Faculty Bibliography

BACKGROUND:Decreased heart rate variability (HRV) is associated with adverse outcomes in cardiovascular diseases and has been observed in patients with systemic lupus erythematosus (SLE). We examined the relationship of HRV with SLE disease activity and selected cytokine pathways. METHODS:Fifty-three patients from the Oklahoma Lupus Cohort were evaluated at two visits each. Clinical assessments included the Systemic Lupus Erythematosus Disease Activity Index (SLEDAI), British Isles Lupus Assessment Group (BILAG) index, physician global assessment (PGA), and Safety of Estrogens in Lupus Erythematosus National Assessment-SLEDAI Flare Index. HRV was assessed with a 5-minute electrocardiogram, and the following HRV parameters were calculated: square root of the mean of the squares of differences between adjacent NN intervals (RMSSD), percentage of pairs of adjacent NN intervals differing by more than 50 milliseconds (pNN50), high-frequency power (HF power), and low frequency to high frequency (LF/HF) ratio, which reflects sympathetic/vagal balance. Plasma cytokine levels were measured with a multiplex, bead-based immunoassay. Serum B lymphocyte stimulator (BLyS) and a proliferation-inducing ligand (APRIL) were measured with an enzyme-linked immunosorbent assay. Linear regression analysis was applied. RESULTS:Baseline HRV (pNN50, HF power, LF/HF ratio) was inversely related to disease activity (BILAG, PGA) and flare. Changes in RMSSD between visits were inversely related to changes in SLEDAI (p = 0.007). Age, caffeine, tobacco and medication use had no impact on HRV. Plasma soluble tumor necrosis factor receptor II (sTNFRII) and monokine induced by interferon gamma (MIG) were inversely related with all baseline measures of HRV (p = 0.039 to <0.001). Plasma stem cell factor (SCF), interleukin (IL)-1 receptor antagonist (IL-1RA), and IL-15 showed similar inverse relationships with baseline HRV, and weaker trends were observed for interferon (IFN)-α, interferon gamma-induced protein (IP)-10, and serum BLyS. Changes in the LF/HF ratio between visits were also associated with changes in sTNFRII (p = 0.021), MIG (p = 0.003), IFN-α (p = 0.012), SCF (p = 0.001), IL-1RA (p = 0.023), and IL-15 (p = 0.010). On the basis of multivariate linear regression, MIG was an independent predictor of baseline HRV after adjusting for plasma IL-1RA, SCF, IFN-α, IP-10, and serum BLyS. In a similar model, the sTNFRII impact remained significant after adjusting for the same variables. CONCLUSIONS:Impaired HRV, particularly the LF/HF ratio, is associated with lupus disease activity and several cytokines related to IFN type II and TNF pathways. The strongest association was with MIG and sTNFRII, expanding previous immune connections of vagal signaling.

OBJECTIVE:The primary objective was to assess the long-term safety of repeated courses of epratuzumab therapy in patients with moderate-to-severe systemic lupus erythematosus. Secondary objectives were to assess long-term efficacy and health-related quality of life (HRQOL). METHODS:Eligible patients from the 12-week, phase IIb, randomized, placebo-controlled EMBLEM study enrolled into the open-label extension (OLE) study, SL0008. In the SL0008 study, patients received 1,200 mg epratuzumab infusions at weeks 0 and 2 of repeating 12-week cycles, plus standard of care. Safety measures included treatment-emergent adverse events (TEAEs) and serious TEAEs. Efficacy measures included combined treatment response, the British Isles Lupus Assessment Group score, the Systemic Lupus Erythematosus Disease Activity Index score, and the physician's and patient's global assessment of disease activity. Total daily corticosteroid dose and HRQOL (by the Short Form 36 health survey) were also assessed. RESULTS:A total of 113 of the 203 patients (55.7%) who entered the SL0008 study continued epratuzumab therapy until study closure (total cumulative exposure: 381.3 patient-years, median exposure: 845 days, and maximum exposure: 1,185 days/approximately 3.2 years). TEAEs were reported in 192 patients (94.6%); most common were infections and infestations (68.0%, 138 patients). Serious TEAEs were reported in 51 patients (25.1%), and 14 patients (6.9%) had serious infections. In patients treated for 108 weeks (n = 116), the median corticosteroid dose was reduced from 10.0 mg/day at OLE screening to 5.0 mg/day at week 108. Improvements in efficacy and HRQOL measures in EMBLEM were maintained in the OLE, while placebo patients exhibited similar improvements in disease activity upon a switch to epratuzumab. CONCLUSION/CONCLUSIONS:Open-label epratuzumab treatment was well tolerated for up to 3.2 years, and associated with sustained improvements in disease activity and HRQOL, while steroids were reduced.

