Harper BE, Gonzalez EB, Pierangeli SS, Parekh TM, Loeffelholz M, Bufton KK. Real world experience comparing multiplex immunobead assay

vs immunofluorescence assay for anti-nuclear antibody detection at a university hospital. Abstract 1405, ACR Annual meeting, Washington, D.C,

Nov 2012, S605

Comparison of ANA MIA & IFComparison of ANA MIA & IF

  IF positive (≥1:160)IF positive (≥1:160)

Multiplex positive n (%) 12 (10%) TPMultiplex positive n (%) 12 (10%) TP

Multiplex negative n (%) 15 (14%) FNMultiplex negative n (%) 15 (14%) FN

IF negativeIF negative

9 (8%) FP9 (8%) FP

74 (67%) TN74 (67%) TN

Sensitivity: 44%Sensitivity: 44%Specificity: 89%Specificity: 89%Positive predictive value (PPV): 57%Positive predictive value (PPV): 57%Negative predictive value (NPV): 83%Negative predictive value (NPV): 83%

ConclusionsConclusions• Patients tested negative by the MIA (bioplex) included Patients tested negative by the MIA (bioplex) included

patients with definite ANA-associated autoimmune diseasespatients with definite ANA-associated autoimmune diseases

• These data suggest that screening with an immunoassay These data suggest that screening with an immunoassay would result in misclassification and potential delay or missed would result in misclassification and potential delay or missed diagnoses of certain systemic autoimmune diseases - diagnoses of certain systemic autoimmune diseases - Multiplex immunobead assay unreliableMultiplex immunobead assay unreliable

• Immunofluorescence (IF) should remain the preferred assay Immunofluorescence (IF) should remain the preferred assay for ANA testing in patients with suspicion of autoimmune for ANA testing in patients with suspicion of autoimmune disorders until platforms with sensitivities comparable to IF or disorders until platforms with sensitivities comparable to IF or better are developed. better are developed. IF the preferred method – Endorsed by IF the preferred method – Endorsed by the American College of Rheumatology (ACR)the American College of Rheumatology (ACR)

Dang N, Harper BE, Gonzalez EB, Pierangeli SS, Parekh TM, Loeffelholz M, Bufton KK. Real world experience Dang N, Harper BE, Gonzalez EB, Pierangeli SS, Parekh TM, Loeffelholz M, Bufton KK. Real world experience comparing multiplex immunobead assay versus immunofluorescence assay for anti-nuclear antibody detection at a comparing multiplex immunobead assay versus immunofluorescence assay for anti-nuclear antibody detection at a university hospital. Abstract 1405, ACR Annual meeting, Washington, D.C, Nov 2012, S605 university hospital. Abstract 1405, ACR Annual meeting, Washington, D.C, Nov 2012, S605

The Genetics of SLEThe Genetics of SLE

SLE – Genetic SusceptibilitySLE – Genetic Susceptibility

MHC RelatedMHC Related• HLA-DR1, 2, 3, 4HLA-DR1, 2, 3, 4• Alleles of HLA-DRB1, IRF5, Alleles of HLA-DRB1, IRF5,

and STAT4 and STAT4 • C2 - C4 deficiencyC2 - C4 deficiency• TNF-TNF- polymorphisms polymorphisms

Not MHC RelatedNot MHC Related• C1q deficiency (rare but highest risk)C1q deficiency (rare but highest risk)• Chromosome 1 region 1q41-43 Chromosome 1 region 1q41-43

(PARP), region 1q23 (Fc(PARP), region 1q23 (FcγγRIIA, RIIA, FcFcγγRIIIA)RIIIA)

• IL-10, IL-6 and MBL polymorphismsIL-10, IL-6 and MBL polymorphisms• Chromosome 8.p23.1: reduced Chromosome 8.p23.1: reduced

expression of expression of BLK BLK and increased and increased expression of expression of C8orf13 C8orf13 (B cell tyrosine (B cell tyrosine kinase), chromosome 16p11.22: kinase), chromosome 16p11.22: integrin integrin genes IGAM-ITGAX genes IGAM-ITGAX

