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Introduction Coagulation factor XIII (FXIII) is a plasma fibrin-stabilizing factor comprising A and B subunits (FXIII-A and FXIII-B, respectively) in the form of a heterotetramer (FXIII-A 2 B 2 ). A humanized monoclonal antibody to the interleukin-6 receptor (tocilizumab, TCZ) has emerged as an effective treatment for rheumatoid arthritis (RA), because it drastically reduces the inflammation of RA. We previously reported that two TCZ-treated RA patients with acquired FXIII deficiency developed pelvic hemorrhage. Methods Because TCZ treatment had been shown to be related to low FXIII ammonia release activity and FXIII antigen in the two RA cases, we further examined FXIII-related parameters in 36 TCZ-treated RA patients and compared to 29 healthy controls by employing functional and immunologic assays for FXIII. Results FXIII-A antigen and FXIII amine incorporation and ammonia release activities were significantly lower in the TCZ-treated group than the control group. The TCZ-treated group also showed mildly low FXIII-A 2 B 2 and FXIII-B levels, and their fibrinogen levels were the lower limit of normal. A significant correlation between FXIII-B and fibrinogen was observed in the control and the TCZ groups, suggesting a common metabolic mechanism(s) for these two hepatic proteins. Because the specific activities of FXIII were normal and neither anti-FXIII-A nor anti-FXIII-B antibody was detected, the overall low FXIII level may have resulted from its impaired synthesis under an unbalanced cytokine milieu caused by TCZ treatment. Conclusion Concomitant deficiencies in multiple hemostatic factors, including FXIII, may lead to an increased risk for hemorrhage in TCZ-treated RA patients.

Objective To evaluate the efficacy and safety of switching from intravenous (IV) tocilizumab (TCZ) to subcutaneous (SC) TCZ monotherapy in rheumatoid arthritis patients. Methods Patients who had completed 24 weeks of TCZ-SC (162 mg/2 weeks) or TCZ-IV (8 mg/kg/4 weeks) monotherapy in the double-blind period of the MUSASHI study were enrolled in an 84-week open-label extension period. All received TCZ-SC (162 mg/2 weeks) monotherapy. Effects of the IV to SC switch were evaluated at week 36 (12 weeks after switching). Results Overall, 319 patients received ≥1 dose of TCZ-SC during the open-label extension period; 160 switched from TCZ-IV to TCZ-SC (TCZ IV/SC) and 159 continued TCZ-SC (TCZ SC/SC). Disease Activity Score in 28 joints using the erythrocyte sedimentation rate clinical remission rates were 62.5% (100 of 160) for TCZ IV/SC and 50.0% (79 of 158) for TCZ SC/SC at week 24, and were maintained at 62.5% (100 of 160) and 57.0% (90 of 158), respectively, at week 36. In the TCZ IV/SC group, 9% of patients (9 of 100) who had achieved remission at week 24 could not maintain remission at week 36. In TCZ IV/SC patients weighing ≥70 kg, the percentage with a sufficient serum TCZ concentration (≥1 μg/ml) decreased from 90.9% (10 of 11) at week 24 to 45.5% (5 of 11) at week 36. Overall safety profiles were similar in TCZ IV/SC and TCZ SC/SC except for mild injection site reactions in TCZ IV/SC. Conclusion Efficacy is adequately maintained in most patients switching from TCZ-IV (8 mg/kg/4 weeks) to TCZ-SC (162 mg/2 weeks) monotherapy. Patients receiving TCZ-IV can switch to TCZ-SC without serious safety concerns. Clinical efficacy may be reduced after switching in some patients with high body weight.

Objective Anti–citrullinated protein antibodies (ACPAs) are highly specific to rheumatoid arthritis (RA), and strong associations between HLA–DRB1 alleles and ACPA levels have been detected in RA patients. We undertook this study to elucidate the associations between particular amino acid positions in HLA–DRB1 and ACPA levels in patients with RA. Methods We analyzed ACPA data on a total of 4,371 Japanese ACPA-positive RA patients in whom HLA–DRB1 allele genotyping had been performed. Generalized linear regression analysis and omnibus testing were carried out to determine associations of HLA–DRB1 alleles, amino acid residues, or amino acid positions with levels of ACPA. Results HLA–DRB1*09:01 and HLA–DR15 were confirmed to be associated with ACPA levels. HLA–DRB1*08:03 and DRB1*14:06 were associated with reduced and increased ACPA levels, respectively. We detected a strong association between ACPA levels and amino acid position 74 (P = 1.9 × 10−51). The association was mainly conferred by alanine residue (P = 4.5 × 10−51). After adjustment for position 74, amino acid positions 60 and 57 were found to be associated with ACPA levels. Amino acid positions 74 and 57 had previously been reported to be associated with susceptibility to ACPA-positive RA in Asians. Combinations of the amino acid residues at position 74 and position 60 or 57 could induce improvement in Akaike's information criterion comparable to that induced by the 5 significant HLA–DRB1 alleles (HLA–DRB1*08:03, DRB1*09:01, DRB1*14:06, DRB1*15:01, and DRB1*15:02). Conclusion Amino acid position 74 in HLA–DRB1 is strongly associated with ACPA levels in ACPA-positive RA, as well as with RA susceptibility. The mechanisms of ACPA production and susceptibility to ACPA-positive RA seem to partly overlap.

