Pharmacology & Therapeutics 141 (2014) 125–139

Contents lists available at ScienceDirect

Pharmacology & Therapeutics

journal homepage: www.elsevier.com/locate/pharmthera

Associate editor: B. Teicher

Targeting interleukin-6 in inflammatory autoimmune diseases

and cancers
Xin Yao a, Jiaqi Huang a, Haihong Zhong a, Nan Shen c, Raffaella Faggioni b, Michael Fung a, Yihong Yao a,⁎
a
MedImmune, LLC, Gaithersburg, MD 20878, USA
b
MedImmune, LLC, Hayward, CA 94545, USA
c
Joint Molecular Rheumatology Laboratory of Institute of Health Sciences and Shanghai Renji Hospital, Shanghai, China

a r t i c l e i n f o a b s t r a c t

Keywords: Interleukin-6 (IL-6) is a pleiotropic cytokine with significant functions in the regulation of the immune system. As a
Interleukin-6 potent pro-inflammatory cytokine, IL-6 plays a pivotal role in host defense against pathogens and acute stress. How-
Autoimmune ever, increased or deregulated expression of IL-6 significantly contributes to the pathogenesis of various human dis-
Inflammation eases. Numerous preclinical and clinical studies have revealed the pathological roles of the IL-6 pathway in
Cancer inflammation, autoimmunity, and cancer. Based on the rich body of studies on biological activities of IL-6 and its
Targeted therapy
pathological roles, therapeutic strategies targeting the IL-6 pathway are in development for cancers, inflammatory
Monoclonal antibody
and autoimmune diseases. Several anti-IL-6/IL-6 receptor monoclonal antibodies developed for targeted therapy
have demonstrated promising results in both preclinical studies and clinical trials. Tocilizumab, an anti-IL-6 receptor
antibody, is effective in the treatment of various autoimmune and inflammatory conditions notably rheumatoid ar-
thritis. It is the only IL-6 pathway targeting agent approved by the regulatory agencies for clinical use. Siltuximab, an
anti-IL-6 antibody, has been shown to have potential benefits treating various human cancers either as a single agent
or in combination with other chemotherapy drugs. Several other anti-IL-6-based therapies are also under clinical de-
velopment for various diseases. IL-6 antagonism has been shown to be a potential therapy for these disorders refrac-
tory to conventional drugs. New strategies, such as combination of IL-6 blockade with inhibition of other signaling
pathways, may further improve IL-6-targeted immunotherapy of human diseases.
© 2013 Elsevier Inc. All rights reserved.

Contents

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126
125
2. Interleukin-6 (IL-6) in inflammatory and autoimmune diseases . . . . . . . . . . . . . . . . . . . . . . . 127
126
3. Interleukin-6 (IL-6) as a therapeutic target for inflammatory and autoimmune diseases . . . . . . . . . . . . 129
126
4. Interleukin-6 (IL-6) and cancer development . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131
126
5. Interleukin-6 (IL-6) targeted therapy for human cancer . . . . . . . . . . . . . . . . . . . . . . . . . . 134
126
6. Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135
127
Conflict of interest statement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135
128
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135
128

Abbreviations: AML, acute myeloid leukemia; COPD, chronic obstructive pulmonary disease; CRC, colorectal cancer; CRP, C-reactive protein; CSC, cancer stem cells; DLT, dose-limiting
toxicity; EAE, experimental autoimmune encephalitis; EGFR, epidermal growth factor receptor; IBD, inflammatory bowel diseases; IFN, interferon; IL-6, interleukin-6; IL-6R, IL-6 receptor;
mAb, monoclonal antibody; MM, multiple myeloma; MS, multiple sclerosis; MTX, methotrexate; NSCLC, non-small cell lung cancer; RA, rheumatoid arthritis; RCC, renal cell carcinoma;
sgp130, soluble gp130; sIL-6R, soluble IL-6R; SJIA, systemic juvenile idiopathic arthritis; SLE, systemic lupus erythematosus; SOCS, suppressor of cytokine signaling; SSc, systemic sclerosis;
STAT, signal transducers and activators of transcription; TAM, tumor-associated macrophage; TLR, Toll-like receptor; TNF, tumor necrosis factor; VEGF, vascular endothelial growth factor.
⁎ Corresponding author at: MedImmune, LLC, One MedImmune Way, Gaithersburg, MD 20878, USA. Tel.: 301 398 5116; fax: 301 398 8116.
E-mail address: YaoY@medimmune.com (Y. Yao).

0163-7258/$ – see front matter © 2013 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.pharmthera.2013.09.004
126 X. Yao et al. / Pharmacology & Therapeutics 141 (2014) 125–139
1. Introduction
Human interleukin-6 (IL-6) is a 26 kDa glycoprotein consisting of
184 amino acids, and it was originally identified as a regulator of B-cell
differentiation in 1986 (Kishimoto, 2006). IL-6 can be synthesized by a
wide variety of cells, including monocytes, macrophages, lymphocytes,
fibroblasts, keratinocytes, endothelial cells, and some tumor cells (Lotz,
1995). The IL-6 receptor (IL-6R, CD126) exists in two forms, which are
the membrane-bound and soluble forms. The transmembrane IL-6R is
an 80 kDa protein that contains the IL-6 binding site and a very short
cytoplamic domain. Its expression is restricted mainly to leukocytes
and hepatocytes. After binding to IL-6, the complex IL-6/IL-6R recruits
another transmembrane glycoprotein gp130, also known as IL-6 signal
transducer (IL-6ST) or CD130. Gp130 is the signaling subunit of the func-
tional IL-6R complex, which belongs to the type I cytokine receptor fam-
ily (Kishimoto et al., 1992). In contrast to IL-6R, gp130 is ubiquitously
expressed and is also the signaling subunit of other cytokine members
in the IL-6 family, including IL-11, IL-27, IL-31, cardiotrophin-1 (CTF1),
cardiotrophin-like cytokine (CLC), ciliary neurotrophic factor (CNTF),
oncostatin M, and leukemia inhibitory factor (LIF) (Heinrich et al.,
2003; Lauta, 2003). Through IL-6R and gp130, IL-6 signaling activates ty-
rosine kinases JAK1, JAK2, and TYK2, which leads to the phosphorylation
of signal transducers and activators of transcriptions 1 and 3 (STAT1 and
STAT3). STAT3 is an important regulator for a number of anti-apoptotic
genes, and its activity is associated with tumor growth, survival, angio-
genesis, and metastatic processes (Yu et al., 2009). STAT3 is not IL-6 spe-
cific as it is activated by all other cytokine signaling associated with
gp130 and JAK1/2 (Akira, 1997). The modulation and termination of
this JAK/STAT3 pathway are regulated by the suppressor of cytokine sig-
naling (SOCS) feedback inhibition and protein inhibitor of activated STAT
(PIAS) proteins. In addition to the JAK–STAT3 pathway, IL-6 activates
RAS–MAPK, and PI3K–AKT signaling pathways which also contribute to
anti-apoptotic and tumorigenic function (Ara & Declerck, 2010) (Fig. 1).
1.1. Classical and trans interleukin-6 (IL-6) signaling pathway
Signaling through membrane-bound IL-6R is called the classical or
the cis-signaling pathway. The presence of soluble IL-6R (sIL-6R) also al-
lows IL-6 to function through a pathway known as trans-signaling
(Rose-John et al., 2006). The soluble IL-6R, generated by either mRNA
alternative splicing (10%) or shedding of membrane-bound IL-6R medi-
ated by metalloproteases ADAM10 and ADAM17 (90%), is mainly pro-
duced by hepatocytes, neutrophils, macrophages, and some CD4+ T
cells (Mullberg et al., 1994; Desgeorges et al., 1997; Briso et al., 2008).
The soluble IL-6R forms a complex with IL-6 and interacts with cell sur-
face gp130. The fully assembled, activated IL-6 receptor complex is a
hexameric structure containing two of each IL-6, sIL-6R (or membrane-
bound IL-6R), and gp130 molecules, and this complex activates signaling
pathway in a broader range of cell types (Boulanger et al., 2003). Both
classical and trans-signaling are mediated by gp130, and both activate
the identical intracellular pathway (Fig. 1). The trans-signaling mecha-
nism enables IL-6 to function on non-leukocytes including fibroblasts, ep-
ithelial cells, synoviocytes, and cancer cells, which lack membrane bound
IL-6R expression and normally do not respond to IL-6 (Miyazawa et al.,
1999). Trans-signaling is considered as a potential danger signal because
it enhances IL-6 responsiveness and inflammatory events. In response
to apoptosis activation and C-reactive protein (CRP), localized levels of
sIL-6R are elevated by shedding by infiltrating neutrophils, and it is asso-
ciated with leukocyte infiltration and tissue damage (McLoughlin et al.,
2004; Chalaris et al., 2007). In addition, a soluble form of gp130
(sgp130) is formed by alternative splicing and exists in human serum
(Narazaki et al., 1993). Soluble gp130 acts as a natural antagonist of the
IL-6–sIL-6R complex and an inhibitor for trans-signaling, but cis-
signaling is not affected (Jostock et al., 2001; Lemmers et al., 2009)
(Fig. 1).
1.2. Regulation of interleukin-6 (IL-6) signaling
In normal cells, IL-6 production can be regulated by different signals
including IL-1, tumor necrosis factor (TNF), interferons (IFNs), DNA vi-
ruses, RNA viruses, and bacterial endotoxin (Hong et al., 2007). During
acute inflammation, monocytes and macrophages are the main pro-
ducers of IL-6 after activation of Toll-like receptors (TLRs) via a
MyD88-dependent pathway, whereas T cells appear to be the major
source of IL-6 during chronic inflammation (Naugler & Karin, 2008). In
a study with human bronchial epithelial cells, TLR3 activation by poly I:
C was demonstrated to differentially regulate TLR2 expression through
autocrine signaling of IL-6, IL-6R activation and subsequent phosphoryla-
tion of STAT3 (Melkamu et al., 2013). A recent study showed that
microRNA miR-7578 functions as a negative regulator of IL-6 and TNF-
α via targeting EGR1, a transcription factor that activates TNF-α and
NF-κB expressions, suggesting that microRNAs may regulate IL-6 related
inflammatory responses (J. Zhang et al., 2013). In another study on in-
flammatory hepatitis, microRNA let-7a was shown to inhibit Th17 differ-
entiation by down-regulating IL-6 secretion. Significantly reduced Th17
cells and remarkably increased regulatory T (Treg) cell frequency in the
liver tissue were detected after transduction of let-7a (Y. Zhang et al.,
2013).
1.3. Interleukin-6 (IL-6) as a modulator of the immune system
IL-6 signaling plays a crucial role in the differentiation of dendritic
cells (DCs). IL-6 produced by DCs, mainly plasmacytoid dendritic cells
(pDCs), is critical for differentiation of B cells into plasma cells and pro-
duction of antibodies (Jego et al., 2003). IL-6 is an important modulator
to maintain the balance between Th1 and Th2 effector functions (Diehl
& Rincon, 2002). It promotes the production of two Th2-type cytokines,
IL-4 and IL-13, and enhances the differentiation of Th2 cells (Neveu
et al., 2009). IL-6 also inhibits Th1 cell differentiation and interferes
with IFN-γ production through up-regulation of SOCS1 or SOCS3 in
CD4+ T cells (Diehl et al., 2000). Importantly, in combination with
transforming growth factor-β (TGF-β), IL-6 promotes the differentia-
tion of Th17 cells by activating transcription factors including retinoic
acid-related orphan receptor RORγt and RORα (Veldhoen et al., 2006).
The effect of IL-6 on Th17 differentiation was reported to be mediated
by STAT3, and another study suggested that IL-1β and IL-23 are also in-
volved in this process (Chen et al., 2007; Ghoreschi et al., 2010). IL-6
was previously reported to block Treg cell activity and inhibit Treg gen-
eration induced by TGF-β; thus IL-6 is also considered as a regulator of
Treg/Th17 balance (Kimura & Kishimoto, 2010). In addition, IL-6 plays
a role in early differentiation processes of T follicular helper cells
(Tfh), which is the main T helper cell subset that provides support for
germinal center induction, affinity maturation, and generation of mem-
ory B cells and long-lived plasma cells. Early Bcl6+CXCR5+ Tfh differen-
tiation was severely impaired in the absence of IL-6, and IL-6 signaling
was shown as a major early inducer of the Tfh differentiation program
mediated by both STAT3 and STAT1 (Choi et al., 2013). IL-6 is necessary
and sufficient for IL-21 production by memory and naïve CD4+ T cells.
Recent studies have shown that IL-6 induces antibody production indi-
rectly by acting on CD4+ T cells to promote production of high levels of
IL-21 which in turn promotes B cell differentiation and increases anti-
body production (Dienz et al., 2009; Diehl et al., 2012).
1.4. Interleukin-6 (IL-6) and acute phase response
Results from studies of acute inflammation have indicated that IL-6
and sIL-6R play important roles in regulating the recruitment of inflam-
matory cells (Fielding et al., 2008). Because of high expression of IL-6R
on hepatocytes, IL-6 is the main inducer of acute phase proteins pro-
duced by the liver, including CRP, fibrinogen, hepcidin, haptoglobin,
and serum amyloid protein A (Heinrich et al., 1990). High levels of
acute phase proteins are observed in both acute and chronic
 X. Yao et al. / Pharmacology & Therapeutics 141 (2014) 125–139 127

