B-lymphocytes are lymphoid cells, which are a part of the adaptive/innate immune system and generate antibodies. Recently, many studies have supported hypothesis that different rather minor B-lymphocyte subpopulations may play a direct and indirect role in immunopathogenesis in human pathologies such as Crohn's disease (CD). The aim of current study was therefore to investigate distribution of frequencies of B lymphocyte subpopulations (from transient to mature effector B cell stages) in peripheral blood of healthy subjects (CO), patients with Crohn's disease (CD) and ulcerative colitis (UC). Thus, using 11-colour flow cytometry we have analysed 30 blood samples of individuals, including 14 healthy controls, 11 patients with Crohn's disease and 5 with UC. In 6 patients with CD we have had an opportunity to analyze blood samples collected 2 hours after an administration of anti-TNF therapy. Higher frequencies of memory B-lymphocytes (CD19+ CD27+ , CD19+ CD20+ CD27+ and CD19+ CD20+ CD27+ IgM+) were found in patients with CD as compared to COs. (20.06±13.58%; 17.61±13.48%; 88.60±20.56% vs. 11.75±26.47%; 11.25±26.50%; and 66.82±22.60%), in case of CD19+CD20-CD27-IgM+ B-lymphocytes the difference was statistically significant (57.15±17.21% in CD vs. 19.59±31.79% in CO; p=0.0341), which is in accordance...

No description available.

Los receptores Fc-gamma (Fc-gR) median muchas de las funciones inmunes de la IgG. Están presentes en numerosas células del sistema inmune y su activación (tras la unión al fragmento Fc de la IgG) permite el desarrollo de funciones tales como la fagocitosis, la citotoxicidad dependiente de anticuerpos y la liberación de enzimas proteolíticas. Existen polimorfismos genéticos que modifican la afinidad de los Fc-gR y por tanto su capacidad funcional. Estos polimorfismos se han relacionado con enfermedades autoinmunes, infecciosas y con la eficacia de agentes monoclonales. El penfigoide ampolloso (PA) es una patología ampollosa autoinmune caracterizada por el deposito de autoanticuerpos en la membrana basal de la piel. Estos anticuerpos activan a neutrófilos vía el receptor Fc-gR, los cuales liberan enzimas proteolíticas que degradan la membrana basal causando el daño tisular. Los agentes monoclonales han revolucionado el tratamiento de las formas moderadas y graves de psoriasis. Sin embargo, en torno a un 30% de los pacientes no presentarán una respuesta adecuada. En la actualidad no existen factores farmacogenéticos definidos que puedan predecir la respuesta a biológicos en la psoriasis. Teniendo en cuenta el contrastado papel del los Fc-gR en modelos animales de PA, los polimorfismos genéticos de Fc-gR podrían relacionarse a nivel clínico con el PA, tanto como marcadores como modificadores de esta enfermedad. Por otra parte, los polimorfismos de Fc-gR también podrían predecir la respuesta a biológicos en la psoriasis, ya que los agentes empleados (etanercept, infliximab y adalimumab) contienen el fragmento Fc en su estructura. Esta influencia podría venir dada por un aumento en las capacidades citotóxicas de estos agentes, o por una alteración de los mecanismos de eliminación de estos fármacos dependientes del sistema reticuloendotelial. El objetivo de esta tesis fue estudiar la influencia de los polimorfismos de Fc-gR en 2 patologías cutáneas inmunomediadas mediante el estudio genético de grupos de pacientes y controles. Por un lado, se pretendía detectar si los polimorfismos de Fc-gR se asocian al PA o si modifican el pronostico de esta enfermedad, y por otro, si dichos polimorfismos son marcadores farmacogenéticos de respuesta clínica en aquellos pacientes psoriásicos tratados con agentes biológicos. Se realizó estudio genético de los polimorfismos Fc-gRIIA-H131R, Fc-gRIIB-I187T y Fc-gRIIIA-V158F en un grupo de 41 pacientes con PA y un grupo control de 115 individuos sanos y de Fc-gRIIA-H131R y Fc-gRIIIA-V158F en un grupo de 70 pacientes con psoriasis tratados agentes anti-TNF-alfa. Se realizó un análisis retrospectivo de los datos clínicos de los pacientes con PA y una valoración clínica retrospectiva de la respuesta a biológicos en pacientes con psoriasis. En el caso del PA observamos, en un modelo multivariante, una tendencia a la asociación del alelo F de Fc-gRIIIA-V158F con las formas más graves de PA, definidas como la necesidad de añadir tratamiento inmunosupresor. Por otra parte, los pacientes psoriáticos con alelos de alta afinidad (aislados o en combinación) de los polimorfismos a estudio presentaron, de forma independiente, una respuesta terapéutica más rápida a terapia biológica en forma de un porcentaje de superficie corporal afecta menor a las 6-8 semanas de tratamiento, probablemente en