Antiphospholipid syndrome (APS) is an autoimmune disorder characterized by thrombosis and/or pregnancy complications. β2-glycoprotein I (β2GPI) complexed with phospholipid is recognized as a major target for autoantibodies in APS; however, less than half the patients with clinical manifestations of APS possess autoantibodies against the complexes. Therefore, the range of autoantigens involved in APS remains unclear. Recently, we found that human leukocyte antigen (HLA) class II molecules transport misfolded cellular proteins to the cell surface via association with their peptide-binding grooves. Furthermore, immunoglobulin G heavy chain/HLA class II complexes were specific targets for autoantibodies in rheumatoid arthritis. Here, we demonstrate that intact β2GPI, not peptide, forms a complex with HLA class II molecules. Strikingly, 100 (83.3%) of the 120 APS patients analyzed, including those whose antiphospholipid antibody titers were within normal range, possessed autoantibodies that recognize β2GPI/HLA class II complexes in the absence of phospholipids. In situ association between β2GPI and HLA class II was observed in placental tissues of APS patients but not in healthy controls. Furthermore, autoantibodies against β2GPI/HLA class II complexes mediated complement-dependent cytotoxicity against cells expressing the complexes. These data suggest that β2GPI/HLA class II complexes are a target in APS that might be involved in the pathogenesis.

To evaluate the safety and efficacy of retreatment with tocilizumab (TCZ) in patients who had participated in the DREAM study (Drug free remission/low disease activity after cessation of tocilizumab [Actemar] monotherapy study) and had experienced loss of efficacy.Patients were retreated with TCZ or other disease modifying antirheumatic drugs (DMARDs). Disease activity was measured using the 28-joint disease activity score (DAS28) for 12 weeks.A total of 164 eligible patients, including 161 who experienced loss of efficacy within 52 weeks of the DREAM study, resumed treatment: 157 with TCZ and 7 with DMARDs and/or infliximab. Of TCZ-treated patients, 88.5 % (139 patients) achieved DAS282.6 within 12 weeks, whereas among patients treated with DMARDs and/or infliximab only 14.3 % (1 patient) achieved DAS282.6. Adverse events were observed in 70 TCZ-treated patients (44.0 %), but no serious infusion reactions were observed.Retreatment with TCZ was well-tolerated and effective in patients who had responded to the preceding TCZ monotherapy but had experienced loss of efficacy after cessation of TCZ.

The expression level of CD64 on neutrophils can be used to differentiate between an infection and a disease flare in rheumatoid arthritis (RA) patients. However, the CD64 expression is elevated by both bacteria and viruses, so it cannot be used to distinguish the type of infection. We herein investigated the results of a simultaneous quantitative analysis of the expression of CD64 and CD35 on neutrophils to determine whether these molecules can be used to distinguish between bacterial and viral infections in RA patients. We collected blood from 22 RA patients with pathogen-proven infections (15 bacterial and 7 viral infections). Blood samples were stained with QuantiBRITE CD64PE/CD45PerCP and CD35PE, and the mean fluorescence intensities were assessed by a flow cytometer. The mean numbers of molecules were calculated using QuantiBrite PE beads. We calculated the ratio of CD64 to the CD35 level (CD35/CD64), and used a cut-off value of 2.8 for the CD35/CD64 ratio. At this value, the sensitivity for diagnosing a bacterial infection was 87%, and the specificity was 86%. Simultaneous quantitative analysis of CD64 and CD35 expression on neutrophils might be useful to distinguish between bacterial and viral infections in RA patients.

Background HLA-DRB1 is associated with rheumatoid arthritis (RA). However, it has recently been suggested that HLA-DRB1 is only associated with patients with RA who have anticitrullinated peptide/protein antibodies (ACPA), which are specific to RA. Objective To elucidate whether specific HLA-DR alleles are associated with ACPA-negative RA development. Methods HLA-DRB1 typing was carried out in 368 Japanese ACPA-negative patients with RA and 1508 healthy volunteers as the first set, followed by HLA-DRB1 typing of 501 cases and 500 controls as the second set. The HLA-DRB1 allele frequency and diplotype frequency were compared in each group, and the results of the two studies were combined to detect HLA-DRB1 alleles or diplotypes associated with ACPA-negative RA. Results HLA-DRB1*12:01 was identified as a novel susceptibility allele for ACPA-negative RA (p = 0.000088, OR=1.72, 95% CI 1.31 to 2.26). HLA-DRB1*04:05 and *14:03 showed moderate associations with ACPA-negative RA (p = 0.0063, OR=1.26, 95% CI 1.07 to 1.49 and p = 0.0043, OR=1.81, 95% CI 1.20 to 2.73, respectively). The shared epitope was weakly associated with ACPA-negative RA, but no dosage effect was detected (p = 0.016, OR=1.17, 95% CI 1.03 to 1.34). A combination of HLA-DRB1*12:01 and DRB1*09:01 showed a strong association with susceptibility to ACPA-negative RA (p = 0.00013, OR=3.62, 95% CI 1.79 to 7.30). Homozygosity for HLA-DR8 was significantly associated with ACPA-negative RA (p = 0.0070, OR=2.16, 95% CI 1.22 to 3.82). It was also found that HLA-DRB1*15:02 and *13:02 were protective against ACPA-negative RA (p = 0.00010, OR=0.68, 95% CI 0.56 to 0.83 and p = 0.00059, OR=0.66, 95% CI 0.52 to 0.84, respectively). Conclusions In this large-scale association study multiple alleles and diplotypes were found to be associated with susceptibility to, or protection against, ACPA-negative RA.