Fig. 1. IL-6 signaling pathways and their roles in pathogenesis of human diseases. A. Classical and trans-signaling pathways are thought to contribute to anti-inflammatory and pro-
inflammatory activities of IL-6, respectively. The classical signaling is mediated by the membrane-associated IL-6R, whereas the trans-signaling by the soluble form sIL-6R. sIL-6R is pro-
duced via cleavage by metalloproteinase ADAM-17 or alternative splicing, whereas sgp130 by alternative splicing only. gp130 is ubiquitously expressed on a broad range of cell types, thus
accounting for the pluripotent activities of IL-6 via the trans-signaling mechanism. Both classical and trans-signaling pathways activate the identical intracellular pathways including JAK1–
STAT3, RAS–MAPK, and, PI3K–AKT. Anti-IL-6R mAb (red) blocks the binding of IL-6 to both membrane bound IL-6R and sIL-6R. Anti-IL-6 mAb (yellow) binds to IL-6 molecule and inhibits
both classical and trans-signaling. sgp130 functions as a decoy inhibitor of trans-signaling of IL-6. B. Biological functions of IL-6 contribute to pathogenesis of inflammatory autoimmune
diseases and cancers. IL-6 activates hepatocytes to release acute-phase proteins during inflammation. IL-6 is produced by a wide range of activated cell types involving in autoimmunity.
Activated plasmacytoid dendritic cells (pDC), conventional dendritic cells (DC), B cells and T cells produce IL-6. IL-6 is an important cytokine for B cell differentiation and plasma B cell
survival. It is important for the activity of T follicular helper cells (Tfh) in the germinal center of lymphoid tissues critical for autoreactive B cell generation via IL-21 production. IL-6 pro-
motes Th17 differentiation, while conversely suppresses CD4+ Foxp3+ T regulatory cells (Treg). Therefore, inhibition of IL-6 signaling has profound effects in controlling autoimmunity
and inflammation mediated by T and B cells. In addition, the inflammatory effects of IL-6 are mediated by other cell types, including macrophages, neutrophils, fibroblasts, fibroblast-like
synoviocytes (FLS), and endothelial cells. IL-6 is fibrogenic, inducing collagen production by fibroblasts. It supports differentiation of osteoclasts and augments angiogenesis by receptor
activator of nuclear factor kappa B ligand (RANKL) and vascular endothelial growth factors (VEGF), respectively. The proliferation and survival of tumor cells are promoted by IL-6 through
both paracrine and autocrine mechanisms. After activation by IL-6, various types of cells, such as tumor-associated macrophages (TAM), myeloid derived suppressor cells (MDSCs), and
endothelial cells, are involved in the development of pro-inflammatory and metastatic tumor microenvironment. In addition, IL-6 modulates the balance between Treg and Th17 in tumor
microenvironment and promotes the generation of cancer stem cells (CSC) from non-cancer stem cells.

inflammatory diseases and contribute to the disease pathology. CRP is
an indicator of systemic inflammatory response and participates in tis-
sue damage. Elevated levels of CRP have been reported in serum of pa-
tients with rheumatoid arthritis (RA), Crohn's disease, or other chronic
inflammatory diseases (Rhodes et al., 2011). For diagnostic purpose,
CRP is used mainly as a marker of inflammation and can be a useful bio-
marker of disease progression or effectiveness of treatments. Serum CRP
is generally elevated by infection and is mainly controlled by IL-6. Inter-
estingly, in patients with severe bacterial infections without increases in
CRP, immuno-compromised phenotypes and a lack of IL-6 function was
suggested. Further studies indicated that anti-IL-6 autoantibodies
blocked IL-6 signaling and inhibited increases in serum CRP (Nanki
et al., 2013).
IL-6 is thus a pluripotent cytokine that plays important roles in he-
matopoiesis, immune defense, and oncogenesis (Rincon, 2012). Dysreg-
ulation of IL-6 expression has been implicated in the pathogenesis of
various disorders. In the following sections, we will discuss the patho-
logical significance of IL-6 signaling in inflammatory autoimmune dis-
eases and various cancer types, as well as the therapeutic implication
of IL-6 targeted therapy in these diseases.
2. Interleukin-6 (IL-6) in inflammatory and autoimmune diseases
IL-6 was initially considered to be a marker for various inflammatory
diseases. For example, elevated IL-6 levels were reported in serum and
synovial tissues of patients with RA, as well as in serum in other inflam-
matory diseases such as Castleman disease and Crohn's disease
(Kishimoto, 2010). However, other evidence indicated that IL-6 could
actively contribute to the development of diseases. As described
above, IL-6 has been shown to play a key role in autoantibody pro-
duction and autoreactive T cell activation. Numerous studies have
128 X. Yao et al. / Pharmacology & Therapeutics 141 (2014) 125–139
confirmed the pathological roles of IL-6 and its signaling in inflammato-
ry and autoimmune diseases (Fig. 1).
2.1. Rheumatoid arthritis
RA is an autoimmune disease that results in chronic, progressive in-
flammatory disorders of the joints and surrounding tissues, often lead-
ing to irreversible joint damage and systemic complications (Smolen
et al., 2007). High levels of IL-6/sIL-6R complex in synovial fluids in pa-
tients with RA and juvenile RA are associated with joint destruction and
disease progression (Keul et al., 1998). IL-6 produced by bone mar-
row stromal cells can induce the receptor activator of NF-κB ligand
(RANKL), which is critical for the differentiation and activation of os-
teoclasts and bone resorption (Palmqvist et al., 2002). IL-6 was re-
ported to control vascular permeability through inducing vascular
endothelial growth factor (VEGF) production in fibroblast-like
synoviocytes (FLS) in RA, and increased permeability enhances the
recruitment of inflammatory cells into the tissues and aggravates
the damage (Nakahara et al., 2003). A genome-wide association
study has identified seven new RA risk loci, and several gene prod-
ucts, including GP130 (IL6ST), to be associated with STAT3 signaling
(Stahl et al., 2010). Recently, both alternative splicing and proteolyt-
ic cleavage have been shown to participate in sIL-6R generation in
RA. A polymorphism rs8192284, which is located at the proteolytic
cleavage site of IL-6R, determines the sIL-6R plasma level through
differential proteolytic cleavage mediated by ADAM17 (Lamas
et al., 2013). IL-6 deficiency resulted in complete protection against
collagen-induced arthritis (CIA) in mice (Alonzi et al., 1998) and an
anti-mouse IL-6R monoclonal antibody (mAb) suppressed develop-
ment of CIA in mice (Takagi et al., 1998).
2.2. Systemic sclerosis (SSc)
IL-6 plays a role in SSc, an autoimmune connective tissue disease
characterized by fibrosis of the skin and internal organs (O'Reilly et al.,
2012). Elevated IL-6 levels were observed in SSc, and peripheral leuko-
cytes from SSc patients produce higher amounts of IL-6 and sIL-6R com-
pared to healthy donors (Hosokawa et al., 1999). Increased activities of
IL-6 may contribute to the pathological collagen production in dermal
fibroblasts (Duncan & Berman, 1991). Using the bleomycin mouse
model of SSc, IL-6 has been demonstrated to play a pivotal role in SSc
disease pathogenesis. Serum IL-6 levels are related to erythrocyte sedi-
mentation rate (ESR), CRP and immunoglobulin levels, and disease ac-
tivity of SSc. The level of IL-6 is correlated with total skin score and
the extent of skin thickening (Kitaba et al., 2012; Muangchan & Pope,
2012). A recent study suggested that single nucleotide polymorphisms
in the IL-6 gene may influence the development of SSc and its progres-
sion (Cenit et al., 2012).
2.3. Multiple sclerosis (MS)
MS is an inflammatory autoimmune disease in which myelin
sheaths around the axons of the brain and spinal cord are damaged,
leading to inflammation, demyelination and axon degeneration in the
central nervous system (CNS) (Glass et al., 2010). Elevated IL-6 levels
were reported in the CNS of MS patients and in a mouse experimental
autoimmune encephalitis (EAE) model of MS (Gijbels et al., 1990;
Maimone et al., 1991). IL-6 blockade was shown to inhibit antigen-
specific Th17 and Th1 cells and prevent the development of EAE
(Serada et al., 2008). In a recent report, CD4+ effector T (Teff) cells
from patients with relapsing–remitting multiple sclerosis (RRMS)
were resistant to suppression by Treg cells through a mechanism linked
to IL-6 pathway. Teff cells from active RRMS patients were more respon-
sive to IL-6, and impaired Treg suppression of Teff cells was reversed by
STAT3 inhibition (Schneider et al., 2013). IL-6 producing B cells have
been shown to contribute to the development of EAE in mice (Mann
et al., 2012), and another study demonstrated that IL-6 produced by B
cells plays a pathogenic role in the development of EAE by promoting
Th17 cell differentiation (Barr et al., 2012).
2.4. Systemic lupus erythematosus (SLE)
SLE is a systemic autoimmune disease and a chronic inflammatory
condition caused mainly by a Type III hypersensitivity reaction (Ruiz-
Irastorza et al., 2001). Elevated serum levels of IL-6 suggest a patholog-
ical role of IL-6 in SLE patients (Hirohata & Miyamoto, 1990; Linker-
Israeli et al., 1991). IL-6 and IL-6R blockade by antibodies has been
shown to prevent the onset and progression of the disease in a mouse
SLE model (Mihara et al., 1998; Liang et al., 2006). IL-6 deficient mice
showed delayed onset of lupus nephritis, improved kidney function
and prolonged survival in murine SLE (Cash et al., 2010). In a study of
pro-inflammatory cytokines and joint status in 47 SLE patients, IL-6
levels were found to be correlated with ESR, anti-dsDNA antibody and
hemoglobin, suggesting that IL-6 may promote arthritis and joint defor-
mation in patients with SLE arthritis (Eilertsen et al., 2011). A meta-
analysis including 11 studies showed an association between SLE and
the functional IL-6 promoter −174G/C polymorphisms in all subjects
(Lee et al., 2011). The production of autoantibodies in SLE results from
the defective regulation of secondary immunoglobulin V(D)J gene rear-
rangement, which is regulated by recombination activating genes
(RAGs). Deregulated production of IL-6 makes the SLE B cells constitu-
tively express the RAG proteins, therefore promoting secondary gene
rearrangements of immunoglobulin and production of autoantibodies
in SLE (Hillion et al., 2007). Furthermore, increased levels of circulating
plasma cells and activated lymphocyte were observed in SLE. In vivo
blockade of the IL-6R decreases B and T cell activations and restores nor-
mal lymphocyte homoeostasis in patients with SLE (Shirota et al.,
2012).
2.5. Crohn's disease/inflammatory bowel diseases (IBD)
Crohn's disease is a chronic inflammatory bowel disease that may
affect any part of the gastrointestinal tract. IL-6 has been reported to
play an important role in the development of Crohn's disease (Ito,
2004). Increased levels of serum IL-6 were detected in serum of pa-
tients with Crohn's and cultures of colonic mucosal specimens
(Hosokawa et al., 1999). Blocking the IL-6 pathway with an anti-IL-
6R antibody was shown to prevent the development of colitis in a T
cell transfer mouse model of Crohn's disease by inhibiting ICAM-1
and VCAM-1 expressions, T cell proliferation, and IFN-γ and proin-
flammatory cytokine production (Yamamoto et al., 2000). Levels of
IL-6 are elevated in patients with IBD (Atreya & Neurath, 2008). Fur-
ther studies have shown that IL-6 is a critical regulator of IBD patho-
genesis by influencing immune cells (Neurath & Finotto, 2011). In
patients with IBD, trans-signaling of IL-6 can activate T cells in the
lamina propria and up-regulate anti-apoptotic factors Bcl-2 and
Bcl-xl (Atreya et al., 2000).
2.6. Asthma and inflammatory pulmonary diseases
Allergic asthma is a chronic inflammatory disease of the airways that
occurs in response to inhaled allergens. CD4+ Th2 and Th17 cells and
their associated cytokines play important roles in the pathogenesis of al-
lergic asthma (Rincon & Irvin, 2012). IL-6 is an important regulator of
CD4+ T cell differentiation, and may play an important role in the path-
ogenesis of asthma. Blockade of IL-6R induced lung CD4+ T cell apoptosis
mediated by FOXP3+ Treg cells in mice (Finotto et al., 2007). Elevated
levels of serum IL-6 have been reported in asthmatic patients
(Yokoyama et al., 1995), and increased IL-6 levels in serum correlated
with impaired lung function in obese asthmatic patients (Dixon et al.,
2006). An association of IL-6 with a risk factor for allergic asthma was re-
ported from recent genome wide studies, suggesting that IL-6 could be a
 X. Yao et al. / Pharmacology & Therapeutics 141 (2014) 125–139
target for allergic asthma (Ferreira et al., 2011; Hawkins et al., 2012). In
two studies on inflammatory markers in chronic obstructive pulmonary
disease (COPD), increased levels of IL-6 in serum were shown to be pre-
dictive of increased mortality in COPD patients (Agusti et al., 2012; Celli
et al., 2012). Two polymorphisms in IL-6 gene, −174G/C in promoter and
321G/T in 5′ flanking region, were associated with an increased COPD
risk (He et al., 2009; Yanbaeva et al., 2009).
2.7. Castleman disease
Castleman disease is a rare lymphoproliferative disorder with benign
hyperplastic lymph nodes, follicular hyperplasia, and vascular hyperpla-
sia. In studies on Castleman disease using transgenic mice, constitutive
over-expression of IL-6 caused various lymphoproliferative disorders
associated with Castleman's disease, including IgG1 plasmacytosis,
mesangial proliferative glomerulonephritis, leukocytosis, thrombocytosis,
and anemia. Treatment with anti-IL-6R mAb completely prevented all
these symptoms and prolonged the lifetime of the mice (Katsume et al.,
2002). Very high levels of IL-6 were detected in the hyperplastic lymph
nodes of patients with Castleman disease. Both human and viral IL-6
can contribute to the pathogenesis of virus-infected Castleman disease
(Yoshizaki et al., 1989; Aoki et al., 2001).
2.8. Other inflammatory and autoimmune diseases
The pathological role of IL-6 has been reported in other inflam-
matory and autoimmune diseases. Over-expression of hypoxia in-
ducible factor 1α (HIF-1α) and IL-6 was found in patients with
psoriasis, and the expression of HIF-1α is closely correlated with
IL-6 expression, suggesting a close interaction of HIF-1α and IL-6 in
the psoriasis immuno-microenvironment (Vasilopoulos et al.,
2013). A functional amino acid change in IL-6R (Asp358Ala) was
shown to be significantly associated with atopic dermatitis (AD)
and disease prognosis. This amino acid change determines the bal-
ance between the membrane-bound IL-6R versus sIL-6R, and sIL-6R
levels were higher in patients with AD than in control subjects
(Esparza-Gordillo et al., 2013). Systemic juvenile idiopathic arthritis
(SJIA) is a type of chronic childhood arthritis that leads to joint dam-
age, systemic inflammation, and growth retardation (Yokota &
Kishimoto, 2010). Increased high levels of IL-6 were found in the
blood and synovial fluid of SJIA patients, and IL-6 level was associat-
ed with disease activity (De Benedetti et al., 1997).
3. Interleukin-6 (IL-6) as a therapeutic
target for inflammatory and autoimmune diseases
In conventional therapy, a number of agents that inhibit the expres-
sion of IL-6 and its signaling are effective in treating IL-6-mediated disor-
ders (Ataie-Kachoie et al., 2013). Corticosteroids are routinely used in the
treatment of chronic inflammatory and autoimmune diseases such as RA
and SLE, and may inhibit IL-6 production at the transcription level
through a receptor-mediated mechanism (Waage et al., 1990). Nonste-
roidal anti-inflammatory drugs (NSAIDs) are known immunoregulators,
and may inhibit the expression of IL-6 and its activity while increasing
the production of TNF-α, IFN-γ, IL-12, and IL-2 (Tsuboi et al., 1995).
Based on the large number of studies conducted on biological activities
of IL-6 and its pathological roles, targeted therapeutic strategies using
IL-6 blockade by antibody drugs are in development for inflammatory
and autoimmune diseases (Table 1). IL-6 antagonism has been shown
as a potential therapy for inflammatory diseases that are refractory to
conventional drugs such as corticosteroids.
3.1. Tocilizumab (TCZ, Actemra®)
A Japanese group led by Tadamitsu Kishimoto at the Osaka Uni-
versity developed tocilizumab, an anti-IL-6R antibody that blocks
129
both membrane-bound IL-6R and sIL-6R. Tocilizumab is a human-
ized antibody generated by grafting the complementarity determin-
ing regions (CDRs) of a mouse anti-human IL-6R antibody into
human IgG1κ (Sato et al., 1993). Tocilizumab binds to the IL-6 bind-
ing site of membrane-bound human IL-6R and sIL-6R and neutralizes
IL-6-mediated activities (Mihara et al., 2005). The inhibition of the
IL-6 pathway by tocilizumab is a clinical breakthrough in the treat-
ment of RA (Smolen et al., 2008). This therapy has been proven to
treat RA effectively, and tocilizumab has been approved for RA in
more than 90 countries worldwide. Tocilizumab treatment causes a
rapid decrease in the number of tender and swollen joints in RA pa-
tients, and is widely used as an alternative therapy to improve the in-
flammation and symptoms of this disease (Kremer et al., 2011).
Tocilizumab treatment also reduces structural joint damage
(Kremer et al., 2011). Patients treated with tocilizumab showed re-
duced counts of neutrophils, which accumulate in the synovium
and are harmful to the joints (Tanaka et al., 2011; Ogata & Tanaka,
2012). The reduction of neutrophils in synovium by tocilizumab
may be a mechanism by which the number of inflamed joints is de-
creased in RA patients. Serum levels of CRP remain suppressed
whenever free tocilizumab levels are above 1 μg/mL, suggesting
that CRP is a downstream biomarker that allow to estimate the dura-
tion and magnitude of IL-6 suppression in vivo (Nishimoto et al.,
2008). Furthermore, treatment with tocilizumab was reported to de-
crease the frequency of Th17 cells in peripheral blood of RA patients
(Samson et al., 2012).
Tocilizumab is the first FDA approved drug for SJIA, which affects
children primarily by causing joint destruction (Yokota et al., 2008).
Two open-label clinical trials of tocilizumab for Castleman disease
showed good patient responses (Nishimoto et al., 2000, 2005). It was
approved as an orphan drug for Castleman disease in Japan in 2005.
A number of case studies suggest that tocilizumab can be an effective
therapy for other inflammatory rheumatic diseases. For example, toci-
lizumab has shown promises in treating diseases such as adult-onset
Still's disease, amyloidosis, giant cell arteritis, polymyalgia rheumatica,
relapsing polychondritis, remitting seronegative symmetrical synovi-
tis with pitting edema-syndrome, SLE, SSc, and Takayasu arteritis
(Tanaka & Kishimoto, 2012; Alten & Maleitzke, 2013). Clinical re-
sponse was reported in treatment of Crohn's disease (Ito et al.,
2004). In a case report, two SSc patients treated with tocilizumab
showed small improvement in skin score thickness and a reduction
in tissue collagen levels (Shima et al., 2010). In an open-label Phase I
study of SLE, tocilizumab treatment decreased the levels of anti-
double-stranded DNA antibodies and reduced the frequency of circu-
lating CD38highCD19lowIgD− plasma cells (Illei et al., 2010), resulting
in improvement of clinical scores. More well controlled studies are
needed to better understand the potential clinical benefit of toci-
lizumab in these diseases.
Tocilizumab monotherapy has been proven very effective in RA, and
showed better efficacy and an acceptable benefit-risk profile compared
to methotrexate (MTX) monotherapy in patients with RA (Jones et al.,
2010). Tocilizumab was assessed in RA treatments in combination with
MTX and other disease modifying antirheumatic drugs (DMARDs) in-
cluding leflunomide, sulfasalazine, and chloroquine/hydroxychloroquine
(Burmester et al., 2011). Combination therapy, as compared with toci-
lizumab monotherapy, did not show superior clinical effects in patients
with established RA and active diseases (Dougados et al., 2013), suggest-
ing that combination tocilizumab therapy is not significantly superior to
monotherapy. A recent report shows that tocilizumab is superior to
adalimumab (anti-TNFα) in a monotherapy study of RA patients intoler-
ant to MTX (Gabay et al., 2013). In addition, the most recent data
presented at the European League Against Rheumatism (EULAR) support
the use of tocilizumab monotherapy. The new EULAR 2103 recommen-
dations state that tocilizumab monotherapy may be chosen over other
biologic monotherapies for patients who are intolerant to or contraindi-
cated to MTX (www.eular.org).
 130
Table 1
Clinical studies on targeting IL-6 in inflammatory autoimmune diseases and cancers.
Compound name Target/specificity Developer Indication(s) Phase/Status Trial ID Reference