relación con una mayor eliminación de células patogénicas con TNF-alfa en membrana. Nuestros resultados tienen implicación clínica ya que, por un lado, los pacientes con PA y presencia del alelo F, podría beneficiarse de la introducción temprana de inmunosupresores y, por otro, la presencia de alelos de alta afinidad en los polimorfismos de Fc-gR podría predecir una respuesta clínica mas precoz en pacientes con psoriasis tratados con biológicos, lo cual puede ser de especial importancia en casos graves. / Fc gamma receptors (Fc-gammaR) mediate most of the immune functions of IgG. There are single-nucleotide polimorphims affecting Fc-gammaR genes that influence affinity and thus functions of Fc-gammaR. These polymorphisms have been linked clinically with infectious and autoimmune disease but also with the degree of response to monoclonal antibodies containing the Fc fragment. Bullous pemphigoid (BP) is an autoimmune disease where pathogenic antibodies bind antigens in the basal membrane of the skin. Such antibodies activate neutrophils through Fc-gammaR, which make these cells liberate proteolytic enzymes that cause tissue injury and blisters in the skin. Monoclonal agents have improved greatly the outcome of patients with psoriasis. However up to 30% does not achieve a significant response. There are not currently pharmacogenetic markers that could predict the outcome of biological therapy in psoriasis. The main objective of this thesis was to study the influence of Fc-gammaR polymorphisms in 2 immune-mediated skin diseases: a) a possible influence, in terms of susceptibility or disease modification, of Fc-gammaR polymorphisms in BP; and b) the potential role of Fc-gammaR polymorphisms as pharmacogenetic markers in patients with psoriasis treated with anti-TNF-alpha therapy. We performed the determination of the genotype of Fc-gammaRIIA-H131R, Fc-gammaRIIB-I187T and Fc-gammaRIIIA-V158F in 41 patients with BP and 115 controls and Fc-gammaRIIA-H131R and Fc-gammaRIIIA-V158F genotypes in 70 patients with psoriasis that underwent anti-TNF-alpha treatment. Clinical charts were reviewed in order to establish correlations. In the BP study, we observed an association between the presence of Fc-gammaRIIIA-158F with the most severe forms of BP, defined as the need for immunosuppressants. With regard to the psoriasis study, we detected that patients with high affinity alleles (alone or in combination) presented a quick response to biologics, measured as a lower body surface area affected in the week 6-8. Our results present clinical implications, since for example, patients with BP harboring the F allele may benefit from an early introduction of immunosuppressants. On the other hand, the presence of Fc-gammaR high affinity alleles may predict an early response to biologics in psoriasis, which may be critical especially in severe cases.

Bei juveniler idiopathischer Arthritis konnte eine prämature Immunoseneszenz nachgewiesen werden. Ein Erklärungsmodell ist, dass die prämature Immunoseneszenz den primären Defekt darstellt, der das Immunsystem zum Versagen der Selbsttoleranz führt. Eine andere Deutungsmöglichkeit stellt die prämature Immunoseneszenz als Folge von chronischer Stimulation und Aktivierung des Immunsystems durch die Autoimmunerkrankung selbst dar. In dieser Arbeit wurden die Immunoseneszenz-Parameter (naive T-Zellen, RTE, IL-7-Level, TRECs, relative Telomerlänge, Ki-67-Expression) von JIA-Patienten - unterteilt in eine DMARD-Gruppe und eine TNFα-Inhibitor-Gruppe - mit denen von gesunden Vergleichsprobanden verglichen. Eine fortgeschrittenere Immunoseneszenz bei den Gesunden könnte möglicherweise durch vermehrte chronische Virusinfekte erklärt werden, die jedoch in dieser Arbeit nicht erfasst wurden. In der vorliegenden Arbeit konnte eine potenzielle Rekonstitutionsfähigkeit mit Verbesserung der Immunoseneszenz-Parameter bei DMARD-Therapie demonstriert werden. So trat ein höherer Anteil an naiven T-Zellen und an RTE auf, was vermuten lässt, dass der fortschreitende Verlust der Thymusfunktion bei Patienten mit Autoimmunerkrankung reversibel sein könnte. Bei Vergleich der TNFi-Patienten mit der DMARD-Gruppe konnte eine weiter fortgeschrittene Immunoseneszenz festgestellt werden. Dies könnte durch die Ansammlung von schwereren, DMARD-refraktären Patienten, aber auch durch die unterschiedliche, aber nicht-signifikante Altersverteilung bedingt sein. Bei längerer Einnahmedauer des TNFα-Inhibitors zeigte sich ein tendenziell stärkeres Auftreten von naiven T-Zellen und RTE, kombiniert mit geringeren Anteilen differenzierterer Subpopulationen. So scheinen TNFα-Inhibitoren die Fähigkeit zu besitzen, die prämature Immunoseneszenz positiv zu