We report successful tocilizumab (TCZ) use in a patient with adult-onset Still’s disease (AOSD) complicated by chronic hepatitis B (CHB) and AA amyloidosis (AAA). Treatments with corticosteroid and various types of immunosuppressants were unsuccessful. Aggravation of CHB ensued, and entecavir was started. Normalisation of liver function and hepatitis B virus (HBV) DNA were confirmed. TCZ was then started. His arthritis and AAA improved dramatically. TCZ is an excellent treatment for refractory AOSD and is feasible in an HBV-infected patient.

We aimed to investigate the frequency of moderate-to-severe sleep apnea syndrome (SAS) that possibly influences long-term prognosis in patients with rheumatoid arthritis (RA), and to analyze the risk factors for this group.We examined respiratory disturbance index (RDI) by polysomnography in 62 hospitalized RA patients. Risk factors of moderate-to-severe SAS (RDI ≥20) were analyzed using a multivariate logistic regression analysis.RA was complicated by moderate-to-severe SAS in 13/62 (20.9%) cases. The highest stage of temporomandibular joint abnormality (TMJA) and a high value of health assessment questionnaire-disability index (HAQ-DI) were significant risk factors, according to the results of the multivariate logistic regression analysis (p 0.0001 and p = 0.010, respectively). Contrary to these results, RDI was not related to the disease activity indexes of RA and other clinical characteristics.We clarified that the highest TMJA stage and a high value of HAQ-DI are novel important risk factors for moderate-to-severe SAS in RA patients.

Introduction Proto-oncogene survivin is a member of the inhibitor of apoptosis (IAP) family of proteins. The presence of serous antibodies against survivin in patients with systemic sclerosis has been previously reported; however, there are few reports regarding the pathophysiological relationship between survivin and systemic sclerosis. We herein investigated the expression and function of survivin in SSc patients. Methods We performed immunohistochemistry analyses to determine the expression of XIAP, cIAP and survivin in skin lesions from patients with SSc and non-SSc. The expression levels of survivin in peripheral blood mononuclear cells (PBMCs) obtained from SSc patients and healthy controls were evaluated using RT-PCR and flow cytometry. Additionally, the function of survivin was verified with overexpression experiments using monocyte-derived dendritic cells (Mo-DCs). Results The expression patterns of both XIAP and cIAP were similar, while only the survivin expression differed between the SSc and non-SSc skin lesions. Survivin-overexpressing cells were detected in the SSc dermis frequently. The positive rate of survivin in SSc dermis (64.3 %, 9/14) was higher than that in non-SSc dermis (11.2 %, 1/9). Furthermore, survivin+ cells expressed CD1a, one of the DC markers. Real-time PCR and FACS analyses revealed that the survivin-WT (wild type) expression levels in PBMCs, in particular CD14+ monocytes, from SSc patients were higher than that from healthy controls. Additionally, the overexpression experiments showed that survivin-WT-overexpressing CD1a+ Mo-DCs have the characteristics of promoting cell cycle progression and decreasing apoptotic cells. Conclusions These findings suggest that dermal survivin+ CD1a+ cell infiltration may be a potential biomarker of SSc skin lesions. PBMCs and monocytes from SSc patients also overexpressed survivin; therefore, dermal survivin+ DC may be derived from peripheral blood monocytes. Additionally, survivin may be involved in dermal CD1a+ DC proliferation through cell cycle activation and resistance to apoptosis. Survivin may be an important molecule for the pathogenesis of SSc.

Survivin is an independent prognostic factor for joint destruction in rheumatoid arthritis (RA). However, the expression and function of survivin in RA synoviocytes remain unclear. We certified the expression of survivin in RA synovial tissues and performed the experiment using RA fibroblast-like synoviocytes (RA-FLS) treated with siRNA. As a result, the expression levels of wild type (WT) survivin and the 2B splice variants in RA synovial tissues were higher than those in osteoarthritis tissue samples, and, these variants were highly expressed in RA-FLS. The expression levels of survivin-WT and -2B in the RA-FLS were upregulated by PDGF. Treatment with siRNA against survivin-2B led to decreased viability of PDGF-treated RA-FLS due to cell cycle suppression and apoptosis promotion, while the siRNA against all survivin isoforms did not affect the viability. Moreover, an overexpression of survivin-2B in RA-FLS led to cell proliferation through cell cycle activation and by conferring resistance to apoptosis. In conclusion, survivin-2B has an important role in RA-FLS proliferation. These data suggest that survivin-2B might contribute to rheumatoid synovial hyperplasia and have the potential as a novel therapeutic target for RA.

To the Editor, MTX-associated lymphoproliferative disorder (MTX-LPD) is categorized as “other iatrogenic immunodeficiency-associated lymphoproliferative disorders” according to the WHO classificati...

