Professional Documents
Culture Documents
Targeting Cytokines
JOCHEN ZWERINA, KURT REDLICH, GEORG SCHETT, AND JOSEF S. SMOLEN
Division of Rheumatology, Internal Medicine III,
Medical University of Vienna, Vienna, Austria
INTRODUCTION
Ann. N.Y. Acad. Sci. 1051: 716–729 (2005). © 2005 New York Academy of Sciences.
doi: 10.1196/annals.1361.116
716
ZWERINA et al.: PATHOGENESIS OF RA 717
was first described over 120 years ago and was termed “caries of the joint ends;”1
the invading synovial tissue was called “tumor albus” or “fungoid synovitis.” The ra-
diologic occurrence of bone erosions inversely correlates to quality of life and in the
long term leads to severe loss of functional capacity of RA patients.
PATHOGENETIC ASPECTS OF RA
TNF
TNF, discovered in the 1970s, binds to two receptors, the type 1 TNF receptor
(p55) and the type 2 TNF receptor (p75).11,12 TNF can be produced by mesenchymal
cells (fibroblasts, osteoblasts), monocytes, and T and B cells, whereas both receptors
are commonly expressed in many cells. TNF expression is induced by cytokines, en-
dotoxin, heat stress, neoplastic transformation, viral agents, and other stimuli. TNF
itself induces proinflammatory cytokines, activates polymorphnuclear leukocytes,
natural killer cells, and cytotoxic T cells, drives osteoclastogenesis, inhibits collagen
synthesis, and enhances cartilage breakdown.13 The proinflammatory effects of TNF
are mostly mediated via the p55 receptor (TNF-RI), whereas its proapoptotic effects
are exerted mainly via the p75 receptor (TNF-RII). In RA, TNF is highly expressed
in the rheumatoid synovium and synovial fluid.14–17 It is highly efficient in inducing
the differentiation of monocytes to osteoclasts in the presence of RANKL, a critical
factor in osteoclastogenesis.18 Furthermore, TNF increases the synthesis of proin-
flammatory cytokines and metalloproteases by synovial fibroblasts and decreases
the synthesis of proteoglycans by chondrocytes.19,20 Animal studies have shown the
importance of TNF in joint inflammation. Mice that overexpress TNF systemically
develop an erosive polyarticular symmetric arthritis.21 Moreover, these mice devel-
op systemic bone loss similar to that seen in RA patients.22 Consistent with these
findings, TNF blockade is highly effective in animals and inhibits synovial inflam-
mation, cartilage degradation, and bone erosion.23–25
Currently, three TNF blockers are approved for treatment of RA: infliximab (a
chimeric monoclonal antibody to TNF), adalimumab (a human monoclonal antibody
to TNF), and etanercept (a fusion protein of the p75 TNF receptor). All three agents
are efficacious in patients who have previously failed methotrexate (MTX) treat-
ment. Typically, American College of Rheumatology 20% improvement criteria
(ACR20) responses between ~50% to 70% and ACR50 responses between ~30% to
50% have been achieved.26–31 In terms of radiographic progression of RA, the Trial
of Etanercept and Methotrexate with Radiographic Patient Outcomes (TEMPO)
showed superiority of etanercept plus MTX versus etanercept or MTX alone.32
Patients who received etanercept alone showed some progression, whereas patients
ZWERINA et al.: PATHOGENESIS OF RA 719
who received combination therapy showed a slight reduction in total Sharp scores.
Interestingly, anti-TNF treatment appears to halt radiographic progression even in
patients not achieving clinically significant reduction of disease activity.33 More-
over, a trial in patients with early RA (disease duration ≤ 3 years) showed that com-
bined treatment with infliximab plus MTX or etanercept plus MTX reduced disease
activity and halted bone damage.34 Recently, a small 1-year trial with very early RA
patients (disease duration ≤ 1 year) investigated the combination of infliximab plus
MTX versus MTX alone, followed by another year of therapy with MTX only.35 Af-
ter 1 year, the combination therapy showed better ACR20 responses and radio-
graphs. Even after discontinuation of infliximab after 12 months, a sustained benefit
in quality of life and functional capacity was observed; however, ACR responses, ra-
diologic progression, and DAS28 scores were similar in both groups. Currently,
forms of humanized anti-TNF antibodies that have been PEGylated to obtain a pro-
720 ANNALS NEW YORK ACADEMY OF SCIENCES
longed plasma half-life are in clinical development (see TABLE 1). Another question
is whether patients who did not respond to one TNF blocker respond to another. Data
from a registry in Sweden suggest that a switch from etanercept to infliximab or vice
versa could be of benefit.36
IL-1
Originally discovered as a fever-inducing humoral factor, two forms of IL-1 are
now known: IL-1α is a nonsecreted locally acting form, whereas IL-1β is secreted
and is measurable in the serum of patients with an activated immune system.37 IL-1
acts via the type I IL-1 receptor (IL-1R1), whereas binding of IL-1 to the type II IL-
1 receptor (IL-1R2) does not transduce signaling. Interleukin-converting enzyme
(ICE) sheds IL-1 from the membranes of cells. IL-1 receptor antagonist (IL-1ra) is
a naturally occurring counterregulatory cytokine.38 Binding of IL-1ra to IL-1 recep-
tor blocks activation and signal transduction. Intracytoplasmically, IL-1RI engage-
ment by IL-1 activates Myd88, then TRAF-6, and subsequently leads to