beeinflussen oder zumindest eine Verlangsamung des prämaturen Alterungsvorgangs zu bewirken. / In juvenile idiopathic arthritis, a premature immunosenescence was shown. One possible explanation is that premature immunosenescence causes the primary defect which leads to the break-down of self-tolerance. Another possibility is that premature immunosenescence is the consequence of chronical stimulation and immune activation through the disease itself. For this dissertation, parameters of premature immunosenescence (namely naive T-cells, RTE, IL-7, TREC, RTL, expression of Ki-67) were determined in JIA patients - divided into two distinct groups with and without TNF alpha inhibitor (“DMARD”, “TNFi”) - and compared to healthy controls. More advanced immunosenescence in healthy subjects might be due to increased occurrence of chronic viral infections, which were not examined here. In DMARD, potential reconstitution with improvement of aging parameters was demonstrated. Higher percentages of naive T-cells and RTE could lead to the hypothesis that the progressive loss of thymic function might be reversible in patients with autoimmune diseases. In TNFi, parameters indicated more advanced immunosenescence. This could be explained by more severe cases of JIA, refractory to conventional treatment, or slightly, not-significant differences in the age distribution. With longer intake of TNFi, increased percentages of naive T-cells and RTE with decrease of further differentiated subsets were shown. Hence, TNFα inhibitors seem to have the ability to influence the immune system positively or to lead at least to a deceleration of the premature aging process.

No description available.

京都大学 / 新制・課程博士 / 博士(医学) / 甲第23796号 / 医博第4842号 / 新制||医||1058(附属図書館) / 京都大学大学院医学研究科医学専攻 / (主査)教授 森信 暁雄, 教授 椛島 健治, 教授 杉田 昌彦 / 学位規則第4条第1項該当 / Doctor of Medical Science / Kyoto University / DFAM

A artrite reumatoide (AR) é uma doença autoimune, inflamatória, crônica, sistêmica e de etiologia desconhecida que pode ser induzida experimentalmente em animais por administração de colágeno e adjuvante (CIA). Os medicamentos biológicos contra o fator de necrose tumoral (TNF)-α são indicações terapêuticas atualmente consolidadas para os casos mais severos de AR. As limitações ao uso dessa classe de medicamentos têm sido o alto custo e a dificuldade em fabricar genéricos ou similares com composição, qualidade e desempenho equivalentes na mesma dose e via de administração. O presente estudo avaliou a hipótese de que drogas sintéticas que inibam a produção de TNF-α e / ou fatores relacionados teriam potencial para tornarem-se terapias complementares ou alternativas eficientes para esta doença. Para isso, foram utilizados ratos submetidos ao modelo CIA e tratados cronicamente com pentoxifilina (PTX), rolipram (ROL), talidomida (TAL) e rupatadina (RUP). Um tratamento com prednisolona (PRED) foi também efetuado para avaliar sua influência na eventual ação antiartrítica de PTX, ROL, TAL e RUP, de modo a mimetizar seu efeito imunossupressor, quando administrada agudamente (AG) antes de medicamentos biológicos, bem como pelo seu conhecido efeito anti-inflamatório, quando administrada cronicamente (CR) no tratamento da AR. O desenvolvimento da AR e a efetividade dessas drogas sobre a AR foram avaliadas, de forma seletiva e sequencial, por meio da detecção de eritema e cianose, bem como medidas de edema, massa corporal, hemograma, TNF-α no plasma, fator reumatoide (FR) e anticorpo antinuclear (ANA) no soro, interleucina (IL)-1β e IL-6 no soro e líquido sinovial, atividade de aminopeptidase básica (APB) na fração solúvel (FS) do tecido sinovial (TS) e de células mononucleares do sangue periférico (PBMCs), densitometria óssea e análise histológica. A hepatotoxicidade dessas drogas foi avaliada pelas medidas de alanina-transaminase (ALT) e aspartato-transaminase (AST) no plasma. A AR caracterizou-se pelo aumento de TNF-α plasmático e de IL-1β e IL-6 no líquido sinovial, alterações histológicas na articulação tíbio-tarsal, bem como edema, cianose, eritema, diminuição de linfócitos e atividade APB de FS aumentada no TS e diminuída em PBMCs. A AR aumentou ALT e AST. O tratamento com PRED crônico promoveu um efeito antiedematogênico. O coquetel (MIX de PTX+ROL+RUP+TAL) também apresentou efeito antiedematogênico. A administração concomitante de PRED AG ou PRED CR com MIX não produziu sinergismo ou potenciação do efeito antiedematogênico da administração isolada do MIX ou da PRED crônica. Além do MIX, ROL e TAL diminuíram o edema. MIX, ROL e TAL melhoraram TNF-α no plasma e APB na FS do TS e não causaram hepatotoxicidade, tal como refletido nos níveis de ALT e AST. TAL recuperou ALT e AST, sem alteração