• B cell gene BANK1B cell gene BANK1• X chromosome-linked gene IRAK1X chromosome-linked gene IRAK1

MHC = Major Histocompatibility ComplexMHC = Major Histocompatibility Complex

The Genetics of Lupus – A Complex The Genetics of Lupus – A Complex DiseaseDisease

Immune complex processing: C1q, C2-4, CRP,

ITGAM, FcGR2A, etc

TLR/type I, IFN pathway:STAT 1, IRAK1,

TREX1, etc

Immune signal transduction: HLA-DR, IRF5, STAT4, BANK1, PTPN22, BLK,

TNFSF4, etc

TLR = Toll-like receptorTLR = Toll-like receptorIFN = interferonIFN = interferon

The Future: Epigenetic alterations and potential biomarkers identified in The Future: Epigenetic alterations and potential biomarkers identified in SLESLEMechanismMechanism TargetTarget Cell TypeCell Type AlterationAlteration ConsequenceConsequence

DNA methylationDNA methylation

ITGAL (CD11a)ITGAL (CD11a)CD70 (TNFSF7)CD70 (TNFSF7)CD154 (CD40L)CD154 (CD40L)PerforinPerforinKIR familyKIR family

CD4 T cellsCD4 T cellsCD4 T cellsCD4 T cellsCD4 T cellsCD4 T cellsCD4 T cellsCD4 T cellsCD4 T cellsCD4 T cells

HypomethylationHypomethylationHypomethylationHypomethylationHypomethylationHypomethylationHypomethylationHypomethylationHypomethylationHypomethylation

Increased CD11a expressionIncreased CD11a expressionIncreased CD70 expression and B-cell Increased CD70 expression and B-cell costimulationcostimulationIncreased B-cell costimulationIncreased B-cell costimulationIncreased perforin expressionIncreased perforin expressionIncreased KIR expressionIncreased KIR expression

   RUNX3RUNX3 CD4 T cellsCD4 T cells HypermethylationHypermethylationDysregulation of ITGAL (CD11a) Dysregulation of ITGAL (CD11a) expressionexpression

   MMP9MMP9 CD4 T cellsCD4 T cells HypomethylationHypomethylation Cellular basement membrane breakdownCellular basement membrane breakdown

   CD9CD9 CD4 T cellsCD4 T cells HypomethylationHypomethylation T-cell activationT-cell activation

Histone Histone modificationmodification

Histone H4Histone H4 MonocytesMonocytesIncreased Increased acetylationacetylation

Increased expression of proinflammatory Increased expression of proinflammatory cytokinescytokines

MicroRNAMicroRNA miR-146amiR-146a PBMCsPBMCs UnderexpressionUnderexpression Type I IFN overproductionType I IFN overproduction

   miR-21miR-21 CD4 T cellsCD4 T cells OverexpressionOverexpressionDownregulation of DNMT1 (indirect) Downregulation of DNMT1 (indirect) and thus decreased DNA methylationand thus decreased DNA methylation

   miR-148amiR-148a CD4 T cellsCD4 T cells OverexpressionOverexpressionDownregulation of DNMT1 (direct) and Downregulation of DNMT1 (direct) and decreased DNA methylationdecreased DNA methylation

   miR-125amiR-125a PBMCsPBMCs UnderexpresssionUnderexpresssionIncreased KLF expression and thus Increased KLF expression and thus RANTES overproductionRANTES overproduction

   miR-126miR-126 CD4 T cellsCD4 T cells overexpressionoverexpressionDownregulation of DNMT1 and Downregulation of DNMT1 and decreased DNA methylationdecreased DNA methylation

Increased Interferon Alpha Increased Interferon Alpha (IFN(IFNαα) in Lupus ) in Lupus

The signature cytokine for the The signature cytokine for the disease? disease?

Pascual V, Banchereau J, Palucka KA. The central role of dendritic cells and interferon-alpha in SLE. Curr Opin Rheumatol. 2003; 15(5):548–556

Is It Lupus or IFN-Is It Lupus or IFN- Side Effects? Side Effects?