phosphorylation of IκB and to release of NFκB, a proinflammatory transcription
factor. IL-1, like TNF, is produced by many cells, although monocytes and macroph-
ages produce the highest amounts of it under inflammatory conditions.39 IL-1 induc-
es production of TNF, IL-1, IL-6, and other cytokines, stimulates osteoclastogenesis,
drives the expression of cartilage- and matrix-degrading metalloproteases, enhances
chemokine production, and plays a role in neoangiogenesis.40–44 Animal models of
joint inflammation suggested the importance of IL-1. Injection of IL-1 in knee joints
induces joint inflammation,45 and inhibition of IL-1 by administration of either IL-
1ra or antibodies against IL-1 leads to significant reduction of joint inflammation,
cartilage destruction, and bone erosion in the collagen-induced arthritis (CIA) mod-
el.46–49 Furthermore, IL-1ra knockout mice develop an RA-like disease with an ero-
sive polyarthritis.50 However, in TNF-driven RA models such as adjuvant-induced
arthritis (AIA) and the TNF transgenic mice, inhibition of IL-1 is much less effica-
cious.23,51 In RA patients, IL-1 is detectable in synovial fluid specimens and occa-
sionally in serum, and its levels correlate with disease activity.52 Increased
expression of IL-1 and decreased production of IL-1ra has been detected in RA syn-
ovial tissues, suggesting a disturbed IL-1/IL-1ra balance.53 Ex vivo studies with syn-
ovial fibroblasts demonstrated the cartilage-degrading potency of IL-1.54
Anakinra, a recombinant nonglycosylated form of human IL-1ra produced in
Escherichia coli, is successful in preventing joint inflammation in animal models of
RA. After a dose-finding and frequency study,55 a large, randomized, placebo-con-
trolled trial with 472 patients was conducted.56 Active RA patients, who had failed
no more than two DMARDs and had stopped treatment for 6 weeks, received either
placebo or one of three doses of anakinra (30 mg, 75 mg, 150 mg) by daily subcuta-
neous injections. The primary end point was the ACR20 response. After 24 weeks,
27% of the placebo-treated patients and 43% of the patients in the 150-mg-dose
group reached an ACR20 response (P < 0.014); the lower two anakinra doses did not
result in significant efficacy. Anakinra at the 150-mg dose also reduced swollen and
tender joint counts, HAQ score, pain, erythrocyte sedimentation rate, and serum C-
reactive protein statistically more than placebo. A combined analysis of all three
doses showed a 45% reduction in the progression of bone erosions as determined by
the Larsen score method. A second trial compared MTX plus placebo versus MTX
ZWERINA et al.: PATHOGENESIS OF RA 721
plus anakinra at five different doses (0.04, 0.1, 0.4, 1.0, and 2.0 mg/kg/day s.c.).57
Patients had to be active despite stable MTX treatment. After 12 weeks, increasing
anakinra doses led to improvement of patients, with 46% of patients receiving 1 mg/
kg and 38% of patients receiving 2 mg/kg reaching an ACR20 response, compared
with 19% of placebo-treated patients. This effect was sustained after 24 weeks of
treatment. Also, more treated patients reached an ACR50 and ACR70 response. This
was accompanied by significant reduction in secondary end points, as in the above-
described study. Radiographic data of these patients showed a 36% lower joint dam-
age progression as determined by the Sharp score method.58 A third study compared
the currently approved dose of daily subcutaneous 100 mg anakinra plus MTX with
placebo plus MTX.59 Confirming the former two studies, significantly more patients
reached ACR responses when treated with anakinra in addition to MTX versus pla-
cebo plus MTX (ACR20: 38% vs. 22%; ACR50: 17% vs. 8%; ACR70: 6% vs. 2%,
respectively). A large, placebo-controlled trial evaluated the safety of adding anak-
inra to traditionally used DMARDs. Although serious adverse events were slightly
higher in the anakinra-treated group (2.1% vs. 0.4%), mortality was similar, suggest-
ing an acceptable safety profile. Thus, IL-1 antagonism by IL-1ra is safe and effec-
tive and slows joint damage, although to a lesser degree than observed in clinical
trials of TNF blockers. Another IL-1 inhibitor developed is IL-1 trap, which binds to
IL-1 and inhibits ligation of the latter to IL-1RI. Although a phase Ib study showed
positive results, a phase II study revealed no superiority to placebo.60 Pralnacasan,
an orally available ICE inhibitor, also did not achieve significant ACR20 responses
compared with placebo, and serious liver enzyme elevations in mice led to discon-
tinuation of another phase II trial.61
IL-6
IL-6 was originally described in 1982 as a B cell differentiation marker.62,63 It
belongs to a family of cytokines with a helical structure, such as leukemia inhibitory
factor, IL-11, oncostatin M, cardiotrophin-1, and ciliary neurotrophic factor.64 IL-6
binds the membrane-bound IL-6 receptor (gp80) and then subsequently binds to
gp130, the common signal transducer for the IL-6 family cytokines. Alternatively,
IL-6 can bind to soluble IL-6R and then generate signal transduction by binding of
membrane-bound gp130. IL-6 is produced by a wide variety of cells, including T
cells, B cells, macrophages, fibroblasts, endothelial cells, and tumor cells. It also in-