do hemograma. Uma vez que PTX e RUP não apresentaram efeito antiedematogênico, ROL e TAL foram hipotetizados como os prováveis responsáveis pela atividade antiartrítica do MIX. Então, os tratamentos com ROL, TAL e ROL+TAL foram selecionados para avaliação da histologia óssea e medidas de parâmetros diferenciais entre animais controles sadios e artríticos. Esta avaliação mostrou que o tratamento isolado da AR com ROL ou TAL não alterou IL-6, mas recuperou IL-1β no líquido sinovial, efeitos esses que não se diferenciaram do tratamento combinado de ROL+TAL, exceto pelo fato de que essa combinação também diminuiu a massa corporal. TAL se destacou por seu efeito hepatoprotetor nos animais AR. Considerando os efeitos conhecidos de RUP, PTX, TAL e ROL é possível hipotetizar que a ação antiartrítica de TAL e ROL deve-se à inibição da síntese de TNF-α decorrente da inibição de PDE4 em suas principais fontes celulares. Os dados deste estudo prospectivo fornecem subsídios adicionais que estimulam a realização de novos ensaios clínicos, mais amplos e sistematizados, sobre os efeitos antiartríticos de ROL e TAL. Conclui-se que o uso isolado de TAL emerge como uma alternativa terapêutica econômica, simples e eficaz para a AR, enquanto a combinação de ROL+TAL pode ser uma opção viável para portadores de AR com sobrepeso ou obesidade / Rheumatoid arthritis (RA) is an autoimmune, inflammatory, chronic and systemic disease with unknown etiology that can be experimentally induced in animals by administration of collagen and adjuvant (CIA). Biological drugs against tumor necrosis factor (TNF)- α are therapeutic indications currently consolidated for the most severe cases of RA. The limitations for the use of this class of drugs have been the high cost and the difficulty to manufacture a generic or similar ones with equivalent composition, quality and performance under the same dosage and route of administration. The present study evaluated the hypothesis that synthetic drugs that inhibit the production of TNF-α and/or related factors would have potential to become efficient complementary or alternative therapies for this disease. For this purpose, male rats submitted to the CIA model were chronically treated with pentoxifylline (PTX), rolipram (ROL), thalidomide (TAL) and rupatadine (RUP). The treatment with prednisolone (PRED) was also performed to evaluate its influence on the possible antiarthritic action of PTX, ROL, TAL and RUP, in order to mimic its immunosuppressive effect when acutely (AG) administered prior to biological drugs, as well as due to its known anti-inflammatory effect when administered chronically (CR) to treat RA. The development of RA and the efficacy of these drugs on RA were evaluated, by selective and sequential ways, through the detection of erythema and cyanosis, as well as measurements of edema, body mass, hemogram, plasma TNF-α, rheumatoid factor (FR) and anti-nuclear antibody (ANA) in serum, interleukin (IL)-1β and IL-6 in serum and synovial fluid, basic aminopeptidase activity (APB) in soluble fraction (FS) from synovial tissue (TS) and from peripheral blood mononuclear cells (PBMCs), bone densitometry and histological analysis. The hepatotoxicity of these drugs was evaluated by measurements of alanine-transaminase (ALT) and aspartate-transaminase (AST). RA was characterized by increased TNF-α in plasma and IL-1β and IL-6 in synovial fluid, histological alterations in the tibio-tarsal joint, as well as edema, cyanosis, erythema, decreased lymphocyte number and increased APB activity in TS and decreased APB activity in PBMCs. RA produced increased ALT and AST. As expected, the chronic treatment with PRED promoted an antiedematogenic effect. The cocktail (MIX of PTX+ROL+RUP+TAL) also presented antiedematogenic effect. Concomitant administration of acute or chronic PRED with MIX did not produce synergism or potentiation of the antiedematogenic effect due to the single administration of MIX or chronic PRED. In addition to MIX, ROL and TAL were also antiedematogenic. MIX, ROL and TAL ameliorated plasma TNF-α and APB in FS from TS without hepatotoxicity, as reflected by ALT and AST levels. TAL recovered ALT and AST, but it did not affect the hemogram. Since PTX and RUP did not present antiedematogenic effects, ROL and TAL were hypothesized as probable responsible for the antiarthritic activity of MIX. Thus, the treatments with ROL, TAL and ROL+TAL were selected for evaluation of bone histology and measurements of differential parameters between healthy control and arthritic animals. This evaluation showed that the treatment of RA with ROL or TAL alone did not alter IL-6 levels, but recovered IL-1β in the synovial fluid. Both