- - (cid:9)
`
`-
`
`Jrnal of rheumatology.(IM)
`26, no. 11 (Nov. 1999)
`in eral Collection
`1 JD87H
`ceved: 11-08-1999
`
`VOLUME 26: NO. 11
`
`NOVEMBER 1999
`
`Editorials
`Treatment of RA — We're Getting Closer
`I. Kushner, S.P. Ballou (cid:9)
`Glucosamine Therapy for OA
`T.E. Towheed, T.P. Anastassiades (cid:9)
`•
`
` 2291
`
`2294
`
`Give ObservationalStudies a Chance: Better
`Observational Studies Make Better Economic
`Evaluations
`A. Maetzel, C. Bombardier (cid:9)
`Current Controversies in Cost Effectiveness
`Analysis of Osteoporosis Therapies
`A. Cranney, D. Coyle, V. Welch, K. Lee,
`
`P. Tug well (cid:9)
`
` 2298
`
`2300
`
`2303
`
`ticles
`Microsatellite Markers TNFa5b5 and TNFa6b5
`Jence Adverse Reactions to Parenteral Gold in
`‘casians T.I. Evans, R.E. Small,
`T.W. Redford, J. Han , G. Moxley (cid:9)
`The Engineered Human Anti-TNF-a Antibody
`CDP571 Inhibits Inflammatory Pathways But
`Not T Cell Activation in Patients with RA
`E.H.S. Choy, E.C.C. Rankin, D. Kassimos, et al . . . 2310
`Evaluation of Bone Turnover and Osteoclastic
`Cytokines in Early RA Treated with Alendronate
` 2318
`Cantatore, C.A. Acquista, V Pipitone (cid:9)
`Equivalence of the Acute Phase Reactants CRP,
`Plasma Viscosity, and Westergren ESR
`When Used to Calculate ACR 20% Improvement
`Criteria or the Disease Activity Score in
`Patients with Early RA
` 2324
`H.E. Paulus, B. Ramos, W.K. Wong, et al (cid:9)
`Tacrolimus (FK506) in the Treatment of Severe,
`Refractory RA: Initial Experience in 12 Patients
`R.B. Gremillion, J.O. Posever, N. Manek,
`J.P. West, R.F. van Vollenhoven (cid:9)
`Disappointing Longterm Results with Disease
`Modifying Antirheumatic Drugs.
`A Practice Based Study
`G. Galindo-Rodriguez, J.A. Avitia-Zubieta,
`A.S. Russell, M.E. Suarez-Almazor (cid:9)
`
`2332
`
`2337
`
`2352
`
`
`
`
`
`2363
`
`2369
`
`Thalidomide in the Treatment of Refractory RA
`N. Keesal, M.J. Wasserman, A.A.M. Bookman,
`V Lapp, D.A. Weber, E.C. Keystone (cid:9)
`2344
`Myopathy and Neuropathy in RA. A Quantitative
`Controlled Electromyographic Study
`S.I. Bekkelund, T. Torbergsen, G. Husby,
`S.I. Mellgren (cid:9)
` 2348
`Associates of Health Status in Patients with SLE
`N. Sutcliffe, A.E. Clarke, C. Levinton, C. Frost,
`C. Gordon, D.A. Isenberg (cid:9)
`Immunological Analysis of Pulmonary
`Hypertension in CTD
`T Nishimaki, S. Aotsuka, H. Kondo, et al (cid:9)
` 2357
`Contribution of Traditional Risk Factors to Coronary
`Artery Disease in Patients with SLE
`P. Rahman, M.B. Urowitz, D.D. Gladman,
`I.N. Bruce, J. Genest Jr (cid:9)
`Solvent Oriented Hobbies and the Risk of SSc
`P.J. Nietert, S.E. Sutherland, R.M. Silver,
`J.P. Pandey, M. Dosemeci (cid:9)
`Sex Differences in Primary SS
`M.T. Brennan, P.C. Fox (cid:9)
`2373
`Elevation of Cytokeratin 19 Fragment in Patients
`with Interstitial Pneumonia Associated with PM/DM
`J. Fujita, N. Dobashi, M. Tokuda,et al (cid:9)
` 2377
`Elevated Homocysteine Levels in Patients with
`Raynaud's Syndrome
`Y Levy, J. George, P. Langevitz, et al (cid:9)
`Endothelial and Adrenergic Dysfunction in
`Raynaud's Phenomenon and Scleroderma
`R.R. Freedman, R. Girgis, M.D. Mayes (cid:9)
`Skin Blood Flow in Patients with SSc and
`Raynaud's Phenomenon: Effects of Oral
`L-Arginine Supplementation
` 2389
`F Khan, J.J.F. Belch (cid:9)
`HLA-DRB1, DQA1, and DQB1 Alleles Associated
`with GCA in Northern Italy
`C. Salvarani, L. Boiardi, V Mantovani, et al (cid:9)
` 2395
`HLA and Self-Limiting, Unclassified Rheumatism.