Systemic lupus erythematosus (SLE) and antiphospholipid syndrome have an increased risk to develop cognitive impairment. A possible role for antiphospholipid antibodies (aPL) and antiglutamate receptor (anti-NMDA) antibodies in the pathogenesis of neurological manifestations of these two conditions, have been suggested. In particular, the role of anti-NMDA antibodies in the pathogenesis of neuropsychiatric SLE is supported by several experimental studies in animal models and by the finding of a correlation between anti-NMDA positivity in cerebrospinal fluid and neurological manifestations of SLE. However, data from the literature are controversial, as several studies have reported a correlation of these antibodies with mild cognitive impairment in SLE, but more recent studies have not confirmed this finding. The synergism between anti-NMDA and other concomitant autoantibodies, such as aPL, can be hypothesized to play a role in inducing the tissue damage and eventually the functional abnormalities. In line with this hypothesis, we have found a high incidence of at least one impaired cognitive domain in a small cohort of patients with primary APS (PAPS) and SLE. Interestingly, aPL were associated with low scoring for language ability and attention while anti-NMDA titers and mini-mental state examination scoring were inversely correlated. However, when patients were stratified according to the presence/absence of aPL, the correlation was confirmed in aPL positive patients only. Should those findings be confirmed, the etiology of the prevalent defects found in PAPS patients as well as the synergism between aPL and anti-NMDA antibodies would need to be explored.

OBJECTIVE:Systemic lupus erythematosus (SLE) is a relapsing autoimmune disease that affects multiple organ systems. T cells play an important role in the pathogenesis of lupus; however, early T cell events triggering disease flares are incompletely understood. This study was undertaken to examine DNA methylation in naive CD4+ T cells from lupus patients to determine if epigenetic remodeling in CD4+ T cells is an early event in lupus flares. METHODS:A total of 74 lupus patients with an SLE Disease Activity Index score of 0-18 were included. Naive CD4+ T cells were isolated from peripheral blood samples, and DNA was extracted for genome-wide methylation assessment. RNA was also extracted from a subset of patients to determine the relationship between epigenetic changes and transcription activity using RNA sequencing and microRNA arrays. RESULTS:We demonstrated that naive CD4+ T cells in lupus undergo an epigenetic proinflammatory shift, implicating effector T cell responses in lupus flare. This epigenetic landscape change occurs without changes in expression of the corresponding genes, poises naive CD4+ T cells for Th2, Th17, and follicular helper T cell immune responses, and opposes inhibitory transforming growth factor β signaling. Bioinformatics analyses indicate that the epigenetic modulator EZH2 might play an important role in shifting the epigenetic landscape, with increased disease activity in lupus naive CD4+ T cells. Further, the expression of microRNA-26a, which is sensitive to glucose availability and targets EZH2, was negatively correlated with disease activity in lupus patients. CONCLUSION:An epigenetic landscape shift in naive CD4+ T cells that favors T cell activation and non-Th1 immune responses predates transcription activity and correlates with lupus activity. A role for EZH2 dysregulation in triggering lupus flares warrants further investigation.

