;INE
`
`.41
`
`WI AR )51t,:',
`NO.12 (cid:9)
`Wies
`------ sEQ: Af,e4Joo00
`TI: ARTuRrris AND PHEW4ATI:114
`12/22/98
`
`Ex. 1016 - Page 1
`
`

`

`Arthritis & Rheumatism®
`
`Official Journal of the American College of Rheumatology
`
`Editor
`William I). Arend, MD
`Medical School Room 2834
`UCIISC, RheimialologY
`4200 East Ainth Avenue, 8-117
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`
`Clinical Asso(iate Editor
`Sterling G. West, MD, Denver
`
`Associate Editors
`David I I. Collier, MD, Denver
`J. Woodruff Emlen, MD, Denver
`Richard I li!.mman, MD, DrPH, Denver
`V. Michael Holers, MD, Denver
`J. Roger I lallister, MD, Denver
`I lalsted R. Holman, MD, Palo Alto
`Ray Kilcoyle, MD, Denver
`Brian L. Knzin, MD, Denver
`MD, Denver
`Jerome (cid:9)
`
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`Anna E Baron, PhD, Denver
`
`journal Publications Committee
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`Edward H. Giannini, DrPH, Cincinnati
`Donna J. Hawley, RN, EdD, Wichita
`Robert P. Kimberly, MD, Birmingham
`Geri B. Neuberger, RN, EdD, Kansas City
`Cornelia M. Weyand, MD, PhD, Rochester
`Marie D. Westby, BSc, PT, Vancouver
`Subcommittee for the Publication of Arthritis & Rheumatism
`Robert P. Kimberly, MD, Chair; Birmingham
`Edward H. Giannini, DrPH, Cincinnati
`Jorg J. Goronzy, MD, PhD, Rochester
`Ellen M. Gravallese, MD, Boston
`Nancy J. Olsen, MD, Nashville
`Paul H. Plotz, MD, Bethesda
`Editorial Staff
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`
`Advisory Editors
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`Carol M. Black, MD, London
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`Steven E. Carsons, MD, Mined('
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`Thomas R. Cupps, MI), Washington
`Lawren II. Daltroy, I)rP11, B009
`SYamal K. pawl, MI3, Chicago
`Jan I)equeker, Ml), Pellenbox
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`
`Keith B. Elkon, MD, New York
`Christopher H. Evans, PhD, Pittsburgh
`Marc Feldmann, MB, BS, I'hD, London
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`
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`L.B.A. van de Putte, MD, Nijmegen
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`Michael H. Weisman, MD, San Diego
`Cornelia M. Weyand, MD, PhD, Rochester
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`
`Bevra I I. Halm, MD Los Angeles, President
`Joseph D. Croft, Jr., MD, Chety Chase, President-Elect
`
`AMERICAN COLLEGE OF RHEUMATOLOGY
`Michael E. Weinblatt, MD, Boston, Vice-President
`Allan Gibofsky, MD, JD, New York, Secretary-Treasurer
`Mark Andrejeski, Atlanta, Executive Vice-President
`
`Published for the College by Lippincott Williams & Wilkins
`Rheumatism, (ISSN 0004-3591), is published monthly for the American College of Rheumatology by Lippincott Williams & Wilkins, 12107
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`(cid:9) and other communicalions published in Arthritis (cid:9)
`„
`miler
`l'uplisher, or American Collqe of Rheumatology. The publisher and the American College of Rheumatology do not investigate the information contained
`rn the classified advertisements in this journal and assume no responsibility concerning them. Further, the publisher and the American College of
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`OSTMASTER: Send addres< changes to ARTHRITIS & RHEUMATISM, P.O. Box 1550, Hagerstown, MD 21741.
`m punted on acid-free raper.
`
`at '.-
`
`Laws
`
`Ex. 1016 - Page 2
`
`

