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Cd11c As a Transcriptional Biomarker to Predict Response to Anti-TNF Monotherapy with Adalimumab in Patients with Rheumatoid Arthritis

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Cd11c As a Transcriptional Biomarker to Predict Response to Anti-TNF Monotherapy with Adalimumab in Patients with Rheumatoid Arthritis nature publishing group ARTICLES CD11c as a Transcriptional Biomarker to Predict Response to Anti-TNF Monotherapy With Adalimumab in Patients With Rheumatoid Arthritis B Stuhlmüller1, T Häupl1, MM Hernandez1, A Grützkau2, R-J Kuban3, N Tandon1, JW Voss4, J Salfeld4, RW Kinne5 and GR Burmester1 We performed transcription profiling using monocytes to identify predictive markers of response to anti–tumor necrosis factor (anti-TNF) therapy in patients with rheumatoid arthritis (RA). Several potential predictors of response were identified, including CD11c. Validation in samples from independent cohorts (total of n = 27 patients) using reverse transcription–PCR confirmed increased expression of CD11c in responders to adalimumab (100% sensitivity; 91.7% specificity, power 99.6%; α = 0.01). Pretherapy CD11c levels significantly correlated with the response criteria as defined by the American College of Rheumatology (ACR) (r = 0.656, P < 0.0001). However, CD11c was neither predictive of response to methotrexate (MTX) alone (n = 34) nor to MTX in combination with adalimumab (n = 16). Clinical responders revealed a reset to a normal expression pattern of resident/inflammatory monocyte markers, which was absent in nonresponders. Therefore, an analysis of key cell types identifies potentially predictive biomarkers that may help to restrict the use of adalimumab to therapy responders. Larger studies, including studies of monotherapy with other drugs, are now needed to confirm and validate the specificity of CD11c for anti-TNF biologics. Tumor necrosis factor (TNF), a cytokine known to be produced Approximately 40% of RA patients either do not respond at by monocytes,1,2 promotes the synthesis of proinflammatory all or only inadequately respond to anti-TNF monotherapy,8–10 cytokines, stimulates endothelial cells to express adhesion and predictors of outcome for monotherapies are currently molecules, and accelerates the synthesis of metalloproteinas- not available. This is a major drawback, considering the risk es.1 Systemic TNF neutralization in rheumatoid arthritis (RA) involved in exposing nonresponders to the sometimes serious responders is associated with a remarkable suppression of local side effects of TNF blockade11–15 (http://jama.ama-assn.org/ and systemic inflammation, as well as with a reduction in bone cgi/reprint/296/18/2203.pdf; http://jama.ama-assn.org/cgi/ destruction1,3 and radiological progression of joint destruction.4 reprint/296/18/2203-a.pdf) and the substantial costs of this Thus, TNF blockade inhibits inflammatory mechanisms and local treatment. tissue destruction initiated by cells of the monocytic lineage.5 Assessing gene-expression changes in circulating blood TNF-blocking agents lead to the control of RA activity in cells6,7,16 is an attractive approach for the following reasons: the 60–80% of patients when used in combination with meth- blood transcriptome constitutes a source of potential markers; otrexate (MTX). Gene profiling at baseline shows that levels response to factors undetectable in the serum may be measured of different small subsets of transcripts are suitable for reliably in circulating immune cells; and commercial microarrays, at predicting response to either infliximab/MTX in MTX-resistant affordable costs and with good reproducibility, allow measure- RA subjects6 or etanercept in combination with various disease- ment of blood transcriptional profiles on an unprecedented modifying antirheumatic drugs.7 scale using mainstream microarray technology. As a result, a 1Department of Rheumatology and Clinical Immunology, Charité University Hospital, Humboldt University of Berlin, Berlin, Germany; 2Deutsches Rheumaforschungszentrum, Cell Sorting Unit, Berlin, Germany; 3Laboratory of Functional Genomics, Charité-Universitätsmedizin Berlin, Berlin, Germany; 4Abbott Bioresearch Center, Worcester, Massachusetts, USA; 5Department of Orthopedics, Experimental Rheumatology Unit, University Hospital Jena, Jena, Germany. Correspondence: B Stuhlmüller ([email protected]) Received 6 July 2009; accepted 16 October 2009; advance online publication 23 December 2009. doi:10.1038/clpt.2009.244 CLINICAL PHARMACOLOGY & THERAPEUTICS | VOLUME 87 NUMBER 3 | MARCH 2010 311 ARTICLES number of studies have been carried out on the blood profiles application) were examined before and during adalimumab of patients with autoimmune diseases,17–19 including RA,6,7,16 monotherapy and compared with monocytes from seven age- in an attempt to discover diagnostic and prognostic biomarker matched normal donors. signatures. As shown by Batliwalla et al., 21 of 52 