IFN IFN side effects side effects CytopeniasCytopenias AnemiaAnemia Arthralgias/myalgiasArthralgias/myalgias Skin rashSkin rash AlopeciaAlopecia (+) autoantibodies(+) autoantibodies Fever, malaise/flu-like Fever, malaise/flu-like

syndromesyndrome Seizures, pneumonitis, Seizures, pneumonitis,

etcetc

Lupus clinical Lupus clinical featuresfeatures

Basically the same Basically the same constellation of constellation of signs/symptoms plus signs/symptoms plus (+) autoantibodies(+) autoantibodies

One and the same?One and the same?

SLESLE

How Does Tissue Injury Occur?How Does Tissue Injury Occur?

SLE – Several Pathogenetic MechanismsSLE – Several Pathogenetic Mechanisms• Immune complex-mediated damage: glomerulonephritisImmune complex-mediated damage: glomerulonephritis

• Direct autoantibody-induced damage: thrombocytopenia and Direct autoantibody-induced damage: thrombocytopenia and hemolytic anemiahemolytic anemia

• APS-induced thrombosis and pregnancy morbidityAPS-induced thrombosis and pregnancy morbidity

• BLyS (BAFF)-APRIL (B lymphocyte stimulators) over-BLyS (BAFF)-APRIL (B lymphocyte stimulators) over-expression: expression: IFN IFN, TNF, TNF, IL-1, IL-6, IL-17, etc, IL-1, IL-6, IL-17, etc

• Complement-mediated inflammation: CNS lupus (C3a), Complement-mediated inflammation: CNS lupus (C3a), hypoxemia, and also anti-phospholipid mediated fetal losshypoxemia, and also anti-phospholipid mediated fetal loss

• Either failure of or abnormal response to normal apoptosisEither failure of or abnormal response to normal apoptosis

Lupus – Complement LevelsLupus – Complement Levels

Patients who are always hypocomplementemic Patients who are always hypocomplementemic regardless of clinical disease activity may have regardless of clinical disease activity may have

an underlying complement deficiency!an underlying complement deficiency!

Mortality in Lupus - Bimodal PeaksMortality in Lupus - Bimodal Peaks

Early:Early:• Increased disease activity Increased disease activity • Infections due to immunosuppressionInfections due to immunosuppression

Late:Late:• Deaths the result of permanent damage: treatment side Deaths the result of permanent damage: treatment side

effects, atherosclerosis with CAD and heart attacks, effects, atherosclerosis with CAD and heart attacks, strokes, pulmonary, end-stage renal disease (ESRD), etcstrokes, pulmonary, end-stage renal disease (ESRD), etc

Urowitz MB et al. Am J Med 1976Urowitz MB et al. Am J Med 1976Cervera R et al. Cervera R et al. Medicine Medicine 19991999

Survival rates significantly improved in patients diagnosed 1980-1992, vs 1950-79However, survival is significantly worse than in the general population Uramoto KM, et al. A & R. 1999;42:46-46-50; Bernatsky S, et al. A & R. 2006;54:2550-2557

Coronary Heart Disease in Lupus: Premature or Accelerated Coronary Heart Disease in Lupus: Premature or Accelerated AtherosclerosisAtherosclerosis

The prevalence ranges from 6 to 15%The prevalence ranges from 6 to 15%

The incidence of a MI is 5 times higher in lupus than in The incidence of a MI is 5 times higher in lupus than in the general populationthe general population

The risk of adverse cardiovascular outcomes is The risk of adverse cardiovascular outcomes is by a by a factor of 7 to 17 in patients with lupus as compared with factor of 7 to 17 in patients with lupus as compared with the Framingham cohort the Framingham cohort

Young women (between ages 35 and 44) are significantly Young women (between ages 35 and 44) are significantly more likely (52-fold increased risk) to experience an MI if more likely (52-fold increased risk) to experience an MI if they have lupusthey have lupus