`A Role for HLA-B35?
`J.J. Dubost, F Demarquilly, M. Soubrier,
`C. Coussediere, J-M. Ristori, B.J.M. Sauvezie. . . 2400
`
`
`
`
`
`2383
`
`2386
`
`Contents continued opposite inside back cover . .
`
`PRINTED IN CANADA — ISSN 0315-162X
`
`Ex. 1026 - Page 1
`
`

`

`EDITOR
`Duncan A. Gordon
`DEPUTY EDITOR
`Robert D. Inman
`PEDIATRIC EDITOR
`Earl D. Silverman
`BOOK REVIEW EDITOR
`Peter Lee
`ASSOCIATE EDITORS
`Simon Carette
`Dafna D. Gladman
`Andre Lussier
`Waldemar Pruzanski
`Hugh A. Smythe
`Murray B. Urowitz
`
`MANAGING EDITOR
`Yvonne Pigott
`EDITORIAL
`John Meyers
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`Bill McCausland
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`Carlyle Rodrigo
`SUBSCRIPTIONS
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`
`EDITORIAL BOARD
`
`George E. Ehrlich
`PHILADELPHIA, PA, USA
`John Esdaile
`VANCOUVER, BC, CANADA
`Adel G. Fam
`TORONTO, ON, CANADA
`David T. Felson
`BOSTON, MA, USA
`Marcos Ferraz
`SAO PAULO, BRAZIL
`Irving H. Fox
`CAMBRIDGE, MA, USA
`James F. Fries
`PALO ALTO, CA, USA
`Marvin J. Fritzler
`CALGARY, AB, CANADA
`Daniel E. Furst
`SEATTLE, WA, USA
`Charles H. Goldsmith
`HAMILTON, ON, CANADA
`Rose Goldstein
`OTTAWA, ON, CANADA
`Bevra Hahn
`LOS ANGELES, CA, USA
`David E. Hastings
`TORONTO, ON, CANADA
`Gillian Hawker
`TORONTO, ON, CANADA
`John Highton
`DUNEDIN, NEW ZEALAND
`Marc C. Hochberg
`BALTIMORE, MD, USA
`Gary Hoffman
`CLEVELAND, OH, USA
`Graham R. V. Hughes
`LONDON, ENGLAND
`Gene C. Hunder
`ROCHESTER, MN, USA
`Gunnar Husby
`OSLO, NORWAY
`
`David Isenberg
`LONDON, UK
`Marcel-Francis Kahn
`PARIS, FRANCE
`Edward C. Keystone
`TORONTO, ON, CANADA
`John H. Klippel
`BETHESDA, MD, USA
`Joel Kremer
`ALBANY, NY, USA
`Nancy Lane
`SAN FRANCISCO, CA, USA
`Ronald M. Laxer
`TORONTO, ON, CANADA
`Peter E. Lipsky
`DALLAS, TX, USA
`Geoffrey 0. Littlejohn
`CLAYTON, AUSTRALIA
`K. Wayne Marshall
`TORONTO, ON, CANADA
`Johanne Martel-Pelletier
`MONTREAL, PQ, CANADA
`Alphonse T. Masi
`PEORIA, IL, USA
`Gale A. McCarty
`INDIANAPOLIS, IN, USA
`Henri Menard
`SHERBROOKE, PQ, CANADA
`Alastair G. Mowat
`HEADINGTON, OXFORD, ENGLAND
`Kenneth D. Muirden
`MELBOURNE, AUSTRALIA
`Ola Nived
`LUND, SWEDEN
`Akihide Ohta
`SAGA, JAPAN
`Ignazio Olivieri
`POTENZA, ITALY
`Gabriel S. Panayi
`LONDON, ENGLAND
`
`Richard Panush
`LIVINGSTON, NJ, USA
`Eliseo Pascual
`ALICANTE, SPAIN
`Michelle Petri
`BALTIMORE, MD, USA
`Ross E. Petty
`VANCOUVER, BC, CANADA
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`NASHVILLE, TN, USA
`Kenneth P. H. Pritzker
`TORONTO, ON, CANADA
`Naomi Rothfield
`FARMINGTON, CT, USA
`Anthony S. Russell
`EDMONTON, AB, CANADA
`Philip N. Sambrook
`SYDNEY, AUSTRALIA
`H. Ralph Schumacher, Jr.