`

`V.<4.2 ir,.....6.?......,....11.1234.21.V.01.94.1.4.44VI
`
`Arthritis & Rheumatism
`
`Official Journal of the American College of Rheumatology
`
`=====11=111=
`
`VOLUME 41
`
`Special Articles
`
`DECEMBER 1998
`
`NO. 12
`
`Review: The Epidemiology of Systemic Lupus Erythematosus in Populations of African Ancestry:
`A Critical Review of the "Prevalence Gradient Hypothesis"
`Sang-Cheol Bae, Patricia Fraser and Matthew H Liang (cid:9)
`
`Review: Treatment of Polyarteritis Nodosa and Microscopic Polyangiitis
`
`LoIc Guillevin and Francois Lhote (cid:9)
`
`Winners of the 1998 American College of Rheumatology Slide Competition
`Erie L. Matteson and The ACR Audiovisual Aids Subcommittee (cid:9)
`
`Basic Science
`
`Functional Subsets of CD4 T Cells in Rheumatoid Synovitis
`Takashi Namekawa, Ulf G. Wagner, Pkg.]. Goronzy, and Cornelia M. Weyand (cid:9)
`C14+ T cells deficient for the CI 28 molecule accumulate and clonally expand in patients with rheumatoid
`arthritis. The functionalproperties of these unusual lymphocytes were examined by a candidate molecule
`c.ipproach. CD4+ CD28 'I' cells possess a cytolytic machinery and are able to lyse target cells. By staining
`for the cytolytic molecule perforin, these cells could be detected in rheumatoid synovial tissue. The data
`suggest that cytotoxicity by a specialized subset of CD4 T cells represents an important effector mechanism
`Ian rheumatoid arthritis.
`Blockage of Interleukin-6 Receptor Ameliorates Joint Disease in Murine Collagen-Induced Arthritis
`7,
`N0611hiro Takagi, Masahiko Mihara, Yoichim Moriya, Norihiro Nishimoto, Kazuyuki Yoshizaki,
`adamusu Kishimoto, Yasuhisa Takeda, and Yoshiyuki Ohsugi (cid:9)
`To clarify the role of IL-6 in the pathogenesis of collagen-induced arthritis, rat anti-mouse IL-6 receptor
`tuonoclonal antibody MR16-1 was injected into mice immediately after immunization with type II collagen.
`This suppressed the development of arthritis in a dose-dependent manner, inhibited IgG anti—type II
`col lagen antibody production, and reduced the responsiveness of lymphocytes to type II collagen. These
`results suggest that IL-6 plays an essential role in the development of collagen-induced arthritis.
`
`
`
`
`
`2091
`
` 2100
`
`2106
`
`
`
`2108
`
`2117
`
`Id
`Major Hisloeompatibility Complex Genetic Locus on Chromosome
`entification of a New Non—
`that, ,v-ontrols Disease Severity in Collagen-Induced Arthritis in Rats
`is,'ercio S. Gulko, Yutaka Kawahito, Elaine E Remmers, Van R. Reese, Jianping Wang,
`let aibi ,sVnailv)iii zit kct'llera, Lynn Ge, Ryan E. Longman, Jennifer S. Shepard, Grnnt W Cannon,
`Allen
`Ronald L.1Vilder and Marie M. Griffiths ............................................................... 7 1.77
`)1t) iiiisdit'eis report describes a new non-MHC genetic locus that controls the severity of rat collagen-induced
`This finding mayprovide new opportunities to define critical biochemical pathways involved in
`p
`oid arthritis severity, as well as mechanisms that regulate immune tolerance to
`ltliign (cid:9)
`g u rs leumat e
`
`l.
`cautt
`Transcriptional
`,,_
`(cid:9) Activation of the al(I) Procollagen Gene and Up-Regulation of al(I) and a WIT)
`
`Procollagen jk lge,n Messenger RNA in Dermal Fibroblasts from Tight Skin 2 Mice
`pLac:t
`J. Chi-ismer, Elena G. Hitraya, Josephine Peters, Rodney McGrath, and Sergio A. Jimenez (cid:9)
`These studies examined the levels of messenger RNA for 2 collagen types (I and III) and the role of
`transcriptional regulation of the gene encoding the al chain of type I procollagen in the exaggerated
`TvIc2 mouse, a newly described animal model
`Production of collagen in dermal fibroblasts obtained from the
`for systemic sclerosis. The results of these studies may provide valuable insights into the mechanisms
`responsible for the excessive accumulation of collagen in systemic sclerosis and other diseases in which
`
` 2132
`
`tissue fibrosis occurs.
`
`4.Z.Vrfif0i4'
`
`Ex. 1016 - Page 3
`
`