Reasons: multifactorial and not explained just by the Reasons: multifactorial and not explained just by the traditional CAD risk factors traditional CAD risk factors

Ward MM. Arthritis Rheum 1999; 42(2): 338-46; Manzi S et al. Am J Epidemiol 1997; 145: 408-15; Petri M, et al. Am J Ward MM. Arthritis Rheum 1999; 42(2): 338-46; Manzi S et al. Am J Epidemiol 1997; 145: 408-15; Petri M, et al. Am J Med 1992; 93: 513-9; Sturfelt G, et al. Medicine (Baltimore) 1992; 71: 216-23; Esdaile JM, et al. Arthritis Rheum Med 1992; 93: 513-9; Sturfelt G, et al. Medicine (Baltimore) 1992; 71: 216-23; Esdaile JM, et al. Arthritis Rheum 2001; 44: 2331-72001; 44: 2331-7

Leading Causes of Death in SLELeading Causes of Death in SLE

Active lupusActive lupus

InfectionInfection

Cardiovascular diseaseCardiovascular disease

SLE - MortalitySLE - MortalityStudy Site:Study Site: CaliforniaCalifornia¹¹ Toronto Toronto²²

DenmarkDenmark³³

Patient #:Patient #: 408 408 665 665 513 513

Deaths: 144 124 122Deaths: 144 124 122

Active lupus: 49 (34%) 20 (16%) 19 (15.5%)Active lupus: 49 (34%) 20 (16%) 19 (15.5%)

Infection: 32 (22%) 40 (32%) 25 (20.5 %)Infection: 32 (22%) 40 (32%) 25 (20.5 %)

CV disease: 23 (16%) 19 (15.4%) 32 (26.2%)CV disease: 23 (16%) 19 (15.4%) 32 (26.2%)

1. Ward MM, et al. A&R 1995; 38: 1492-91. Ward MM, et al. A&R 1995; 38: 1492-9

2. Abu-Shakra M, et al. J Rheum 1995; 22: 1259-642. Abu-Shakra M, et al. J Rheum 1995; 22: 1259-64

3. Jacobsen S, et al. Scand J Rheumatol 1999; 28: 75-803. Jacobsen S, et al. Scand J Rheumatol 1999; 28: 75-80

SLESLE

Therapeutic ApproachesTherapeutic Approaches

Treatment of LupusTreatment of Lupus• Vitamin D (an immunomodulator!) Vitamin D (an immunomodulator!)

• Hydroxychloroquine (HCQ) (PlaquenilHydroxychloroquine (HCQ) (Plaquenil®®))

• Corticosteroids – Minimize to the extent possibleCorticosteroids – Minimize to the extent possible

• Immunosuppressive agents (MTX, azathioprine, Immunosuppressive agents (MTX, azathioprine, mycophenolate mofetil, etc)mycophenolate mofetil, etc)

• Targeted biologic therapies: belimumab (BenlystaTargeted biologic therapies: belimumab (Benlysta®), ®), rituximab (Rituxan®)rituximab (Rituxan®)

• Statins? especially for APS (antiphospholipid syndrome)?*Statins? especially for APS (antiphospholipid syndrome)?* *Erkan D, Willis R, Murthy VL, Basra G, Vega J, Ruiz-Limón P, Carrera AL, Papalardo E, Martínez-Martínez LA, González *Erkan D, Willis R, Murthy VL, Basra G, Vega J, Ruiz-Limón P, Carrera AL, Papalardo E, Martínez-Martínez LA, González

EB, Pierangeli SS. A prospective open-label pilot study of fluvastatin on proinflammatory and prothrombotic biomarkers EB, Pierangeli SS. A prospective open-label pilot study of fluvastatin on proinflammatory and prothrombotic biomarkers in antiphospholipid antibody positive patients.in antiphospholipid antibody positive patients. Ann Rheum Dis. 2013 Aug 9. doi: 10.1136/annrheumdis-2013-203622. Ann Rheum Dis. 2013 Aug 9. doi: 10.1136/annrheumdis-2013-203622. [Epub ahead of print] PMID: 23933625[Epub ahead of print] PMID: 23933625