duces terminal differentiation of macrophages, and acts as a growth factor for both
T and B cells.65,66 Furthermore, it enhances differentiation of megakaryocytes to
produce platelets,67 and is a stem cell growth factor.68 More evidence of the physi-
ological importance of IL-6 in vivo comes from IL-6 transgenic mice. These mice
develop multiple complications: (1) polyclonal plasmocytosis with autoantibody
production, (2) increased levels of fibrinogen and a reduction of serum albumin, (3)
increased megakaryopoeisis, and (4) eventual development of mesangial prolifera-
tive glomerulonephritis and lymphocytic interstitial lung disease.69–72 Treatment of
these mice with anti–IL-6R antibodies ameliorates disease.73
Because RA is characterized at least partially by events also induced by IL-6,
synovial fluid (SF) IL-6 levels of RA patients were first assessed. Indeed, high levels
of IL-6 in SF were observed.74 Moreover, serum IL-6 levels were increased and cor-
related with levels of acute-phase proteins. IL-6 may contribute to autoantibody pro-
722 ANNALS NEW YORK ACADEMY OF SCIENCES
IL-15
IL-15 was first described in 1994, with functional similarities to IL-2.90 IL-15
uses components of the IL-2 receptor but also requires its own α receptor chain. IL-
15 is primarily produced by macrophages.91 Infectious agents (BCG), TNF, IL-1,
and cell–cell contacts (T cell–macrophage) induce IL-15 production. IL-15 is tightly
regulated, because many human tissues express IL15 mRNA but not protein. The
regulation is on both a transcriptional and a post-transcriptional level. IL-15 stimu-
lates T cell proliferation and migration in vitro and in vivo.92 IL-15 drives naive T
cells in the Th1-type direction by inducing IFN-γ production. Additionally, a single
intradermal injection of recombinant human (rh)IL-15 is sufficient to induce a local
inflammatory infiltrate. These cell aggregates mainly consist of CD3+ T cells.93
Moreover, IL-15 induces natural killer cell toxicity.94 IL-15 also binds to macroph-
ages and induces TNF, IL-1, and IL-6 production.95 IL-15 induces the differentiation
ZWERINA et al.: PATHOGENESIS OF RA 723
of bone marrow mononuclear cells into osteoclast precursors and enhances the
expression of calcitonin receptor and TRAP, two osteoclast lineage markers.96
The proinflammatory actions of IL-15 led to the investigation of the expression
of this cytokine in RA. It was first noted in 1996 that IL-15 is present in RA synovial
tissue but is detectable far less often in synovial samples from reactive arthritis or
osteoarthritis (OA).93 IL-15–positive cells were detected in the synovial lining layer,
sublining layer, and perivascular aggregates, and the majority of these cells were
macrophages and fibroblasts.97 Furthermore, soluble (s)IL-15 was detected in RA
synovial fluid specimens, but not in specimens from OA patients, and levels of sIL-
15 correlated with synovial fluid TNF levels.
Synovial T cells produced significant amounts of TNF upon incubation with IL-
15, but not with IL-2.98 IL-15–stimulated T cells also elicit TNF production of syn-
ovial fluid macrophages in a cell–cell contact–dependent fashion. In turn, TNF and
IL-1 are able to induce IL-15 production in synovial fibroblasts and therefore might
perpetuate local T cell proliferation.99 As it has been shown for many other cytok-
ines, IL-15 potently synergizes with other cytokines to enhance T cell growth as well
as proliferation and macrophage activation. IL-12 and IL-18 in combination with IL-
15 promote macrophage activation at low concentrations.100 Hence, IL-15 is likely
to play a role in RA.
Consequently, therapeutic inhibition of IL-15 has been investigated in animal
models of RA. Administration of a soluble fragment of the IL-15R α-chain was test-
ed in the collagen-induced arthritis model in mice.101 Daily treatment after collagen
challenge diminished incidence and severity of disease. Histologically, infiltration of
polymorphonuclear cells, cartilage destruction, and bone erosion were prevented.
Serologically, antibody levels raised against collagen were significantly reduced.
Moreover, levels of IFN-γ and IL-6 in sera of treated CIA mice were lower compared
with levels in untreated mice. Discontinuation of treatment, however, exacerbated
disease immediately. Another study evaluated the efficacy of a mutant fusion protein
(CRB-15) that binds to the IL-15 receptor but does not trigger intracellular signal
transduction in CIA mice.102 Again, incidence and severity of disease were reduced
when CRB-15 was administered after collagen challenge, and CRB-15 also alleviat-
ed disease when given after clinical onset.
In 2003, a first report of an anti–IL-15–targeted therapy in RA patients was present-
ed.103 In a phase I study, 30 active RA patients received either a human monoclonal
anti–IL-15 antibody (HuMax-IL15) at various doses (0.15 mg/kg up to 8 mg/kg) or
placebo. Administration was safe, and patients did not have an increase of antibodies
against HuMax-IL15. A combined analysis of the anti–IL-15–treated patients
showed an ACR20 response in 63%, an ACR50 response in 38%, and 25% achieved
an ACR70 response. Recently, these data were confirmed by a phase II study with
comparable ACR responses.104 This suggests that targeting IL-15 in RA may be
beneficial.