`

`Basic Science (Cont'd)
`
`Inhibition of Interleukin-la—Induced Cartilage Oligomeric Matrix Protein Degradation in Bovine
`Articular Cartilage by Matrix Metalloproteinase Inhibitors: Potential Role for Matrix
`Metalloproteinases in the Generation of Cartilage Oligomeric Matrix Protein Fragments in Arthritic
`Synovial Fluid
`
`Vishwas Ganu, Ronald Goldberg, Jane Peppard,John Rediske, Richard Melton,
`(cid:9) 2143
`. .....
`Weigwang Wang, Charlotte Duvander, and Dick Heinega (cid:9)
`rd ...........................................................
`they
` r(ie ()t (cid:9)
`Fragments of COMP are present at elevated levels in synovial fluid of (cid:9)
`arthritis.
`id v
`(cid:9) in
`have the potential to serve as markers of altered cartilage turnover. In (cid:9)
`the
`study,
`
`s nnation
`COMP fragmentation was investigated. An understanding of the mechanism of COMP fragment formation
`is
`is of value in the diagnosis and treatment of arthritis.
`
`.Sliott-//: Hu,
`
`Parathyroid Hormone—Related Protein is Abundant in Osteoarthritic Cartilage, and the 1
`Hormone—Related Protein 1-173 Isoform is Selectively Induced by Transforming Growth Factor P
`rophosphate
`in Articular Chondrocytes and Suppresses Generation of Extracellular Inorganic Pyrophosphate
`Robert
`Robert Terkeltaub, Martin Lotz, Kristen Johnson, Dahill Deng„Sanshiro Hashimoto, Mary B. Gobbing,
`Doug Burton, and Leonard J. Deltos ........................................................................................
`PTHrP critically regulates long hone growth by affecting growth plate cartilage chondrocyte differentiation
`and mineralization (deposition of basic calcium phosphate crystals in the ossification process). Chondrocytes
`in articular cartilage do not normally proceed through to the terminal phases of this differentiation
`program, and do not deposit basic calcium phosphate crystals, except in degenerative joint disease. This
`study characterized PTI-IrP expression by articular chondrocytes and demonstrated the overabundance of
`PTI-IrP in cartilage from patients with advanced osteoarthritis. The results suggest a novel mineralization-
`related function that is selective for one of the three PTI IrP isolorms.
`
`")
`
`15")
`
`-
`
`
`Enhanced and Coordinated In Vivo Expression of Inflammatory Cytokines and Nitric Oxide
`Synthase by Chondrocytes from Patients with Osteoarthritis
`Cinzia Melchiorri, Riccardo Meliconi, Luigi Fri,ziem, 'Mina Silvestri, Liu
`Rosa Maria Borzi, Mariagrazia Uguccioni, and Andrea Facchini (cid:9)
`This study provides evidence that interleukin-113, tumor necrosis factor o, and inducible nitric oxide synthase
`are highly expressed by chondrocytes from patients with osteoarthritis, but not from patients with
`rheumatoid arthritis or psoriatic arthritis. Conversely, synovial expression of these inflammation mediators is
`(cid:9) role of
`elevated only in patients with inflammatory arthritides. These results suggest a primary active.
`chondrocytes in the pathogenesis of osteoarthritis and further support the use of anticytokme therapy in this
`disease.
`
`liana Alazzetti,
`
`Murine Cytomegalovirus Induces a SjOgren's Syndrome—Like Disease in C57131 /6-iprfipr Mice
`Martin Fleck, Earl R. Kern, Tong Zhou, Bernhard Lang, and John D. Mountz
`In this study, MCMV infection triggered the development of salivary gland inflammation as well as anti-Ito
`and anti-La autoantibodies in B6-/pr//pr mice. The sialadenitis continued after the infectious MCMV was
`cleared from the salivary glands. Defective Fas-mediated apoptosis can lead to a postinfection, chronic
`inflammatory response that may trigger an autoimmune disease resembling Sjiigren's syndrome.
`
`Gelatin/Chondroitin 6-Sulfate Microspheres for the Delivery of Therapeutic Proteins to the Joint
`Graham D. Green,
`
`Kimberly E. Brown, Kalil Leong, Chia-Hui Huang, Rooshin (cid:9)
`Howard B. ['climes, Pablo A. Jimenez, and Joan Bathon (cid:9)
`Proteins, unlike synthetic drugs, are often subject to rapid proteolytic degradation in vivo, which may
`significantly limit the effective local concentration and efficacy of a delivered protein when used in the
`treatment of joint disease. Encapsulation of proteins in microspheres may partially protect them from
`proteolytic degradation and allow for slow, continuous release of protein to the locally affected site. This
`report describes a novel microsphere encapsulation system for therapeutic proteins that appears to be
`biocompatible and nontoxic. Furthermore, the rate of release of encapsulated protein is shown to he
`responsive to the degree of inflammation in the joint.
`
`Erratum
`Abstract Omitted from September 1998 Supplement
`
`
`
`2165
`
` 2175
`
` -)185
`
` 2195
`
`Thi: -Tat •E'ial (cid:9)
`
`cried
`
`Ex. 1016 - Page 4
`
`(cid:9)
`(cid:9)
`(cid:9)
`