`PHILADELPHIA, PA, USA
`Alan J. Silman
`MANCHESTER, ENGLAND
`Virginia D. Steen
`WASHINGTON, DC, USA
`Roger Sturrock
`GLASGOW, SCOTLAND
`Eric M. Veys
`GHENT, BELGIUM
`Michael E. Weinblatt
`BOSTON, MA, USA
`Arthur Weinstein
`WASHINGTON, DC, USA
`Keith Whaley
`LEICESTER, ENGLAND
`Frederick Wolfe
`WICHITA, KS, USA
`Robert B. Zurier
`WORCESTER, MA, USA
`
`The Journal of Rheumatology (ISSN 0315-162X) is published monthly for
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`HAMILTON, ON, CANADA
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`BEER SFIEVA, ISRAEL
`Jeffrey P. Callen
`LOUISVILLE, KY, USA
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`
`Copyright 1999.
`All rights reserved.©
`Microforms available from
`University Microfilms,
`300 N. Zeeb Rd.,
`Ann Arbor, MI 48106 USA.
`
`This material was copied
`atthe NLM and may be
`Subject US Copyright Laws
`
`Ex. 1026 - Page 2
`
`

`

`The Engineered Human Anti-Tumor Necrosis Factor-a
`Antibody CDP571 Inhibits Inflammatory Pathways But
`Not T Cell Activation in Patients with Rheumatoid
`Arthritis
`ERNEST H.S. ICHOY, ELIZABETH C.CFRANKIN, DIMITRI rKASSIMOS, OLIVIAIVETTERLEIN,
`ALEX rdARYFALLOS, CHELLIAH T. lq—AVIRAJAN, MARK(SOPWITHLRICHARUEASTELL,
`GABRIELLE H. IrZINGSLEY, DAVID A! ISENBERG, and GABRIEL S.rPANAYI
`
`ABSTRACT Objective. We investigated the effect of an engineered human anti-tumor necrosis factor-a antibody,
`CDP571, on immune functions as well as bone and cartilage turnover in patients with rheumatoid
`arthritis (RA) in a placebo controlled trial. We also assessed the effects of repeated treatment with
`CDP571 in an open label continuation study.
`Method. Thirty-six patients were treated with either placebo or 0.1, I, or 10 mg/kg of CDP571 given
`as an intravenous infusion. The followup period was 8 weeks. Lymphocyte phenotype, soluble CD4
`(sCD4), soluble interleukin 2 receptor (sIL-2R), IL-6, and stromelysin levels in the blood were
`measured before and after treatment; bone and cartilage markers (pyridinoline, deoxypyridinoline,
`N-terminal telopeptide) were similarly assessed in the urine. Patients who completed a placebo
`controlled trial of CDP571 were offered further treatment with CDP571. They received a maximum
`of 2 further doses of 1 mg/kg (7 patients) or 10 mg/kg (9 patients) in an open study.
`Results. Plasma IL-6 level was statistically significantly reduced in the 1 and 10 mg/kg groups. In
`the 10 mg/kg group, there were also reductions in plasma stromelysin and urine bone markers,
`although there was no change in sCD4 and sIL-2R levels. Repeat doses of CDP57 I were well toler-
`ated and continued to suppress the acute phase response and disease activity.
`Conclusion. Treatment with 10 mg/kg of CDP571 reduced lL-6 and surrogate markers of bone
`turnover in RA, suggesting that CDP571 might prevent joint damage in RA. Since there was no
`effect on lymphocyte markers despite the marked reduction in inflammation, CDP571 appears to
`have no effect on ongoing CD4 T cell activation. (J Rheumatol 1999;26:2310-7)
`
`Key Indexing Terms:
`RHEUMATOID ARTHRITIS (cid:9)
`ANTI-TNF-a (cid:9)
`
`IMMUNOTHERAPY (cid:9)
`BONE MARKERS (cid:9)
`
`TUMOR NECROSIS FACTOR
`STROMELYSIN
`
`From therDepartment of Clinical and Molecular Rheumatology, The
`Guy
`(cid:9) King's College, mid St. Thonws'illasyntal/Medical and Dental
`School, London:' the Bloomsbury Rheumatology Unit, Middlesex Hospital,
`London; (Ailed! Therapeutics Ltd., Slough; and the Clinical Science
`Centre, University of Sheffield, Sheffield,'United Kingdom.,1
`Financed by Celltech Therapeutics Ltd. The Rheumatology Unit at Guy's
`Hospital is supported by an integrated clinical arthritis centre grant
`(P0526) from the Arthritis Research Campaign.
`E.H.S. Choy, MD, Arthritis Research Campaign Senior Lecturer in
`Rheumatology; D. Kassimos, MD, Consultant Rheumatologist; A.