Tocilizumab (Actemra, RoActemra) Humanized anti-IL-6R mAb Roche, Chugai Rheumatoid arthritis 2008, Japan; 2009, EMA; 2010 FDA Approved
Systemic juvenile idiopathic arthritis 2008, Japan; 2011, FDA; 2011, EMA Approved
Castleman disease 2005, Japan Approved
Systemic lupus erythematosus Phase I open-label, Japan Illei, 2010
Systemic sclerosis Case report, Japan Shima, 2010
Crohn’s disease Japan Ito, 2004
Relapsing polychondritis Case report, Japan NCT01041248

Cancer cachexia in lung cancer Case report, Japan Ando, 2013

Multiple Myeloma Open-label phase I, USA; Phase II, France

Sarilumab (REGN88, SAR5319)
Fully human anti-IL-6R mAb Regeneron/Sanofi-Aventiis Rheumatoid arthritis Phase I, completed NCT01055899
Rheumatoid arthritis Phase I, completed NCT01011959
Rheumatoid arthritis Phase I, completed NCT01026519
Rheumatoid arthritis Phase II+III, ongoing NCT01061736
Rheumatoid arthritis Phase I, completed NCT01328522
Ankylosing spondylitis Phase II, completed NCT01061723

X. Yao et al. / Pharmacology & Therapeutics 141 (2014) 125–139

ALX-0061 IL-6R nanobody Ablynx Rheumatoid arthritis Phase I+II, completed NCT01284569

Olokizumab (CP6038)
Humanized anti-IL-6 mAb UCB Rheumatoid arthritis Phase I+II, completed NCT01009242
Rheumatoid arthritis Phase II, completed NCT01242488
Rheumatoid arthritis Phase II, ongoing NCT01296711
Rheumatoid arthritis Phase II, completed NCT01463059
Rheumatoid arthritis Phase II, ongoing NCT01533714

Sirukumab (CNTO136) Fully human anti-IL-6 mAb Johnson & Johnson/GSK Rheumatoid arthritis Phase II, completed; Phase III, ongoing NCT00718718
Cutaneous and systemic lupus erythematosus Phase I, completed NCT01702740
Lupus nephritis Phase II, ongoing NCT01273389

Siltuximab (CNTO328) Chimeric anti-IL-6 mAb Johnson & Johnson Castleman disease Phase II, ongoing NCT01024036 van Rhee, 2010

Multiple myeloma Phase II, completed NCT00911859 Voorhees, 2007

Multiple myeloma Phase II, completed NCT00402181 Voorhees, 2009
Multiple myeloma Phase II, ongoing NCT00401843 Voorhees, 2013
Multiple myeloma Phase I+II, ongoing NCT01531998
Multiple myeloma Phase I, ongoing NCT01219010
B-cell non-Hodgkin's lymphoma, multiple myeloma Phase I, completed NCT00412321 Kurzrock, 2013
Prostate cancer Phase I, completed NCT00401765 Karkera, 2011
Prostate cancer Phase II, completed NCT00385827 Dorff, 2010
Prostate cancer Phase II, completed NCT00433446 Hudes, 2013
Renal cell carcinoma Phase I+II, completed NCT00265135 Rossi, 2010
Solid tumors Phase II, completed NCT00841191
Ovarian cancer Coward, 2011

Clazakizumab (BMS945429, ALD518) Humanized, aglycosylated anti-IL-6 mAb Alder/BMS Rheumatoid arthritis Phase II, ongoing NCT01373151
Psoriatic arthritis Phase II, ongoing NCT0149050
Oral mucositis in head and neck cancer Phase I, ongoing NCT01403064

Non-Small Cell Lung Cancer-related Cachexia Phase II, completed NCT00866970 Bayliss, 2011

PF-423691 Humanized anti-IL-6 mAb Pfizer Crohn's disease Phase II, ongoing NCT01345318
Rheumatoid arthritis Phase I, ongoing NCT00838565
Systemic lupus erythematosus Phase I, ongoing NCT01405196

Elsilimomab (BE-8) murine anti-IL-6 mAb Diaclone Multiple myeloma Bataille, 1995
Multiple myeloma Moreau, 2000
Multiple myeloma Rossi, 2005
Renal cell carcinoma Phase II Blay, 1997

MEDI5117 Fully human anti-IL-6 mAb AstraZeneca Rheumatoid arthritis Phase I, ongoing NCT01559103

