The 1rst Kuwait-North American
Update in Internal Medicine Conference
8-9 February 2014
BIOMARKERS TO GUIDE
TREATMENT IN RA
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 yrs
depending on the severity of the disease
Textbook
RA Biomarkers
Clinical 2010
AutoAbs 2010
Genetic
Imaging
Prognosis
RA
TEXTBOOK
љњҗ
EA/ERA
Office
Early Intervention
CLINICAL PROGRES
The ACR-EULAR 2010
Classification Criteria
A probabilistic approach to
early diagnosis
1987 CRITERIA
Mean Disease Duration: 8 Years
Arthritis and Rheumatism 31:315-24,1988
Goals 2010
In 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§
Score
1 large joint
0
2-10 large joints
1
1-3 small joints (with or without involvement of large joints)#
2
4-10 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
0
Low-positive RF or low-positive ACPA
2
High-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
0
Abnormal CRP or abnormal ESR
1
D. Duration of symptoms§§ < 6 weeks
> 6 weeks
0
1
HYPOTHETICAL COURSE of RA
1987 Established RA
2010 Early RA
Inflammation
clinical
threshold
Auto-Ab
Pre-RA
Time
POST-2010 PERSPECTIVES
• New treatment approaches
• New remission criteria
• Extrapolation
• Validation
• Stratification
• No erosions
• 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
12
12
KUWAIT
Biomarkers For Early Disease
1. Clinical : ACR-EULAR 2010 Criteria
2. Serological : Citrullinated Immune Systems
Studying Auto-Immune Systems
Auto-Abs
Clinician
Auto-Ags
Biologist
 DIAGNOSIS
 PROGNOSIS
 MONITORING
 TOOLS FOR BIOLOGY
 PHYSIOPATHOLOGY
 CLUES TO ETIOLOGY
Roadmap to Personalized Medicine
Rheumatoid Arthritis
An In Vivo ELISA
n
Ag
Abn
(Many)
(Many)
Anti-IgGs
(RFs)
Primary Systems
Secondary Systems
Specificity
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
ACPAs
• Anti-Citrullinated PEPTIDE Antibodies.
• Anti-Citrullinated PROTEINS Antibodies
The Antigen(s)
Citrullination is
the Enzymatic Conversion of
Arginine To Citrulline
Citrullination: A Mechanism
To Recycle Aminoacids
1
2
4
5
3
Citrullination
An 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 ACPAcontaining 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
Ceiling effect
ULT
O.D.
ULN
Low Threshold
Anti-CCP2 Titer
van Venrooij W 2003
Retrospective Study
Scandinavian Blood Donors
Cumulative percentage of patients with one
or more positive test results before symptoms
Percentage of positive patients
60
50
49%
40
41%
30
28%
20
IgM-RF or anti-CCP
anti-CCP
10
IgM-RF
0
15
14
13
12
11
10
9
8
7
6
5
4
3
2
1
0
Years before start of symptoms
SR Dahlqvist et al. A&R 2003
Hypothetical Course of RA
1987 Established RA
2010 Early RA
Inflammation
clinical
threshold
Auto-Ab
Pre-RA
Time
Prospective Study
North 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…
Co-PI : HA Ménard
Montreal, Quebec
PI : H El-Gabalawy,
Winnipeg, Manitoba
Anti-Sa ELISA (2004) : Design
For Prognosis and Monitoring
Individual RA Patients
ULT
ULT
O.D.