CONCLUSION
at least to a certain (and sometimes greater) degree. Why some patients benefit from
TNF blockade whereas others do not is unclear but points to different dominance of
cytokine pathways in different patients. We have proposed an “inflammatory house
of cards model,” where more than one molecule has to be targeted for optimal treat-
ment of RA.105 This is underlined by the fact that combining biologicals with tradi-
tional DMARDs such as MTX is superior to treatment with a single agent, especially
in terms of radiological and clinical response. Furthermore, animal studies suggest
a synergistic action of cytokines, and combined inhibition of TNF and IL-1 is highly
efficacious in treating TNF-mediated arthritis and the AIA model.23 Moreover, some
combination therapies lead to healing phenomena in mice.106
In summary, the novel and expanding insights into cellular and molecular events
governing the evolution of RA, in conjunction with results of therapeutic trials, sug-
gest that multiple cell systems and cytokines are involved in the generation of the
joint damage characteristic of the disease. Targeting these events has already im-
proved the fate of patients refractory to other treatment modalities and has led to
shifts in treatment paradigms. Further progress is to be expected, with the ultimate
aim of remission and cure of the disease.
REFERENCES
14. CHU, C.Q., M. FIELD, S. ALLARD, et al. 1992. Detection of cytokines at the cartilage/
pannus junction in patients with rheumatoid arthritis: implications for the role of
cytokines in cartilage destruction and repair. Br. J. Rheumatol. 31: 653–661.
15. STEINER, G., M. TOHIDAST-AKRAD, G. WITZMANN, et al. 1999. Cytokine production by
synovial T cells in rheumatoid arthritis. Rheumatology (Oxford) 38: 202–213.
16. PARTSCH, G., G. STEINER, B.F. LEEB, et al. 1997. Highly increased levels of tumor
necrosis factor-alpha and other proinflammatory cytokines in psoriatic arthritis syn-
ovial fluid. J. Rheumatol. 24: 518–523.
17. CHU, C.Q., M. FIELD, M. FELDMANN & R.N. MAINI. 1991. Localization of tumor necro-
sis factor alpha in synovial tissues and at the cartilage-pannus junction in patients
with rheumatoid arthritis. Arthritis Rheum. 34: 1125–1132.
18. LAM, J., S. TAKESHITA, J.E. BARKER, et al. 2000. TNF-alpha induces osteoclastogenesis
by direct stimulation of macrophages exposed to permissive levels of RANK ligand.
J. Clin. Invest. 106: 1481–1488.
19. JORGENSEN, C., I. COURET, F. CANOVAS, et al. 1996. Mononuclear cell retention in
rheumatoid synovial tissue engrafted in severe combined immunodeficient (SCID)
mice is up-regulated by tumour necrosis factor-alpha (TNF-alpha) and mediated
through intercellular adhesion molecule-1 (ICAM-1). Clin. Exp. Immunol. 106: 20–
25.
20. FIRESTEIN, G.S. & M.M. PAINE. 1992. Stromelysin and tissue inhibitor of metallopro-
teinases gene expression in rheumatoid arthritis synovium. Am. J. Pathol. 140:
1309–1314.
21. KEFFER, J., L. PROBERT, H. CAZLARIS, et al. 1991. Transgenic mice expressing human
tumour necrosis factor: a predictive genetic model of arthritis. EMBO J. 10: 4025–
4031.
22. SCHETT, G., K. REDLICH, S. HAYER, et al. 2003. Osteoprotegerin protects against gener-
alized bone loss in tumor necrosis factor-transgenic mice. Arthritis Rheum. 48:
2042–2051.
23. ZWERINA, J., S. HAYER, M. TOHIDAST-AKRAD, et al. 2004. Single and combined inhibi-
tion of tumor necrosis factor, interleukin-1, and RANKL pathways in tumor necrosis
factor-induced arthritis: effects on synovial inflammation, bone erosion, and carti-
lage destruction. Arthritis Rheum. 50: 277–290.
24. LEWTHWAITE, J., S. BLAKE, T. HARDINGHAM, et al. 1995. Role of TNF alpha in the
induction of antigen induced arthritis in the rabbit and the anti-arthritic effect of spe-
cies specific TNF alpha neutralising monoclonal antibodies. Ann. Rheum. Dis. 54:
366–374.
25. THORBECKE, G.J., R. SHAH, C.H. LEU, et al. 1992. Involvement of endogenous tumor
necrosis factor alpha and transforming growth factor beta during induction of col-
lagen type II arthritis in mice. Proc. Natl. Acad. Sci. USA 89: 7375–7379.
26. LIPSKY, P.E., D.M. VAN DER HEIJDE, E.W. ST. CLAIR, et al. 2000. Infliximab and meth-
otrexate in the treatment of rheumatoid arthritis. Anti-Tumor Necrosis Factor Trial in
Rheumatoid Arthritis with Concomitant Therapy Study Group. N. Engl. J. Med. 343:
1594–1602.
27. MAINI, R., E.W. ST. CLAIR, F. BREEDVELD, et al. 1999. Infliximab (chimeric anti-
tumour necrosis factor alpha monoclonal antibody) versus placebo in rheumatoid
arthritis patients receiving concomitant methotrexate: a randomised phase III trial.
ATTRACT Study Group. Lancet 354: 1932–1939.
