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
Dec 16, 2015
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
љњҗ
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
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.
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
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…
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