these effects were not different from those of the concomitant treatment with ROL+TAL, except that this combination also decreases the body mass. TAL stands out for its hepatoprotective effect in RA animals. Considering the known effects of RUP, PTX, TAL and ROL it can be hypothesized that antiarthritic action of TAL and ROL is due to the inhibition of TNF-α synthesis as consequence of its inhibition in its main cellular sources by PDE4. Data from this prospective study provide additional subsidies that stimulate further and more comprehensive clinical trials on the antiarthritic effects of ROL and TAL. In conclusion, the treatment with TAL alone emerges as an economical, simple and effective therapeutical alternative for RA, while the combination of ROL+TAL can be a viable option for RA sufferers with overweight or obesity

A artrite reumatoide (AR) é uma doença autoimune, inflamatória, crônica, sistêmica e de etiologia desconhecida que pode ser induzida experimentalmente em animais por administração de colágeno e adjuvante (CIA). Os medicamentos biológicos contra o fator de necrose tumoral (TNF)-α são indicações terapêuticas atualmente consolidadas para os casos mais severos de AR. As limitações ao uso dessa classe de medicamentos têm sido o alto custo e a dificuldade em fabricar genéricos ou similares com composição, qualidade e desempenho equivalentes na mesma dose e via de administração. O presente estudo avaliou a hipótese de que drogas sintéticas que inibam a produção de TNF-α e / ou fatores relacionados teriam potencial para tornarem-se terapias complementares ou alternativas eficientes para esta doença. Para isso, foram utilizados ratos submetidos ao modelo CIA e tratados cronicamente com pentoxifilina (PTX), rolipram (ROL), talidomida (TAL) e rupatadina (RUP). Um tratamento com prednisolona (PRED) foi também efetuado para avaliar sua influência na eventual ação antiartrítica de PTX, ROL, TAL e RUP, de modo a mimetizar seu efeito imunossupressor, quando administrada agudamente (AG) antes de medicamentos biológicos, bem como pelo seu conhecido efeito anti-inflamatório, quando administrada cronicamente (CR) no tratamento da AR. O desenvolvimento da AR e a efetividade dessas drogas sobre a AR foram avaliadas, de forma seletiva e sequencial, por meio da detecção de eritema e cianose, bem como medidas de edema, massa corporal, hemograma, TNF-α no plasma, fator reumatoide (FR) e anticorpo antinuclear (ANA) no soro, interleucina (IL)-1β e IL-6 no soro e líquido sinovial, atividade de aminopeptidase básica (APB) na fração solúvel (FS) do tecido sinovial (TS) e de células mononucleares do sangue periférico (PBMCs), densitometria óssea e análise histológica. A hepatotoxicidade dessas drogas foi avaliada pelas medidas de alanina-transaminase (ALT) e aspartato-transaminase (AST) no plasma. A AR caracterizou-se pelo aumento de TNF-α plasmático e de IL-1β e IL-6 no líquido sinovial, alterações histológicas na articulação tíbio-tarsal, bem como edema, cianose, eritema, diminuição de linfócitos e atividade APB de FS aumentada no TS e diminuída em PBMCs. A AR aumentou ALT e AST. O tratamento com PRED crônico promoveu um efeito antiedematogênico. O coquetel (MIX de PTX+ROL+RUP+TAL) também apresentou efeito antiedematogênico. A administração concomitante de PRED AG ou PRED CR com MIX não produziu sinergismo ou potenciação do efeito antiedematogênico da administração isolada do MIX ou da PRED crônica. Além do MIX, ROL e TAL diminuíram o edema. MIX, ROL e TAL melhoraram TNF-α no plasma e APB na FS do TS e não causaram hepatotoxicidade, tal como refletido nos níveis de ALT e AST. TAL recuperou ALT e AST, sem alteração do hemograma. Uma vez que PTX e RUP não apresentaram efeito antiedematogênico, ROL e TAL foram hipotetizados como os prováveis responsáveis pela atividade antiartrítica do MIX. Então, os tratamentos com ROL, TAL e ROL+TAL foram selecionados para avaliação da histologia óssea e medidas de parâmetros diferenciais entre animais controles sadios e artríticos. Esta avaliação mostrou que o tratamento isolado da AR com ROL ou TAL não alterou IL-6, mas recuperou IL-1β no líquido sinovial, efeitos esses que não se diferenciaram do tratamento combinado de ROL+TAL, exceto pelo fato de que essa combinação também diminuiu a massa corporal. TAL se destacou por seu efeito hepatoprotetor nos animais AR. Considerando os efeitos conhecidos de RUP, PTX, TAL e ROL é possível hipotetizar que a ação antiartrítica de TAL e ROL deve-se à inibição da síntese de TNF-α decorrente da inibição de PDE4 em suas principais fontes celulares. Os dados deste estudo prospectivo fornecem subsídios adicionais que estimulam a realização de novos ensaios clínicos, mais