Rev. Bras. Reumatol. vol.57 número6

r e v b r a s r e u m a t o l . 2017;57(6):637–640

w w w . r e u m a t o l o g i a . c o m . b r

REVISTA

BRASILEIRA

DE

REUMATOLOGIA

Brief

communication

Hepcidin-25

gives

an

indication

of

the

therapeutic

effectiveness

of

tocilizumab

in

rheumatoid

arthritis

–

Relationship

between

disease

activity

of

rheumatoid

arthritis

and

anemia

A

hepcidina-25

dá

uma

indicac¸ão

da

eficácia

terapêutica

do

tocilizumab

na

artrite

reumatoide

–

Relac¸ão

entre

a

atividade

da

doenc¸a

na

artrite

reumatoide

e

a

anemia

Satoshi

Suzuki

,

Souichiro

Nakano

,

Seiichiro

Ando

,

Ran

Matsudaira

,

Yoshinori

Kanai

_,

_Kenjiro

_Yamanaka

_,

_Yoshinari

_Takasaki

a_{KyoundoHospital,SasakiInstitute,DepartmentofRheumatologyandInternalMedicine,Tokyo,Japan}

b_{JuntendoUniversitySchoolofMedicine,DepartmentofRheumatologyandInternalMedicine,Tokyo,Japan}

a

r

t

i

c

l

e

i

n

f

o

Articlehistory:

Received16June2015 Accepted24July2016

Availableonline18October2016

Introduction

Therapy for RA has improved rapidly since the advent of biologics. However, although biologics have a greater effectcomparedtothatwithconventionaldiseasemodifying antirheumaticdrugs(DMARDs),thecostofthesenewer ther-apiesremainsextremely high.1 _{Patientsinwhom biologics}

areeffectivehaveincreasedemploymentopportunitiesdueto reduceddiseaseactivity,meaningthatthecost-effectiveness ofthetreatmentisvalid.However,incaseswherethe admin-istrationofbiologicsisnotassociatedwitharesponse,disease activity during the period of treatment and the progres-sionofjoint damageplace anincalculable burdenon both

∗ _{Correspondingauthor.}

E-mail:satsuzu@juntendo.ac.jp(S.Suzuki).

patients and the entire medical system. For this reason, the identification of factors that can predict the effective-nessofbiologicsineachpatient,beforeadministration,isa critical issue; tailor-made therapiesusing singlenucleotide polymorphisms (SNPs) are currently being investigated. In Japan,biologicscurrentlyavailableforuseinRAincludethose that target tumornecrosisfactor (TNF)-␣ (infliximab,

etan-ercept, adalimumab, golimumab, and certolizumab pegol), tocilizumab(TCZ),whichtargetsIL-6,and abatacept,which targetsCD80/86.Wehavepreviouslyreportedonthe relation-shipbetweenTNF-␣therapyandautoantibodies(anti-dsDNA

antibodiesandanti-SS-Aantibodies)inpatientswith insuffi-cientresponses.2_{Inthepresentstudy,weexaminedpredictive}

factorsforthetherapeuticeffectofbiologics,whilefocusing

http://dx.doi.org/10.1016/j.rbre.2016.09.004

638

Table1–Patientcharacteristics.

Patients Sex Age (y.o)

Duration (years)

Hb(g/dL) CRP (mg/dL)

MMP3 (ng/mL)

CDAI(CDAIat24 weekslater)

MTX (mg/w)

PSL (mg/day)

Previous biologics

1 F 78 4 13.0 0.8 96 8.0(6.2) 8 4 ETN

2 M 58 2 13.6 2.3 258 34.2(24.9) 7.5 10 –

3 F 73 3 11.4 5.1 243 31.6(29.7) – – –

4 F 51 4 11.1 2.7 170 26.0(1.0) 10 10 INF

5 F 61 7 12.5 0.6 284 16.3(4.0) 8 7.5 –

6 F 46 7 13.3 1.8 176 14.3(10.9) 6 8 INF

7 F 49 13 13.6 0.2 – 19.5(1.1) – – ETN

8 F 73 21 10.0 0.1 150 16.0(24.0) 10 7.5 –

9 F 60 20 12.4 3.2 714 24.5(40.0) 6 4 INF

10 F 39 6 10.1 4.2 403 29.2(8.0) 8 4 INF

Hb,hemoglobin;CRP,C-reactiveprotein;MMP3,matrix metalloproteinase3;CDAIclinicaldiseaseactivityindex;MTX,methotrexate;PSL, prednisolone;INF,infliximab;ETN,etanercept.

on the effect of TCZ in ameliorating anemia of chronic

inflammation,viadirectinhibitionofIL-6receptor-mediated

signaling.3 _{Hepcidin-25,amajorcauseofanemiaofchronic}

inflammation,4_{wasmeasured inthe serumofRApatients.}

Wecomparedserumhepcidin-25levelswithclinicaldataand cytokinelevels,toexaminewhetherhepcidin-25couldactas apredictivefactorfortheeffectivenessofTCZ.