Background When found in the absence of antibodies toextractable nuclear antigens (ENA) or anti-double-stranded DNA(dsDNA) (i.e., monospecific), autoantibodies to the nuclear autoantigen dense fine speckles 70 (DFS70) are purported to ruleout SLE. The reported frequency of anti-DFS70 by chemiluminescence (CIA) in SLE is low compared to healthy individuals(0-5.7% vs. 1.3-23.2%), while the frequency of monospecificanti-DFS70 in SLE is even lower at 0-0.4%. There are no studies examining the frequency of anti-DFS70 in an early inceptionSLE cohort. This study determined the prevalence of antiDFS70 in a multi-national, multi-ethnic early inception SLEcohort and examined demographic, clinical, and autoantibodyassociations.Materials and methods Patients fulfilling ACR Classification Criteria for SLE were enrolled in the Systemic Lupus InternationalCollaborating Clinics (SLICC) inception cohort within 15months of diagnosis. Demographic and clinical data were collected at enrollment. ANAs were detected by indirect immunofluorescence on HEp-2 cells (ImmunoConcepts, Sacramento)and ENAs and dsDNA by an addressable laser bead immunoassay (FIDIS Connective13, TheraDiag, Paris). Anti-DFS70 antibodies were measured by CIA (Inova Diagnostics, San Diego).The association between anti-DFS70 and baseline demographic,clinical, and autoantibody profiles was assessed using univariateand multivariate logistic regression. For the most informativemodel, only the remaining statistically significant predictors atthe 95% CI: were included, after eliminating other potentialpredictors individually, starting with the least likely to be associated with the outcome.Results 1137 patients were included; 89.9% were female and93.8% were ANA positive (Table 1). The frequency of antiDFS70 was 7.1% [95% CI: 5.7-8.8%]. 13 of 1137 (1.1%)[95% CI: 0.6-1.9%] were positive for anti-DFS70 only (monospecific). In univariate analysis, patients with musculoskeletalactivity (based on SLEDAI items) or anti-b-2 glycoprotein-1(anti-b2GP1) were more likely to have anti-DFS70, whereasthose with anti-dsDNA, anti-SSA/Ro60, anti-SSB/La, or antiU1RNP were less likely to have anti-DFS70. In multivariateanalysis, patients with musculoskeletal activity (Odd Ratio (OR)1.25 [95% CI: 1.10, 1.41]) or anti-b2GP1 (OR 2.15, 95% CI:1.21, 3.84) were more likely to have anti-DFS70, while thosewith anti-dsDNA (OR 0.53, 95% CI: 0.31, 0.92) or anti-SSB/La(OR 0.25, 95% CI:0.08, 0.82) were less likely to have antiDFS70.Conclusions The prevalence of anti-DFS70 in newly diagnosedSLE patients was at the high end of the range previouslypublished for SLE (7.1% vs. 0-5.7%) and was associated withmusculoskeletal activity and anti-b2GP1. However, 'monospecific' anti-DFS70 was rare (1.1%) and is potentially useful to discriminate between ANA positive healthy individuals and SLE

