title: Epitope-specific immunotherapy of rheumatoid arthritis: clinical responsiveness occurs with immune deviation and relies on the expression of a cluster of molecules associated with T cell tolerance in a double-blind, placebo-controlled, pilot phase II trial.
abstract: OBJECTIVE
  Induction of immune tolerance to maintain clinical control with a minimal drug regimen is a current research focus in rheumatoid arthritis (RA). Accordingly, we are developing a tolerization approach to dnaJP1, a peptide part of a pathogenic mechanism that contributes to autoimmune inflammation in RA. We undertook this study to test 2 hypotheses: 1) that mucosal induction of immune tolerance to dnaJP1 would lead to a qualitative change from a proinflammatory phenotype to a more tolerogenic functional phenotype, and 2) that immune deviation of responses to an inflammatory epitope might translate into clinical improvement.
  
  
  METHODS
  One hundred sixty patients with active RA and with immunologic reactivity to dnaJP1 were enrolled in a pilot phase II trial. They received oral doses of 25 mg of dnaJP1 or placebo daily for 6 months.
  
  
  RESULTS
  The dnaJP1 peptide was safe and well-tolerated. In response to treatment with dnaJP1, there was a significant reduction in the percentage of T cells producing tumor necrosis factor alpha and a corresponding trend toward an increased percentage of T cells producing interleukin-10. Coexpression of a cluster of molecules (programmed death 1 and its ligands) associated with T cell regulation was also found to be a prerequisite for successful tolerization in clinical responders. Analysis of the primary efficacy end point (meeting the American College of Rheumatology 20% improvement criteria at least once on day 112, 140, or 168) showed a difference between treatment groups that became significant in post hoc analysis using generalized estimating equations. Differences in clinical responses were also found between treatment groups on day 140 and at followup. Post hoc analysis showed that the combination of dnaJP1 and hydroxychloroquine (HCQ) was superior to the combination of HCQ and placebo.
  
  
  CONCLUSIONS
  Tolerization to dnaJP1 leads to immune deviation and a trend toward clinical efficacy. Susceptibility to treatment relies on the coexpression of molecules that can down-regulate adaptive immunity.
authors.affiliation: University of California, San Diego, La Jolla, CA, USA.
authors.forename: Eva C
authors.initials: EC
authors.lastname: Koffeman
authors.forename: Mark
authors.initials: M
authors.lastname: Genovese
authors.forename: Diane
authors.initials: D
authors.lastname: Amox
authors.forename: Elissa
authors.initials: E
authors.lastname: Keogh
authors.forename: Ernesto
authors.initials: E
authors.lastname: Santana
authors.forename: Eric L
authors.initials: EL
authors.lastname: Matteson
authors.forename: Arthur
authors.initials: A
authors.lastname: Kavanaugh
authors.forename: Jerry A
authors.initials: JA
authors.lastname: Molitor
authors.forename: Michael H
authors.initials: MH
authors.lastname: Schiff
authors.forename: James O
authors.initials: JO
authors.lastname: Posever
authors.forename: Joan M
authors.initials: JM
authors.lastname: Bathon
authors.forename: Alan J
authors.initials: AJ
authors.lastname: Kivitz
authors.forename: Rodrigo
authors.initials: R
authors.lastname: Samodal
authors.forename: Francis
authors.initials: F
authors.lastname: Belardi
authors.forename: Carolyn
authors.initials: C
authors.lastname: Dennehey
authors.forename: Theo
authors.initials: T
authors.lastname: van den Broek
authors.forename: Femke
authors.initials: F
authors.lastname: van Wijk
authors.forename: Xiao
authors.initials: X
authors.lastname: Zhang
authors.forename: Peter
authors.initials: P
authors.lastname: Zieseniss
authors.forename: Tho
authors.initials: T
authors.lastname: Le
authors.forename: Berent A
authors.initials: BA
authors.lastname: Prakken
authors.forename: Gary C
authors.initials: GC
authors.lastname: Cutter
authors.forename: Salvatore
authors.initials: S
authors.lastname: Albani
mesh_terms: D056704:Adaptive Immunity / Q000276:immunology; D000328:Adult; D001172:Arthritis, Rheumatoid / Q000276:immunology / Q000628:therapy*; D004305:Dose-Response Relationship, Drug; D004311:Double-Blind Method; D004359:Drug Therapy, Combination; D005260:Female; D050956:HSP40 Heat-Shock Proteins / Q000235:genetics / Q000276:immunology / Q000627:therapeutic use; D006801:Humans; D006886:Hydroxychloroquine / Q000627:therapeutic use; D007108:Immune Tolerance / Q000235:genetics / Q000276:immunology*; D016056:Immunodominant Epitopes / Q000235:genetics / Q000276:immunology / Q000627:therapeutic use*; D007167:Immunotherapy / Q000379:methods*; D016753:Interleukin-10 / Q000378:metabolism; D008297:Male; D008875:Middle Aged; D010455:Peptides / Q000235:genetics / Q000276:immunology / Q000627:therapeutic use; D010865:Pilot Projects; D013601:T-Lymphocytes / Q000276:immunology* / Q000378:metabolism / Q000473:pathology; D014409:Tumor Necrosis Factor-alpha / Q000378:metabolism
chemical_list: D050956:HSP40 Heat-Shock Proteins; D016056:Immunodominant Epitopes; D010455:Peptides; D014409:Tumor Necrosis Factor-alpha; D016753:Interleukin-10; D006886:Hydroxychloroquine