28. MAINI, R.N., F.C. BREEDVELD, J.R. KALDEN, et al. 1998. Therapeutic efficacy of multi-
ple intravenous infusions of anti-tumor necrosis factor alpha monoclonal antibody
combined with low-dose weekly methotrexate in rheumatoid arthritis. Arthritis
Rheum. 41: 1552–1563.
29. MORELAND, L.W., M.H. SCHIFF, S.W. BAUMGARTNER, et al. 1999. Etanercept therapy in
rheumatoid arthritis. A randomized, controlled trial. Ann. Intern. Med. 130: 478–
486.
30. VAN DE PUTTE, L.B., C. ATKINS, M. MALAISE, et al. 2004. Efficacy and safety of adali-
mumab as monotherapy in patients with rheumatoid arthritis for whom previous dis-
ease modifying antirheumatic drug treatment has failed. Ann. Rheum. Dis. 63: 508–
516.
726 ANNALS NEW YORK ACADEMY OF SCIENCES
31. WEINBLATT, M.E., E.C. KEYSTONE, D.E. FURST, et al. 2003. Adalimumab, a fully
human anti-tumor necrosis factor alpha monoclonal antibody, for the treatment of
rheumatoid arthritis in patients taking concomitant methotrexate: the ARMADA
trial. Arthritis Rheum. 48: 35–45.
32. GENOVESE, M.C., J.M. BATHON, R.W. MARTIN, et al. 2002. Etanercept versus methotr-
exate in patients with early rheumatoid arthritis: two-year radiographic and clinical
outcomes. Arthritis Rheum. 46: 1443–1450.
33. SMOLEN, J.S., C. HAN, M. BALA, et al. 2005. Evidence of radiographic benefit of
infliximab plus methotrexate in rheumatoid arthritis patients who had no clinical
improvement: a detailed subanalysis of the ATTRACT trial. Arthritis Rheum. 52:
1020–1030.
34. ST. CLAIR, E.W., D.M. VAN DER HEIJDE, J.S. SMOLEN, et al. 2004. Combination of
infliximab and methotrexate therapy for early rheumatoid arthritis: a randomized,
controlled trial. Arthritis Rheum. 50: 3432–3443.
35. QUINN, M.A., P.G. CONAGHAN, P.J. O’CONNOR, et al. 2005. Very early treatment with
infliximab in addition to methotrexate in early, poor-prognosis rheumatoid arthritis
reduces magnetic resonance imaging evidence of synovitis and damage, with sus-
tained benefit after infliximab withdrawal: results from a twelve-month randomized,
double-blind, placebo-controlled trial. Arthritis Rheum. 52: 27–35.
36. VAN VOLLENHOVEN, R., A. HARJU, S. BRANNEMARK & L. KLARESKOG. 2003. Treatment
with infliximab (Remicade) when etanercept (Enbrel) has failed or vice versa: data
from the STURE registry showing that switching tumour necrosis factor alpha block-
ers can make sense. Ann. Rheum. Dis. 62: 1195–1198.
37. DINARELLO, C.A. 1991. Interleukin-1 and interleukin-1 antagonism. Blood 77: 1627–1652.
38. AREND, W.P., H.G. WELGUS, R.C. THOMPSON & S.P. EISENBERG. 1990. Biological prop-
erties of recombinant human monocyte-derived interleukin 1 receptor antagonist. J.
Clin. Invest. 85: 1694–1697.
39. DINARELLO, C.A. 2002. The IL-1 family and inflammatory diseases. Clin. Exp. Rheu-
matol. 20: S1–S13.
40. FOX, S.W., K. FULLER & T.J. CHAMBERS. 2000. Activation of osteoclasts by interleu-
kin-1: divergent responsiveness in osteoclasts formed in vivo and in vitro. J. Cell
Physiol. 184: 334–340.
41. LORENZO, J.A., A. NAPRTA, Y. RAO, et al. 1998. Mice lacking the type I interleukin-1
receptor do not lose bone mass after ovariectomy. Endocrinology 139: 3022–3025.
42. KOBAYASHI, M., G.R. SQUIRES, A. MOUSA, et al. 2005. Role of interleukin-1 and tumor
necrosis factor alpha in matrix degradation of human osteoarthritic cartilage. Arthri-
tis Rheum. 52: 128–135.
43. RATHANASWAMI, P., M. HACHICHA, W.L. WONG, et al. 1993. Synergistic effect of inter-
leukin-1 beta and tumor necrosis factor alpha on interleukin-8 gene expression in
synovial fibroblasts. Evidence that interleukin-8 is the major neutrophil-activating
chemokine released in response to monokine activation. Arthritis Rheum. 36: 1295–
1304.
44. COXON, A., B. BOLON, J. ESTRADA, et al. 2002. Inhibition of interleukin-1 but not
tumor necrosis factor suppresses neovascularization in rat models of corneal angio-
genesis and adjuvant arthritis. Arthritis Rheum. 46: 2604–2612.
45. PETTIPHER, E.R., G.A. HIGGS & B. HENDERSON. 1986. Interleukin 1 induces leukocyte
infiltration and cartilage proteoglycan degradation in the synovial joint. Proc. Natl.
Acad. Sci. USA 83: 8749–8753.
46. KIM, J.M., J.G. JEONG, S.H. HO, et al. 2003. Protection against collagen-induced
arthritis by intramuscular gene therapy with an expression plasmid for the interleu-
kin-1 receptor antagonist. Gene Ther. 10: 1543–1550.