Anti-citrullinated peptide antibody (ACPA) is a highly specific serological marker for rheumatoid arthritis (RA).1,–,3 Different HLA-DRB1 alleles have been shown to be associated with the susceptibility to ACPA-positive RA.4 5 Former studies demonstrated that HLA-DRB alleles carrying a shared epitope (SE),6 consisting of a conserved amino acid motif at positions 70–74 of the HLA-DRβ chain, were strongly associated with ACPA-positive RA and with higher ACPA levels in European and Japanese populations.7,–,9 On the other hand, HLA-DRB1*09:01 was recently found to be negatively associated with ACPA levels in the Japanese.9 These observations imply that combinations of HLA-DRB1 alleles differentially influence ACPA levels in ACPA-positive RA. To address this question, we conducted a genetic association study employing 2457 ACPA-positive Japanese RA patients. ACPA was quantified by MESACUP CCP ELISA kit (MBL Co Ltd, Nagoya, Japan) with a cut-off level of 4.5 U/ml. The patients were then divided into three groups …

Anti-citrullinated protein antibodies (ACPAs) are highly specific to rheumatoid arthritis (RA), and strong associations between HLA-DRB1 alleles and ACPA levels have been detected in RA patients. We undertook this study to elucidate the associations between particular amino acid positions in HLA-DRB1 and ACPA levels in patients with RA.We analyzed ACPA data on a total of 4,371 Japanese ACPA-positive RA patients in whom HLA-DRB1 allele genotyping had been performed. Generalized linear regression analysis and omnibus testing were carried out to determine associations of HLA-DRB1 alleles, amino acid residues, or amino acid positions with levels of ACPA.HLA-DRB1*09:01 and HLA-DR15 were confirmed to be associated with ACPA levels. HLA-DRB1*08:03 and DRB1*14:06 were associated with reduced and increased ACPA levels, respectively. We detected a strong association between ACPA levels and amino acid position 74 (P = 1.9 × 10(-51) ). The association was mainly conferred by alanine residue (P = 4.5 × 10(-51) ). After adjustment for position 74, amino acid positions 60 and 57 were found to be associated with ACPA levels. Amino acid positions 74 and 57 had previously been reported to be associated with susceptibility to ACPA-positive RA in Asians. Combinations of the amino acid residues at position 74 and position 60 or 57 could induce improvement in Akaike's information criterion comparable to that induced by the 5 significant HLA-DRB1 alleles (HLA-DRB1*08:03, DRB1*09:01, DRB1*14:06, DRB1*15:01, and DRB1*15:02).Amino acid position 74 in HLA-DRB1 is strongly associated with ACPA levels in ACPA-positive RA, as well as with RA susceptibility. The mechanisms of ACPA production and susceptibility to ACPA-positive RA seem to partly overlap.

Specific HLA class II alleles are strongly associated with susceptibility to rheumatoid arthritis (RA); however, how HLA class II regulates susceptibility to RA has remained unclear. Recently, we found a unique function of HLA class II molecules: their ability to aberrantly transport cellular misfolded proteins to the cell surface without processing to peptides. Rheumatoid factor (RF) is an autoantibody that binds to denatured IgG or Fc fragments of IgG and is detected in 70-80% of RA patients but also in patients with other diseases. Here, we report that intact IgG heavy chain (IgGH) is transported to the cell surface by HLA class II via association with the peptide-binding groove and that IgGH/HLA class II complexes are specifically recognized by autoantibodies in RF-positive sera from RA patients. In contrast, autoantibodies in RF-positive sera from non-RA individuals did not bind to IgGH/HLA class II complexes. Of note, a strong correlation between autoantibody binding to IgG complexed with certain HLA-DR alleles and the odds ratio for that allele's association with RA was observed (r = 0.81; P = 4.6 × 10(-5)). Our findings suggest that IgGH complexed with certain HLA class II alleles is a target for autoantibodies in RA, which might explain why these HLA class II alleles confer susceptibility to RA.

Anti-cytokine therapy is reportedly useful in amyloid A (AA) amyloidosis complicating rheumatic diseases. However, to date no studies have directly compared the utility of tumour necrosis factor (TNF) inhibition to that of interleukin-6. The aim of our retrospective study was to compare the clinical utility of tocilizumab (TCZ) and anti-TNF (TNF inhibitor) therapy.We studied 42 patients treated with anti-cytokine agents at our hospital: 31 had received a single agent, ten had received two agents and one had received three agents. Patients were divided into a TCZ group (22 patients) and a TNF inhibitor group (32 patients). The main parameters compared were treatment retention rate, serum amyloid A (SAA) profile, renal function profile and clinical disease activity index.The 5-year retention rates were 90.4 (TCZ group) and 34.3 % (TNF inhibitor group) (p = 0.0154, log-rank test). The median SAA fell from 219.2 μg/mL at treatment initiation to 5.0 μg/mL at last observation (TCZ), and from 143.6 to 38.1 μg/mL (TNF inhibitor) (p = 0.0194). Estimated glomerular filtration rate was improved in 72.7 (TCZ) and 34.4 % (TNF inhibitor) of patients (p = 0.0062). The rates of clinical remission or low disease activity at last observation for the TCZ and TNF inhibitor groups were 72.7 and 40.7 % (p = 0.0201), respectively.Based on these results, we conclude that TCZ was of greater clinical utility than anti-TNF therapy in our patients with AA amyloidosis complicating rheumatic diseases.