The majority of the data are taken from www.clinicaltrials.gov. Only completed and ongoing clinical trials are shown.
Clinical trials on cancers are highlighted. EMA, European Medicines Agency; FDA, Food and Drug Administration.
 X. Yao et al. / Pharmacology & Therapeutics 141 (2014) 125–139
3.2. Clazakizumab (BMS945429, ALD518)
Clazakizumab is a humanized anti-IL-6 mAb under development
by Alder Biopharmaceuticals and Bristol-Myers Squibb. It was evalu-
ated in a Phase II randomized study to determine the efficacy and
safety in patients with active RA and an inadequate response to
MTX. BMS945429 was associated with rapid and significant im-
provements in disease activity and health-related quality of life in
patients with active RA. There were no serious infusion reactions or
apparent immunogenicity (Mease et al., 2012). ALD518 is being eval-
uated in an ongoing Phase I/II clinical trial with glucocorticoid-
refractory acute graft versus host disease (GVHD) after allogeneic
hematopoietic stem cell transplant (NCT01530256). Subcutaneous
administration of clazakizumab achieved significant improvement
of clinical signs and inflammation based on ACR scores in active RA
patients inadequately controlled by MTX (NCT00867516). The anti-
body was also found to be well tolerated.
3.3. Sirukumab (CNTO136)
Sirukumab is a human anti-IL-6 mAb that binds human IL-6 with high
affinity and specificity. In a Phase I randomized trial involving 45 healthy
adult subjects, sirukumab exhibited linear pharmacokinetics with long
half-life, a low incidence of immunogenicity, and a well-tolerated safety
profile. Compared with patients that received placebo, a sustained de-
crease from baseline in CRP was observed in sirukumab-treated patients.
No patients were positive for antibodies to sirukumab (Xu et al., 2011). In
another Phase I randomized study, sirukumab was evaluated for pharma-
cokinetics, immunogenicity, safety, and tolerability. Following subcutane-
ous administration, sirukumab pharmacokinetics was linear at doses
ranging from 25 to 100 mg and was comparable between 25 Japanese
and 24 Caucasian subjects. Adverse events were mild and did not appear
to be dose-related (Zhuang et al., 2013). In a Phase II study in combination
with MTX, subcutaneous administration of sirukumab was reported to
show substantial improvement in symptoms and inflammation in active
RA patients (NCT00718718) as compared to placebo. There are two ongo-
ing studies of the safety and pharmacokinetics of sirukumab in patients
with SLE and cutaneous lupus erythematosus (NCT01702740) and with
active lupus nephritis (NCT01273389). Most recently, two Phase III stud-
ies of sirukumab have started in RA patients who were non-responders to
anti-TNF-α (NCT01606761) and DMARD (NCT01604343) therapies.
3.4. Siltuximab (CNTO328)
Siltuximab is a chimeric murine anti-human IL-6 antibody devel-
oped by Centocor. Siltuximab was evaluated in an open-label Phase I
trial for Castleman disease. Eighteen of 23 patients demonstrated clini-
cal benefit response (CBR), with 12 achieving objective response (van
Rhee et al., 2010). No dose-limiting toxicity (DLT) was found in this
study, suggesting that siltuximab may be an effective treatment with fa-
vorable safety for the treatment of Castleman disease.
3.5. Sarilumab (REGN88, SAR5319)
Sarilumab is a human mAb that binds human IL-6R and inhibits ac-
tivation of IL-6 signaling pathways. Sarilumab has been studied in
multiple Phase I/II clinical trials in patients with RA and ankylosing
spondylitis (Table 1). Combination therapy of sarilumab and MTX is cur-
rently evaluated in a Phase II/III randomized trial in patients with RA,
and positive results have been reported (NCT01061736).
3.6. Olokizumab (CP6038)
Olokizumab is a humanized anti-IL-6 antibody that is currently
under clinical development by UCB. Positive results had been obtained
from a Phase IIb study in adult patients with RA and previously failed
131
anti-TNF therapy (NCT01463059). In this Phase IIb study, all doses of
olokizumab demonstrated statistically significant improvement in dis-
ease activity score (DAS 28) when compared with placebo. Olokizumab
and tocilizumab demonstrated comparable efficacy, as determined by
DAS scores.
4. Interleukin-6 (IL-6) and cancer development
Although the link between inflammation and cancer has long been in
debate, IL-6 has been reported to be involved in the inflammation-
associated tumorigenesis. For example, IL-6 produced by tumor-
associated macrophages (TAMs) may contribute to tumor progression.
TAMs are a major supportive component within neoplasms and are char-
acterized by a plethora of functions that facilitate tumor outgrowth. High
numbers of TAMs are associated with poor prognosis in cancer patients
(Pollard, 2004). IL-6 plays a role in differentiation of myeloid-derived
suppressor cells (MDSCs) which may be important for intra-tumoral in-
flammatory processes (Gabrilovich & Nagaraj, 2009; Peranzoni et al.,
2010). Expression of IL-6 may promote tumor growth by inhibiting apo-
ptosis and inducing tumor angiogenesis (Naugler & Karin, 2008). Dysreg-
ulated production of IL-6 and aberrant IL-6 activation pathways have
been reported in many human cancers and play important roles in vari-
ous tumor behaviors such as proliferation, migration, and adhesion
(Santer et al., 2010; Suchi et al., 2011). IL-6–JAK–STAT signaling plays
an important role in various tumorigenesis models, including breast,
colon, lung, ovarian, prostate cancer, and multiple myeloma (Gao et al.,
2007; Grivennikov & Karin, 2008; Leslie et al., 2010).
IL-6 plays important roles in regulating the self renewal of cancer
stem cells (CSCs). IL-6 was implied in inducing malignant phenotypes
in Notch-3-expressing stem cells from human breast cancer and normal
mammary glands. Higher levels of IL-6 expression were detected in
human primary mammospheres from invasive breast cancer tissues as
compared to levels detected in normal mammary glands. Autocrine IL-
6 was shown to promote the growth of mammospheres and MCF-7-
derived spheroids and induces a hypoxia-resistant invasive phenotype
(Sansone et al., 2007). In another study using CSC-like human breast can-
cer cells and non-CSCs, the IL-6–JAK1–STAT3 signaling pathway played
an important role in the conversion of non-CSCs into CSCs through regu-
lation of the expression of OCT-4 gene, which is involved in the self-
renewal of undifferentiated embryonic stem cells (Kim et al., 2013).
IL-6 is a key player in systemic inflammation, regulating both the in-
flammatory response and tissue metabolism during acute stimulations.
Chronic inflammatory responses to cancer promote the synthesis of cy-
tokines including IL-6. These cytokines may induce cachexia by altering
metabolism of lipids and proteins. IL-6 inhibits lipid biosynthesis by ad-
ipocytes, and IL-6 over-expression is associated with atrophy and in-
creases catabolism of muscle protein (Barton, 2001). Cachexia and its
consequences contribute to an estimated 30% of cancer deaths. In a
study on patients with prostate cancer, serum IL-6 was shown to be a
factor contributing to the complex syndrome of cachexia (Kuroda
et al., 2007).
Due to its low molecular weight, IL-6 is able to rapidly diffuse through
cells and tissues and be present in the tumor microenvironment. Elevated
expression of IL-6 was reported in both the epithelium and stroma of the
tumor compartment of renal cancer specimens, but low expression of IL-
6 was detected in the surrounding normal tissue (Cardillo & Ippoliti,
2007). High levels of IL-6, together with a number of other pro-
inflammatory cytokines, were reported in the tissue microenvironment
of pancreatic cancer (Bellone et al., 2006). IL-6 can up-regulate the
acute phase response by inducing the synthesis of acute phase proteins,
such as CRP, by hepatocytes. Elevated levels of IL-6 in circulation have
been reported to associate with increased CRP concentration in various
cancers. A positive correlation between elevated levels of IL-6 and CRP
was observed in patients with breast cancer (Ravishankaran &
Karunanithi, 2011), renal cancer (Yoshida et al., 2002), lung cancer
(McKeown et al., 2004), and colorectal cancer (Chung & Chang, 2003;
132 X. Yao et al. / Pharmacology & Therapeutics 141 (2014) 125–139
Miki et al., 2004). Numerous preclinical studies revealed a potential
role of IL-6 in pathogenesis of many human cancer types, and these
data provide the rationale for developing IL-6 targeted cancer
immunotherapy.
4.1. Multiple myeloma (MM)
Considering the role of IL-6 in B-cell differentiation, MM has been
shown associated with IL-6 expression in many early cancer studies.
IL-6 functions as a major paracrine growth factor for the survival of
MM cells. Anti-IL-6 antibody inhibited the proliferation of myeloma
cells in vitro and in vivo (Kishimoto et al., 1992; Hideshima et al.,
2007). IL-6 promotes MM cell survival through the activation of
STAT3 and up-regulation of the bcl-2 family proteins including bcl-
xl, which may contribute to chemotherapy resistance in myeloma
cells (Derenne et al., 2002). IL-6 may up-regulate expression of
VEGF to stimulate angiogenesis in bone marrow infiltrated MM
cells (Dankbar et al., 2000). Significantly higher levels of IL-6 were
detected in patients with stage II/III MM than in patients with stage
I or plateau diseases (Solary et al., 1992), and survival was associated
with high sIL-6R levels in MM patients (Kyrtsonis et al., 1996).
Bortezomib, a proteasome inhibitor, was reported to inhibit MM pro-
gression by suppressing IL-6 signaling cascades (Hideshima et al.,
2003). Siltuximab, an anti-IL-6 antibody, enhanced the activity of
melphalan, a nitrogen alkylating agent for chemotherapy. Siltuximab
increased the cytotoxicity of melphalan in multiple human myeloma
cell lines in a synergistic manner; combination of these two agents
enhanced activation of caspase-8, caspase-9, and the downstream
caspase-3 compared to either of the single agents. The combination
of siltuximab and melphalan regimen demonstrated enhanced anti-
proliferative effects against primary plasma cells derived from pa-
tients with myeloma. These results provide a rationale for combina-
tion of siltuximab treatment with melphalan-based therapies or
other chemotherapies (Hunsucker et al., 2011).
4.2. Colorectal cancer (CRC)
Inflammation and IL-6/sIL-6R expression play important roles in the
pathogenesis of CRC (Atreya & Neurath, 2005). Elevated levels of IL-6
have detected in the serum and tumor tissues of patients with CRC
(Chung & Chang, 2003). Levels of IL-6 in CRC patients are associated
with tumor stage, tumor burden, metastasis, and overall survival
(Atreya & Neurath, 2005; Knupfer & Preiss, 2010). IL-6 plays an impor-
tant role in modulating Th17 and Treg cells in CRC, and also in recruit-
ment of immune cells that produce pro-inflammatory cytokines (Jones
et al., 2005). Furthermore, IL-6 was shown to be localized at the sites of
macrophage infiltration, suggesting an interaction between IL-6 and im-
mune cells in the tumor microenvironment (Li et al., 2010). IL-6 also pro-
motes the survival of cholangiocytes by altering microRNAs including
let-7a, which contribute to the constitutive activation of STAT3 (Meng
et al., 2007). Two recognized IL-6 polymorphisms have been associated
with a significantly reduced risk of CRC. Current users of NSAIDs with ei-
ther polymorphism had the lowest risk of colon cancer (Slattery et al.,
2007). In a study of 46 patients with CRC, multivariate analysis showed
that the serum IL-6 level and the blood granulocyte/lymphocyte ratio
were independent risk factors for poor prognosis, suggesting that both
factors may be significantly predictive for CRC cancer progression
(Shimazaki et al., 2013).
4.3. Prostate cancer
Both IL-6 and IL-6R are expressed in prostate tissue and prostate can-
cer cell lines. IL-6 has been shown to be an autocrine tumor growth factor
for prostate cancer cells (Culig et al., 2005). Myeloid cell leukemia-1
(mcl-1) protein, a member of the bcl-2 family, mediated the survival sig-
nal initiated by IL-6 in prostate cancer. In a study using LNCap-IL-6-
positive cells as a model for advanced prostate cancer, treatment with
siltuximab resulted in down-regulation of mcl-1 expression and induc-
tion of apoptosis (Cavarretta et al., 2007). In a similar study, treatment