`Garyfallos, MD, Consultant Rheumatologist; G.H. Kingsley, FRCP,
`Senior Lecturer in Rheumatology; G.S. Panayi, ScD, Arthritis Research
`Campaign Professor of Rheumatology, Department of Clinical and
`Molecular Rheumatology, The Guy's, King's College, and St. Thomas'
`Hospitals Medical and Dental School; E.C.C. Rankin, PhD, Consultant
`Rheumatologist; C.T. Ravirajan, P/iD, Scientist; D.A. Isenberg, MD,
`Arthritis Research Campaign Professor of Rheumatology; 0. Vetterlein,
`PhD, Scientist; M. &Twill', MD, Director of Medicine, Celltech
`Therapeutics Ltd.; R. Eastell, PhD, Professor of Clinical Biochemistry,
`Clinical Science Centre, University of Sheffield.
`Address reprint requests to Dr E. Choy , Depart ment of Clinical and
`Molecular Rheumatology, Sth flow; Thomas Guy House, Guy's Hospital,
`St. Thomas Street, London, UK SE! 9RT.
`Submitted October 6, 1998 revision accepted March 12, 1999.
`
`The pathogenesis of rheumatoid arthritis (RA) remains
`unclear, although a number of mediators, including tumor
`necrosis factor-alpha (TNF-a), are believed to have pivotal
`roles. Placebo controlled trials using either chimeric or engi-
`neered human anti-TNF-a antibodies have shown that these
`agents can reduce inflammation and ameliorate symptoms
`in RA (cid:9)
`Clinical improvement was accompanied by a
`marked reduction in the erythrocyte sedimentation rate
`(ESR) and C-reactive protein (CRP).
`One of the advantages of using antibodies and similar
`molecules, such as soluble TNF receptor conjugated to
`human Fc (sTNFR:Fc) for the treatment of RA is that the
`outcome can be used to analyze pathogenetic concepts of
`the disease. The association of RA with HLA-DR4/DR I has
`led to the hypothesis that RA is initiated by an arthritogenic
`peptide activating CD4+ T cells. These activated CD4+ T
`cells stimulate monocytes/macrophages and synoviocytes
`through direct contact' and release of lymphokines such as
`interferon-gamma (IFN-y). These cells amplify the Milani-
`
`2310
`
`This material was capled
`at the NMI and may be
`Subject US Copyright Laws
`
`The Journal of Rheumatology /999; 26://
`
`Ex. 1026 - Page 3
`
`(cid:9)
`

`

`1
`
`•
`
`oratory cascade through the release of monokines including
`interleukin 1 (IL-1)and TNF-a. Both INF-a and IL-1 can
`stimulate mesenchymal cells such as fibroblasts/synovio-
`cytes and chondrocytes to release IL-64, granulocyte-mono-
`cyte colony stimulating factor (GM-CSF), and matrix
`metalloproteinases (MMP)5. The MMP stromelysin and
`collagenase are found in rheumatoid synovium6 and are
`thought to be the mediators of joint damage. As well as
`their role in inflammation, both IL-1 and INF-a inhibit
`osteoblast function and may therefore have important path-
`ogenic roles in rheumatoid osteoporosis'. IL-6 is an impor-
`tant mediator of the acute phase response through its
`stimulatory effect on hepatocytes. The latter produce serum
`amyloid A protein, fibrinogen, and CRP that are responsible
`for the acute phase response.
`However, it is disputed whether T cell dependent mecha-
`nisms are involved in the chronic stage of the disease, and
`there are 2 hypotheses that attempt to explain the chronicity
`of synovitis. The T cell hypothesis`' postulates that antigen-
`specific T cells are the main stimulus for the maintenance of
`synovitis. The mesenchymal hypothesisw postulates that, in
`chronic RA, monocyte and synoviocyte activation is inde-
`pendent of a T cell drive. The latter argument is based on the
`paucity of T cell cytokines, IFN-y, and IL-2 found in the
`synovium while monokines are present in abundance.
`We investigated the effects of the anti-TNF-a antibody
`CDP57I on T cell functions (T cell number and phenotype,
`sCD4 and sIL-2R), on acute phase response (IL-6, ESR,
`CRP), and on hone/cartilage turnover [pyridinoline (Pyr),
`deoxypyridinoline (Dpyr), and N-terminal telopeptide
`(NTP-CI) crosslinks of collagen]. The hypothesis is that
`anti-TNF-a would inhibit the effector phase of rheumatoid
`inflammation (acute phase response and bone/cartilage
`turnover), but not T cell function.
`We also report the results of repeated therapy with the
`engineered human anti-TNF-a antibody CDP57I (Celltech
`Therapeutics Ltd.) that establishes the efficacy and safety of
`retreatment. Information on pharmacokinetics, the immune
`response to CDP57I, and side effects is provided.