Factor XIII is one of the twelve coagulation factors and also known as a fibrin-stabilizing factor. In 2012, we encountered a male RA patient with hemorrhagic factor XIII deficiency who had been treated with tocilizumab for two years. There are few reports regarding the relationship between tocilizumab (a humanized monoclonal antibody against the interleukin-6 receptor (IL-6R)) and factor XIII. We measured the factor XIII activity levels in the plasma of 40 RA patients (10 patients treated without biologics, 30 patients treated with biologics (15 patients treated with necrosis factor inhibitors and 15 patients treated with tocilizumab)) and 19 healthy controls. Consequently, the tocilizumab group exhibited lower levels than the other three groups according to the Steel-Dwass test (P

HLA-DRB1, especially the shared epitope (SE), is strongly associated with rheumatoid arthritis (RA). However, recent studies have shown that SE is at most weakly associated with RA without anti-citrullinated peptide/protein antibody (ACPA). We have recently reported that ACPA-negative RA is associated with specific HLA-DRB1 alleles and diplotypes. Here, we attempted to detect genetically different subsets of ACPA-negative RA by classifying ACPA-negative RA patients into two groups based on their positivity for rheumatoid factor (RF). HLA-DRB1 genotyping data for totally 954 ACPA-negative RA patients and 2,008 healthy individuals in two independent sets were used. HLA-DRB1 allele and diplotype frequencies were compared among the ACPA-negative RF-positive RA patients, ACPA-negative RF-negative RA patients, and controls in each set. Combined results were also analyzed. A similar analysis was performed in 685 ACPA-positive RA patients classified according to their RF positivity. As a result, HLA-DRB1*04:05 and *09:01 showed strong associations with ACPA-negative RF-positive RA in the combined analysis (p = 8.8×10(-6) and 0.0011, OR: 1.57 (1.28-1.91) and 1.37 (1.13-1.65), respectively). We also found that HLA-DR14 and the HLA-DR8 homozygote were associated with ACPA-negative RF-negative RA (p = 0.00022 and 0.00013, OR: 1.52 (1.21-1.89) and 3.08 (1.68-5.64), respectively). These association tendencies were found in each set. On the contrary, we could not detect any significant differences between ACPA-positive RA subsets. As a conclusion, ACPA-negative RA includes two genetically distinct subsets according to RF positivity in Japan, which display different associations with HLA-DRB1. ACPA-negative RF-positive RA is strongly associated with HLA-DRB1*04:05 and *09:01. ACPA-negative RF-negative RA is associated with DR14 and the HLA-DR8 homozygote.

Rheumatoid arthritis is a common autoimmune disease characterized by chronic inflammation. We report a meta-analysis of genome-wide association studies (GWAS) in a Japanese population including 4,074 individuals with rheumatoid arthritis (cases) and 16,891 controls, followed by a replication in 5,277 rheumatoid arthritis cases and 21,684 controls. Our study identified nine loci newly associated with rheumatoid arthritis at a threshold of P < 5.0 × 10(-8), including B3GNT2, ANXA3, CSF2, CD83, NFKBIE, ARID5B, PDE2A-ARAP1, PLD4 and PTPN2. ANXA3 was also associated with susceptibility to systemic lupus erythematosus (P = 0.0040), and B3GNT2 and ARID5B were associated with Graves' disease (P = 3.5 × 10(-4) and 2.9 × 10(-4), respectively). We conducted a multi-ancestry comparative analysis with a previous meta-analysis in individuals of European descent (5,539 rheumatoid arthritis cases and 20,169 controls). This provided evidence of shared genetic risks of rheumatoid arthritis between the populations.

Objectives. ACPA is a highly specific marker for RA. It was recently reported that ACPA can be used to classify RA into two disease subsets, ACPA-positive and ACPA-negative RA. ACPA-positive RA was found to be associated with the HLA-DR shared epitope (SE), but ACPA negative was not. However, the suspicion remained that this result was caused by the ACPA-negative RA subset containing patients with non-RA diseases. We examined whether this is the case even when possible non-RA ACPA-negative RA patients were excluded by selecting only patients with bone erosion. Methods. We genotyped HLA-DRB1 alleles for 574 ACPA-positive RA, 185 ACPA-negative RA (including 97 erosive RA) and 1508 healthy donors. We also tested whether HLA-DR SE is associated with RF-negative or ANA-negative RA. Results. ACPA-negative RA with apparent bone erosion was not associated with SE, supporting the idea that ACPA-negative RA is genetically distinct from ACPA-positive RA. We also tested whether these subsets are based on autoantibody-producing activity. In accordance with the ACPA-negative RA subset, the RF-negative RA subset showed a clearly distinct pattern of association with SE from the RF-positive RA. In contrast, ANA-negative as well as ANA-positive RA was similarly associated with SE, suggesting that the subsets distinguished by ACPA are not based simply on differences in autoantibody production. Conclusions. ACPA-negative erosive RA is genetically distinct from ACPA-positive RA.

We report an excellent clinical response to treatment with a humanized anti-interleukin-6 receptor antibody, tocilizumab, in a patient with progressive amyloid A (AA) amyloidosis complicating very active juvenile idiopathic arthritis. Treatment with tocilizumab immediately normalized the serum AA (SAA) level, and subsequently all of the clinical symptoms of AA amyloidosis disappeared. Serial gastrointestinal biopsy specimens showed marked lasting regression of AA protein deposits. The patient's functional ability score improved dramatically, she maintains her mobility, and she has regained her previous quality of life. Tocilizumab appears to have an excellent ability to suppress SAA levels and could therefore be an important therapeutic strategy in AA amyloidosis secondary to rheumatic diseases.