Every patient with lupus should be on Every patient with lupus should be on vitamin D and hydroxychloroquine (HCQ)!vitamin D and hydroxychloroquine (HCQ)!• A 20-ng/ml increase in the 25 (OH) D level was associated A 20-ng/ml increase in the 25 (OH) D level was associated

with a 21% decrease in the odds of having a high disease with a 21% decrease in the odds of having a high disease activity score activity score

• Fifteen (15%) decrease in the odds of having clinically Fifteen (15%) decrease in the odds of having clinically important proteinuria important proteinuria

• There was no evidence of additional benefit of 25 (OH) D There was no evidence of additional benefit of 25 (OH) D beyond a level of 40 ng/mlbeyond a level of 40 ng/ml

Petri M, et al. A & R 2013; 65: 1865–1871Petri M, et al. A & R 2013; 65: 1865–1871

Willis R, Jajoria P, Harper BE, Gonzalez EB, Petri M, Akhter E, Fang H, Pierangeli SS, Willis R, Jajoria P, Harper BE, Gonzalez EB, Petri M, Akhter E, Fang H, Pierangeli SS, Abstract Abstract

691, ACR Annual meeting, Washington, D.C, Nov 2012, S296.691, ACR Annual meeting, Washington, D.C, Nov 2012, S296.

HydroxychloroquineHydroxychloroquine (HCQ)(HCQ)• It prevents thrombotic events in lupus patients. Ongoing randomized It prevents thrombotic events in lupus patients. Ongoing randomized

multi-center trial, APS-ACTION, including UTMB multi-center trial, APS-ACTION, including UTMB

• HCQ is an anti-platelet agent, inhibiting aPL-induced GPIIb/IIIa HCQ is an anti-platelet agent, inhibiting aPL-induced GPIIb/IIIa expression; it does not prolong bleeding timeexpression; it does not prolong bleeding time

• It prevents lupus flare-ups and progression of disease, including It prevents lupus flare-ups and progression of disease, including lupus nephritis (LUMINA). It prevents diabetes in patients with RA lupus nephritis (LUMINA). It prevents diabetes in patients with RA receiving it receiving it

• It lowers glycemia and lipids (although modestly)It lowers glycemia and lipids (although modestly)

• It downregulates inflammation at different levels: prostaglandins, It downregulates inflammation at different levels: prostaglandins, DNA Abs, T cell activation, inhibits intracellular TLR activation (7 & DNA Abs, T cell activation, inhibits intracellular TLR activation (7 & 9), inhibits IFN-a,9), inhibits IFN-a, IL-1 and IL-6 production, protects the annexin-5 IL-1 and IL-6 production, protects the annexin-5 anticoagulant shield from aCL, etcanticoagulant shield from aCL, etc

Willis R, Pierangeli S, Alarcon G, Seif A, Reveille JD, GonzWillis R, Pierangeli S, Alarcon G, Seif A, Reveille JD, Gonzáález EB, Dang N, Martìnez Martìnez LA, lez EB, Dang N, Martìnez Martìnez LA, Papalardo E, Liu J, McGwin G, Vila LM. Effect of hydroxychloroquine on Pro Inflammatory Cytokines Papalardo E, Liu J, McGwin G, Vila LM. Effect of hydroxychloroquine on Pro Inflammatory Cytokines

and and Disease Activity in SLE Patients: Data from LUMINA (LXXV), a Multiethnic US Cohort. Lupus 2012 Jul; Disease Activity in SLE Patients: Data from LUMINA (LXXV), a Multiethnic US Cohort. Lupus 2012 Jul; 21(8):830-5. Epub 2012 Feb 17. 21(8):830-5. Epub 2012 Feb 17. PMID: 22343096 PMID: 22343096