47. PALMER, G., D. TALABOT-AYER, L. SZALAY-QUINODOZ, et al. 2003. Mice transgenic for
intracellular interleukin-1 receptor antagonist type 1 are protected from collagen-
induced arthritis. Eur. J. Immunol. 33: 434–440.
48. JOOSTEN, L.A., M.M. HELSEN, T. SAXNE, et al. 1999. IL-1 alpha beta blockade prevents
cartilage and bone destruction in murine type II collagen-induced arthritis, whereas
TNF-alpha blockade only ameliorates joint inflammation. J. Immunol. 163: 5049–
5055.
ZWERINA et al.: PATHOGENESIS OF RA 727
49. VAN DEN BERG, W.B., L.A. JOOSTEN, M. HELSEN & F.A. VAN DE LOO. 1994. Ameliora-
tion of established murine collagen-induced arthritis with anti-IL-1 treatment. Clin.
Exp. Immunol. 95: 237–243.
50. HORAI, R., S. SAIJO, H. TANIOKA, et al. 2000. Development of chronic inflammatory
arthropathy resembling rheumatoid arthritis in interleukin 1 receptor antagonist-defi-
cient mice. J. Exp. Med. 191: 313–320.
51. WOOLEY, P.H., J.D. WHALEN, D.L. CHAPMAN, et al. 1993. The effect of an interleukin-1
receptor antagonist protein on type II collagen-induced arthritis and antigen-induced
arthritis in mice. Arthritis Rheum. 36: 1305–1314.
52. FONTANA, A., H. HENGARTNER, E. WEBER, et al. 1982. Interleukin 1 activity in the syn-
ovial fluid of patients with rheumatoid arthritis. Rheumatol. Int. 2: 49–53.
53. DELEURAN, B.W., C.Q. CHU, M. FIELD, et al. 1992. Localization of interleukin-1 alpha,
type 1 interleukin-1 receptor and interleukin-1 receptor antagonist in the synovial
membrane and cartilage/pannus junction in rheumatoid arthritis. Br. J. Rheumatol.
31: 801–809.
54. MULLER-LADNER, U., C.R. ROBERTS, B.N. FRANKLIN, et al. 1997. Human IL-1Ra gene
transfer into human synovial fibroblasts is chondroprotective. J. Immunol. 158:
3492–3498.
55. CAMPION, G.V., M.E. LEBSACK, J. LOOKABAUGH, et al. 1996. Dose-range and dose-fre-
quency study of recombinant human interleukin-1 receptor antagonist in patients
with rheumatoid arthritis. The IL-1Ra Arthritis Study Group. Arthritis Rheum. 39:
1092–1101.
56. BRESNIHAN, B., J.M. ALVARO-GRACIA, M. COBBY, et al. 1998. Treatment of rheumatoid
arthritis with recombinant human interleukin-1 receptor antagonist. Arthritis Rheum.
41: 2196–2204.
57. COHEN, S., E. HURD, J. CUSH, et al. 2002. Treatment of rheumatoid arthritis with anak-
inra, a recombinant human interleukin-1 receptor antagonist, in combination with
methotrexate: results of a twenty-four-week, multicenter, randomized, double-blind,
placebo-controlled trial. Arthritis Rheum. 46: 614–624.
58. SHERGY, W.J., S. COHEN, M.W. GREENWALD, et al. 2003. Anakinra (Kineret) inhibits
the progression of radiographically measured joint destruction in rheumatoid arthri-
tis. Ann. Rheum. Dis. 62: 273.
59. COHEN, S.B., L.W. MORELAND, J.J. CUSH, et al. 2004. A multicentre, double blind, ran-
domised, placebo controlled trial of anakinra (Kineret), a recombinant interleukin 1
receptor antagonist, in patients with rheumatoid arthritis treated with background
methotrexate. Ann. Rheum. Dis. 63: 1062–1068.
60. GULER, H.P. et al. 2001. A phase I, single dose escalation study of IL-1 trap in patients
with rheumatoid arthritis. Arthritis Rheum. 44: 370.
61. PAVELKA, K. et al. 2002. Clinical effects of pralnacasan (PRAL), an orally active inter-
leukin-1beta converting enzyme (ICE) inhibitor in a 285-patient phase II trial in
rheumatoid arthritis (RA). Arthritis Rheum. 48: 281.
62. TOSATO, G., K.B. SEAMON, N.D. GOLDMAN, et al. 1988. Monocyte-derived human B-
cell growth factor identified as interferon-beta 2 (BSF-2, IL-6). Science 239: 502–
504.
63. OKADA, M., N. SAKAGUCHI, N. YOSHIMURA, et al. 1983. B cell growth factors and B
cell differentiation factor from human T hybridomas. Two distinct kinds of B cell
growth factor and their synergism in B cell proliferation. J. Exp. Med. 157: 583–590.
64. HIBI, M., K. NAKAJIMA & T. HIRANO. 1996. IL-6 cytokine family and signal transduc-
tion: a model of the cytokine system. J. Mol. Med. 74: 1–12.
65. YOSHIZAKI, K., T. NAKAGAWA, T. KAIEDA, et al. 1982. Induction of proliferation and Ig
production in human B leukemic cells by anti-immunoglobulins and T cell factors. J.