`

`Clinical Science
`
`Treatment of Rheumatoid Arthritis with Recombinant Human Interleukin-1 Receptor Antagonist
`Bony Bresnihan, Jose Maria Alvaro-Gmcia, Mark Cabby, Michael Doherty, Zlaiko Domhcm,
`Paul Emery, George Nuki, Karel Pavehat, Rolf Rau, Blaz Rozman, lain Watt, Bryan Williams,
`Roger Aitchison, Dorothy McCabe, and Predrag Musikic (cid:9)
`The effects of IL-I on chronic inflammation and cartilage damage in RA are regulated by IL-1Ra, which
`inhibits IL-I by binding to its target cell receptors. In a 24-week, double-blind, randomized, placebo-
`controlled trial of IL-1 Ra, it was observed that a dosage of 150 mg/day resulted in significant clinical
`benefit, with no serious adverse events. Moreover, the rate of radiologic progression was significantly
`reduced. IL-1Ra is the first biologic agent to demonstrate a beneficial effect on the rate of joint erosion in
`RA.
`
`Reduction of NOS2 Overexpression in Rheumatoid Arthritis Patients Treated with Anti—Tumor
`Necrosis Factor a Monoclonal Antibody (cA2)
`Douglas J. Perkins, E. William St. Clan; Maly A. Misukonis, and J. Brice Weinberg (cid:9)
`Treatment of RA patients with a chimeric monoclonal antibody against TNFa (cA2) results in clinical
`improvement in the majority of patients. This work demonstrates that cA2 treatment is associated with a
`reduction in the overexpression of mononuclear cell nitric oxide synthase type 2 (NOS2), an enzyme that
`catalyzes the production of the inflammatory mediator NO. Results presented here indicate that TNFa
`likely plays an important role in enhancing NOS2 expression in RA, and that the antiinflammatory effects
`of cA2 treatment may be mediated by a reduction of NO overproduction.
`
`Functional Analysis of Rheumatoid Factor—Producing B Cells from the Synovial Fluid of
`Rheumatoid Arthritis Patients
`Curdle C. Reparon-Scluujt, Wim .1. E. van Esch, Cees van Kooten, Eleanor(' W N. Levarht,
`Ferdinand C. Breedveld, and Cornelis L. Venveij (cid:9)
`
`This study unambiguously demonstrates that terminally differentiated CD20—,CD38+ IgM-RF—producing
`plasma cells arc specifically present in the inflamed joints of patients with seropositive RA. The high
`frequency of IgM-RF—producing plasma cells provides evidence for a dominant RA-specific antigen-driven
`response in the development of the synovial plasma cell repertoire.
`
`Cytokine-Regulated Expression of Activated Leukocyte Cell Adhesion Molecule (CD166) on
`Monocyte-Lineage Cells and in Rheumatoid Arthritis Synovium
`Marc C Levesque, Craig S. Ileinly, Leona P. Whichard, and Dhavalkumar D. Patel (cid:9)
`CD6 is a 'F cell costimulatory molecule that has been implicated in the pathogenesis of RA. This study
`shows that expression of the CD6 ligand ALCAM on monocytes/macrophages is enhanced by cytokines that
`induce macrophage differentiation. Binding of macrophage ALCAM to CD6 may induce autoreactive T cell
`responses that perpetuate RA.
`
`Predictors of Subjective Fatigue Among Individuals with Rheumatoid Arthritis
`Bruce A. Huyser, Jerry C. Parker; Richard Thoreson, Karen L. Shan; Jane C. Johnson, and
`1?obertloffitum (cid:9)
`
`Fatigue is both common and troublesome for individuals with RA. The present study suggests that fatigue is
`strongly associated with a number of psychosocial variables, apart from disease activity per se.
`Correspondingly, the treatment of RA-related fatigue may be enhanced by interventions that address
`relevant cognitive and/or behavioral dimensions.
`
`Detection of Anti-Ro/SSA and Anti-La/SSB Autoantibody—Producing Cells in Salivary Glands from
`Patients with Sjogren's Syndrome
`Pia Magner, Anne-Kristine Hulse, Hans-Jacob Haga, Roland Jonsson, and Marie Wahren-Herlenius (cid:9)
`This report describes the presence of Ro/SSA and La/SSB autoantibody—producing cells in the salivary
`glands of Sjogren's syndrome patients. The detection method used could be developed into a potential
`confirmatory diagnostic test. Furthermore, the findings potentially indicate that Ro and La autoantibodies
`arc involved in the pathogenic process of this autoimmune exocrinopathy.
`
`The Impact of Hemiparalysis on the Expression of Osteoarthritis
`Rafael Segal, Eliezer Avrahami, Ela Lebdinski, Betio Habut, Arthur Leibovitz, Israel Gil, Michael
`Yaron, and Dan Caspi (cid:9)
`
`This first systematic study of hemiparalysis and OA showed that hemiparalysis reduced ipsilateral expression
`of hand OA in elderly patients. Moreover, in elderly patients without paralysis, OA was increased in the
`dominant hand. These results confirm the findings of previous case reports and lend support to the role of
`biomechanical factors in the development of OA.
`
` 2196
`
` 2205
`
` 2211
`
` 2221
`
` 2230
`
` 2235
`
` 2249
`
`Ex. 1016 - Page 5
`
`