of LNCap-IL-6-positive cells with siltuximab resulted in decreased bcl-2
protein levels and phosphorylation of ERK1/ERK2 MAP kinase, which
may contribute to significant inhibition of tumor cell survival (Steiner
et al., 2006). Siltuximab inhibited both androgen-independent and
androgen-resistant growth of prostate cancer in xenograft models
(Wallner et al., 2006). Studies on patients with prostate cancer indicate
that high levels of IL-6 are associated with disease aggressiveness and
cancer mortality (Culig et al., 2005; Kuroda et al., 2007). Over-
expression of IL-6 can block apoptosis induced by chemotherapeutic
drugs in prostate cancer (Giri et al., 2001). In a mouse model of prostate
cancer, combination of siltuximab and cytotoxic agents, such as MTX,
showed enhanced antitumor activity (Fizazi et al., 2012). Sant7, a modi-
fied IL-6 molecule that binds to IL-6R and blocks gp130 signaling, has
been reported to enhance the sensitivity of prostate cancer cells to the
toxicity of etoposide and cisplatin (Borsellino et al., 1999). A peptide mi-
metic of SOCS1, called Tkip, was used to treat prostate cancer cell lines. It
appeared to block IL-6-induced activation of STAT3, which led to down-
regulation of cyclin D1 and inhibition of cell proliferation (Flowers et al.,
2005).
4.4. Breast cancer
High levels of circulating IL-6 are associated with metastatic breast
cancer and correlated with poor survival of patients (Salgado et al.,
2003). Over-expression of IL-6 up-regulates serum VEGF in breast cancer
patients, which may promote angiogenesis and contribute to the
metastasic potential of breast cancer (Benoy et al., 2002). IL-6 expression
is more abundant in aggressive tumors and is inversely associated with
estrogen receptor levels in samples from patients with breast cancer
(Chavey et al., 2007). Autocrine production of IL-6 was reported to in-
duce multi-drug resistance in breast cancer cells (Conze et al., 2001).
The −174G/C polymorphism in the IL-6 promoter is associated with
breast cancer susceptibility and prognosis and with an aggressive pheno-
type (Iacopetta et al., 2004; Smith et al., 2004). In a recent study on
triple-negative breast cancers (TNBCs), inhibition of IL-6 and IL-8 expres-
sions dramatically inhibited tumor cell survival in vitro and suppressed
tumor engraftment in vivo. A multivariable analysis of patient specimens
revealed that IL-6 and IL-8 expressions are predictive factors for TNBC
patient survival (Hartman et al., 2013). HER2 overexpression in breast
CSCs has been shown to increase IL-6 production. IL-6 and IL-8 regulate
breast CSC self-renewal. Studies have shown that Herceptin treatment
of PTEN-ablated HER2-overexpressing breast cancer cells strongly acti-
vates an IL-6 inflammatory loop, further expanding the CSC population,
therefore, indicating a role of IL-6 in Herceptin resistance (Korkaya
et al., 2012).
4.5. Lymphoma
IL-6 and IL-6R are expressed in Hodgkin's disease-derived cell
lines. Human AIDS-related non-Hodgkin lymphoma cell lines are
sensitive to growth inhibition by TGF-β, and IL-6 expression in
these cells overcomes TGF-β inhibition by stimulating STAT3 signal-
ing (Ruff et al., 2007). In patients with diffuse large B-cell lymphoma
(DLBCL), levels of serum IL-6 have been used as a prognostic indica-
tor of clinical response and overall survival (Lossos et al., 2004). Ele-
vated expression of IL-6 plays an important role for the development
of anemia in DLBCL. Levels of IL-6 are inversely correlated with the
levels of hepcidin and inadequate erythropoietin response (Tisi
et al., 2013). Furthermore, IL-6 levels and genotype −174G/G poly-
morphism are associated with the risk of young adult Hodgkin lym-
phoma (Cozen et al., 2004).
 X. Yao et al. / Pharmacology & Therapeutics 141 (2014) 125–139
4.6. Melanoma
IL-6 has been evaluated as a potential biomarker in melanoma pa-
tients (Hoejberg et al., 2012a). In a retrospective study of 135 patients
treated by biochemotherapy, significantly higher levels of serum IL-6
were detected in patients with both localized and metastatic melanoma
when compared with normal controls. A high concentration of IL-6 was
associated with a shorter time to tumor progression and could be con-
sidered a predictive marker of recurrent disease (Mouawad et al.,
2002). An unexpected inverse correlation between levels of IL-6 and
soluble epidermal growth factor receptor (EGFR) was reported in met-
astatic melanoma patients, and concentration of IL-6 was predictive of
survival (Mouawad et al., 2006). In a study on 103 Stage IV melanoma
patients treated with IL-2-based therapy, the concentration of IL-6 in
pretreatment serum was examined as a prognostic marker. Compared
to patients with normal levels of IL-6, patients with high IL-6 levels
showed a significant shorter median overall survival (Hoejberg et al.,
2012b).
4.7. Ovarian cancer
Constitutive production of IL-6 was detected in ovarian carcinoma
cell lines and primary cultures (Watson et al., 1990). Increased IL-6 ex-
pression was found in the recurrent metastatic lesion compared with
the primary metastasis in ovarian cancer. Mutants of p53 protein in-
duced activity of IL-6 promoter by altering AP-1 binding, whereas wild-
type p53 inhibited IL-6 promoter in ovarian cancer cell lines (Asschert
et al., 1999). Autocrine IL-6 produced by ovarian cancer lines induces
high levels of phosphorylated STAT3, which up-regulates matrix
metalloproteinase-9 in these cells and contributes to angiogenesis and
metastasis (Rabinovich et al., 2007). High levels of IL-6 in serum and as-
cites were detected in patients with ovarian cancer; IL-6 levels correlated
with poor clinical outcome (Nilsson et al., 2005). In in vitro studies of
ovarian cancer cells, siltuximab has shown significant effects on apopto-
sis, survival, and resistance to drugs by blocking IL-6 signaling pathway
(Guo et al., 2010). In a recent study on advanced-stage ovarian cancer,
activation of EGFR induced the co-expression of IL-6 and plasminogen
activator inhibitor-1 (PAI-1) via the NF-κB pathway. This result indicates
that EGFR/IL-6/PAI-1 involved pathway may have impacts on the treat-
ment of ovarian cancer, and co-expression of IL-6 and PAI-1 may be a po-
tential prognostic marker (Alberti et al., 2012). Furthermore, a common
polymorphism of the IL-6 −174G/G genotype was found significantly as-
sociated with longer overall survival in patients with ovarian cancer
(Garg et al., 2006).
4.8. Pancreatic cancer
Human pancreatic cancer cell lines secrete IL-6, IL-10, and TGF-β,
which then work together to suppress the proliferation of immature
monocyte-derived dendritic cells and induce a tolerogenic phenotype.
These cytokines also down-regulate the expression of co-stimulatory
molecules including HLA-DR, CD40, and CD80 to prevent dendritic cells
from mediating a proper lymphocyte response, thus inhibiting the im-
mune response against the tumor cells (Bellone et al., 2006). The expres-
sion levels of VEGF were reported to be up-regulated by IL-6 and IL-1α in
pancreatic tumor cells (Tang et al., 2005). Serum IL-6 concentration was
shown associated with different stages of pancreatic cancer (Okada et al.,
1998). A study on 51 patients with pancreatic cancer revealed that the
levels of circulating IL-6 were significantly higher than levels in normal
controls. Patients with high levels of IL-6 had significant lower survival
rate than patients with low levels (Ebrahimi et al., 2004). In a study of
gemcitabine monotherapy in patients with pancreatic cancer, high IL-6
and IL-1β levels were demonstrated as poor prognostic factors for overall
survival. Patients with high serum levels of IL-6 and IL-1β showed short-
ened overall and progression-free survival (Mitsunaga et al., 2013).
133
4.9. Renal cell carcinoma (RCC)
Significantly higher levels of IL-6 have been reported in both RCC cell
lines and fresh RCC tissues as compared to normal renal epithelium
(Chang et al., 1998). A study using nude mice showed that an anti-IL-6
antibody inhibited the growth of human renal cancer cells and de-
creased the serum level of calcium (Weissglas et al., 1995). Up-
regulated IL-6 expression in RCC cell lines may be related to mutation
in the p53 tumor suppressor gene (Angelo et al., 2002). Production of
IL-6 and VEGF by RCC cells inhibits the anti-tumor response of cytotoxic
T cells to RCC by interfering with the cross-talk between lymphocytes
and dendritic cells (Cabillic et al., 2006). High levels of circulating IL-6
were found associated with poor prognosis in patients with RCC. IL-6,
IL-10, and hsp90 are markers for the development and progression of
RCC (Negrier et al., 2004; Cardillo & Ippoliti, 2007). A truncated form
of IL-6 (tIL-6) was reported as an inhibitor for IL-6 activity in RCC
(Alberti et al., 2005). Treatment of RCC cell lines with IL-6 induced
tumor resistance to cytotoxic drugs including cisplatin and doxorubicin;
the combination of anti-IL-6 treatment and cisplatin reversed the resis-
tance in vitro (Mizutani et al., 1995; Pu et al., 2004).
4.10. Lung cancer
Inflammatory pathways contribute to morbidity and mortality asso-
ciated with lung cancer. IL-6 has been associated with poor prognosis
and lung-cancer-related symptoms such as fatigue, thromboembolism,
cachexia and anemia. A therapy targeting IL-6 may be an effective treat-
ment for the inflammatory microenvironment in lung cancer. Siltuximab
has been shown to inhibit the growth of non small cell lung cancer
(NSCLC) cell lines through suppressing STAT3 phosphorylation (Song
et al., 2011). Patients with NSCLC have increased levels of IL-6 and CRP
in serum, and high IL-6 expression is associated with weight loss and
lower survival (Scott et al., 1996). IL-6 has been implicated in resistance
of lung cancer to EGFR inhibitors. In NSCLC cell lines, increased IL-6 se-
cretion can cause drug resistance to EGFR inhibitors, including erlotinib
(Tarceva) and gefitinib (Iressa) (Yao et al., 2010). Constitutively activat-
ed mutant variants of EGFR can promote IL-6 production and activate
JAK/STAT3 signaling pathway in human lung adenocarcinomas. Inhibi-
tion of EGFR activity leads to partially blocked transcription of IL-6 and
decreased IL-6 production (Gao et al., 2007). These data suggest that
IL-6 blockade may help treat NSCLC patients who have EGFR mutations
and those patients who have relapsed from EGFR TKI treatment, and a
combined approach blocking both EGFR and IL-6/JAK/STAT pathways
may benefit cancer therapy.
4.11. Other cancer types
IL-6 can be used as a potential prognostic factor for other cancer
types, such as gastric cancer (Ashizawa et al., 2005) and chronic lym-
phocytic leukemia (CLL) (Fayad et al., 2001). In an analysis on clinical
specimens from patients with bladder cancers, IL-6 was over-
expressed in the bladder cancer specimens compared with non-
malignant tissues at both mRNA and protein levels. Levels of IL-6 were
significantly associated with higher clinical stage, higher recurrence
rate, and reduced survival rate. Growth and invasive capability of
human bladder cancer cell lines were attenuated when IL-6 signaling
was blocked, suggesting that IL-6 could be a potential predictor for clin-
ical stage and prognosis of bladder cancer (Chen et al., 2013a). Signifi-
cance of IL-6 expression was evaluated in a retrospective analysis of
clinical outcomes of 173 patients with esophageal squamous cell carci-
noma (SCC). Elevated level of IL-6 was significantly associated with
poor prognosis in patients with esophageal cancer. When IL-6 expres-
sion was inhibited, aggressive tumor behavior and radiation resistance
could be overcome in vitro and in vivo (Chen et al., 2013b). In a study
on tumor-initiating cells (TICs) in head and neck squamous cell carcino-
mas (HNCs), suppression of miR-145 or ADAM17 over-expression
134 X. Yao et al. / Pharmacology & Therapeutics 141 (2014) 125–139
increased expression and secretion of IL-6 and sIL-6R in these cells. miR-
145 appears to suppress a paracrine signaling pathway of IL-6 and sIL-6R
in the tumor microenvironment vital to maintain TICs in HNC (Yu et al.,
2013). IL-6 up-regulates the VEGF production through activation of
STAT3 in glioblastoma cells, which may contribute to angiogenesis and
metastasis of tumor (Loeffler et al., 2005). Tocilizumab inhibits the
growth of U87MG glioma cell through an inhibitory effect of the IL-6–