`
`MATERIALS AND METHODS
`Patients. Thirty-six patients who fulfilled the 1987 American College of
`Rheumatology revised criteria for the diagnosis of RA" were recruited
`from outpatient clinics of Guy's, Lewisham, and Middlesex Hospitals. All
`patients had RA for 5 10 years and had active disease defined by the pres-
`ence of at least 3 of 4 criteria: (I) > 3 swollen joints, (2) 6 tender joints,
`(3) early morning stiffness 45 minutes, and (4) ESR 28 mm/h. They
`had failed at least one disease modifying antirheumatic drug (DMARD).
`DMARD were withdrawn at least 4 weeks before treatment with CDP57I.
`The study was approved by the local ethics committees. All the patients
`gave informed consent.
`Antibody and treatment regimen. CDP57I is a recombinant neutralizing
`anti-TNF-a antibody, in which the hypervariable regions derived from a
`mouse anti-TNF-a antibody have been grafted onto human immunoglob-
`ulin (1gG4, kappa light chain). Patients were allocated into 4 groups, one
`placebo and 3 active treatment groups. The study had 2 phases, an initial
`placebo controlled study lasting 8 weeks, followed by continuation and
`
`extension phases. In the placebo controlled phase, 12 patients received a
`single infusion of placebo. There were 8 patients in each of 3 active treat-
`ment groups receiving either 0.1, I, or 10 mg/kg of CDP57 I. All infusions
`were given intravenously over 60 min. Subsequently, patients who had
`completed the placebo controlled phase were invited to enter the continua-
`tion phase, in which they received either I (Group A) or 10 mg/kg of
`CDP57I (Group B); each dose level was allocated alternately to patients
`entering this phase of the trial. An extension phase was added to the
`protocol in response to patient demand for further treatment. Patients who
`had completed the continuation phase were invited to enter the extension
`phase, in which 2 further doses of CDP57 I were given 8 weeks apart.
`Disease activity assessments were not carried out in the patients who
`entered the open study (3rd and 4th infusions). Patients having 3rd and 4th
`infusions could recommence DMARD if they wished.
`Clinical and laboratory assessments. Disease activity assessment was
`based on the European League Against Rheumatism core data set''.
`Assessments were performed before and after treatment at 0, 1, 2, 4, and 8
`weeks. Blood and urine samples were collected at the same visits for
`measurement of full blood count, ESR, CRP, stromelysin, Pyr, Dpyr, and
`NTP-CI.
`Peripheral blood lymphocyte phenotype. In the 18 patients from Lewisham
`and Guy's Hospitals only, peripheral blood lymphocyte phenotypes were
`measured before and after treatment by flow cytometry as described" using
`the following monoclonal antibodies: Leu 4-FITC, Leu 4-PE, Leu 3a-PE,
`Leu 2a-PE, Leu l8-FITC, Leu I 1 a-FITC, Leu 16-FITC (all Becton
`Dickinson), and UCHLI-FITC (Dako).
`Plasma IL-6, sCD4, and sIL-2R. Soluble IL-6, sCD4, and sIL-2R were
`measured by enzyme linked immunoassay (Medgenix Diagnostics Ltd., T
`Cell Diagnostics Inc., and Dako, respectively) in all patients before and
`after the first infusion at Weeks 0, 1, 2, 4, and 8.
`Plasma stromelysin and urine markers of bone and cartilage turnover.
`Plasma stromelysin was measured using enzyme linked immunoassay as
`described'. Patients recorded the time of their first void in the morning and
`were instructed not to pass urine until samples were taken. When patients
`were assessed, they were instructed to empty their bladder completely. The
`volume of urine was recorded and samples were taken and stored at —20°C
`within 30 min. Urine Pyr and Dpyr were measured using high performance
`liquid chromatography (HPLC) as described". Urinary crosslinked NTP-
`CI was measured by ELISA (Ostex International, Seattle, WA, USA) as
`described15.
`CDP571 assays and anti-CDP57I antibodies. Serum CDP57 I levels and
`anti-CDP57I antibodies were measured by sandwich ELISA and a double
`antigen sandwich ELISA, respectively, as described l". Determination of
`anti-CDP57I antibody class of immunoglobulin (1gG or IgM) was carried
`out using an HPLC method. One hundred microliters of filtered plasma
`were applied to a size exclusion column (Zorbax GF250XL, range
`4000-400,000 MW; Anachem, Luton, UK) run at a flow rate of 1.0 ml/min
`with 0.2 M Na,PO4, pH 7.0, on a 1090 M liquid chromatograph with an
`HPLC Chemstation (HP79994A; Hewlett-Packard, Waldbrown, Germany).
`The column was calibrated for IgM with human IgM myeloma (Jackson
`Laboratories, Westgrove, PA, USA) and for IgG with CDP57I.
