CONNECTIVE TISSUE

DISEASESLesley Davila, MD

Assistant Professor, Rheumatic Diseases

December 11, 2014

OUTLINEAutoantibodies

SLE

Systemic sclerosis

Mixed Connective Tissue Disease

ANA – anti nuclear antibody

Order ANA by IIFA

• Indirect Immunofluorescent Assay

• Detects up to 150 autoantigens

• Results = titer with pattern (eg 1:160 speckled)

• Formal recommendation of the ACR

• Recent international group = same recommendation

• Cheaper solid phase assays

• Only detect 6-8 autoantigens

• Higher number of false negatives

• Value results given as a # units or as “neg” or “pos”

ANA

Homogeneous

(DNA, histone)

Speckled

(U1-RNP, SM,

La)

Centromere Nucleolar

(RNA pol 1,3

PM-SCL)

Disease associated with a positive ANA

Disease associated with positive ANA

Antibodies occur before diagnosis

- 115 out of 130 SLE patients

- Up to 9.4 years before diagnosis

- Many times + earliest available samples

- Most likely occur significantly earlier

- Average of 3.3 years

- ANA (78%)

- dsDNA (55%)

- SSA (47%); SSB (34%)

- Smith (32%); RNP (26%)

- APLAs (18%)

Arbuckle et al., Development of autoantibodies before the clinical onset of systemic lupus erythematosus.

NEJM 2003;349(16):1526

Autoantibodies in SLE

Antibodies Lupus Specificity Clinical Associations

ANA Low Nonspecific

Anti-dsDNA High Nephritis

Anti-Sm High Nonspecific

Anti-RNP Low Arthritis, myositis, lung disease

Anti-SSA Low Dry eyes/mouth, subacute

cutaneous lupus erythematosus

(SCLE), neonatal lupus,

photosensitivity

Anti-SSB Low Same as above

Antiphospholipid Intermediate Clotting diathesis

SYSTEMIC LUPUS

ERYTHEMATOSUSDiagnostic review

Therapeutic considerations

How Do You Diagnose Lupus?

• Technically, you can’t

• “Classification Criteria” differentiate SLE from other

autoimmune conditions

• Not infectious

• Not malignant

• Etc.

• American College of Rheumatology

• 1987 – validated against Expert Opinion (4/11 criteria)

• 1992 revision – not validated; 83% Sens/96% Spec

• Systemic Lupus International Collaborating Clinics

• 2012 – Used modern recursive partitioning methods

• 4/17 criteria; clinical and lab; or LN and labs; 97% Sens/84% Spec

The Best Mnemonics are Remembered

H Hematologic – thrombocytopenia, leukopenia or lymphopenia, AIHA

I Immunologic – anti-Sm, anti-DNA, anti-phospholipid, low complement

M Mucocutaneous – ACLE, SCLE, DLE, and/or oral/nasal ulcers (4 criteria!)

R Renal – proteinuria or red cell casts or LN by biopsy

S Serositis – must be provider documented

A Arthritis – must be provider documented

N Neurologic – Seizures or psychosis

A ANA

Technically, there are ~4,000 combinations of 4 different

items, but lupus commonly presents in a few ways…

Lupus on the Outside

Malar rash

Synovitis Subacute

cutaneous lupus

erythematosus

Oral ulcer

Discoid rash Lupus profundus

Vasculitis

Jaccoud’s arthropathy

Lupus on the Inside

Serositis Pericardial

effusion

Cerebral infarct

GlomerulonephritisSpherocytesRPLE

C

Lupus Treatments

AM CS NSAIDs

MTX/L

EF

MMF/A

ZA CYC

PLEX/I

VIG

Skin + + ±

Joints + + ± ±

Serositis + + ±

Heme + ++ ± +

NPSLE + ++ ± +

LN + ++ + +

Pregnancy + + x x/+ x

General: photoprotection, CVD, and osteoporosis treatment

Toll-like Receptors and SLE

• Toll-Like Receptors (TLRs) sense patterns associated

with pathogenic organisms – LPS, peptidoglycan,

bacterial and viral DNA/RNA

• TLR7 and TLR9 are endosomal – designed to sense

ingested microbial nucleic acids

• IgG-NA complexes are targeted to TLR7/9 leading to B

cell activation and autoantibody production

• Activation of TLR9 leads to anti-DNA in mouse models;

TLR7 to anti-RNA Abs. Genetic deficiency or chemical

inhibition reverse this.