`

`Clinical Science (Cont'd)
`Wegener's Granulomatosis: Patient-Reported Effects of Disease on Health, Function, and Income
`Gary S. Hoffman, Yoel Drucker, Mary Frances Catch, Geri A. Locker, Kirk Easley, and Kent Kwoh (cid:9)
`Advances in medical care have transformed Wegener's granulomatosis from a disease with a high potential
`for short-term mortality to a chronic illness with significant morbidity. This is the first study of patients'
`assessments of the medical, socioeconomic, and quality of life impact of Wegener's granulomatosis and its
`treatment. The results show that the costs of this illness to individuals, their families, and society arc
`substantial.
`
`The Bath Ankylosing Spondylitis Radiology Index (BASRI): A New, Validated Approach to
`Disease Assessment
`Kirsten MacKay, Christopher• Mack, Sinead Brophy, and Andrei Calin (cid:9)
`A simple, valid, and reproducible outcome measure for AS is described. If used in conjunction with other
`outcome measures, it will help the rheumatologist predict the potential disease course in an individual
`patient. It can be used as an outcome measure in clinical trials. If used in longitudinal and cross-sectional
`epidemiologic studies, it will improve our basic knowledge of the natural history and disease progression in
`AS.
`
`Erratum
`Error in Reference in Article by Stone et al (Arthritis Rheum, August 1998) (cid:9)
`
`Case Report
`Malignancy-Associated Remission of Systemic Lupus Erythematosus Maintained by Autologous
`Peripheral Blood Stem Cell Transplantation
`Lionel Schachna, Peter F. J. Ryan, and Anthony P. Schwarer (cid:9)
`
`Concise Communication
`Thalidomide Induces Amenorrhea in Patients with Lupus Disease
`Jose Ordi, Film Cor•tes, Nuria Martinez, Montse Mattri, Ines De Torres, and Miguel Vilar•dell (cid:9)
`
`Clinical Image
`Osteolytic Lesions in T Cell Lymphoma
`Alexandros A. Drosos and Maria K. Bai (cid:9)
`
`Letters
`
`Assessing Lupus
`David Isenberg and Mina Madman (cid:9)
`
`Broad-Range Bacterial Polymerase Chain Reaction for Identification of Bacteria in Inflamed Joints:
`Comment on the Article by Wilbrink et al
`Charles R. Steinman (cid:9)
`
`Reply
`B. Wilbr•ink, I. M. van der fletjden, L. M. Schouls, J. D. el. Van Lill/Well, .1. M. W. Hazes,
`Pi C. Breedveld, and P. P. Tak (cid:9)
`
`"Disablement" Framework Variables in the Assessment of Juvenile Arthritis Outcomes: Comment
`on the Article by Giannini et al
`Janjaap van der Net and Paul J. M. fielders (cid:9)
`Reviewers (cid:9)
`Contents, Volume 41, 1998 (cid:9)
`Indexes (cid:9)
`ACR Announcements (cid:9)
`
` 2257
`
` 2263
`
` 2270
`
` 2271
`
` 2273
`
` 2275
`
` 2276
`
` 2276
`
` 1278
`
` 2279
` 1281
` 2285
` 2307
` 1()A
`
`Thi:
`
`Subject 1_, '1 (cid:9)
`
`=•; •i='t
`
`Ex. 1016 - Page 6
`
`