Materials

and

methods

Patients

The10patientsselectedforinclusioninthestudyhad previ-ouslybeenadmittedtotheSasakiInstituteKyoundoHospital Division of Internal Medicine and Rheumatology between September 2008 and September 2010. Patients had com-mencedTCZtherapyduringthisperiod,andwereeithernaive to biologics or had changed from other biologics to TCZ. AllRApatientsmettheAmerican CollegeofRheumatology (ACR)1987revisedcriteriafortheclassificationofrheumatoid arthritis.5_{BasedontheDeclarationofHelsinkiandthe}

guide-linesofthe institutionalreviewboardofKyoundoHospital, writtenconsentwasobtainedfromallpatientspriortothe startofthestudy.Thecharacteristicsofthe10patientsare showninTable1.

Methods

Hepcidin-25andIL-6levelsweremeasuredbefore introduc-tion of TCZ and 3 months after introduction. The serum sampleswerestoredat−80◦C.Serumhepcidin-25,whichis

thoughttobetheformofhepcidinwiththegreatest bioactiv-ity,wasmeasured usinganenzyme-linked immunosorbent assay (ELISA) (Hepcidin-25 EIA Kit; BACHEM, Bubendorf, Switzerland). Serum IL-6 was also measured using ELISA (HumanIL-6QuantikineELISAKit;R&DSystems, Minneapo-lis,MN,USA).Bothhepcidin-25andIL-6weremeasuredusing theSandwichELISAprotocol.Testresultsfromroutinetests undertakenduringgeneralexaminationatKyoundo Hospi-tal, including serum hemoglobin, C-reactive protein (CRP), anderythrocytesedimentationrate(ESR),werealsousedin ouranalysis.RAdiseaseactivitywasassessedusingclinical

diseaseactivityindex(CDAI).Student’st-testwasusedfor sta-tisticalanalysis.Ap-value<0.05wasconsideredstatistically significant.

Results

TherapeuticeffectivenessofTCZinRApatients

CDAIforpatientspriortoandaftertreatmentwithTCZare showninFig.1A.

SixmonthsafterinitiationoftreatmentwithTCZ, lower CDAIwerenotedin8of10patients.

Comparisonofhepcidin-25levelsinRApatientsand healthysubjects

Inacomparisonofserumhepcidin-25levelsinRApatients beforereceivingtreatmentwithTCZandinhealthysubjects, hepcidin-25levelsweresignificantlyelevatedinRApatients (Fig.1B).

Changesinhepcidin-25andIL-6levelsinRApatients

Serum hepcidin-25 and IL-6 levels in RA patients before administrationofTCZand12weeks(3months)after admin-istrationareshowninFig.1C.

Hepcidin-25

Serumhepcidin-25levelswerehighin8of10patientsbefore administrationofTCZ;inthese8patients,levelsdecreased aftertreatmentwithTCZ.However,inthe2patientsthathad comparatively low levels before administration, treatment with TCZ was associated with an increase inhepcidin-25. TheseresultsreflectedtheeffectivenessofTCZtherapy.Inthe 8patientswhoexhibitedadecreaseinhepcidin-25,TCZ ther-apywaseffective,whileinthelatter2patients,TCZtherapy wasdeterminedtobeineffective.

IL-6

ItisknownthatbecauseTCZisanIL-6receptorantagonist, serumIL-6levelstemporarilyincreaseafteradministration.6

rev bras reumatol.2017;57(6):637–640

639

A

C

D

45

40

35

30

CD

AI 25

20

15

10

5

0

180

p<0.01

n.s 160

140

120

100

80

60

40

20

0 0W

0W

24W AR

(n=10)

Cont. (n=5)

12W 0W 12W 0W 12W

180

Serum level of

hepcidin-25(ng/mL)

Serum level of

hepcidin-25(ng/mL

)

Serum level of IL-6(pg/mL

)

Serum level of Hb(g/dL)