JAK–STAT3 pathway (Kudo et al., 2009). The amplification of the IL-6
gene was reported in patients with glioblastoma and was associated
with shortened survival (Tchirkov et al., 2007). Low levels of IL-6 and
high levels of IL-10 were found as favorable prognostic factors for survival
in acute myeloid leukemia (AML) patients, suggesting that deregulated
cytokines may be useful markers for predicting clinical outcome in AML
(Sanchez-Correa et al., 2013). STAT3 plays a critical role in IL-6-
mediated drug resistance in human neuroblastoma cells. Treatment of
neuroblastoma cells with IL-6 and sIL-6R protected them from drug-
induced apoptosis, and the protective effect of IL-6 was STAT3-
dependent because it was reversed by a STAT3 inhibitor (Ara et al., 2013).
5. Interleukin-6 (IL-6) targeted therapy for human cancer
Preclinical and translational findings suggest that IL-6 plays impor-
tant roles in tumor malignancies, and IL-6 signaling blockade may be
therapeutic for cancer when IL-6 is over-expressed. IL-6 expression cor-
relates with cancer drug resistance, and potentially regulates drug resis-
tance through activation of STAT3 signaling (Duan et al., 2006). The use
of murine or humanized mAbs in clinical investigations on cancers
started in the early 1990's. Current IL-6 targeted therapies of cancer
focus on (1) monotherapy using mAbs against IL-6/IL-6R, and (2) combi-
nation therapy of IL-6/IL-6R mAbs with conventional chemotherapy
agents.
5.1. Siltuximab (CNTO328)
Siltuximab has been reported to reduce cancer-related anorexia and
cachexia and neutralize the effect of IL-6 in different types of human
malignancies. In a clinical study of siltuximab for ovarian cancer, one
out of eighteen evaluated patients had a partial response, and seven
others showed stable disease (Coward et al., 2011). Siltuximab therapy
has shown prolonged periods of disease stabilization in ovarian cancer
patients with recurrent, drug-resistant diseases. After six months of
treatment, there was a significant decline in plasma levels of CCL2,
CXCL12, and VEGF, which are regulated by IL-6 signaling. Furthermore,
in the microarray analyses of ovarian cancer biopsies, expression levels
of genes that were reduced by siltuximab treatment correlated with
high IL-6 pathway gene expression and macrophage markers. In Phase
I/II trials in metastatic renal cancer, siltuximab stabilized disease in
more than 50% of patients and one partial response was reported
(Rossi et al., 2010). Siltuximab was well tolerated in this trial with no
immune response and no DLT observed. Siltuximab was evaluated in
an open-label, seven-cohort, Phase I study in patients with B-cell non-
Hodgkin's lymphoma (NHL), MM, or Castleman disease. Two of four-
teen evaluable NHL patients had a partial response; 2/13 MM patients
had complete response and 12/36 evaluable Castleman disease patients
had radiologic response. CRP suppression was most pronounced at a
dose of 12 mg/kg administered 3 times a week. There was no DLT, anti-
bodies to siltuximab, or dose-toxicity relationship observed. Random-
ized studies are ongoing in MM and Castleman disease (Kurzrock
et al., 2013). In a recent case report, complete remission was achieved
with siltuximab monotherapy in relapsed and refractory myeloma
(Chari et al., 2013).
No adverse events related to siltuximab treatment were observed in
a Phase I study of prostate cancer (Karkera et al., 2011). A decrease in
phosphorylation of STAT3 and p44/p42 mitogen-activated protein ki-
nases was observed in this study. Gene analysis in tumor specimens
also indicated down-regulation of genes downstream of IL-6 signaling
and important enzymes of the androgen signaling pathway. A multicen-
ter Phase II study of siltuximab was completed in patients with
castration-resistant prostate cancer. None of the 31 patients with mea-
surable disease had a RECIST (Response Evaluation Criteria in Solid Tu-
mors) response but 7 (23%) exhibited stable disease. Thirty-two of 38
patients had a decreased CRP plasma levels at 6 weeks (Dorff et al.,
2010). In a recent Phase I study, siltuximab in combination with
docetaxel appears to be safe and shows preliminary efficacy in patients
with castration-resistant prostate cancer. Of the 17 patients with
measurable disease, 2 confirmed and 2 unconfirmed radiologic partial
responses were achieved. CRP concentrations were suppressed
throughout treatment in all patients. DLT was reported in 1 of 11 pa-
tients (Hudes et al., 2013).
Siltuximab-based treatment may be improved in combination with
other chemotherapeutic drugs. Combined treatment with siltuximab
and bortezomib attenuated inducible chemoresistance in MM, potentially
through enhanced activation of caspase-8 and caspase-9 and/or de-
creased induction of antiapoptotic hsp-70. Combination treatment of
siltuximab and bortezomib/dexamethasone has shown enhanced anti-
MM activity in preclinical studies, and these regimens are under investi-
gation for treatment of MM (Voorhees et al., 2007, 2009). A Phase 2
multicentre study of siltuximab, alone or in combination with dexameth-
asone, was completed for patients with relapsed or refractory MM. De-
creased serum CRP levels were observed. There were no responses to
siltuximab monotherapy, but combination therapy yielded a partial/min-
imal response rate of 23%. Further study of siltuximab in modern
corticosteroid-containing myeloma regimens is ongoing (Voorhees
et al., 2013).
5.2. Elsilimomab (BE-8)
BE-8 is a murine anti-IL-6 mAb developed by Diaclone, and it was
the first antibody used in studies on IL-6 blockade. In a clinical trial of
10 patients with advanced and progressive MM treated with BE-6,
three patients showed marked inhibition of plasmablastic proliferation,
but none of them showed significant responses to this therapy (Bataille
et al., 1995). Further study demonstrated that BE-6 cannot block the
daily production of IL-6 levels (N18 μg) efficiently because of its neutral-
ization by human anti-mouse responses (Trikha et al., 2003). Three pa-
tients with RCC were included in a Phase II trial of BE-8 given daily for
21 days. Reductions of CRP, haptoglobin, and serum alkaline phospha-
tases were observed in all 3 patients during anti-IL-6 administration;
toxicity was minimal (Blay et al., 1997). When combined therapy with
dexamethasone and high-dose melphalan followed by autologous
stem cell transplantation, BE-8 therapy induced high response rates in
advanced MM with significantly inhibited IL-6 activity and no toxic or
allergic reaction (Moreau et al., 2000). However, the incidence of
thrombocytopenia and neutropenia increased during the combination
treatment. In another similar combination therapy study, neutralization
of IL-6 activity by BE-8 was evidenced by decreased CRP levels and re-
ductions in mucositis and fever (Rossi et al., 2005).
Development of BE-8 was associated with challenges including neu-
tralization by human anti-mouse responses and a short half life. To
overcome these issues, a fully human version of BE-8 called mAb 1339
(Azintrel OP-R003) has been developed through ActivMAb technology
and examined in preclinical studies. MAb 1339 inhibits the growth of
MM cells in the presence of bone marrow stromal cells in vitro with in-
hibition of activation of STAT3, ERK1/2, and Akt. In a SCID-hu mouse
model of MM, mAb 1339 significantly enhanced the function of cytotox-
icity drugs dexamethasone in vivo in a synergistic fashion (Fulciniti
et al., 2009).
5.3. Tocilizumab
Tocilizumab suppresses in vivo growth of human oral squamous cell
carcinoma (OSCC) by inhibiting IL-6/STAT3 signaling pathway and
 X. Yao et al. / Pharmacology & Therapeutics 141 (2014) 125–139
angiogenesis (Shinriki et al., 2009). Tocilizumab also inhibits lymph
node metastasis in OSCC, which is associated with resistance to conven-
tional therapy and poor survival of patients (Shinriki et al., 2011). In a
recent case report, tocilizumab was used to treat a patient with cancer
cachexia. This patient had high levels of IL-6 expression and multiple
symptoms characterized by an IL-6-induced inflammatory response.
Tocilizumab had a dramatic effect on cachexia induced by lung cancer,
and their survival was prolonged for 9 months without chemotherapy
(Ando et al., 2013). In addition, because blockade of IL-6R may be effec-
tive in suppressing MM cell growth, tocilizumab is now being evaluated
in open-label Phase I (USA) and II (France) trials as monotherapy in MM
patients.
5.4. Clazakizumab (BMS945429, ALD518)
While BMS is focusing on evaluating efficacy of Clazakizumab in RA
patients, Alder Biopharmaceuticals Inc. retains their right in developing
Clazakizumab as supportive care for cancer patients. Alder has complet-
ed Phase IIa testing of Clazakizumab to treat NSCLC-related fatigue and
cachexia. Treatment with Clazakizumab appears well tolerated with
minimal adverse effects. Clazakizumab improves anemia and the lung
symptom score, reverses fatigue, and there is less loss of lean body
mass. Another Phase II randomized clinical trial is ongoing to evaluate
the safety and efficacy of Clazakizumab for reducing oral mucositis in
head and neck cancer patients (NCT01403064). Further studies may in-
clude effects on overall survival and combination therapy with EGFR in-
hibitors in lung cancer (Bayliss et al., 2011).
5.5. Other interleukin-6 (IL-6) targeted therapeutic agents
In human tumor xenograft models, sarilumab inhibits the growth of
tumors with active IL-6/STAT3 signaling, both as a single agent and in
combination with aflibercept, an inhibitor of VEGF. Sarilumab is a poten-
tial candidate for the treatment of multiple types of cancer. NRI is an IL-
6R inhibitor developed from tocilizumab. It is encoded on a single gene
which consists of VH and VL of tocilizumab in a single chain format
dimerized by fusion to human IgG1 Fc. NRI has a similar binding activity
as the parental molecule, tocilizumab, to IL-6R. NRI showed inhibitory
effects on MM cells in vitro (Yoshio-Hoshino et al., 2007). Another
study on NRI suggests that it may have beneficial effects in the treatment
of mesotheliomas by inhibition of VGEF production in mesothelioma
cells (Adachi et al., 2010). A novel blocker of IL-6 signaling, soluble
gp130 faction linked to IgG-Fc (sgp130Fc), has been developed and
showed promising results in preclinical studies. SANT-7, an IL-6R antag-
onist, has shown strong antiproliferative and apoptotic effects on MM
cells when in combination with dexamethasone, all-trans-retinoic
acid, and zoledronic acid (Honemann et al., 2001; Tassone et al., 2002).
ERBA is a novel non-peptide antagonist of IL-6R. It is a specific small
molecule inhibitor of IL-6 activity, and it does not affect other IL-6 family
members. ERBA dose-dependently inhibited IL-6 binding to IL-6R and
suppressed IL-6-induced cell growth. In an experimental model of can-
cer cachexia, ERBA significantly inhibited body weight loss (Enomoto
et al., 2004).
Several small molecule compounds inhibiting IL-6 and its down-
stream targets have been developed and evaluated in preclinical and
clinical studies of various human cancers (Ara & Declerck, 2010).
Atiprimod, a JAK2/JAK3 small molecule inhibitor, blocks IL-6 signaling
by inhibiting STAT3 and Akt and induces apoptosis of multiple myeloma
cells in vitro. Atiprimod is in preclinical development (Quintas-Cardama
et al., 2010). Ruxolitinib, a small molecule JAK1/2 inhibitor, has shown
promising results in a Phase II clinical trial for myeloproliferative neo-
plasms (MPN) and AML (Eghtedar et al., 2012). Another JAK2 inhibitor,
CEP-33779, reduced tumor growth in a mouse model of colitis-
associated cancer (Seavey et al., 2012).
135
6. Conclusions
Through diverse mechanisms, IL-6 plays important roles in the path-
ogenesis of inflammatory diseases and cancer. Components of the IL-6
signaling pathway, including IL-6, IL-6R, sIL-6R, gp130, JAK, and STAT3,
have been used as promising targets for therapy for these indications.
Several mAbs developed for anti-IL-6/IL-6R therapy, either as a single
agent or in combination with other chemotherapeutic drugs, have
shown promising results in both preclinical studies and clinical trials in
human cancer (Table 1). In clinical studies on tocilizumab for the treat-
ment of RA, it appears that combination therapy (with MTX) is not
significantly superior to monotherapy. For treatment of cancer, combina-