`Autoantibodies. Human epithelial cell (HEp-2) immunofluorescence was
`used to detect antinuclear antibody (ANA). Anti-single and double stranded
`DNA (and-ss and dsDNA) were measured by ELISA as described".
`Antibodies to extractable nuclear antigens — antibodies to Ro, La, Sm, and
`RNP — were measured by a commercial ELISA (Shield Diagnostics,
`Dundee, UK). Anticardiolipin antibody (aCL) was determined by a direct
`binding ELISA, as described".
`Statistical analysis. The percentage change in bone markers was calculated
`as follows: the value at each assessment time point minus pretreatment
`value divided by their pretreatment value and multiplied by 100%. All
`results were compared by Kruskal-Wallis test. If p value was < 0.05, further
`comparisons were made using Mann-Whitney U test (for differences
`between treatment groups) and Wilcoxon sign rank-sum test (for differ-
`
`Cho): et al: CDP57I and immune functions
`
`2311
`
`This material was copied
`atthe NLM and may be
`Subject US Copyright Laws
`
`Ex. 1026 - Page 4
`
`(cid:9)
`

`

`if
`
`
`
`w
`
`--- --
`
`**
`
`2 (cid:9)
`
`4 (cid:9)
`
`6 (cid:9)
`
`8 (cid:9)
`
`10
`
`200 -
`
`E
`X150
`a.
`
`-
`
`° oo
`Cci
`
`a)
`co 50-
`0 0
`
`0
`
`0 (cid:9)
`
`Serum interleukin-6
`
`Weeks
`Figure 1. Changes in plasma IL-6 after treatment with CDP571.
`Placebo treated patients. A: Patients treated with 0.1 mg/kg of CDP571.
`V: Patients treated with I mg/kg of CDP571. ¤: Patients treated with 10
`mg/kg of CDP571. *Statistically significant result with p < 0.05 comparing
`treated with placebo. **Statistically significant result with p < 0.01
`comparing treated with placebo.
`
`percentage change in plasma levels of stromelysin between
`the placebo group compared with either the 1 mg/kg or 10
`mg/kg group at Weeks 1, 2, and 4 (p < 0.05). These differ-
`ences mirrored changes in ESR, CRP, and IL-6 (data not
`shown).
`Changes in urine bone markers (Figures 2B, 2C, 2D). In the
`placebo group, urine bone markers did not change. In the 10
`mg/kg group, there was a transient decrease in Pyr (20 ±
`6%), Dpyr (21 ± 6%), and NTP-CI (22 ± 10%) by Week 1.
`There were statistically significant differences (p < 0.05) in
`the percentage change of Pyr between the placebo and 10
`mg/kg groups from Week 1 through to Week 8 (borderline at
`Week 2; p = 0.06). Percentage change of Dpyr level showed
`a significant difference at Week 4 between the placebo
`group and the 10 mg/kg group (p = 0.034). Percentage
`change of NTP-CI level showed a significant difference (p
`
`ences before and after treatment with the same treatment group). Results
`are shown as mean ± standard error. Multiple statistical comparison was
`corrected with the Bonferroni method.
`
`RESULTS
`Thirty-six patients were recruited; their demographic details
`are published'-. Details of the 16 patients who received
`repeated treatment with CDP57 I are shown in Table I. Two
`patients dropped out of Group B (10 mg/kg): one did not
`want a 4th infusion and one was unable to receive a 4th infu-
`sion because an intravenous cannula could not be inserted.
`Two patients were taking prednisolone 5 mg/day, one in
`each group.
`The mean intervals between the end of the followup
`period after one infusion (Week 8) and the next infusion
`were as follows: 9 days (range 6-28) between first and
`second infusions, 42 days (range 7-78) between the 2nd and
`3rd infusions, and 6 days (range 3-10) between the 3rd and
`4th infusions.
`Changes in disease activity and serum IL-6. Clinical
`improvement after CDP571 treatment was accompanied by
`a statistically significant reduction in ESR and CRP, as
`described'-. Before treatment, the placebo and active treat-
`ment groups had similar IL-6 levels. IL-6 levels remained
`unchanged in the placebo and 0.1 mg/kg group throughout
`treatment. However, in the 1 mg/kg and 10 mg/kg groups,
`there were statistically significant reductions, from 174 ± 47
`to 58 ± 19 pg/ml (p = 0.006) and from 159 ± 46 to 40 ± 10
`pg/ml (p = 0.0001), respectively, one week after treatment
`compared with placebo. In the 10 mg/kg group, statistically
`significant reductions in IL-6 persisted up to Week 8
`(Wilcoxon sign rank-sum test, p = 0.045) (Figure 1). The
`changes paralleled decreases in ESR, CRP, and disease
`activity (data not shown).