amplos e sistematizados, sobre os efeitos antiartríticos de ROL e TAL. Conclui-se que o uso isolado de TAL emerge como uma alternativa terapêutica econômica, simples e eficaz para a AR, enquanto a combinação de ROL+TAL pode ser uma opção viável para portadores de AR com sobrepeso ou obesidade / Rheumatoid arthritis (RA) is an autoimmune, inflammatory, chronic and systemic disease with unknown etiology that can be experimentally induced in animals by administration of collagen and adjuvant (CIA). Biological drugs against tumor necrosis factor (TNF)- α are therapeutic indications currently consolidated for the most severe cases of RA. The limitations for the use of this class of drugs have been the high cost and the difficulty to manufacture a generic or similar ones with equivalent composition, quality and performance under the same dosage and route of administration. The present study evaluated the hypothesis that synthetic drugs that inhibit the production of TNF-α and/or related factors would have potential to become efficient complementary or alternative therapies for this disease. For this purpose, male rats submitted to the CIA model were chronically treated with pentoxifylline (PTX), rolipram (ROL), thalidomide (TAL) and rupatadine (RUP). The treatment with prednisolone (PRED) was also performed to evaluate its influence on the possible antiarthritic action of PTX, ROL, TAL and RUP, in order to mimic its immunosuppressive effect when acutely (AG) administered prior to biological drugs, as well as due to its known anti-inflammatory effect when administered chronically (CR) to treat RA. The development of RA and the efficacy of these drugs on RA were evaluated, by selective and sequential ways, through the detection of erythema and cyanosis, as well as measurements of edema, body mass, hemogram, plasma TNF-α, rheumatoid factor (FR) and anti-nuclear antibody (ANA) in serum, interleukin (IL)-1β and IL-6 in serum and synovial fluid, basic aminopeptidase activity (APB) in soluble fraction (FS) from synovial tissue (TS) and from peripheral blood mononuclear cells (PBMCs), bone densitometry and histological analysis. The hepatotoxicity of these drugs was evaluated by measurements of alanine-transaminase (ALT) and aspartate-transaminase (AST). RA was characterized by increased TNF-α in plasma and IL-1β and IL-6 in synovial fluid, histological alterations in the tibio-tarsal joint, as well as edema, cyanosis, erythema, decreased lymphocyte number and increased APB activity in TS and decreased APB activity in PBMCs. RA produced increased ALT and AST. As expected, the chronic treatment with PRED promoted an antiedematogenic effect. The cocktail (MIX of PTX+ROL+RUP+TAL) also presented antiedematogenic effect. Concomitant administration of acute or chronic PRED with MIX did not produce synergism or potentiation of the antiedematogenic effect due to the single administration of MIX or chronic PRED. In addition to MIX, ROL and TAL were also antiedematogenic. MIX, ROL and TAL ameliorated plasma TNF-α and APB in FS from TS without hepatotoxicity, as reflected by ALT and AST levels. TAL recovered ALT and AST, but it did not affect the hemogram. Since PTX and RUP did not present antiedematogenic effects, ROL and TAL were hypothesized as probable responsible for the antiarthritic activity of MIX. Thus, the treatments with ROL, TAL and ROL+TAL were selected for evaluation of bone histology and measurements of differential parameters between healthy control and arthritic animals. This evaluation showed that the treatment of RA with ROL or TAL alone did not alter IL-6 levels, but recovered IL-1β in the synovial fluid. Both these effects were not different from those of the concomitant treatment with ROL+TAL, except that this combination also decreases the body mass. TAL stands out for its hepatoprotective effect in RA animals. Considering the known effects of RUP, PTX, TAL and ROL it can be hypothesized that antiarthritic action of TAL and ROL is due to the inhibition of TNF-α synthesis as consequence of its inhibition in its main cellular sources by PDE4. Data from this prospective study provide additional subsidies that stimulate further and more comprehensive clinical trials on the antiarthritic effects of ROL and TAL. In conclusion, the treatment with TAL alone emerges as an economical, simple and effective therapeutical alternative for RA, while the combination of ROL+TAL can be a viable option for RA sufferers with overweight or obesity