tion therapy with IL-6 blockade and conventional drugs achieved better
treatment efficacy and patient responses compared to monotherapy.
New strategies such as combination of IL-6 blockade and EGFR inhibition
or other targeted therapy may be helpful to improve IL-6 targeted immu-
notherapy of human cancer.
Conflict of interest statement
All authors (except Nan Shen) are full time employees of MedImmune
and hold AstraZeneca stocks. The authors have no other conflicts of inter-
est regarding the content of this article. No funding sources were used in
preparation of this article.
References
Adachi, Y., Yoshio-Hoshino, N., Aoki, C., & Nishimoto, N. (2010). VEGF targeting in meso-
theliomas using an interleukin-6 signal inhibitor based on adenovirus gene delivery.
Anticancer Res 30, 1947–1952.
Agusti, A., Edwards, L. D., Rennard, S. I., MacNee, W., Tal-Singer, R., Miller, B. E., et al.
(2012). Persistent systemic inflammation is associated with poor clinical outcomes
in COPD: a novel phenotype. PLoS One 7, e37483.
Akira, S. (1997). IL-6-regulated transcription factors. Int J Biochem Cell Biol 29, 1401–1418.
Alberti, L., Bachelot, T., Duc, A., Biota, C., & Blay, J. Y. (2005). A spliced isoform of interleu-
kin 6 mRNA produced by renal cell carcinoma encodes for an interleukin 6 inhibitor.
Cancer Res 65, 2–5.
Alberti, C., Pinciroli, P., Valeri, B., Ferri, R., Ditto, A., Umezawa, K., et al. (2012).
Ligand-dependent EGFR activation induces the co-expression of IL-6 and PAI-1 via the
NFkB pathway in advanced-stage epithelial ovarian cancer. Oncogene 31, 4139–4149.
Alonzi, T., Fattori, E., Lazzaro, D., Costa, P., Probert, L., Kollias, G., et al. (1998). Interleukin 6
is required for the development of collagen-induced arthritis. J Exp Med 187,
461–468.
Alten, R., & Maleitzke, T. (2013). Tocilizumab: a novel humanized anti-interleukin 6 (IL-6)
receptor antibody for the treatment of patients with non-RA systemic, inflammatory
rheumatic diseases. Ann Med 45, 357–363.
Ando, K., Takahashi, F., Motojima, S., Nakashima, K., Kaneko, N., Hoshi, K., et al. (2013).
Possible role for tocilizumab, an anti-interleukin-6 receptor antibody, in treating can-
cer cachexia. J Clin Oncol 31, e69–e72.
Angelo, L. S., Talpaz, M., & Kurzrock, R. (2002). Autocrine interleukin-6 production in renal
cell carcinoma: evidence for the involvement of p53. Cancer Res 62, 932–940.
Aoki, Y., Narazaki, M., Kishimoto, T., & Tosato, G. (2001). Receptor engagement by viral
interleukin-6 encoded by Kaposi sarcoma-associated herpesvirus. Blood 98, 3042–3049.
Ara, T., & Declerck, Y. A. (2010). Interleukin-6 in bone metastasis and cancer progression.
Eur J Cancer 46, 1223–1231.
Ara, T., Nakata, R., Sheard, M. A., Shimada, H., Buettner, R., Groshen, S. G., et al. (2013).
Critical role of STAT3 in IL-6-mediated drug resistance in human neuroblastoma.
Cancer Res 73, 3852–3864.
Ashizawa, T., Okada, R., Suzuki, Y., Takagi, M., Yamazaki, T., Sumi, T., et al. (2005). Clinical
significance of interleukin-6 (IL-6) in the spread of gastric cancer: role of IL-6 as a
prognostic factor. Gastric Cancer 8, 124–131.
Asschert, J. G., De Vries, E. G., De Jong, S., Withoff, S., & Vellenga, E. (1999). Differential reg-
ulation of IL-6 promoter activity in a human ovarian-tumor cell line transfected with
various p53 mutants: involvement of AP-1. Int J Cancer 81, 236–242.
Ataie-Kachoie, P., Pourgholami, M. H., & Morris, D. L. (2013). Inhibition of the IL-6 signal-
ing pathway: a strategy to combat chronic inflammatory diseases and cancer.
Cytokine Growth Factor Rev 24, 163–173.
Atreya, R., Mudter, J., Finotto, S., Mullberg, J., Jostock, T., Wirtz, S., et al. (2000). Blockade of
interleukin 6 trans signaling suppresses T-cell resistance against apoptosis in chronic
intestinal inflammation: evidence in crohn disease and experimental colitis in vivo.
Nat Med 6, 583–588.
Atreya, R., & Neurath, M. F. (2005). Involvement of IL-6 in the pathogenesis of inflamma-
tory bowel disease and colon cancer. Clin Rev Allergy Immunol 28, 187–196.
Atreya, R., & Neurath, M. F. (2008). New therapeutic strategies for treatment of inflamma-
tory bowel disease. Mucosal Immunol 1, 175–182.
Barr, T. A., Shen, P., Brown, S., Lampropoulou, V., Roch, T., Lawrie, S., et al. (2012). B cell de-
pletion therapy ameliorates autoimmune disease through ablation of IL-6-producing
B cells. J Exp Med 209, 1001–1010.
136 X. Yao et al. / Pharmacology & Therapeutics 141 (2014) 125–139
Barton, B. E. (2001). IL-6-like cytokines and cancer cachexia: consequences of chronic in-
flammation. Immunol Res 23, 41–58.
Bataille, R., Barlogie, B., Lu, Z. Y., Rossi, J. F., Lavabre-Bertrand, T., Beck, T., et al. (1995). Bi-
ologic effects of anti-interleukin-6 murine monoclonal antibody in advanced multiple
myeloma. Blood 86, 685–691.
Bayliss, T. J., Smith, J. T., Schuster, M., Dragnev, K. H., & Rigas, J. R. (2011). A humanized
anti-IL-6 antibody (ALD518) in non-small cell lung cancer. Expert Opin Biol Ther 11,
1663–1668.
Bellone, G., Carbone, A., Smirne, C., Scirelli, T., Buffolino, A., Novarino, A., et al. (2006). Co-
operative induction of a tolerogenic dendritic cell phenotype by cytokines secreted
by pancreatic carcinoma cells. J Immunol 177, 3448–3460.
Bellone, G., Smirne, C., Mauri, F. A., Tonel, E., Carbone, A., Buffolino, A., et al. (2006). Cyto-
kine expression profile in human pancreatic carcinoma cells and in surgical speci-
mens: implications for survival. Cancer Immunol Immunother 55, 684–698.
Benoy, I., Salgado, R., Colpaert, C., Weytjens, R., Vermeulen, P. B., & Dirix, L. Y. (2002).
Serum interleukin 6, plasma VEGF, serum VEGF, and VEGF platelet load in breast can-
cer patients. Clin Breast Cancer 2, 311–315.
Blay, J. Y., Rossi, J. F., Wijdenes, J., Menetrier-Caux, C., Schemann, S., Negrier, S., et al.
(1997). Role of interleukin-6 in the paraneoplastic inflammatory syndrome associat-
ed with renal-cell carcinoma. Int J Cancer 72, 424–430.
Borsellino, N., Bonavida, B., Ciliberto, G., Toniatti, C., Travali, S., & D'Alessandro, N. (1999).
Blocking signaling through the Gp130 receptor chain by interleukin-6 and oncostatin
M inhibits PC-3 cell growth and sensitizes the tumor cells to etoposide and
cisplatin-mediated cytotoxicity. Cancer 85, 134–144.
Boulanger, M. J., Chow, D. C., Brevnova, E. E., & Garcia, K. C. (2003). Hexameric structure and
assembly of the interleukin-6/IL-6 alpha-receptor/gp130 complex. Science 300,
2101–2104.
Briso, E. M., Dienz, O., & Rincon, M. (2008). Cutting edge: soluble IL-6R is produced
by IL-6R ectodomain shedding in activated CD4 T cells. J Immunol 180,
7102–7106.
Burmester, G. R., Feist, E., Kellner, H., Braun, J., Iking-Konert, C., & Rubbert-Roth, A. (2011).
Effectiveness and safety of the interleukin 6-receptor antagonist tocilizumab after 4
and 24 weeks in patients with active rheumatoid arthritis: the first phase IIIb
real-life study (TAMARA). Ann Rheum Dis 70, 755–759.
Cabillic, F., Bouet-Toussaint, F., Toutirais, O., Rioux-Leclercq, N., Fergelot, P., de la Pintiere,
C. T., et al. (2006). Interleukin-6 and vascular endothelial growth factor release by
renal cell carcinoma cells impedes lymphocyte-dendritic cell cross-talk. Clin Exp
Immunol 146, 518–523.
Cardillo, M. R., & Ippoliti, F. (2007). Interleukin-6, interleukin-10 and heat shock protein-90
expression in renal epithelial neoplasias and surrounding normal-appearing renal paren-
chyma. Int J Immunopathol Pharmacol 20, 37–46.
Cash, H., Relle, M., Menke, J., Brochhausen, C., Jones, S. A., Topley, N., et al. (2010). Inter-
leukin 6 (IL-6) deficiency delays lupus nephritis in MRL-Faslpr mice: the IL-6 path-
way as a new therapeutic target in treatment of autoimmune kidney disease in
systemic lupus erythematosus. J Rheumatol 37, 60–70.
Cavarretta, I. T., Neuwirt, H., Untergasser, G., Moser, P. L., Zaki, M. H., Steiner, H., et al.
(2007). The antiapoptotic effect of IL-6 autocrine loop in a cellular model of advanced
prostate cancer is mediated by Mcl-1. Oncogene 26, 2822–2832.
Celli, B. R., Locantore, N., Yates, J., Tal-Singer, R., Miller, B. E., Bakke, P., et al. (2012). Inflam-
matory biomarkers improve clinical prediction of mortality in chronic obstructive
pulmonary disease. Am J Respir Crit Care Med 185, 1065–1072.
Cenit, M. C., Simeon, C. P., Vonk, M. C., Callejas-Rubio, J. L., Espinosa, G., Carreira, P., et al.
(2012). Influence of the IL6 gene in susceptibility to systemic sclerosis. J Rheumatol
39, 2294–2302.
Chalaris, A., Rabe, B., Paliga, K., Lange, H., Laskay, T., Fielding, C. A., et al. (2007). Apoptosis
is a natural stimulus of IL6R shedding and contributes to the proinflammatory
trans-signaling function of neutrophils. Blood 110, 1748–1755.
Chang, S. G., Shin, C., Rho, S. K., Kim, D. K., & Kim, J. H. (1998). Cytokine production in pri-
mary histoculture by human normal kidney, renal cell carcinoma and benign renal
angiomyolipoma tissues. Anticancer Res 18, 4195–4200.
Chari, A., Pri-Chen, H., & Jagannath, S. (2013). Complete remission achieved with single
agent CNTO 328, an anti-IL-6 monoclonal antibody, in relapsed and refractory myelo-
ma. Clin Lymphoma Myeloma Leuk 13, 333–337.
Chavey, C., Bibeau, F., Gourgou-Bourgade, S., Burlinchon, S., Boissiere, F., Laune, D., et al.
(2007). Oestrogen receptor negative breast cancers exhibit high cytokine content.
Breast Cancer Res 9, R15.
Chen, M. F., Chen, P. T., Lu, M. S., Lin, P. Y., Chen, W. C., & Lee, K. D. (2013). IL-6 expression
predicts treatment response and outcome in squamous cell carcinoma of the esoph-
agus. Mol Cancer 12, 26.
Chen, Z., Laurence, A., & O'Shea, J. J. (2007). Signal transduction pathways and tran-
scriptional regulation in the control of Th17 differentiation. Semin Immunol 19,
400–408.
Chen, M. F., Lin, P. Y., Wu, C. F., Chen, W. C., & Wu, C. T. (2013). IL-6 expression regu-
lates tumorigenicity and correlates with prognosis in bladder cancer. PLoS One 8,
e61901.
Choi, Y. S., Eto, D., Yang, J. A., Lao, C., & Crotty, S. (2013). Cutting edge: STAT1 is required
for IL-6-mediated Bcl6 induction for early follicular helper cell differentiation. J
Immunol 190, 3049–3053.
Chung, Y. C., & Chang, Y. F. (2003). Serum interleukin-6 levels reflect the disease status of
colorectal cancer. J Surg Oncol 83, 222–226.
Conze, D., Weiss, L., Regen, P.S., Bhushan, A., Weaver, D., Johnson, P., et al. (2001). Auto-
crine production of interleukin 6 causes multidrug resistance in breast cancer cells.
Cancer Res 61, 8851–8858.
Coward, J., Kulbe, H., Chakravarty, P., Leader, D., Vassileva, V., Leinster, D. A., et al. (2011).
Interleukin-6 as a therapeutic target in human ovarian cancer. Clin Cancer Res 17,
6083–6096.
Cozen, W., Gill, P.S., Ingles, S. A., Masood, R., Martinez-Maza, O., Cockburn, M. G., et al.
(2004). IL-6 levels and genotype are associated with risk of young adult Hodgkin
lymphoma. Blood 103, 3216–3221.
Culig, Z., Steiner, H., Bartsch, G., & Hobisch, A. (2005). Interleukin-6 regulation of prostate
cancer cell growth. J Cell Biochem 95, 497–505.
Dankbar, B., Padro, T., Leo, R., Feldmann, B., Kropff, M., Mesters, R. M., et al. (2000). Vascu-
lar endothelial growth factor and interleukin-6 in paracrine tumor–stromal cell inter-
actions in multiple myeloma. Blood 95, 2630–2636.
De Benedetti, F., Pignatti, P., Gerloni, V., Massa, M., Sartirana, P., Caporali, R., et al. (1997).
Differences in synovial fluid cytokine levels between juvenile and adult rheumatoid
arthritis. J Rheumatol 24, 1403–1409.
Derenne, S., Monia, B., Dean, N. M., Taylor, J. K., Rapp, M. J., Harousseau, J. L., et al. (2002).
Antisense strategy shows that Mcl-1 rather than Bcl-2 or Bcl-x(L) is an essential sur-
vival protein of human myeloma cells. Blood 100, 194–199.
Desgeorges, A., Gabay, C., Silacci, P., Novick, D., Roux-Lombard, P., Grau, G., et al. (1997).
Concentrations and origins of soluble interleukin 6 receptor-alpha in serum and sy-
novial fluid. J Rheumatol 24, 1510–1516.
Diehl, S., Anguita, J., Hoffmeyer, A., Zapton, T., Ihle, J. N., Fikrig, E., et al. (2000). Inhibition
of Th1 differentiation by IL-6 is mediated by SOCS1. Immunity 13, 805–815.
Diehl, S., & Rincon, M. (2002). The two faces of IL-6 on Th1/Th2 differentiation. Mol
Immunol 39, 531–536.
Diehl, S. A., Schmidlin, H., Nagasawa, M., Blom, B., & Spits, H. (2012). IL-6 triggers IL-21
production by human CD4+ T cells to drive STAT3-dependent plasma cell differenti-