• X-linked TLR7 may explain some of the gender effects in

both mouse and human models

Genes

Sunlight

Viruses

Estrogen

Etc.

B cell

Plasmacytoid

Dendritic Cell

Anti-Nucleic Acid

Binding Proteins

Interferon a

PMN

“Nets”

Interferon a

Monocyte

Disease-

Causing

Autoantibodies

T and B cells

Hydroxychloroquine in SLE

• Concentrated in

endosomes where it

raises pH and inhibits

TLR7/9 function

• Shuts off IFN-a

production by pDCs

• Improves plasma

glucose

• Improves lipid profile

• Anti-thrombotic

Wallace, DJ, et al, Nat Reviews Rheum, online ahead of print, 17 July 2012

Clinical Effects of Hydroxychloroquine in

Systemic Lupus Erythematosus

Reduced Flares Increased Survival

Less Organ DamageDelayed Disease Onset

NEJM (1991), 324:150-154; Arth & Rheum (2005) 52:1473-1480

Arth & Rheum (2010) 62:855-862; Lupus (2007) 16:401-409

B Cell Cytokines BAFF and APRIL

• BAFF (BLyS) and APRIL are homotrimeric TNF family

members expressed by neutrophils, macrophages,

monocytes and dendritic cells

• Critical roles in B cell development and proliferation

• Overexpression in animal models leads to a lupus-like

illness; blockade prevents it.

• Increased levels of BAFF and APRIL seen in human SLE

and rheumatoid arthritis

BAFF – B cell activating factor; BLyS – B Lymphocyte stimulator; APRIL – a

proliferation inducing ligand; BCMA – B cell maturation antigen; TACI –

transmembrane activator and calcium modulator and cyclophilin ligand

interactor

Mackay and Schneider, Nature Rev Immunol, 9:491-502, 2009

Mackay and Browning, Nature Rev Immunol, 2:465-475, 2002)

Elevated BLyS Levels in SLE and RA

Zhang, et al., J Immunol., 166:6-10, 2001

BLISS-52 – Phase III Trial of Belimumab

867 pts

SLEDAI ≥ 6

Placebo

1 mg/kg Belimumab

10 mg/kg Belimumab

0 2 4 8 12 16 20 24 28 32 36 40 44 48

Week

SRI

Week 52

Patients from Latin America, Asia-Pacific, and Eastern Europe

Allowed to take regional ‘standard of care’ including immunosuppresants

and prednisone (taper attempted after 24 weeks)

SRI: Improvement/lack of worsening in 3 different composite measures

Navarra, et al., Lancet, 377:721-731, 2011

BLISS-52 Demographics

Belimumab

1 mg/kg (288)

Belimumab

10 mg/kg (290) Placebo (287)

Age (yr) 35.0 35.4 36.2

Female 272 (94%) 280 (97%) 270 (94%)

Ethnicity

Amerindian 98 (34%) 92 (32%) 89 (31%)

White 76 (26%) 71 (24%) 82 (29%)

African American 8 (3%) 11 (4%) 11 (4%)

Asian 106 (37%) 116 (40%) 105 (37%)

Hispanic 141 (49%) 136 (47%) 143 (50%)

Disease duration (yr) 5.0 5.0 5.9

SLEDAI 9.6 ± 3.8 10.0 ± 3.9 9.7 ± 3.6

Prednisone 96% 96% 96%

> 7.5 mg/d 71% 70% 67%

Dose (mg/d) 12.9 ± 8.6 13.2 ± 9.5 11.9 ± 7.9

BLISS-52 Results

Belimumab

1 mg/kg (288)

Belimumab

10 mg/kg (290) Placebo (287)

SRI Response 51% 58% 44%

SLEDAI decrease 53% 58% 46%

BILAG stable 78% 81% 73%

PGA stable 79% 80% 69%

Patients with flare 70% 71% 80%

Time to flare (d) 126 (5-375) 119 (1-367) 84 (1-368)