L’utilisation d’agents anti-TNF a grandement amélioré la prise en charge de certaines maladies inflammatoires chroniques comme la polyarthrite rhumatoïde (PR) ou les maladies inflammatoires chroniques de l’intestin (MICI). Cependant, le quart des patients environ ne vont pas répondre au traitement ou présenteront une perte de réponse secondaire. Des marqueurs prédictifs de réponse sont nécessaires afin limiter les effets secondaires et les coûts inutiles en ciblant les patients qui pourraient être améliorés par les anti-TNF. Ces travaux de recherche se sont dans un premier temps concentrés sur l’importance de l’immunogénicité de ces traitements. Des anticorps anti-médicaments (ADAs) étaient bien associés à un taux bas d’anti-TNF avec des conséquences cliniques en termes de perte de réponse clinique et d’absence de cicatrisation muqueuse dans les MICI. Des seuils cliniques d’interprétation des tests biologiques pour la détection du médicament et de ses anticorps ont pu être définis et correspondent à 4.9 μg/ml pour l’infliximab et 200 ng/ml pour les ADAs. Ces résultats obtenus par ELISA sont bien corrélés avec les tests fonctionnels réalisés en parallèle et confirment l’intérêt de cette technique dans ce dépistage. Les ADAs étaient diminués par traitement immunosuppresseur concomitant. Ensuite, la persistance d’une infection chronique mise en évidence par des anticorps anti-bactériens a été évaluée en tant que marqueur prédictif de réponse aux anti-TNF. Aucun résultat statistiquement significatif n’a pu être relevé sur ces premières données, que ça soit pour les anticorps dirigés contre la flore intestinale pour les MICI ou contre le microbiote oral dans la PR. Seul un taux élevé de MMP-3 à l’initiation de l’infliximab chez les patients PR prédisait d’une bonne réponse clinique selon les critères de l’EULAR par la suite / The use of anti-TNF agents has greatly improved the management of chronic inflammatory diseases such as rheumatoid arthritis (RA), or chronic inflammatory bowel disease (IBD). However, about a quarter of patients will not respond to treatment or will present a secondary loss of response. Predictive biomarkers of response are needed to reduce side effects and unnecessary costs by targeting patients that could be improved by anti-TNF. This research work was initially focused on the importance of immunogenicity of these treatments. Anti-drug antibodies (ADAs) were well associated with low levels of anti-TNF with clinical consequences in terms of loss of clinical response and absence of mucosal healing in IBD. Clinical thresholds for drug and ADAs have been defined and correspond to 4.9 μg/ml for infliximab and 200 ng/ml for ADAS. These results obtained by ELISA correlate well with functional tests done in parallel, and confirm the value of this technique for screening. The ADAs were decreased with concomitant immunosuppressive therapy. Then, the persistence of chronic infection as evidenced by anti-bacterial antibody was evaluated as a predictive marker for response to anti-TNF. No statistically significant results could be raised on these first data, for antibodies against the intestinal flora in IBD or against the oral microbiota in RA. Only high levels of MMP-3 at the initiation of infliximab in RA patients predicted a good clinical response according to the EULAR criteria

Les stratégies de traitement biologiques ciblant le TNF-α se sont avérées efficaces pour réduire l'inflammation et les symptômes cliniques dans plusieurs maladies inflammatoires chroniques et sont maintenant couramment utilisées pour les patients qui ne répondent pas aux AINS au cours de la spondyloarthrite (SpA). Cependant, 30 à 40% des patients ne répondent pas aux anti-TNF, et il est actuellement impossible de prédire la réponse des patients à ces biomédicaments. Pour améliorer les résultats cliniques, nous avons besoin d’une part d’une meilleure compréhension des mécanismes d’action des anti-TNF sur le système immunitaire, et d’autre part de biomarqueurs permettant de prédire la réponse à ces biomédicaments afin de guider la décision thérapeutique. Mon projet de doctorat a porté sur deux objectifs complémentaires: (i) l'objectif principal était de progresser dans notre compréhension des mécanismes pathogéniques impliqués dans la SpA axiale et de définir de quelle façon les anti-TNF-α affectent les réponses immunitaires des patients, (ii) de développer des biomarqueurs pour prédire la réponse thérapeutique aux inhibiteurs du TNF. En collaboration avec l'équipe du Pr. Dougados à l'Hôpital Cochin, nous avons recruté deux cohortes indépendantes de patients SpA ayant une maladie active et pour lesquels nous avons collecté des échantillons de sang avant l'initiation du traitement par anti-TNF puis 1 semaine et 3 mois après le début du traitement. Les réponses immunitaires de ces patients ont été analysées à l'aide de tests hautement standardisés