`

`ARTHRITIS & RHEUMATISM
`Vol. 41, No. 1/, December 1998, pp 2205-2210
`et 1998, American College of Rheumatology
`
`1,..1a=a.
`
`2205
`
`REDUCTION OF NOS2 OVEREXPRESSION IN
`RHEUMATOID ARTHRITIS PATIENTS TREATED WITH
`ANTI—TUMOR NECROSIS FACTOR a MONOCLONAL ANTIBODY (cA2)
`
`DOUGLAS J. PERKINS, E. WILLIAM ST. CLAIR, MARY A. MISUKONIS, and J. BRICE WEINBERG
`
`significantly reduced NOS2 protein expression and
`NOS enzyme activity. Changes in NOS activity following
`treatment correlated significantly with changes in the
`number of tender joints.
`Conclusion. These results indicate that TNFa
`likely plays an important role in enhancing NOS2
`expression in RA, and that the antiinflammatory effects
`of cA2 treatment may be mediated by a reduction of NO
`overproduction.
`
`Rheumatoid arthritis (RA) is a systemic disease
`of unknown etiology characterized by chronic synovial
`inflammation with frequent progression to articular car-
`tilage and bone destruction. Pathologic hallmarks of
`disease include synovial cell proliferation, abundant
`secretion of proinflammatory cytokines such as tumor
`necrosis factor a (TNFa) and interleukin-1 (IL-1), and
`infiltration of mononuclear cells into the synovial tissue.
`Several lines of evidence indicate that release of TNFa
`from mononuclear phagocytes in the synovial microen-
`vironment plays a crucial role in stimulating the chronic
`inflammatory response. For example, transgenic mice
`that overexpress human TNFa develop a chronic inflam-
`matory polyarthritis that is abrogated by administration
`of anti-TNFa monoclonal antibody (I). Inflammation
`and tissue destruction are also attenuated in DBA/1
`mice with type R collagen—induced arthritis treated with
`a neutralizing hamster anti-murine TNF monoclonal
`antibody (2). In addition, clinical trials of TNFa neutral-
`izing antibodies or a soluble recombinant TNF receptor
`fusion protein (p75) in RA patients demonstrate that
`TNFa blockade leads to reductions in disease activity
`(3,4).
`
`Nitric oxide (NO) overproduction may also be
`important in the pathogenesis of RA. Increased expres-
`sion of inducible NO synthase (iNOS or NOS2) and NO
`production in peripheral blood mononuclear cells
`(PBMC), and elevated serum and synovial fluid levels of
`
`Objective. Peripheral blood mononuclear cells
`(PBMC) from patients with rheumatoid arthritis (RA)
`have increased expression of nitric oxide synthase type
`2 (NOS2) protein and enhanced formation of nitric
`oxide (NO) that correlate with disease activity. NO may
`Play a role in the inflammation of RA. Treatment of RA
`Patients with a chimeric monoclonal antibody against
`tumor necrosis factor a (TNFa; cA2) results in clinical
`improvement in the majority of patients. The present
`study was designed to determine if cA2 therapy de-
`creases PBMC NOS2 protein expression and NOS
`enzyme activity in RA patients.
`Methods. RA patients receiving background oral
`methotrexate participated in a double-blind, placebo-
`controlled clinical trial in which they were randomly
`assigned to receive a single infusion of either placebo or
`cA2 at 5, 10, or 20 mg/kg. NOS2 protein and NOS
`chzYme activity were measured in PBMC at baseline
`and 4 weeks following cA2 therapy. These results were
`Compared with the degree of clinical change in disease
`activity.
`Results. At baseline, elevated levels of NOS2
`1:1)teih and NOS enzyme activity were more frequently
`( criected
`PBMC from RA patients than in those from
`healthy controls. Treatment of the RA patients with cA2
`
`5r. Perkins' work was supported by NIH Training Grant
`AI-07?
`Dr. St. Clair's work was supported by NM grant MO-1-
`-50 and Centocor, Inc. Dr. Weinberg's work was supported by
`AR-39162, the James R. Swiger Hematology Research Fund,
`and the
`u the VA Research Service.
`Douglas J. Perkins, PhD, E. William St. Clair, MD, Mary A.
`J. Brice Weinberg, MD: Veterans Affairs and Duke
`University Medical Centers, Durham, North Carolina.
`Dr. St. Clair has served as an ad hoc consultant for Centocor,
`Inc (cid:9)
`fe ,,..and participated in a clinical trial of chimeric anti-TNF antibody
`1v2) in rheumatoid arthritis.
`g
`Address reprint rquests t J. Brice Weinber, MD, VA and
`o
`e
` Durham, NC
`271;Ke os.Un
` 508 Fulton Street,
`versity Medical
` Centers,
`
`A i
`
`f„
`Submitted for publication April 22, 1998; accepted in revised
`ki .
`rm June 15, 1998.
`
`ThIz
`at (cid:9)
`bj
`
`E
`
`Ex. 1016 - Page 7
`
`(cid:9)
`