Sustained

reduction in

prednisone

24% 28% 15%

All statistically significant p<0.05

No differences in adverse events or lab abnormalities

BAFF/APRIL as Therapeutic Targets

• Belimumab (Benlysta) approved by FDA in 2011 for active, autoantibody-positive SLE in addition to standard therapy• Trial endpoint not obvious in practice

• In combined analysis, all benefit seen in patients with low C3 and high anti-DNA titers

• Not tested in nephritis or CNS disease

• Expensive ($35,000/yr)

• Atacicept (Merck) – TACI-Ig fusion protein blocks both BAFF and APRIL; trial suspended for safety

• Tabalumab (Lilly) – Anti-BAFF in Phase 2/3

• Blisibimod (Amgen/Anthera) – BAFF inhibitor fusion protein

Lupus Nephritis (LN) is:

• Common

• Affects 60% of adults and 80% of children with systemic lupus

erythematosus

• Severe

• 10-30% progress to ESRD in 15 yr

• Most important predictor of mortality in SLE

• Treatable

• But how should we treat it?

• How well are we doing?

Austin, et al., NEJM 314:614-9 (1986)

Cyclophosphamide – The Drug to Beat in

Lupus Nephritis• Boumpas, et al., Lancet 1992

• “NIH Regimen” of 6 monthly followed by 6 quarterly doses of 0.5-

1.0 g/m2 IV CTX

• Gourley, et al., Ann Intern Med 1996

• IV cyclophosphamide plus IV methylprednisolone achieved 85%

remission compared to 62% for CTX alone and 29% for MP alone

• Houssiau, et al., Arthritis Rheum 2002

• Euro-Lupus Trial: Induction with 500 mg CTX every 2 wk x 6

followed by azathioprine as effective as high-dose CTX with less

toxicity

Aspreva Lupus Management Study

Appel GB et al, JASN, 2009

Dooley MA et al, NEJM, 2011

MMF 1.5 g BID

IVC 0.5-1 g/m2 monthly

Response or Remission

MMF 1 g BID

AZA 2mg/kg/day

Exit study

YESRe-randomization

NO

24-wk induction phase 36-mo maintenance phase

370 pts 227 pts

ALMS induction: response to treatment

Appel GB et al, JASN, 2009

African-American

Aspreva Lupus Management Study

Appel GB et al, JASN, 2009

Dooley MA et al, NEJM, 2011

MMF 1.5 g BID

IVC 0.5-1 g/m2 monthly

Response or Remission

MMF 1 g BID

AZA 2mg/kg/day

Exit study

YESRe-randomization

NO

24-wk induction phase 36-mo maintenance phase

370 pts 227 pts

Primary endpoint: time to treatment failure

• Death

• ESRD

• Sustained doubling of serum creatinine

• Need for rescue therapy

Time to treatment failure

Time to renal flare

ALMS Conclusions

• Induction therapy

• NIH protocol IV CYC and MMF have similar efficacy and toxicity

• MMF may be superior in African-ancestry pts

• Maintenance therapy

• In pts who have achieved a renal response with induction therapy,

MMF is superior to AZA for maintenance therapy

• None of the tested therapies helped >60% patients

SYSTEMIC SCLEROSISSmall vessel vasculopathy

Pathological fibrosis

Autoimmunity

Diffuse Cutaneous Systemic Sclerosis

• Skin thickening proximal to

elbows and knees

• RP present within one year

of diagnosis

• Progressive, often fatal ILD

• Cardiac, renal and GI

involvement

• Associated with anti-topo-I

(Scl-70)