Immunol 128: 1296–1301.
66. NISHIMOTO, N., A. OGATA, Y. SHIMA, et al. 1994. Oncostatin M, leukemia inhibitory
factor, and interleukin 6 induce the proliferation of human plasmacytoma cells via
the common signal transducer, gp130. J. Exp. Med. 179: 1343–1347.
67. ISHIBASHI, T., H. KIMURA, T. UCHIDA, et al. 1989. Human interleukin 6 is a direct pro-
moter of maturation of megakaryocytes in vitro. Proc. Natl. Acad. Sci. USA 86:
5953–5957.
728 ANNALS NEW YORK ACADEMY OF SCIENCES
68. IKEBUCHI, K., G.G. WONG, S.C. CLARK, et al. 1987. Interleukin 6 enhancement of inter-
leukin 3-dependent proliferation of multipotential hemopoietic progenitors. Proc.
Natl. Acad. Sci. USA 84: 9035–9039.
69. GOYA, S., H. MATSUOKA, M. MORI, et al. 2003. Sustained interleukin-6 signalling
leads to the development of lymphoid organ-like structures in the lung. J. Pathol.
200: 82–87.
70. HILL, R.J., M.K. WARREN, P. STENBERG, et al. 1991. Stimulation of megakaryocyto-
poiesis in mice by human recombinant interleukin-6. Blood 77: 42–48.
71. SUEMATSU, S., T. MATSUDA, K. AOZASA, et al. 1989. IgG1 plasmacytosis in interleukin
6 transgenic mice. Proc. Natl. Acad. Sci. USA 86: 7547–7551.
72. FATTORI, E., R.C. DELLA, P. COSTA, et al. 1994. Development of progressive kidney dam-
age and myeloma kidney in interleukin-6 transgenic mice. Blood 83: 2570–2579.
73. KATSUME, A., H. SAITO, Y. YAMADA, et al. 2002. Anti-interleukin 6 (IL-6) receptor
antibody suppresses Castleman’s disease like symptoms emerged in IL-6 transgenic
mice. Cytokine 20: 304–311.
74. HOUSSIAU, F.A., J.P. DEVOGELAER, J. VAN DAMME, et al. 1988. Interleukin-6 in synovial
fluid and serum of patients with rheumatoid arthritis and other inflammatory arthriti-
des. Arthritis Rheum. 31: 784–788.
75. GUERNE, P.A., B.L. ZURAW, J.H. VAUGHAN, et al. 1989. Synovium as a source of inter-
leukin 6 in vitro. Contribution to local and systemic manifestations of arthritis. J.
Clin. Invest. 83: 585–592.
76. OKAMOTO, H., M. YAMAMURA, Y. MORITA, et al. 1997. The synovial expression and
serum levels of interleukin-6, interleukin-11, leukemia inhibitory factor, and oncos-
tatin M in rheumatoid arthritis. Arthritis Rheum. 40: 1096–1105.
77. POLI, V., R. BALENA, E. FATTORI, et al. 1994. Interleukin-6 deficient mice are protected
from bone loss caused by estrogen depletion. EMBO J. 13: 1189–1196.
78. BELLIDO, T., R.L. JILKA, B.F. BOYCE, et al. 1995. Regulation of interleukin-6, osteo-
clastogenesis, and bone mass by androgens. The role of the androgen receptor. J.
Clin. Invest. 95: 2886–2895.
79. KUDO, O., A. SABOKBAR, A. POCOCK, et al. 2003. Interleukin-6 and interleukin-11 support
human osteoclast formation by a RANKL-independent mechanism. Bone 32: 1–7.
80. KURIHARA, N., D. BERTOLINI, T. SUDA, et al. 1990. IL-6 stimulates osteoclast-like
multinucleated cell formation in long term human marrow cultures by inducing IL-1
release. J. Immunol. 144: 4226–4230.
81. TAKAGI, N., M. MIHARA, Y. MORIYA, et al. 1998. Blockage of interleukin-6 receptor
ameliorates joint disease in murine collagen-induced arthritis. Arthritis Rheum. 41:
2117–2121.
82. MIHARA, M., M. KOTOH, N. NISHIMOTO, et al. 2001. Humanized antibody to human
interleukin-6 receptor inhibits the development of collagen arthritis in cynomolgus
monkeys. Clin. Immunol. 98: 319–326.
83. SASAI, M., Y. SAEKI, S. OHSHIMA, et al. 1999. Delayed onset and reduced severity of
collagen-induced arthritis in interleukin-6-deficient mice. Arthritis Rheum. 42:
1635–1643.
84. ALONZI, T., E. FATTORI, D. LAZZARO, et al. 1998. Interleukin 6 is required for the
development of collagen-induced arthritis. J. Exp. Med. 187: 461–468.
85. WENDLING, D., E. RACADOT & J. WIJDENES. 1993. Treatment of severe rheumatoid
arthritis by anti-interleukin 6 monoclonal antibody. J. Rheumatol. 20: 259–262.
86. YOSHIZAKI, K., T. MATSUDA, N. NISHIMOTO, et al. 1989. Pathogenic significance of
interleukin-6 (IL-6/BSF-2) in Castleman’s disease. Blood 74: 1360–1367.