`

`2206 (cid:9)
`
`PERKINS ET AL
`
`Table 1. (cid:9) Summary of patient characteristics and treatment responses*
`
`Age, years
`Sex
`Disease duration, years
`RF status
`Prednisone
`NSAIDs
`ESR, % change from baseline
`Improvement by 20°) at week 4t
`Improvement by 50% at week 4t
`Swollen joint count, % change from baseline
`Tender joint count, % change from baseline
`
`5 mg/kg
`
`10 mg/kg
`
`P3
`
`52
`M
`5.7
`
`Y
`Y
`—56
`Y
`Y
`—62
`—75
`
`P7
`
`48
`
`9.9
`
`Y
`Y
`—75
`N
`N
`18
`—18
`
`PI
`
`62
`M
`8.4
`
`Y
`Y
`—83
`Y
`Y
`—51
`—64
`
`P4
`
`62
`F
`6.5
`
`Y
`Y
`—12
`N
`N
`—5
`—78
`
`cA2
`
`P9
`
`59
`F
`1.2
`
`Y
`N
`—16
`Y
`N
`—40
`—67
`
`20 mg/kg
`
`Placebo
`
`P5
`24
`F
`3.1
`
`Y
`Y
`23
`Y
`Y
`—68
`—65
`
`P8
`
`41
`
`1.7
`
`N
`Y
`N
`N
`—58
`—4
`
`P2
`
`49
`
`0.7
`
`N
`N
`+17
`N
`N
`—4
`—15
`
`P6
`
`52
`
`3.4
`
`N
`N
`—33
`N
`N
`—30
`—34
`
`= rheumatoid factor; Y = yes; N = no; NSAIDs = nonsteroidal antiinflammatory drugs; ESR = erythrocyte sedimentation rate.
`t All patients (P1—P9) were assessed by the American College of Rheumatology improvement criteria.
`
`NO have been reported in patients with RA (5,6).
`Previous studies in our laboratory demonstrated that
`PBMC from RA patients express high levels of NOS2
`and that NOS2 expression correlates with disease activ-
`ity (6). Since TNFct can promote NOS2 expression and
`increased NO production (7), we postulated that anti-
`TNFa therapy with cA2 would reduce NOS2 overex-
`pression and NOS enzyme activity in the PBMC of
`patients with RA.
`
`PATIENTS AND METHODS
`
`Patients (n = 9; 7 women and 2 men) were selected
`from the rheumatology outpatient clinics at the Duke Univer-
`sity Medical Center (DUMC). All patients met the American
`College of Rheumatology (ACR; formerly, the American
`Rheumatism Association) 1987 revised criteria for the classi-
`fication of RA (8). Eligible subjects were between ages 18 and
`75 years, had been diagnosed as having RA at least 6 months
`before the study, and had a disease duration of >15 years. All
`subjects had been treated with methotrexate for at least 3
`months before baseline and had received a stable dosage of
`methotrexate (10 mg/week) during the 4 weeks before baseline
`and for the duration of the trial. The patients also received 1
`mg/day of folic acid for at least 4 weeks before baseline and
`throughout the study. Treatment with other disease-modifying
`antirheumatic drugs (DMARDs) was not permitted for 1
`month prior to baseline or during the study. If patients were
`taking nonsteroidal antiinflammatory drugs (NSAIDs) and/or
`corticosteroids, the dosages had been stable for at least 4
`weeks before screening and throughout the study, and pred-
`nisone dosages were no more than 7.5 mg/day.
`Patients were excluded if their serum contained anti—
`double-stranded DNA antibodies or if there was a history of
`treatment with any murine, chimeric, or humanized monoclo-