ULN
ULN
Anti-CCP Titer
Anti-Sa titer
Anti-Sa / anti-CCP2 In NAN
A Prospective Study
Anti-CCP2
ELISA
Anti-Sa
ELISA
79%
20%
9%
RA
FDR
UNRELATED
51%
0%
0%
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
Titers at Inclusion (n)
Erosive (≥ 5) % (n)
Very Erosive (≥14) % (n)
RF (n=253)
Neg (140)
Pos (113)
Low (21)
Moderate/High (92)
42.9 (60)
55.8 (63)
42.9 (9)
58.7 (54) p<0.05
29.3 (41)
40.7 (46)
38.1 (8)
32.6 (38)
Anti-CCP2 (n=253)
Neg (156)
Pos (97)
Low (11)
Moderate/High (86)
42.9 (67)
57.7 (56)
54.5 (6)
58.1 (50) p<0.05
31.4 (49)
39.2 (38)
36,4 (4)
39.5 (34)
Anti-Sa (n=253)
Neg (195)
Pos (58)
Low (18)
Moderate/High (40)
41.0 (80)
74.1 (43) p<0.0001
66.7 (12)
77.5 (31) p<0.0001
29.2 (57)
51.7 (30) p<0.005
33.3 (6)
60.0 (24) p<0.0005
Guzian C et al. (Boire G, Ménard H) AR&T 2010
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.
MONITORING RA WITH ANTI-Sa
Lili R-L.
Citrulline
4100
0.4
0.3
3900
0.2
3700
0.1
3500
0
29
36
41
0.5
5000
0.4
0.3
4500
0.2
4000
SR
Week
0.6
5500
3500
Citrulline
6000
1
5000
0
211
CSR
Week
MonoA
Aghda D.
RA
1.8
1
0.8
3500
0.6
0.4
3000
0.2
0
Anti-Sa
4000
0.05
0
56
-0.05
1
76
1
36
56
80
99
Week
Clotilde Z.
Citrulline
3
Anti-Sa
4500
Palindrome
0.8
2
5000
1.5
4500
1
4000
0.5
Citrulline
0.7
2.5
5500
CSR
Anti-Sa
0.6
4000
0.5
0.4
0.3
3500
0.2
0.1
3500
0
3
11
56
56
93
Week
93
105 133 152 180
CR
0
1
1
2
30
53
79
CSR
Week
CSR = Clinical Serological Remission
Anti-CCP2 never changed significantly
CR
Rotman J (Ménard HA) European Workshop Rheum Res Toulouse 2008
17
Week
40
RA VASC
1
1.2
11
0.1
2700
3000
Anti-Sa
1.4
1
0.15
2900
Citrulline
1.6
4500
2500
24
6000
Citrulline (nmol/mL)
4000
Citrulline (nmol/mL)
6500
0.5
185
0.2
Suzanne C.
Anti-Sa
1.5
Anti-Sa
Citrulline (nmol/mL)
2
136
0.25
Week
7000
5000
20
Anti-Sa
0.3
3100
0
10
Citrulline
0.35
2500
1
1
RTX
3300
0.1
Jasmine C.
ERA
3500
Citrulline (nmol/mL)
28
0.7
0.45
0.4
Anti-Sa
Anti-Sa
1
RTX
6000
Citrulline (nmol/mL)
0.5
3700
Citrulline
0.8
Dieter R.
Anti-Sa
0.6
4300
RA VASC
Citrulline (nmol/mL)
6500
0.7
Anti-Sa
Citrulline (nmol/mL)
Anti-Sa
0.8
4500
Anti-Sa
4700
NHL-RA
Anti - Sa
Lazina H.
ERA
43
Summary Of ACPA in Pre-RA
- 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.
Clinical Summary of ACPA Literature
In 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
3.
4. for DIAGNOSIS
anti-Sa>> CCP > MCV
5. for MONITORING
anti-Sa >> MCV >> CCP = 0
6. ACPA are highly correlated with RF
onset, treatment.
– 80-90% ACPA also have RF
anti-CCP = MCV > anti-Sa
– 50-85% RF also have ACPA
For SCREENING
– 25-30% RF(-) have ACPA
anti-CCP > MCV >> Sa
– Same in children with adult form
more sensitive, less specific.
Interpretation Of The Clinical Data
ANA
NEPHRITIS
ARTHRITIS
SLE
RA
Anti-dsDNA
Anti-CCP
Anti-Sa
“It is not one or the other, it is one and the other”.
Ménard HA. Nature Clin Practice Rheumatol 2007.
SHUKRAN
ALA ALDAWAH