160

140

120

100

80

60

40

20

0

600

500

400

300

200

100

0

15

14.5

14

13.5

13

12.5

12

11.5

11

10.5

10

B

Fig.1–(A)SixmonthsafterinitiationoftreatmentwithTCZ,CDAIwaslowerin8of10patients,andwastherefore consideredtobeeffective.TCZwasfoundtobeineffectivein2of10patients;(B)inacomparisonofserumhepcidin-25 levelsinRApatientsandhealthysubjects,hepcidin-25levelswerefoundtobesignificantlyelevatedinRApatients(p<0.01);

(C)highlevelsofserumhepcidin-25wereobservedpriortoadministrationofTCZ,anddecreased3monthsafterinitiation oftreatment.However,2of10patientshadpre-administrationlevelsthatwerecomparativelylow;theselevelsincreased aftertreatmentwithTCZ.These2caseswereconsistentwiththe2patientsinwhomTCZwasconsideredtobeineffective6 monthsafterinitiationoftreatment.Thegraylineindicatesthesamepatientsasthegraylinein(A);(D)weexamined hemoglobinlevels3monthsafteradministrationofTCZ.Elevatedhemoglobinlevelswerenotedin5of10patients.Elevated levelswereobservedin3of4patientsinwhomanemiawaspresentbeforereceivingtreatment(Hb<12g/dL,dottedline).

patientsafteradministrationofTCZ;however,adecreasewas notedin3patients.

Relationshipbetweenhepcidin-25andanemia

Weobservedchangesinserumhemoglobinlevels3months after the start of TCZ treatment, compared with the pre-TCZhemoglobinlevel(Fig.1D).Hemoglobinlevels,ageneral indicatorofanemia,increasedin5of10patientsafter admin-istrationofTCZ.Whenanalysiswaslimitedtothosepatients inwhomanemiawaspresentpriortoreceivingtreatment(Hb <12g/dL), mostpatientsshowed anincreaseinhemoglobin levels.

Discussion

Hepcidinisapeptidehormonethatisproducedintheliver. There are several known isoforms of hepcidin, including hepcidin-20 and hepcidin-22; hepcidin-25 has the highest bioactivity and is considered tohave astrong relationship withironmetabolism.7_{Irontakenorallyisabsorbedby}

intesti-nalepithelialcells.Inthepresenceofirondeficiency,ironis

releasedtotheperipheralblood.Whennodeficiencyofiron ispresent,ironisexcretedfecallyastheepithelialcellsare sloughedoffintotheintestinallumen.Mostironabsorbedin theintestinaltractisstoredintheliver. Asuitableamount ofironissuppliedfromthelivertotheperipheralblood,for useinerythrocyteproductioninthebonemarrow.Old eryth-rocytesaretrappedanddestroyedinthereticuloendothelial system,andtheironistakenupbythesystem,andreleased againintotheperipheralblood.Inthecaseofchronic inflam-matory diseases suchas RA,thereis anoverproductionof IL-6.When IL-6bindstoitsreceptorsintheliver, hepcidin-25 isproduced.Hepcidin-25bindstoferroportin,expressed inhepatocytesandreticuloendothelialmacrophages,leading to inhibition of intestinal absorption of iron, and inhibi-tionofironreleasefromthereticuloendothelialsystemand hepatocytes; together these factors result in the develop-ment of anemia.8,9 _{Hepcidinexpression isup-regulated by}

ironand inflammationanddown-regulatedbyanemia and hypoxia.10

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anticipatedtobeparticularlyeffectiveinthesepatients. How-ever,inthepresentstudyTCZwasnoteffectivein2cases, despitethefactthatserumIL-6levelsbeforetreatmentwere abnormallyhigh;in1ofthesecasesserumhepcidin-25 lev-els werelow (Fig.1C). Ithaspreviouslybeen reportedthat althoughanemiaofchronicinflammationmaybepresentin RApatients, alowlevelofhepcidinthatisstrongly indica-tive of iron deficiency, was also noted.12 _{In the present}

study, marked iron deficiency was noted in patients who hadabnormallyhighserumIL-6levelswithconcomitantlow hepcidin-25levels.

Weconcludedthatbecausehepcidin-25 levelsdecreased afterTCZadministrationandimprovementintheassociated anemia was noted, TCZcan ameliorate anemia of chronic inflammation.

Patientsthathadhighhepcidin-25levelsbefore adminis-trationofTCZandlowerlevels3monthsaftertreatment,were stillevaluatedashavinghadagoodresponse6monthsafter treatment.Basedonthis,weconsiderthathepcidin-25can actasapredictivefactorfortheeffectivenessofTCZ treat-ment.However,cautionisneededindeterminingcasesofiron deficiencyanemia.Measurementofhepcidincanbeeasily per-formed,andtheapplicationofhepcidinasaclinicalindicator inRApatientscanbeexpectedinthefuture.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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