Background Anifrolumab was evaluated in a Phase IIb study ofadults with moderate to severe systemic lupus erythematosus(SLE), in which 305 patients received intravenous infusions ofanifrolumab (300 mg, 1000 mg) or placebo for 48 weeks. Globaldisease activity was reduced in both dose groups compared withplacebo, although a more favourable risk-benefit profile wasobserved with the 300-mg dose. This analysis of the Phase IIbstudy compared the impact of anifrolumab on individual organdomains in patients.Materials and methods Changes from baseline in organ domainactivity were assessed at Week 52 using the SLE Disease ActivityIndex 2000 (SLEDAI-2K) and British Isles Lupus AssessmentGroup (BILAG). SLEDAI domain improvement required a lowerscore compared with baseline in at least one of its components.BILAG organ domain improvement was defined as the transitioning from A or B to a lower score.Results The majority of patients had baseline involvement of themucocutaneous and/or musculoskeletal domains of SLEDAI-2Kand BILAG. A greater percentage of anifrolumab-treated patientsdemonstrated improvement in these frequently involved domainscompared with placebo (Table 1). Potential benefits were observedin most of the other less frequently active domains, including SLEDAI-2K cardiorespiratory, vascular, haematological, and constitutional; and BILAG cardiorespiratory and constitutional domains.In patients with baseline involvement in the SLEDAI-2K immunological domain (positive anti-double-stranded DNA [anti-dsDNA]and/or low complement level), normalisation of anti-dsDNA and/or hypocomplementemia were seen more frequently at Day 365 inpatients receiving anifrolumab compared with placebo (Table 1).However, among patients who had a normal anti-dsDNA and/ornormal complements at baseline, a slightly greater number ofpatients in the 300-mg anifrolumab group had an increase in thescore representing the development of a new anti-dsDNA or hypocomplementemia compared with baseline (Table 1).Conclusions Treatment with anifrolumab resulted in greaterrates of improvement in multiple organ domains compared withplacebo. The greatest impact was seen with 300-mg anifrolumab

Background To describe cancer incidence in the largest inceptionSLE cohort in the world.Materials and methods Patients meeting ACR criteria for newonset SLE were enrolled across 32 centres. At enrolment and annual assessments, new cancer diagnoses (in the interveningyear) were recorded by the examining physician. Confirmation ofcancers was done by reviewing medical files including pathologyreports. Of 1848 patients enrolled (across 1999-2011), 1676 hadat least one follow-up. Patients were followed until death, lastvisit, or end of study interval for this analysis (August 2015).Results Of 1676 patients followed, the majority (88.7%) werefemale and 828 (49.4%) were Caucasian (16.5% black, 15.2%Asian, 15.2% Hispanic, 3.7% other). Average age at SLE diagnosis was 34.6 (standard deviation, SD 13.3) years. At baseline,1085 (64.7%) patients were never-smokers; the remainder werecurrent (n = 248) or ex-smokers (n = 342). Average follow-upfrom cohort entry was 6.9 (SD 3.6) years. Two patients had cancer (one squamous cell skin and one breast cancer) prior to theirSLE diagnosis; these cancers were not included in our analyses.We observed 46 cancers in 46 subjects (with three other subjects reported to have cervical intraepithelial neoplasia, a premalignant condition). At cancer diagnosis, the average age was 51.7(SD 15.3) years and the average SLE duration was 4.8 (SD 3.1)years. The most common cancer type was breast (n = 9), followed by non-melanoma skin cancer (n = 8, six of which werebasal cell), lung (n = 6), prostate (n = 5), four head and neck(tonsillar, tongue, and two oral), cervical (n = 2), thyroid(n = 2), melanoma (n = 2) and one each of Non-Hodgkin lymphoma, leukaemia, multiple myeloma, meduloblastoma braincancer, renal carcinoma, gastric carcinoid, thymoma, and cutaneous dermatofibrosarcoma. Most of the cancer cases were female(34 cases, 73.9%) and Caucasian (34 cases, 73.9%). Four cancercases were Hispanic, 4 were black, and 4 were Asian. Twenty ofthe 46 patients (43.5%) who developed cancers were current(n = 4) or ex-smokers (n = 16); five of the six lung cancers werecurrent (n = 1) or ex-smokers (n = 4).Conclusions Just under 3% of the incident SLE cohort developed a cancer over an average follow-up of 6.9 years. The mostcommon cancers were breast, non-melanoma skin, and lung cancers. The vast majority of lung cancers were smokers, supportingthe belief that lung cancer risk in SLE (as in the general population) is largely driven by smoking. Further analyses will determine the standardised incidence rates for these cancers in SLE,versus the general population