+Effect of HCQ therapy

Biomarker Before Rx/median After Rx/median p-value

IL6 (pg/mL) 10.68 5.79 0.7956

IL8 (pg/mL) 22.27 16.37 0.9390

VEGF (pg/mL) 164.29 176.97 0.3797

MCP1 (pg/mL) 665.96 738.97 0.5361

IP10 (pg/mL) 525.85 556.81 0.7913

sCD40L (pg/mL) 3053.52 1241.83 0.9027

IFNα (pg/mL) 573.06 381.03 0.2507

IL1 β (pg/mL) 0.00 0.00 0.2645

TNFα (pg/mL) 9.10 7.55 0.8663

aCL IgG (GPL) 9.09 9.60 0.5996

aCL IgM (MPL) 3.04 3.28 0.8870

aCL IgA (APL) 0.12 0.11 0.9096

SLAM-R 9 7 0.0157

Strong positive correlation between the decreases observed in IFN-a and SLAM-R after Strong positive correlation between the decreases observed in IFN-a and SLAM-R after HCQ therapy (Spearman correlation coefficient 0.614, p = 0.0087)HCQ therapy (Spearman correlation coefficient 0.614, p = 0.0087)

Willis R, Pierangeli S, Alarcon G, Seif A, Reveille JD, GonzWillis R, Pierangeli S, Alarcon G, Seif A, Reveille JD, Gonzáález EB, Dang N, Martìnez Martìnez LA, Papalardo E, Liu J, lez EB, Dang N, Martìnez Martìnez LA, Papalardo E, Liu J, McGwin G, Vila LM. McGwin G, Vila LM. Lupus 2012 Jul; 21(8):830-5. Epub 2012 Feb 17. PMID: 22343096 Lupus 2012 Jul; 21(8):830-5. Epub 2012 Feb 17. PMID: 22343096

N = 35 ptsN = 35 pts(LUMINA)(LUMINA)

Two centers:Two centers: • Hospital for Special Surgery (HSS), New York, NY Hospital for Special Surgery (HSS), New York, NY • UTMB, Galveston, TXUTMB, Galveston, TX

Four groups:Four groups:

1.1.Primary APS (PAPS)Primary APS (PAPS)

2.2.SLE /aPL positive SLE /aPL positive

3.3.Secondary APS (SAPS): SLE + APS Secondary APS (SAPS): SLE + APS

4.4.Persistently positive aPL Persistently positive aPL

NCT00674297 Fluvastatin Pilot Trial - 41 Patients, Fluvastatin Pilot Trial - 41 Patients, 24 completing the study24 completing the study

BaselineBaseline

Fluvastatin 40 mg daily

Follow up at 1, Follow up at 1, 2, 3 months2, 3 months

Preliminary Analysis

At 5At 5thth month monthfluvastatin stoppedfluvastatin stopped

Final analysis at 6Final analysis at 6thth month month

Study ProtocolStudy Protocol

* P value <0.0001

Effects of Fluvastatin on Levels of Biomarkers in aPL(+) PatientsEffects of Fluvastatin on Levels of Biomarkers in aPL(+) Patients

Elevated biomarkers in Elevated biomarkers in persistently aPL-positive persistently aPL-positive patients; patients;

– IL6IL6– VEGFVEGF– IP10IP10– sCD40LsCD40L– INFINFα2α2– IL1IL1ββ– TNFTNFαα– sTF sTF – sICAM-1sICAM-1

Fluvastatin 40 mg daily for 3 Fluvastatin 40 mg daily for 3 months reduced the levels of months reduced the levels of the following biomarkers in the following biomarkers in persistently aPL-positive persistently aPL-positive patients patients

– IL1βIL1β– VEGFVEGF– TNFαTNFα– IP10IP10– sCD40LsCD40L– sTFsTF

Summary of ResultsSummary of Results

Fluvastatin significantly and reversibly reduced the levels of 6/12 (50%) Fluvastatin significantly and reversibly reduced the levels of 6/12 (50%) biomarkers (IL1β, VEGF, TNFα, IP10, sCD40L and sTF)biomarkers (IL1β, VEGF, TNFα, IP10, sCD40L and sTF)