• 40-60% 10-yr survival

Limited Cutaneous Systemic Sclerosis

• Proximal skin thickening

• Can follow RP for years

• CREST in a sub-set of these patients

• Later and less severe visceral involvement

• More likely to get pulmonary hypertension

• Associated with anti-centromere antibodies

• >70% 10-yr survival

Features of Systemic Sclerosis

Diffuse Cutaneous Feature Limited Cutaneous

5% Calcinosis 45%

85% Raynaud’s Phenomenon 95%

75% Esophageal Dysmotility 75%

30% Telangiectasias 80%

80% Arthralgia/arthritis 60%

65% Tendon friction rubs 5%

35-59% Pulmonary fibrosis 35%

<1% Pulmonary hypertension 12%

10% LV dysfunction 1%

15% Renal crisis 1%

Sclerodactyly

Images © 2009 American College of Rheumatology

Raynaud’s Phenomenon

Images © 2009 American College of Rheumatology

Raynaud’s Auto-amputation

Pulmonary Arterial Hypertension

• CTD-PAH accounts for 30% of all PAH worldwide

• Prevalence of PAH in SSc is 10-15%

• 80% 5-yr survival without PAH

• 10% 5-yr survival with PAH

• Risk factors

• Limited cutaneous form

• Raynaud’s for > 8 yr

• Anti-centromere or anti-nucleolar ANA (Scl-70 neg)

• DLCO < 60% without ILD

• FVC%/DLCO% ratio > 1.6

• Treatment is complicated – ETRA, PDE5i, prostanoids or

a combination of 2 or all 3

Dyspnea,

RP > 8 yr, or

ACA/anti-nucleolar

DLCO% <60

FVC%/DLCO% >1.6

RVSP, mmHg >40

DLCO% <70

FVC%/DLCO% <1.6

RVSP, mmHg >35

DLCO% >70

FVC%/DLCO% <1.6

RVSP, mmHg <35

PFTs annually x 10

TTE every 2-3 yr

If risk factors, then

PFTs annually

TTE annually

PFTs/TTE in 3-6 mo

Right Heart CathRight Heart Cath

No Yes

Yes

Typically, HRCT to evaluate extent of ILD

6 minute walk test

NT-proBNP?

Fischer, et al., Arthritis Care & Res; 2012, 64:303-310

Raynaud’s Phenomenon

• SSc patients have structural ischemia (fibrosis) as well as

functional ischemia (vasospasm)

• Keep warm, even in summer!

• Extended-release calcium channel blockers

• ACEi, ARBs, SSRI possibly effective

• PDE5 inhibitors – true placebo not possible

• Endothelin receptor antagonists – may help ulcers but not

symptoms

• Topical nitrates – tolerance a problem

Digital ulcer healing by sildenafil treatment as shown for three different patients.

Brueckner C S et al. Ann Rheum Dis 2010;69:1475-1478

©2010 by BMJ Publishing Group Ltd and European League Against Rheumatism

MCTD

Mixed Connective Tissue Disease

• Patients with overlapping features of SLE, polymyositis

and scleroderma

• Associated with high titer U1-RNP antibody

• Not to be confused with “overlap” or “undifferentiated”

connective tissue disease

“Discovery” of MCTD

Rash

Arthritis

Serositis

ANA

SLE

Raynaud’s

Puffy Hands

Mild arthritis

Myositis

High Titer

anti-U1-RNP

MCTD – A New Disease?

• Original Description:

• Mild, highly steroid responsive

• Little, if any, renal, CNS, or pulmonary disease

• Not lupus (anti-Sm or anti-DNA excluded patients)

• But, 8 years later:

• 8 patients had died

• Many had moved toward systemic sclerosis features

• Association with anti-RNP not clear

• Anti-RNP is not unique to MCTD

• Many MCTD patients can fit criteria for RA, SLE, or SSc

• Risk of fitting clinical features to a syndrome based on serology

MCTD – Diagnostic Criteria

• Four competing criteria!

• Alarcón-Segovia, et al.

• Anti-U1-RNP at 1:1600 or greater (no clue what this is now), and

• Three or more clinical criteria

• Edema of the hands

• Raynaud’s phenomenon

• Acrosclerosis

• Myositis

• Synovitis

• 81.3% sensitive; 86.3% specific in anti-RNP+ patients

MCTD – Not Benign

• 11% developed glomerulonephritis

• 17% had neurological manifestations

• Pulmonary disease and esophageal dysmotility both seen

in two-thirds of patients

• Pulmonary HTN (often asymptomatic) seen in 23%,

including all 9 of 47 patients who died of MCTD related

causes

• Other studies

• ILD/PF seen in 20-65%

• PHT seen in 10-45%

• BAL has CD4+ T cell predominance

MCTD

• Not all anti-RNP is MCTD

• These patients may be better classified as

undifferentiated CTD

• Make sure to screen for lung disease.

QUESTIONS?