OBJECTIVES: Following up the systemic lupus erythematosus (SLE) genome-wide association studies (GWAS) identification of NMNAT2 at rs2022013, we fine-mapped its 150 kb flanking regions containing NMNAT2 and SMG7 in a 15 292 case-control multi-ancestry population and tested functions of identified variants. METHODS: We performed genotyping using custom array, imputation by IMPUTE 2.1.2 and allele specific functions using quantitative real-time PCR and luciferase reporter transfections. SLE peripheral blood mononuclear cells (PBMCs) were cultured with small interfering RNAs to measure antinuclear antibody (ANA) and cyto/chemokine levels in supernatants using ELISA. RESULTS: We confirmed association at NMNAT2 in European American (EA) and Amerindian/Hispanic ancestries, and identified independent signal at SMG7 tagged by rs2702178 in EA only (p=2.4x10-8, OR=1.23 (95% CI 1.14 to 1.32)). In complete linkage disequilibrium with rs2702178, rs2275675 in the promoter region robustly associated with SMG7 mRNA levels in multiple expression quantitative trait locus (eQTL) datasets. Its risk allele was dose-dependently associated with decreased SMG7 mRNA levels in PBMCs of 86 patients with SLE and 119 controls (p=1.1x10-3 and 6.8x10-8, respectively) and conferred reduced transcription activity in transfected HEK-293 (human embryonic kidney cell line) and Raji cells (p=0.0035 and 0.0037, respectively). As a critical component in the nonsense-mediated mRNA decay pathway, SMG7 could regulate autoantigens including ribonucleoprotein (RNP) and Smith (Sm). We showed SMG7 mRNA levels in PBMCs correlated inversely with ANA titres of patients with SLE (r=-0.31, p=0.01), and SMG7 knockdown increased levels of ANA IgG and chemokine (C-C motif) ligand 19 in SLE PBMCs (p=2.0x10-5 and 2.0x10-4, respectively). CONCLUSION: We confirmed NMNAT2 and identified independent SMG7 association with SLE. The inverse relationship between levels of the risk allele-associated SMG7 mRNAs and ANA suggested the novel contribution of mRNA surveillance pathway to SLE pathogenesis.

Background/Purpose: Little is known about the association of healthcare costs with damage accrual in SLE. We describe the costs associated with damage states across the disease course using multi-state modeling. Methods: Patients fulfilling the revised ACR classification criteria for SLE from 32 centres in 11 countries were enrolled in the Systemic Lupus International Collaborating Clinics (SLICC) inception cohort within 15 months of diagnosis. Annual data on demographics, SLE disease activity (SLEDAI-2K), damage (SLICC/ACR Damage Index [SDI] if > 6 months from diagnosis), hospitalizations, medications, dialysis, and utilization of selected medical/surgical procedures were collected. Annual health resource utilization was costed using 2015 Canadian prices. Annual costs associated with SDI states were obtained from multiple regressions adjusting for age, race/ethnicity, and disease duration. As there were relatively few transitions to SDI states 5 - 11, these were merged into a single SDI state. Five and 10-year cumulative costs were estimated by multiplying annual costs associated with each SDI state by the expected duration in each state, which was forecasted using a multi-state Markov model (Bruce IN et al. Ann Rheum Dis 2015;74:1706-13). Results: 1641 patients participated, 89.2% female, 48.9% Caucasian, mean age at diagnosis 35.2 years (SD 13.4), mean disease duration at enrollment 0.5 years (SD 0.3), and mean follow up 6.1 years (range 0.1 - 13.7 years). Health resource utilization and annual costs (after adjustment using regression) were markedly higher in those with higher SDIs Conclusion: Patients with the highest baseline SDIs incur annual costs and 10-year cumulative costs that are approximately 20-fold higher than those with the lowest baseline SDI. By estimating the expected duration in each SDI state and incorporating annual costs, disease severity at presentation can be used to predict future healthcare costs, critical knowledge for cost-effectiveness evaluations of novel therapies. (Table Presented)