`nal antibody. Healthy age-matched subjects without RA (n =
`
`9) served as controls for the NOS2 protein expression and
`NOS enzyme activity assays.
`This study was part of a double-blind multicenter trial
`conducted at 3 different sites. Results presented here were
`obtained from the DUMC site. The study protocol was ap-
`proved by the Institutional Review Board at DUMC, and all
`subjects gave written informed consent.
`At the beginning of the study, a complete medical
`history was obtained and a physical examination was done in
`the General Clinical Research Center at DUMC to determine
`eligibility. Clinical assessments for the study included tender
`and swollen joint counts, patient's assessment of pain (on a
`visual analog scale), patient's and physician's global assess-
`ments of disease activity (on a visual analog scale), and
`functional capacity as defined by the modified Stanford I lealth
`Assessment Questionnaire. Clinical assessments were made at
`baseline and were repeated at week 4, and a complete blood
`cell count, routine serum chemistry levels, erythrocyte sedi-
`mentation rate, and rheumatoid factor positivity were assessed
`at these 2 time points.
`Responders were defined according to the ACR im-
`provement criteria, using 20% as well as 50% improvement in
`the composite measures. Detailed clinical results from the
`multicenter trial will be the subject of a separate report.
`Patients were randomly assigned to 1 of 4 treatment
`groups: placebo or 5, 10, or 20 mg/kg of a chimeric (murine—
`human) anti-TNI7a monoclonal antibody (cA2) of IgG IK
`isotype, with specificity for recombinant and natural human
`TNFa. A single dose of cA2/placebo was infused through a
`0.22µ low protein-binding filter (Pal Set Saver in-line filter)
`over a period of not less than 2 hours. The preparation
`(developed by Centocor, Malvern, PA and manufactured by
`Centocor Europe, Leiden, The Netherlands) consisted of a
`sterile, nonpyrogenic solution of 100 mg of cA2 monoclonal
`antibody suspended in 20 ml of 0.15M sodium chloride, 0.0W
`sodium phosphate, pH 7.2, and 0.01% polysorbate 80 (treat-
`ment groups) or 0.1% human serum albumin suspended in the
`vehicle solution (placebo). Mononuclear cells were isolated as
`
`Ex. 1016 - Page 8
`
`

`

`REDUCED NOS2 OVEREXPRESSION INDUCED BY cA2 IN RA PATIENTS (cid:9)
`
`2207
`
`A
`
`130 kD-
`
`Controls (cid:9)
`
`RA Patients
`5 mg
`Pre Post Pre Post (+) (+) (cid:9)
`
`C1 C2 C3 C4 P3 P3 P7 P7 D1 R2
`
`B
`
`Co
`
`3000
`
`—NOS2
`
`=
`2500.
`►
`
`Controls (cid:9)
`
`RA Patients
`
`10 mg
`rre Post Pre Post Pre Post (+)
`
`130 kD-
`
`—NOS2
`
`C5 C6 C7 P1 P1 P4 P4 P9 P9 D1
`
`RA Patients
`
`20 mg
`
`Placebo
`
`Pre Post Pre Post Pre Post Pre Post (+) (+)
`
`fo
`
`ct
`
`C.1) (cid:9)
`0
`
`O
`> CO
`Co cc
`
`2000
`
`1500 -
`
`1000
`
`500
`
`Treatment groups
`Mt
`Placebo
`• Antl-