1. BIOMARKERS TO GUIDE TREATMENT IN RA
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

2. 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 % 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

3. EA/ERA Office Prognosis Early Intervention RA Biomarkers Clinical 2010
AutoAbs 2010
Genetic
Imaging RA
TEXTBOOK
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EA/ERA
Office
Early Intervention

4. Classification Criteria A probabilistic approach to early diagnosis
CLINICAL PROGRES
The ACR-EULAR 2010
Classification Criteria
A probabilistic approach to early diagnosis

5. 1987 CRITERIA Mean Disease Duration: 8 Years
Arthritis and Rheumatism 31:315-24,1988

6. 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

7. 2010 ACR/EULAR RA CRITERIA > 6 weeks 1
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
2-10 large joints
1-3 small joints (with or without involvement of large joints)#
4-10 small joints (with or without involvement of large joints)
>10 joints (at least 1 small joint)**
B. Serology (at least 1 test result is needed for classification)††
Negative RF and negative ACPA
Low-positive RF or low-positive ACPA
High-positive RF or high-positive ACPA
C. Acute-phase reactants (at least 1 test result is needed for classification)‡‡
Normal CRP and normal ESR
Abnormal CRP or abnormal ESR
D. Duration of symptoms§§ < 6 weeks
> 6 weeks

8. HYPOTHETICAL COURSE of RA
1987 Established RA
2010 Early RA
Inflammation
clinical
threshold
40% erosions of hands or feet
median symptom duration 4 months
Pre-RA
Auto-Ab
Time

9. POST-2010 PERSPECTIVES Extrapolation Validation Stratification
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.
Extrapolation
Validation
Stratification
No erosions

10. EXPERT PANEL 12 12
KUWAIT

11. Biomarkers For Early Disease
Clinical : ACR-EULAR 2010 Criteria
Serological : Citrullinated Immune Systems

12. Studying Auto-Immune Systems
DIAGNOSIS
Auto-Abs
Clinician
PROGNOSIS
MONITORING
TOOLS FOR BIOLOGY
Auto-Ags
Biologist
PHYSIOPATHOLOGY
CLUES TO ETIOLOGY
Roadmap to Personalized Medicine

13. Rheumatoid Arthritis An In Vivo ELISA
Anti-IgGs
(RFs)
Agn
(Many)
Abn
Primary Systems
Specificity
Secondary Systems
Amplification

14. 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….

15. RA-Specific Immune Systems
A C P A s
Anti-Citrullinated PEPTIDE Antibodies.
Anti-Citrullinated PROTEINS Antibodies

16. Citrullination is the Enzymatic Conversion of Arginine To Citrulline
The Antigen(s)
Citrullination is the Enzymatic Conversion of Arginine To Citrulline

17. Citrullination: A Mechanism To Recycle Aminoacids3 1 2 4 5

18. Citrullination An Intracellular Agonic Event
PADIs are present in most cells: epithelial, fibroblast, osteoblast, endothelial, myeloid and dentritic cells but NOT IN LYMPHOID CELLS.
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.
Citrullination is thus a cellular agonic event, a NORMAL feature of inflammation and repair.

19. Citrullination Is Also A Secondary Extracellular Event
Fibrin,
Collagen,
ANY PROTEIN
Exocytosis / Apoptosis
No known natural inhibitor

20. Five Points To Remember About Cit-Proteins/ACPAs In Joints
Cit-proteins are found in all inflammed tissues and fluids, not CCP.
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).
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).
The pannus is an ectopic lymphoid tissue producing RF, anti-AgN including ACPAs (Smiley 1970, Serre 2000).
ACPAs are IgGs typical of a mature/ongoing polyclonal Ag-driven response (Ménard 1984, Schellekens 1998 and Ioan-Facsinay 2008, 10) .

21. Anti-CCP2 ELISA : Designed For Screening Populations
Ceiling effect
ULT
O.D.
ULN
Low Threshold
Anti-CCP2 Titer
van Venrooij W 2003
McGill anti-Sa vs Euroimmun anti-Sa
98.5%
McGill anti-Sa vs Euroimmun anti-CCP2
94.2%
Euroimmun anti-Sa vs Euroimmun anti-CCP2
92.5%

22. Scandinavian Blood Donors
Retrospective Study
Scandinavian Blood Donors
Time (years)
IgM-RF 2 (0.3 – 10)
anti-CCP 5 (0 – 14)
IgM-RF or anti-CCP 5 (0 – 14)
SR Dahlqvist et al. A&R 2003

23. Hypothetical Course of RA
1987 Established RA
2010 Early RA
Inflammation
clinical
threshold
40% erosions of hands or feet
median symptom duration 4 months
Pre-RA
Auto-Ab
Time

24. 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…

25. Co-PI : HA Ménard
Montreal, Quebec
PI : H El-Gabalawy,
Winnipeg, Manitoba

26. Anti-Sa ELISA (2004) : Design For Prognosis and Monitoring
Individual RA Patients
ULT
ULT
O.D.
ULN
ULN
Anti-CCP Titer
Anti-Sa titer
McGill anti-Sa vs Euroimmun anti-Sa
98.5%
McGill anti-Sa vs Euroimmun anti-CCP2
94.2%
Euroimmun anti-Sa vs Euroimmun anti-CCP2
92.5%

27. Anti-Sa / anti-CCP2 In NAN A Prospective Study
ELISA
79%
20% 9% RA
FDR
UNRELATED
51% 0% 0%
Anti-Sa
ELISA
Ioan-Facsinay A et al. (El Gabalawy H, Ménard H) A&R 2008

28. Guzian C et al. (Boire G, Ménard H) AR&T 2010
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

29. 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.

30. MONITORING RA WITH ANTI-Sa
CSR SR CR
ERA
MonoA RA CR
RA VASC
RTX
CSR
NHL-RA
Palindrome
RTX
CSR = Clinical Serological Remission
Anti-CCP2 never changed significantly
Rotman J (Ménard HA) European Workshop Rheum Res Toulouse 2008

31. 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.

32. Clinical Summary of ACPA Literature In Early and Established RA
SPECIFICITY (85-100%)
anti-Sa >> CCP > MCV
SENSITIVITY 40% to 80% depending on test and patients i.e. phase of disease, age at onset, treatment.
anti-CCP = MCV > anti-Sa
For SCREENING
anti-CCP > MCV >> Sa
more sensitive, less specific.
for DIAGNOSIS
anti-Sa>> CCP > MCV
for MONITORING
anti-Sa >> MCV >> CCP = 0
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

33. Interpretation Of The Clinical Data
NEPHRITIS
ARTHRITIS
SLE RA
ANA
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.

34. SHUKRAN
ALA ALDAWAH