87. NISHIMOTO, N., M. SASAI, Y. SHIMA, et al. 2000. Improvement in Castleman’s disease
by humanized anti-interleukin-6 receptor antibody therapy. Blood 95: 56–61.
88. CHOY, E.H., D.A. ISENBERG, T. GARROOD, et al. 2002. Therapeutic benefit of blocking
interleukin-6 activity with an anti-interleukin-6 receptor monoclonal antibody in
rheumatoid arthritis: a randomized, double-blind, placebo-controlled, dose-escala-
tion trial. Arthritis Rheum. 46: 3143–3150.
89. NISHIMOTO, N., K. YOSHIZAKI, N. MIYASAKA, et al. 2004. Treatment of rheumatoid
arthritis with humanized anti-interleukin-6 receptor antibody: a multicenter, double-
blind, placebo-controlled trial. Arthritis Rheum. 50: 1761–1769.
ZWERINA et al.: PATHOGENESIS OF RA 729
90. GRABSTEIN, K.H., J. EISENMAN, K. SHANEBECK, et al. 1994. Cloning of a T cell growth
factor that interacts with the beta chain of the interleukin-2 receptor. Science 264:
965–968.
91. DOHERTY, T.M., R.A. SEDER & A. SHER. 1996. Induction and regulation of IL-15
expression in murine macrophages. J. Immunol. 156: 735–741.
92. KANEGANE, H. & G. TOSATO. 1996. Activation of naive and memory T cells by inter-
leukin-15. Blood 88: 230–235.
93. MCINNES, I.B., J. AL MUGHALES, M. FIELD, et al. 1996. The role of interleukin-15 in
T-cell migration and activation in rheumatoid arthritis. Nat. Med. 2: 175–182.
94. CARSON, W.E., J.G. GIRI, M.J. LINDEMANN, et al. 1994. Interleukin (IL) 15 is a novel
cytokine that activates human natural killer cells via components of the IL-2 recep-
tor. J. Exp. Med. 180: 1395–1403.
95. ALLEVA, D.G., S.B. KASER, M.A. MONROY, et al. 1997. IL-15 functions as a potent
autocrine regulator of macrophage proinflammatory cytokine production: evidence
for differential receptor subunit utilization associated with stimulation or inhibition.
J. Immunol. 159: 2941–2951.
96. OGATA, Y., A. KUKITA, T. KUKITA, et al. 1999. A novel role of IL-15 in the develop-
ment of osteoclasts: inability to replace its activity with IL-2. J. Immunol. 162:
2754–2760.
97. THURKOW, E.W., I.M. VAN DER HEIJDEN, F.C. BREEDVELD, et al. 1997. Increased
expression of IL-15 in the synovium of patients with rheumatoid arthritis compared
with patients with Yersinia-induced arthritis and osteoarthritis. J. Pathol. 181: 444–
450.
98. MCINNES, I.B., B.P. LEUNG, R.D. STURROCK, et al. 1997. Interleukin-15 mediates T
cell-dependent regulation of tumor necrosis factor-alpha production in rheumatoid
arthritis. Nat. Med. 3: 189–195.
99. MIRANDA-CARUS, M.E., A. BALSA, M. BENITO-MIGUEL, et al. 2004. IL-15 and the ini-
tiation of cell contact-dependent synovial fibroblast-T lymphocyte cross-talk in rheu-
matoid arthritis: effect of methotrexate. J. Immunol. 173: 1463–1476.
100. GRACIE, J.A., R.J. FORSEY, W.L. CHAN, et al. 1999. A proinflammatory role for IL-18
in rheumatoid arthritis. J. Clin. Invest. 104: 1393–1401.
101. RUCHATZ, H., B.P. LEUNG, X.Q. WEI, et al. 1998. Soluble IL-15 receptor alpha-chain
administration prevents murine collagen-induced arthritis: a role for IL-15 in devel-
opment of antigen-induced immunopathology. J. Immunol. 160: 5654–5660.
102. FERRARI-LACRAZ, S., E. ZANELLI, M. NEUBERG, et al. 2004. Targeting IL-15 receptor-
bearing cells with an antagonist mutant IL-15/Fc protein prevents disease develop-
ment and progression in murine collagen-induced arthritis. J. Immunol. 173: 5818–
5826.
103. MCINNES, I.B. & J.A. GRACIE. 2004. Interleukin-15: a new cytokine target for the
treatment of inflammatory diseases. Curr. Opin. Pharmacol. 4: 392–397.
104. MCINNES, I., R. MARTIN, I. ZIMMERMAN-GORSKA, et al. 2004. Safety and efficacy of a
human monoclonal antibody to IL-15 (AMG 714) in patients with rheumatoid arthri-
tis (RA): results from a multicenter, randomized, double-blind, placebo-controlled
trial. Presented at the Annual Meeting of the American College of Rheumatology.
San Antonio, TX, Oct 18.
105. SMOLEN, J.S. & G. STEINER. 2003. Therapeutic strategies for rheumatoid arthritis.
Nat. Rev. Drug Discov. 2: 473–488.
106. REDLICH, K., B. GORTZ, S. HAYER, et al. 2004. Repair of local bone erosions and
reversal of systemic bone loss upon therapy with anti-tumor necrosis factor in combi-
nation with osteoprotegerin or parathyroid hormone in tumor necrosis factor-medi-
ated arthritis. Am. J. Pathol. 164: 543–555.