Objective Proinflammatory cytokines such as tumor necrosis factor (TNF) were demonstrated to inhibit adrenal steroidogenesis in patients with rheumatoid arthritis (RA), and this was particularly evident in the increase in adrenal androgen levels during anti-TNF therapy. This study investigated the influence on steroidogenesis of an interleukin-6 (IL-6)–neutralizing strategy using IL-6 receptor monoclonal antibodies (referred to as MRA). Methods In a placebo-controlled, double-blind, randomized study over 12 weeks in 29 patients with RA being treated with prednisolone, 13 of whom received placebo and 16 of whom received 8 mg MRA/kg body weight, the effects of MRA on serum levels of adrenocorticotropic hormone (ACTH), cortisol, 17-hydroxyprogesterone (17OHP), dehydroepiandrosterone (DHEA), DHEA sulfate (DHEAS), androstenedione (ASD), estrone, and 17β-estradiol, as well as their respective molar ratios, were determined. Results MRA therapy markedly improved clinical signs of inflammation (the erythrocyte sedimentation rate, swollen joint score, and Disease Activity Score in 28 joints). Serum levels of ACTH and cortisol and the molar ratio of cortisol to ACTH did not change. Although serum levels of DHEA and DHEAS remained stable during therapy, the DHEAS:DHEA molar ratio significantly decreased in treated patients (P = 0.048). Serum levels of ASD as well as the ASD:cortisol and ASD:17OHP molar ratios increased in MRA-treated patients (minimum P < 0.004). Serum levels of estrone and 17β-estradiol did not change. but the estrone:ASD molar ratio (an indicator of aromatization) decreased during 12 weeks of MRA treatment (P = 0.001). Conclusion Neutralization of IL-6 increases secretion of biologically active adrenal androgens in relation to that of precursor hormones and estrogens. This is another important indication that proinflammatory cytokines interfere with adrenal androgen steroidogenesis in patients with RA.

We investigated interobserver variations in the Larsen radiographic scoring method on hand radiographs of rheumatoid arthritis (RA) patients in a multicenter trial and developed a new radiographic scoring method. Thirteen experienced rheumatologists scored 10 representative RA hand radiograms with the Larsen scoring method and clarified the precipitating factors of interobserver variation. Based on this study, it was proved that the ankylotic joint, overlapping joint, and more precise erosive joint are needed for optimal radiographic evaluation. Therefore, we modified the Larsen scoring method on the basis of these precipitating factors and developed a novel radiographic scoring method. Finally, to determine which scoring system was most reliable, the interobserver variation using three methods (original Larsen method, revised Larsen method, our scoring method) were compared by 13 experienced rheumatologists and 13 residents. Our scoring method proved to have simplicity, reliability, and ease of learning. These results suggest that our novel radiological quantitative assessment method has useful applications for clinical studies in patients with RA.

Background Particular HLA class II alleles are strongly associated with susceptibility to rheumatoid arthritis; however, how HLA class II molecules regulate susceptibility to autoimmune diseases has remained unclear. Rheumatoid factor (RF) is an autoantibody that binds to denatured IgG or Fc fragments of IgG, and is detected in about 80% of rheumatoid arthritis (RA) patients, but also in 5-10% of healthy individuals as well as in other autoimmune diseases. However, the natural antigens that are recognized by RF are unknown. On the other hand, we have recently found that HLA class II molecules function as a molecular chaperon to transport cellular misfolded proteins to the cell surface (1). Objectives We addressed whether misfolded or structurally altered IgG heavy chain (IgGH) transported to the cell surface by HLA class II molecules of particular HLA-DR alleles are targets for autoantibodies in RA. Methods Binding of autoantibodies from RA patients (n=112) to IgGH transported to the cell surface by HLA class II molecules of various HLA-DR alleles was analyzed by flow cytometry. In situ association of IgGH with HLA class II molecules in paraffin-embedded tissue sections from RA patients was analyzed by proximity ligation assay. Results Intact IgGH was transported to the cell surface by HLA class II molecules via association with the peptide-binding groove of HLA class II molecules. The IgGH complexed with HLA class II molecules were specifically recognized by autoantibodies in RF-positive sera from RA patients. In contrast, autoantibodies in RF-positive sera from non-RA individuals did not bind to IgGH/HLA-DR complexes (Fig. 1A). Furthermore, a strong correlation between autoantibody binding to IgG complexed with certain HLA-DR alleles and the odds ratio for that allele9s association with RA was observed (r=0.81, P =4.6x10 -5 ) (Fig. 1B). In situ association of autoantigens with HLA class II molecules was detected in autoimmune diseased tissues but not in control tissues. Similar autoantibody binding to misfolded proteins complexed with HLA class II molecules was observed in other autoimmune diseases. Conclusions IgGH complexed with HLA class II molecules is a specific target for autoantibodies in RA. Strong correlation between RA-susceptibility conferred by each HLA-DR allele and autoantibody binding to IgGH complexed with HLA class II molecules suggests that such protein complexes might be involved in pathogenesis of RA. Our findings suggest that misfolded proteins complexed with HLA class II molecules are novel candidates for diagnostic and therapeutic targets in autoimmune diseases. References Jiang, Y., Arase, N., Kohyama, M., Hirayasu, K., Suenaga, T., Jin, H., Matsumoto, M., Shida, K., L. Lanier, L., Saito, T. & Arase, H. (2013) Transport of misfolded endoplasmic reticulum proteins to the cell surface by MHC class II molecules. Int. Immunol. 25:235-246. Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.4810