Erkan D, Willis R, Murthy VL, Basra G, Vega J, Ruiz-Limón P, Carrera AL, Papalardo E, Martínez-Martínez LA, Erkan D, Willis R, Murthy VL, Basra G, Vega J, Ruiz-Limón P, Carrera AL, Papalardo E, Martínez-Martínez LA, González EB, Pierangeli SS. A prospective open-label pilot study of fluvastatin on proinflammatory and González EB, Pierangeli SS. A prospective open-label pilot study of fluvastatin on proinflammatory and prothrombotic biomarkers in antiphospholipid antibody positive patients. Ann Rheum Dis. 2013 Aug 9. doi: prothrombotic biomarkers in antiphospholipid antibody positive patients. Ann Rheum Dis. 2013 Aug 9. doi: 10.1136/annrheumdis-2013-203622. [Epub ahead of print] PMID: 23933625 10.1136/annrheumdis-2013-203622. [Epub ahead of print] PMID: 23933625

NSAIDS and SteroidsNSAIDS and Steroids

New FDA-Approved Agent – New FDA-Approved Agent – Belimumab (BenlystaBelimumab (Benlysta®®))

• Anti-BLYS humanized monoclonal antibody. Anti-BLYS humanized monoclonal antibody. Ongoing Phase IV trials in African-American Ongoing Phase IV trials in African-American patients (multi-center trial including UTMB)patients (multi-center trial including UTMB)

• Problematic indications: not for thrombocytopenia, Problematic indications: not for thrombocytopenia, CNS, or renal lupusCNS, or renal lupus

• Helpful but modest efficacyHelpful but modest efficacy

• It helps reduce steroids, prevent flares, and It helps reduce steroids, prevent flares, and maintain disease remission! maintain disease remission!

Belimumab LBSL02 phase 2 SLE studyBelimumab LBSL02 phase 2 SLE study

Belimumab Significantly ReducedBelimumab Significantly Reduced Anti-dsDNA By Week 4 Anti-dsDNA By Week 4

15% of anti-dsDNA positive subjects treated with belimumab 15% of anti-dsDNA positive subjects treated with belimumab converted to negative compared to 3% of placebo patientsconverted to negative compared to 3% of placebo patients

p=0.0296 week 24; p=0.0015 week 52; anti-dsDNA+ defined as p=0.0296 week 24; p=0.0015 week 52; anti-dsDNA+ defined as ≥ 30 IU/mLby ELISA≥ 30 IU/mLby ELISA

Updated data through 76 weeks to be presented at ACR on 11/14: Abstract #1985 Stohl et al.

The Future - Biomarkers and Targeted TherapiesThe Future - Biomarkers and Targeted Therapies• Develop better biomarkers for flares and predictors of Develop better biomarkers for flares and predictors of

responseresponse

• Corticosteroid-free regimensCorticosteroid-free regimens

• Other B cell blockers, e.g., ocrelizumab, epratuzumab, Other B cell blockers, e.g., ocrelizumab, epratuzumab, TACI-Ig (atacicept, an anti-BLyS/April agent). Ongoing trials TACI-Ig (atacicept, an anti-BLyS/April agent). Ongoing trials

• Interferon alpha (IFNInterferon alpha (IFN) blockers, e.g., sifalimumab. Good ) blockers, e.g., sifalimumab. Good promising data. Ongoing trialspromising data. Ongoing trials

• Anti-C5: humanized monoclonal Ab, especially for APS, Anti-C5: humanized monoclonal Ab, especially for APS, ongoing trials, including UTMB ongoing trials, including UTMB

• Interferon gamma (IFNInterferon gamma (IFNγγ)) blockers: for renal lupus. Ongoing blockers: for renal lupus. Ongoing trials trials

Petri M, et al. Sifalimumab, a human anti-IFN alpha antibody in SLE. A & R 65; 2013: 1011-21Petri M, et al. Sifalimumab, a human anti-IFN alpha antibody in SLE. A & R 65; 2013: 1011-21

FINFIN

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