genes overex- The group of seven patients constituted a representative RA pressed in peripheral blood mononuclear cells of RA patients cohort and demonstrated the expected correlations among clini- were monocyte specific.19 The expression levels of these mono- cal parameters before and after anti-TNF treatment (Table 1). cyte-related genes showed a significant correlation with disease This RA group included two nonresponders to adalimumab activity in patients who were studied just before starting therapy therapy (RA patients 4 and 6) as assessed by the American with a new disease-modifying antirheumatic drug, either MTX College of Rheumatology (ACR) improvement criteria (ACR or an anti-TNF agent. Furthermore, monocyte activation seems score <20; see Table 2 for baseline characteristics of respond- to contribute to flare-ups of RA after pregnancy, as shown by ers and nonresponders; details are available in Supplementary comparative analysis of peripheral blood before and after birth Table S1 online).23 For these two patients, the percentage reduc- and by comparison with the specific expression signatures of tions in markers of local or systemic inflammation (i.e., swol- normal blood cells.20 len joint count, erythrocyte sedimentation rate, and C-reactive A number of studies on the monocyte lineage in RA have focused on the activation of these cells and the appearance of Table 1 Correlations among clinical parameters particular subsets in the periphery. The CD14+/CD16+ mono- (Pearson correlation test; before and after anti-TNF cyte subset appears to be increased in RA patients.21 CD14+/ treatment with adalimumab) CD16+ cells have features that are similar to those of activated r Value P value tissue macrophages; they express altered levels of chemokine Morning stiffness/swollen joint count 28 0.718 0.004 receptors and adhesion molecules and have an enhanced capac- Morning stiffness/swollen joint count 68 0.664 0.010 ity for transendothelial migration. Both subsets (CD16+ and Swollen joint count 28/swollen joint count 68 0.990 0.001 CD16−) of monocytes are able to differentiate into dendritic cells in vitro. The binding of small immunoglobulin G–rheumatoid Painful joint count 28/painful joint count 68 0.794 0.001 factor immune complexes to CD16+ monocytes could enhance ESR/CRP 0.854 0.000 TNF induction in tissue macrophages. ESR/VAS (physician) 0.764 0.001 In the present study, it appeared advantageous to investigate ESR/DAS28 0.813 0.000 enriched monocytes, given their prominent involvement in CRP/morning stiffness 0.733 0.003 the processes of RA pathology that are particularly responsive CRP/swollen joint count 28 0.762 0.002 to anti-TNF.22 By taking this approach, we sought to focus on immune functions of this cell type instead of using whole blood CRP/swollen joint count 68 0.728 0.003 samples and to identify single biomarkers that would be suffi- CRP/DAS28 0.786 0.001 cient for the prediction of anti-TNF response in RA. In addition, DAS28/swollen joint count 28 0.891 0.000 to investigate drug specificity and the effect of comedication, DAS28/swollen joint count 68 0.878 0.000 we tested the informative value of the predictive biomarkers DAS28/painful joint count 28 0.660 0.010 also in patients treated either with MTX alone or with MTX in VAS (physician)/swollen joint count 68 0.672 0.008 combination with adalimumab. VAS (physician)/painful joint count 28 0.697 0.006 RESULTS VAS (physician)/DAS28 0.790 0.001 Gene-expression profiling and microarray analysis Correlation between clinical parameters in RA patients before and after adalimumab In an initial exploratory analysis using microarrays, monocytes treatment (n = 14). CRP, C-reactive protein; DAS28, disease activity score (28 joints); ESR, erythrocyte from seven patients with RA (study DE011; adalimumab anti- sedimentation rate; VAS (physician), visual analog scale of the physician’s global TNF therapy without disease-modifying antirheumatic drug assessment of disease activity. Table 2 Characteristics of RA patients prior to treatment with adalimumab in responders and nonresponders Disease duration (years) Age (years) Gender (F/M) RF (+/−) ESR (mm/h) CRP (mg/l) DAS28 score Responders Mean ± SD 8.6 ± 10.3 48.9 ± 12.2 15/0 13/2 44.9 ± 20.5 31.2 ± 19.7 6.7 ± 0.9 Median (range) 3.0 (<1–38) 47.0 (33–70) 33.0 (22–80) 31.5 (<3.5–61.1) 6.3 (5.2–8.5) Nonresponders Mean ± SD 8.8 ± 11.1 54.8 ± 12.3 11/1 8/4 51.5 ± 25.3 30.4 ± 35.3 6.4 ± 0.8 Median (range) 5.0 (<1–38) 52.5 (34–79) 40.0 (16–90) 16.2 (<3.5–106) 6.4 (4.7–8.0) Patient data extracted from Supplementary Table S1 online. CRP, C-reactive protein; DAS28, disease activity score (28 joints); ESR, erythrocyte sedimentation rate; RF, rheumatoid factor. 312 VOLUME 87 NUMBER 3 | MARCH 2010 | www.nature.com/cpt ARTICLES a b −2.0 1.1 2.0 −2.0 1.1 2.0 RA_4 RA_6 RA_2 RA_3 RA_5 RA_7 RA_1 RA_4 RA_6 RA_2 RA_5 RA_3 RA_7 RA_1 212671_s_at 203097_s_at 214953_s_at 204160_s_at 207008_at
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