Background The repression of negative emotions is a personality factor that received considerable attention in the 1950-60s as being relevant to the onset and course of rheumatoid arthritis (RA). Despite subsequent, repeated criticisms of the cross-sectional nature of the earlier studies, even to date few prospective studies have been reported on this issue. This multicenter study prospectively examined if “rational and antiemotional” behavior (antiemotionality), characterized by an extreme tendency to suppress emotional behaviors and to rationalize negative experiences in conflicting interpersonal situations, is associated with the functional prognosis of patients with RA. Methods 532 patients with RA who regularly visited one of eight hospitals/clinics in Japan in 2000 were recruited for study. All completed a self-administered baseline questionnaire about lifestyle and psychosocial factors including antiemotionality. Two years after, 460 (mean age, 56.1 years; 54 men and 406 women) of 471 patients who continued to visit the clinics agreed to take the follow-up questionnaire. The functional status of the patients was evaluated by rheumatologists based on the ACR classification system. Results A multiple logistic regression model that included baseline demographic, disease activity/severity-related, therapeutic, and socioeconomic factors as covariates found a tendency toward higher antiemotionality to be related to poorer functional status at follow-up. This relationship was not explained by lifestyle factors. Conclusions Antiemotionality may be a prognostic factor for the functional status of patients with RA. This finding sheds light on a seemingly forgotten issue in the care of patients with RA.

Chronic tophaceous gout is the end stage of gout. We employed a blockade of interleukin-6 signaling therapy by tocilizumab instead of anakinra, an interleukin-1 receptor antagonist, for a 61-year-old Japanese woman diagnosed with tophaceous gout. Laboratory data showed that serum interleukin-6 concentration was elevated. Serum interleukin-1β concentration was under the detectable level, although serum uric acid was elevated due to renal dysfunction. The secretion patterns of interleukin-1β, tumor-necrosis factor-α, interleukin-6, and interleukin-8 from peripheral mononuclear cells isolated from the patient exhibited no remarkable differences compared with those of healthy volunteers. After treatment with the interleukin-6 receptor antagonist tocilizumab, serum interleukin-6 concentration decreased followed by improved clinical symptoms, such as reduced size of the subcutaneous nodules, no fever, and no acute gouty attacks during the treatment. Our case suggests that tocilizumab markedly improves clinical and laboratory manifestations in tophaceous gout with arthritis and fever as well as interleukin-1 blockade therapy.

Background Many reports have been published in recent years on the usefulness of anti-cytokine therapy in AA amyloidosis in rheumatic disease but, to date, no reports have been published that directly compare the utility of TNF inhibition to that of IL-6 inhibition. Objectives We retrospectively compared the efficacy and safety of tocilizumab (TCZ) and anti-TNF therapy (TNF) in AA amyloidosis in rheumatic disease at our hospital. Methods Of the 42 patients studied who were receiving anti-cytokine agents, 31 were receiving a single agent, 10 were receiving 2 agents, and 1 was receiving 3 agents. The patients were divided into 2 groups, a TCZ group (22 patients) and a TNF group (32 patients, 20 of whom received etanercept, 10 infliximab, and 2 adalimumab), and the two groups were compared using the following parameters: (1) treatment retention rate (Kaplan-Meier method) and reasons for withdrawing, (2) SAA profile (mcg/dl, median), (3) change in the eGFR (ml/min/1.73 m2, median), (4) proteinuria profile, and (5) severe gastrointestinal lesions. Results In the TCZ group, the 1-year retention rate was 90.4%; the 5-year retention rate was 90.4% as well. Two of the 22 patients withdrew, both due to adverse reactions (lower gastrointestinal perforation and cellulitis of the lower leg). In the 32 patients in the TNF group, the 1-year retention rate was 69.0% and the 5-year retention rate was 34.3%. The 14 patients who withdrew did so due to: primary non-response (2 patients), secondary non-response (7 patients), adverse reactions (5 patients [cancer (2 patients; esophageal cancer, malignant lymphoma], hypersensitivity vasculitis [1 patient], lower gastrointestinal perforation [1 patient], COP pattern IP). The retention rate was significantly higher in the TCZ group (log-rank test: p=0.0154). The SAA fell from 219.2 mcg/dl at treatment initiation to 5.0 mcg/dl at the last observation in the TCZ group and from 143.6 mcg/dl at treatment initiation to 38.1 mcg/dl at the last observation in the TNF group, and therefore decreased significantly more in the TCZ group (p=0.0194) (median observation period: 22.5 months in the TCZ group and 21.0 months in the TNF group). The eGFR increased from 41.6 ml/min/1.73 m2 at treatment initiation to 50.7 ml/min/1.73 m2 at the last observation in the TCZ group and decreased from 76.3 ml/min/1.73 m2 at treatment initiation to 67.4 ml/min/1.73 m2 at the last observation in the TNF group. Therefore, although TCZ treatment was initiated at a more advanced stage, significant improvement in renal function was obtained (p=0.0062). In the TCZ group, proteinuria was found in 13 patients at treatment initiation and, at the last observation, 9 had turned negative (median observation period: 31 months). In the TNF group, proteinuria was found in 3 patients, and 1 patient turned negative (median observation period: 10 months). Severe gastrointestinal lesions were found in 1 patient in the TCZ group and 3 patients in the TNF group. Conclusions We found that TCZ offered greater clinical utility than TNF in AA amyloidosis in rheumatic disease. References Y. Okuda et al. Arthritis Rheum. 54:2997-3000, 2006 D. Kishida, Y. Okuda et al. Mod Rheumatol. 21:215-218, 2011 Y Okuda et al. Challenges of Rheumatology INTECH. 155-168, 2011 Disclosure of Interest Y. Okuda Grant/Research support from: the Intractable Disease Division of the Ministry of Health and Welfare of Japan, a Research Committee for Amyloidosis in Japan, M. Ohnishi: None Declared, K. Takasugi: None Declared