`Changes in plasma stromelysin. In the placebo group, the
`plasma stromelysin concentration increased, while in the
`CDP571 groups, stromelysin levels decreased (Figure 2A).
`There were statistically significant differences in the
`
`Table 1. Patient demographics, means (SD).
`
`Group A (cid:9)
`(3rd and 4th doses I mg/kg) (cid:9)
`
`Group B
`(3rd and 4th doses 10 mg/kg)
`
`No. of patients
`Mean age (SD), yrs
`Male:female
`No. previous DMARD
`No. taking steroids
`Mean disease duration, yrs
`First infusion doses, no. of patients
`Placebo
`().1 mg/kg
`I mg/kg
`10 mg/kg
`No. restarting DMARD after 3rd infusion
`
`7
`56.6 (6.89)
`1:6
`2.3 (0.95)
`1
`6.0 (3.39)
`
`3
`
`2
`
`3
`
`9
`50.7 (17.42)
`1:8
`3.7 (1.66)
`1
`7.4 (1.77)
`
`5
`0
`1
`3
`:")
`
`2312
`
`The Journal of Rheuntatology /999; 26:11
`
`This material was copied
`atthe NLM and maybe
`Subject US Copyright Laws
`
`Ex. 1026 - Page 5
`
`(cid:9)
`

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`
`Figure 2. Changes in plasma stromelysin (Panel a), urine pyridinoline (b), urine deoxypyridinolinc (c), and urine collagen type 1 N-terminal telopeptide (d)
`after treatment with CDP57I. n: Placebo treated patients. A: Patients treated with 0.1 mg/kg of CDP57I. 7: Patients treated with I mg/kg of CDP57I.
`: Patients treated with 10 mg/kg of CDP57I. *Statistically significant result with p < 0.05. **Statistically significant result with p < 0.01.
`
`= 0.041) at Week 8 between the placebo group and the 10
`mg/kg group.
`Changes in plasma sCD4 and sIL-2R. Despite marked
`disease improvement, by both clinical and laboratory
`measures, there were no changes in plasma sCD4 and
`sIL-2R levels in any treatment group (Figure 3A, 3B,
`respectively).
`Changes in peripheral blood lymphocyte phenotypes. These
`were investigated in 18 patients. Six received placebo and
`there were 4 patients in each of the 3 active treatment
`groups. In the 10 mg/kg group, peripheral blood lymphocyte
`number showed a statistically significant increase from 1.22
`± 0.13 x 109/d1 to 1.82 ± 0.2 x 109/d1 (Wilcoxon sign rank-
`sum test, p = 0.0001) one week after treatment. This gradu-
`ally returned to normal values of 1.4 ± 0.15 x 109/dl at Week
`8. This increase involved both CD4 (0.5 x 109/dl to 0.63 x
`109/dl) and CD8 (0.24 x 109/dl to 0.36 x 109/d1) lymphocyte
`subsets. There was a similar increase in both CD45RA+
`naive (0.42 x 109/dl to 0.55 x 109/dl) and CD45RO+
`
`memory (0.26 x 109/dl to 0.40 x 109/dl) subsets. There was
`no significant change in monocyte or neutrophil numbers
`(data not shown).
`Side effects. Repeated infusions of CDP57I were well toler-
`ated. Only one event was classified as severe, namely
`aggravated RA in a patient 11 days after a 4th infusion of
`CDP57I at a dose of 1 mg/kg. Four patients had rashes
`during the 3rd and 4th cycles of treatment. One of these
`rashes, which emerged after the 3rd infusion, was purpuric
`and was limited to the left forefoot. This patient's platelet
`count remained in the normal range throughout the trial. In
`all cases the rash resolved, in 2 cases, including the patient
`who developed the purpuric rash, without treatment.
`Three infections were recorded in the 3rd and 4th cycles
`of treatment in 2 patients. One patient had probable
`Candida infection beneath the breast prior to the 3rd
`infusion. This patient and one other also developed upper
`respiratory tract infections, which resolved without treat-
`ment.
`
`Choy, et al: CDP57I and immune fignetions
`
`2313
`
`This material was copied
`at the NLM and may be
`Subject US Copyright Laws
`
`Ex. 1026 - Page 6
`
`(cid:9)
`(cid:9)
`(cid:9)
`(cid:9)
`(cid:9)
`(cid:9)
`(cid:9)
`(cid:9)
`(cid:9)
`(cid:9)
`(cid:9)
`(cid:9)
`(cid:9)
`(cid:9)
`¤
`(cid:9)
`

`

`constant or prolonged clearance rates for CDP57I.
`Antibodies against CDP57 I in these patients were low, and
`HPLC analysis indicated that they were predominantly of
`the IgM class. Patients receiving 0.1 or 1.0 mg/kg CDP57I
`in the first cycle showed more variable clearance rates after
`subsequent infusions. Where accelerated clearance of
`CDP57I was seen, it was associated with development of
`specific IgG anti-idiotypic antibodies.