réalisés ex-vivo sur sang circulant. Ces tests "TruCulture" se présentent sous forme de seringues, dans lesquelles 1 ml de sang total est mis à incuber avec un stimulus spécifique ; 20 stimuli différents ont été testé et validé avant et après traitement dans les deux cohortes de patients. Nous avons observé une réduction très significative de la sécrétion de IL-1ra, IL-1β, IL-8, and MIP-1β en réponse à des stimuli microbiens et à des agonistes des TLR dans les échantillons de sang prélevés 7 jours et/ou 3 mois après le début du traitement. Pour identifier les bases moléculaires de l’action des inhibiteurs du TNF nous avons analysé l'expression des gènes dans ces différentes conditions de stimulation. L'analyse bioinformatique quantitative de l'expression des gènes (QuSAGE) a révélé que les gènes les plus modulés par le traitement anti-TNF étaient NF-KB et les gènes cibles de NF-kB, y compris le TNF lui-même et l’IL1B. Nos données suggèrent que les inhibiteurs du TNF agissent principalement en perturbant une boucle autorégulatrice pilotée par NF-kB. Afin d'identifier les signatures immunologiques de réponse aux anti-TNF avant le début du traitement, nous avons corrélé les réponses immunitaires chez les patients analysés au temps 0 à la réponse thérapeutique aux anti-TNF mesurée à 3 mois. Nos résultats suggèrent que les patients atteints de SpA et exprimant des niveaux inférieurs de PAX5 et des niveaux supérieurs de SPP1 en réponse à la stimulation avec SEB avant l'initiation de la thérapie anti-TNF ont les meilleures réponses thérapeutiques. Notre recherche montre que les tests TruCulture sont un outil efficace pour étudier les fonctions immunitaires chez les patients atteints de SpA et que les effets du traitement anti-TNF peuvent être mesurés lorsque les cellules immunitaires sont stimulées. En terme de recherche translationnelle, nous avons identifié des molécules qui pourront être utilisés comme biomarqueurs pour aider les cliniciens à prédire les réponses thérapeutiques aux traitements anti TNF / The introduction of anti-TNF therapy has proven effective to reduce inflammation and clinical symptoms in several chronic inflammatory diseases. However, 30-40% of patients do not respond to TNF blockers and it is currently not possible to predict responsiveness of patients to anti-TNF therapy. Furthermore, their impact on the immune system is incompletely understood. The goals of my PhD project were (i) to define the impact of anti-TNF therapy on immune responses to microbial challenges and stimuli targeting specific immune pathways in spondyloarthritis (SpA) patients, and (ii) to identify immunological correlates associated with therapeutic responses to TNF-blockers.Using a set of whole-blood, syringe-based assays to perform ex vivo stimulation while preserving physiological cellular interactions (TruCulture assays), we have performed a pilot study in SpA patients and investigated immune responses to 20 different stimuli before and 3 months after initiation of anti-TNF therapy. These findings were validated in a replication cohort, also assessing the effects of anti-TNF agents after only one week of treatment. We observed a highly significant reduction of the secretion of IL-1ra, IL-1β, IL-8 and MIP-1β in response to selected stimuli after 3 months of treatment compared to the baseline. Interestingly, these changes were already detectable after a single injection of an anti-TNF agent. To gain insight into the molecular mechanism of TNF blockers, we profiled gene expression in the stimulation cultures from all patients. Quantitative set analysis for gene expression (QuSAGE) revealed that the gene modules most affected by anti-TNF therapy are NF-kB transcription factors and inhibitors and NF-kB target genes, including TNF itself and IL1B. Our data suggest that TNF-blockers primarily act by disrupting an autoregulatory loop driven by NF-kB. We also tested whether there is a correlation between the responses of immune cells to specific stimuli and the clinical response to TNF-blockers. The decision tree model that we trained and validated suggests that SpA patients who expressed lower levels of PAX5 and higher levels of SPP1 in response to SEB stimulation before initiation of anti-TNF therapy had the best therapeutic responses. Our study shows that TruCulture assays are an efficient and robust tool to monitor immune functions in SpA patients and that the effects of anti-TNF therapy can be measured when immune cells are challenged, but not at steady state. Our data also indicate that analyzing immune responses in patients before therapy is a promising strategy to develop biomarkers for prediction of therapeutic responses to TNF-blockers