Background HLA-DRB1, especially the shared epitope (SE), is strongly associated with rheumatoid arthritis (RA) [1]. However, recent studies have shown that SE is at most weakly associated with RA without anti-citrullinated peptide/protein antibody (ACPA) [2-3]. We have recently reported that ACPA-negative RA is associated with specific HLA-DRB1 alleles and diplotypes [4]. While HLA-DRB1*04:05 and *09:01 showed strong associations with ACPA-positive RA, they showed just potential associations with ACPA-negative RA. Objectives To detect genetically different subsets of ACPA-negative RA by classifying ACPA-negative RA patients into two groups based on their positivity for rheumatoid factor (RF). Methods HLA-DRB1 genotyping data for totally 866 ACPA-negative RA patients and 2,008 healthy individuals in two independent sets were used. HLA-DRB1 allele and diplotype frequencies were compared among the ACPA-negative RF-positive RA patients, ACPA-negative RF-negative RA patients, and controls in each set. Combined results were also analyzed. A similar analysis was performed in 667 ACPA-positive RA patients classified according to their RF positivity. Results HLA-DRB1*09:01 and *04:05 showed strong associations only with ACPA-negative RF-positive RA in the combined analysis (p=0.00038 and 0.00010, OR: 1.42 (1.17-1.72) and 1.50 (1.22-1.85), respectively). We also found that HLA-DR14 and the HLA-DR8 homozygote were associated only with ACPA-negative RF-negative RA (p=0.00039 and 6.2×10-5, OR: 1.52 (1.20-1.91) and 3.28 (1.78-6.07), respectively). These association tendencies were found in each set. Other alleles and diplotypes shown in our previous study showed associations with both ACPA-negative subsets. While we found clear difference of HLA-DRB1 associations in two ACPA-negative subsets, we could not detect any significant differences between ACPA-positive RA subsets. Conclusions ACPA-negative RA includes two genetically distinct subsets according to RF positivity, which display different associations with HLA-DRB1. ACPA-negative RF-positive RA is strongly associated with HLA-DRB1*04:05 and *09:01, indicating some genetic similarities between ACPA-positive RA and ACPA-negative RF-positive RA. ACPA-negative RF-negative RA is associated with DR14 and the HLA-DR8 homozygote. References Gregersen PK, Silver J, Winchester RJ. Arthritis Rheum. 1987;30(11):1205-13. van der Woude D, Lie BA, Lundstrom E, Balsa A, Feitsma AL, Houwing-Duistermaat JJ, et al. Arthritis Rheum. 2010;62(5):1236-45. Ohmura K, Terao C, Maruya E, Katayama M, Matoba K, Shimada K, et al. Rheumatology (Oxford). 2010;49(12):2298-304. Terao C, Ohmura K, Kochi Y, Ikari K, Maruya E, Katayama M, et al. Ann Rheum Dis. 2011;70(12):1234-9. Disclosure of Interest None Declared

Objective. Acceleration of amyloid A (AA) amyloidosis induction by ageing has not been extensively studied in rheumatoid arthritis (RA). The aim of this study is to clarify contribution of ageing to the development of AA amyloidosis associated with RA in our large cohort. Methods. 388 adultonset RA patients whose RA was complicated by biopsy-proven AA amyloidosis were enrolled. The ages of RA onset and AA amyloidosis diagnosis were estimated in each patient. The contributions of ageing, inflammatory activity, SAA1 exon 3 polymorphism as well as gender to the pathogenesis of AA amyloidosis in 144 cases were also studied by multiple regression analysis. Results. Subjects with RA onset at older age had a shorter period to develop amyloidosis than those with disease onset at younger age (p < 0.001). The interval between RA onset and AA amyloidosis diagnosis was significantly shorter in the SAA1.3 positive group than in the SAA1.3 negative (p = 0.001). Multiple regression analysis indicated that the interval from RA onset to diagnosis of AA amyloidosis is determined by age at RA onset (p < 0.001), the most recent median annual CRP concentration (p = 0.006) and SAA1.3 allele (p = 0.058). Gender did not significantly contribute to the onset of AA amyloidosis (p = 0.569). Conclusion. Ageing is an independent risk factor for the induction of AA amyloidosis complicating RA.

Three cases of complete deficiency of the ninth component of complement (C9D) are described.Case. 1-A 72-year-old male had a 10-year history of arthralgia in knees and fingers joints. He had been treated as rheumatoid arthritis (classical RA, stage III, class 2) with nonsteroid drugs. Clinical and serological features of the patient were completely compatible with RA except persistent hypocomplementemia.Case. 2-A 25-year-old female had mild cervical lymphadenopathy but was otherwise well.Case. 3-A 20-year-old female had a history of frequent erythema on extemities. Biopsy specimen of the skin showed no remarkable change.They were not susceptible to infection. They showed low complement levels (CH50: 10-20.5U/ml vs normal 30-40) and undetectable C9 by both hemolytic and immunochemical assays. Since their sera had no anti-complementary activity and addition of purified C9 to their sera restored the hemolytic activities to normal levels, they were proved to have the complete deficiency of the ninth component of complement (C9D). The husband and one daugther of Case. 2 had half the normal C9 levels (heterozygous C9D) and another daugther showed no detectable C9 (homozygous C9D) who was healthy. These observations suggested an autosomal codominant type of the inhelitance for the C9 deficiency gene.