`
`DISCUSSION
`We previously presented the clinical results of a placebo
`controlled trial that showed that CDP57 I reduced joint
`inflammation and decreased the acute phase response in
`RA2. Here we show that, in parallel with the clinical
`improvement, there was also reduction in IL-6 and surrogate
`markers of joint damage. Our data support the hypothesis
`that IL-6 is the main cytokine responsible for the acute
`phase response in RA since the decrease in plasma IL-6
`paralleled changes in the ESR and CRP. Furthermore, the
`reduction in IL-6 showed a clear dose response with the
`amount of antibody infused, suggesting that TNF-a is a
`major stimulant of IL-6 production.
`One objective in the treatment of RA is reduction in joint
`damage. In this short term study, we have shown that
`CDP57I treatment reduced plasma stromelysin levels and
`urine markers of bone and cartilage turnover. These obser-
`vations suggest that antagonizing TNF-a not only reduces
`synovitis but also reduces production of stromelysin in vivo,
`which confirms the known in vitro effect of TNF-a on the
`production of matrix metalloproteinases5. These enzymes
`are thought to mediate joint damage in RA. Although radio-
`logical assessment remains the gold standard for assessing
`joint damage, it is not sufficiently sensitive for a small study
`lasting less than 6 months. Therefore, we measured urine
`pyridinoline, deoxypyridinoline crosslinks, and N-terminal
`telopeptide of collagen as surrogate markers for bone and
`cartilage turnover. These markers have been studied exten-
`sively in metabolic bone disease, particularly osteoporosis
`and Paget's disease19.20. Pyridinoline, deoxypyridinoline
`crosslinks, and telopeptide of type I collagen are elevated in
`patients with RA and their levels correlated with disease
`activity2 L22. Our data, showing that these markers decreased
`by roughly 25% after treatment, suggest strongly that anti-
`TNF-a antibody reduced bone and cartilage turnover in RA.
`This may be the result of decreased joint damage and/or a
`reduction in generalized rheumatoid osteoporosis, in which
`TNF-a and IL-6 are known to be potent bone resorbing
`cytokines. Clearly, longterm radiological studies with
`repeated doses of CDP57 I are essential to assess whether it
`can be used as disease modifying therapy in RA.
`Both TNF-a and IL- I upregulate the expression of
`endothelial adhesion molecules such as intercellular adhe-
`sion molecule-1 (ICAM-1)23 resulting in increased recruit-
`ment of mononuclear cells into the synovial joint. A study
`
`8
`
`8
`
`120
`
`100
`
`80
`
`60 -
`
`40
`
`20 -
`
`0
`
`Soluble CD4 (U/mL)
`
`a
`
`Weeks
`
`5000 -
`
`4000 -
`
`E
`
`3000
`
`-------------- - -
`CL. 2000 •
`CD
`
`CD
`s--
`
`1000 -
`
`0
`
`1 (cid:9)
`Weeks
`
`b
`
`Soluble Interleukin-2
`
`Figure 3. Changes in plasma soluble CD4 (panel a) and soluble IL-2
`receptor (b) after treatment with CDP57I. MI: Placebo treated patients.
`A: Patients treated with 0.1 mg/kg CDP57I. V: Patients treated with I
`mg/kg CDP57I. *: Patients treated with 10 mg/kg CDP57I .
`
`Autoantibodies. Autoantibodies were absent in all the
`before treatment. After the first 2 infusions, no
`patients
`patient developed positive ANA or aCL. At the end of the
`4th infusion, one patient developed IgG antibodies against
`ssDNA (1.12 OD units, upper limit of normal 0.15). This
`patient had received placebo in the first infusion and 10
`mg/kg in the subsequent 3 infusions. Five patients devel-
`oped low levels of positive IgG aCL. The values were 8.5,
`12.0 GPL units. None developed IgM aCL. No
`8.0 , 9.5, 9.1,
`patient developed clinical features of systemic lupus erythe-
`matosus or the antiphospholipid antibody syndrome. No
`antibodies to dsDNA, Ro, La, Sm, or RNP were detected.
`Anti-CDP57I response. Figure 4 shows the dose dependent
`nature of the anti-CDP57I immune response. Interestingly,
`at the highest dose (10 mg/kg) the immune response is low.
`Pharmacokinetics. Figure 5 shows the mean plasma levels
`of cpP571 following each cycle of treatment, regardless of
`which dose was received in the first cycle. Following 3 or 4
`infusions of 10 mg/kg, the majority of patients showed
`
`2314 (cid:9)
`
`This material was copie-d
`at the NLM an