ation in B cells. Immunol Cell Biol 90, 802–811.
Dienz, O., Eaton, S. M., Bond, J. P., Neveu, W., Moquin, D., Noubade, R., et al. (2009). The
induction of antibody production by IL-6 is indirectly mediated by IL-21 produced
by CD4+ T cells. J Exp Med 206, 69–78.
Dixon, A. E., Shade, D.M., Cohen, R. I., Skloot, G. S., Holbrook, J. T., Smith, L. J., et al. (2006).
Effect of obesity on clinical presentation and response to treatment in asthma. J
Asthma 43, 553–558.
Dorff, T. B., Goldman, B., Pinski, J. K., Mack, P. C., Lara, P. N., Jr., Van Veldhuizen, P. J.,
Jr., et al. (2010). Clinical and correlative results of SWOG S0354: a phase II trial
of CNTO328 (siltuximab), a monoclonal antibody against interleukin-6, in
chemotherapy-pretreated patients with castration-resistant prostate cancer.
Clin Cancer Res 16, 3028–3034.
Dougados, M., Kissel, K., Sheeran, T., Tak, P. P., Conaghan, P. G., Mola, E. M., et al. (2013).
Adding tocilizumab or switching to tocilizumab monotherapy in methotrexate inad-
equate responders: 24-week symptomatic and structural results of a 2-year
randomised controlled strategy trial in rheumatoid arthritis (ACT-RAY). Ann Rheum
Dis 72, 43–50.
Duan, Z., Foster, R., Bell, D. A., Mahoney, J., Wolak, K., Vaidya, A., et al. (2006). Signal trans-
ducers and activators of transcription 3 pathway activation in drug-resistant ovarian
cancer. Clin Cancer Res 12, 5055–5063.
Duncan, M. R., & Berman, B. (1991). Stimulation of collagen and glycosaminoglycan pro-
duction in cultured human adult dermal fibroblasts by recombinant human interleu-
kin 6. J Invest Dermatol 97, 686–692.
Ebrahimi, B., Tucker, S. L., Li, D., Abbruzzese, J. L., & Kurzrock, R. (2004). Cytokines in pan-
creatic carcinoma: correlation with phenotypic characteristics and prognosis. Cancer
101, 2727–2736.
Eghtedar, A., Verstovsek, S., Estrov, Z., Burger, J., Cortes, J., Bivins, C., et al. (2012).
Phase 2 study of the JAK kinase inhibitor ruxolitinib in patients with refractory
leukemias, including postmyeloproliferative neoplasm acute myeloid leukemia.
Blood 119, 4614–4618.
Eilertsen, G. O., Nikolaisen, C., Becker-Merok, A., & Nossent, J. C. (2011). Interleukin-6 pro-
motes arthritis and joint deformation in patients with systemic lupus erythematosus.
Lupus 20, 607–613.
Enomoto, A., Rho, M. C., Fukami, A., Hiraku, O., Komiyama, K., & Hayashi, M. (2004). Sup-
pression of cancer cachexia by 20S,21-epoxy-resibufogenin-3-acetate-a novel
nonpeptide IL-6 receptor antagonist. Biochem Biophys Res Commun 323, 1096–1102.
Esparza-Gordillo, J., Schaarschmidt, H., Liang, L., Cookson, W., Bauerfeind, A., Lee-Kirsch,
M. A., et al. (2013). A functional IL-6 receptor (IL6R) variant is a risk factor for persis-
tent atopic dermatitis. J Allergy Clin Immunol 132, 371–377.
Fayad, L., Keating, M. J., Reuben, J. M., O'Brien, S., Lee, B. N., Lerner, S., et al. (2001).
Interleukin-6 and interleukin-10 levels in chronic lymphocytic leukemia: correlation
with phenotypic characteristics and outcome. Blood 97, 256–263.
Ferreira, M.A., Matheson, M. C., Duffy, D. L., Marks, G. B., Hui, J., Le Souef, P., et al. (2011).
Identification of IL6R and chromosome 11q13.5 as risk loci for asthma. Lancet 378,
1006–1014.
Fielding, C. A., McLoughlin, R. M., McLeod, L., Colmont, C. S., Najdovska, M., Grail, D., et al.
(2008). IL-6 regulates neutrophil trafficking during acute inflammation via STAT3. J
Immunol 181, 2189–2195.
Finotto, S., Eigenbrod, T., Karwot, R., Boross, I., Doganci, A., Ito, H., et al. (2007). Local
blockade of IL-6R signaling induces lung CD4+ T cell apoptosis in a murine model
of asthma via regulatory T cells. Int Immunol 19, 685–693.
Fizazi, K., De Bono, J. S., Flechon, A., Heidenreich, A., Voog, E., Davis, N.B., et al. (2012).
Randomised phase II study of siltuximab (CNTO 328), an anti-IL-6 monoclonal antibody,
in combination with mitoxantrone/prednisone versus mitoxantrone/prednisone alone
in metastatic castration-resistant prostate cancer. Eur J Cancer 48, 85–93.
Flowers, L. O., Subramaniam, P.S., & Johnson, H. M. (2005). A SOCS-1 peptide mimetic in-
hibits both constitutive and IL-6 induced activation of STAT3 in prostate cancer cells.
Oncogene 24, 2114–2120.
Fulciniti, M., Hideshima, T., Vermot-Desroches, C., Pozzi, S., Nanjappa, P., Shen, Z., et al.
(2009). A high-affinity fully human anti-IL-6 mAb, 1339, for the treatment of multi-
ple myeloma. Clin Cancer Res 15, 7144–7152.
Gabay, C., Emery, P., van Vollenhoven, R., Dikranian, A., Alten, R., Pavelka, K., et al.
(2013). Tocilizumab monotherapy versus adalimumab monotherapy for
 X. Yao et al. / Pharmacology & Therapeutics 141 (2014) 125–139
treatment of rheumatoid arthritis (ADACTA): a randomised, double-blind, con-
trolled phase 4 trial. Lancet 381, 1541–1550.
Gabrilovich, D. I., & Nagaraj, S. (2009). Myeloid-derived suppressor cells as regulators of
the immune system. Nat Rev Immunol 9, 162–174.
Gao, S. P., Mark, K. G., Leslie, K., Pao, W., Motoi, N., Gerald, W. L., et al. (2007). Mutations in
the EGFR kinase domain mediate STAT3 activation via IL-6 production in human lung
adenocarcinomas. J Clin Invest 117, 3846–3856.
Garg, R., Wollan, M., Galic, V., Garcia, R., Goff, B.A., Gray, H. J., et al. (2006). Common poly-
morphism in interleukin 6 influences survival of women with ovarian and peritoneal
carcinoma. Gynecol Oncol 103, 793–796.
Ghoreschi, K., Laurence, A., Yang, X. P., Tato, C. M., McGeachy, M. J., Konkel, J. E., et al.
(2010). Generation of pathogenic T(H)17 cells in the absence of TGF-beta signalling.
Nature 467, 967–971.
Gijbels, K., Van Damme, J., Proost, P., Put, W., Carton, H., & Billiau, A. (1990). Interleukin 6
production in the central nervous system during experimental autoimmune enceph-
alomyelitis. Eur J Immunol 20, 233–235.
Giri, D., Ozen, M., & Ittmann, M. (2001). Interleukin-6 is an autocrine growth factor in
human prostate cancer. Am J Pathol 159, 2159–2165.
Glass, C. K., Saijo, K., Winner, B., Marchetto, M. C., & Gage, F. H. (2010). Mechanisms un-
derlying inflammation in neurodegeneration. Cell 140, 918–934.
Grivennikov, S., & Karin, M. (2008). Autocrine IL-6 signaling: a key event in tumorigene-
sis? Cancer Cell 13, 7–9.
Guo, Y., Nemeth, J., O'Brien, C., Susa, M., Liu, X., Zhang, Z., et al. (2010). Effects of
siltuximab on the IL-6-induced signaling pathway in ovarian cancer. Clin Cancer Res
16, 5759–5769.
Hartman, Z. C., Poage, G. M., den Hollander, P., Tsimelzon, A., Hill, J., Panupinthu, N., et al.
(2013). Growth of triple-negative breast cancer cells relies upon coordinate autocrine
expression of the proinflammatory cytokines IL-6 and IL-8. Cancer Res 73, 3470–3480.
Hawkins, G. A., Robinson, M. B., Hastie, A. T., Li, X., Li, H., Moore, W. C., et al. (2012). The
IL6R variation Asp(358)Ala is a potential modifier of lung function in subjects with
asthma. J Allergy Clin Immunol 130(510–515), e511.
He, J. Q., Foreman, M. G., Shumansky, K., Zhang, X., Akhabir, L., Sin, D.D., et al. (2009). Associ-
ations of IL6 polymorphisms with lung function decline and COPD. Thorax 64, 698–704.
Heinrich, P. C., Behrmann, I., Haan, S., Hermanns, H. M., Muller-Newen, G., & Schaper, F.
(2003). Principles of interleukin (IL)-6-type cytokine signalling and its regulation.
Biochem J 374, 1–20.
Heinrich, P. C., Castell, J. V., & Andus, T. (1990). Interleukin-6 and the acute phase re-
sponse. Biochem J 265, 621–636.
Hideshima, T., Chauhan, D., Hayashi, T., Akiyama, M., Mitsiades, N., Mitsiades, C., et al.
(2003). Proteasome inhibitor PS-341 abrogates IL-6 triggered signaling cascades
via caspase-dependent downregulation of gp130 in multiple myeloma. Oncogene
22, 8386–8393.
Hideshima, T., Mitsiades, C., Tonon, G., Richardson, P. G., & Anderson, K. C. (2007). Under-
standing multiple myeloma pathogenesis in the bone marrow to identify new thera-
peutic targets. Nat Rev Cancer 7, 585–598.
Hillion, S., Garaud, S., Devauchelle, V., Bordron, A., Berthou, C., Youinou, P., et al. (2007).
Interleukin-6 is responsible for aberrant B-cell receptor-mediated regulation of RAG
expression in systemic lupus erythematosus. Immunology 122, 371–380.
Hirohata, S., & Miyamoto, T. (1990). Elevated levels of interleukin-6 in cerebrospinal fluid
from patients with systemic lupus erythematosus and central nervous system in-
volvement. Arthritis Rheum 33, 644–649.
Hoejberg, L., Bastholt, L., Johansen, J. S., Christensen, I. J., Gehl, J., & Schmidt, H. (2012).
Serum interleukin-6 as a prognostic biomarker in patients with metastatic melano-
ma. Melanoma Res 22, 287–293.
Hoejberg, L., Bastholt, L., & Schmidt, H. (2012). Interleukin-6 and melanoma. Melanoma
Res 22, 327–333.
Honemann, D., Chatterjee, M., Savino, R., Bommert, K., Burger, R., Gramatzki, M., et al.
(2001). The IL-6 receptor antagonist SANT-7 overcomes bone marrow stromal
cell-mediated drug resistance of multiple myeloma cells. Int J Cancer 93, 674–680.
Hong, D. S., Angelo, L. S., & Kurzrock, R. (2007). Interleukin-6 and its receptor in cancer:
implications for translational therapeutics. Cancer 110, 1911–1928.
Hosokawa, T., Kusugami, K., Ina, K., Ando, T., Shinoda, M., Imada, A., et al. (1999).
Interleukin-6 and soluble interleukin-6 receptor in the colonic mucosa of inflamma-
tory bowel disease. J Gastroenterol Hepatol 14, 987–996.
Hudes, G., Tagawa, S. T., Whang, Y. E., Qi, M., Qin, X., Puchalski, T. A., et al. (2013). A phase
1 study of a chimeric monoclonal antibody against interleukin-6, siltuximab, com-
bined with docetaxel in patients with metastatic castration-resistant prostate cancer.
Invest New Drugs 31, 669–676.
Hunsucker, S. A., Magarotto, V., Kuhn, D. J., Kornblau, S. M., Wang, M., Weber, D.M., et al.
(2011). Blockade of interleukin-6 signalling with siltuximab enhances melphalan cy-
totoxicity in preclinical models of multiple myeloma. Br J Haematol 152, 579–592.
Iacopetta, B., Grieu, F., & Joseph, D. (2004). The -174G/C gene polymorphism in
interleukin-6 is associated with an aggressive breast cancer phenotype. Br J Can-
cer 90, 419–422.
Illei, G. G., Shirota, Y., Yarboro, C. H., Daruwalla, J., Tackey, E., Takada, K., et al. (2010). Toci-
lizumab in systemic lupus erythematosus: data on safety, preliminary efficacy, and
impact on circulating plasma cells from an open-label phase I dosage-escalation
study. Arthritis Rheum 62, 542–552.
Ito, H. (2004). Novel therapy for Crohn's disease targeting IL-6 signalling. Expert Opin Ther
Targets 8, 287–294.
Ito, H., Takazoe, M., Fukuda, Y., Hibi, T., Kusugami, K., Andoh, A., et al. (2004). A pilot ran-
domized trial of a human anti-interleukin-6 receptor monoclonal antibody in active
Crohn's disease. Gastroenterology 126, 989–996 (discussion 947).
Jego, G., Palucka, A. K., Blanck, J. P., Chalouni, C., Pascual, V., & Banchereau, J. (2003).
Plasmacytoid dendritic cells induce plasma cell differentiation through type I inter-
feron and interleukin 6. Immunity 19, 225–234.
137
Jones, S. A., Richards, P. J., Scheller, J., & Rose-John, S. (2005). IL-6 transsignaling: the
in vivo consequences. J Interferon Cytokine Res 25, 241–253.
Jones, G., Sebba, A., Gu, J., Lowenstein, M. B., Calvo, A., Gomez-Reino, J. J., et al. (2010). Com-
parison of tocilizumab monotherapy versus methotrexate monotherapy in patients
with moderate to severe rheumatoid arthritis: the AMBITION study. Ann Rheum Dis
69, 88–96.
Jostock, T., Mullberg, J., Ozbek, S., Atreya, R., Blinn, G., Voltz, N., et al. (2001). Soluble gp130
is the natural inhibitor of soluble interleukin-6 receptor transsignaling responses. Eur
J Biochem 268, 160–167.
Karkera, J., Steiner, H., Li, W., Skradski, V., Moser, P. L., Riethdorf, S., et al. (2011). The
anti-interleukin-6 antibody siltuximab down-regulates genes implicated in tumori-
genesis in prostate cancer patients from a phase I study. Prostate 71, 1455–1465.
Katsume, A., Saito, H., Yamada, Y., Yorozu, K., Ueda, O., Akamatsu, K., 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.
Keul, R., Heinrich, P. C., Muller-newen, G., Muller, K., & Woo, P. (1998). A possible role for
soluble IL-6 receptor in the pathogenesis of systemic onset juvenile chronic arthritis.
Cytokine 10, 729–734.
Kim, S. Y., Kang, J. W., Song, X., Kim, B. K., Yoo, Y. D., Kwon, Y. T., et al. (2013). Role of the
IL-6–JAK1–STAT3–Oct-4 pathway in the conversion of non-stem cancer cells into
cancer stem-like cells. Cell Signal 25, 961–969.
Kimura, A., & Kishimoto, T. (2010). IL-6: regulator of Treg/Th17 balance. Eur J Immunol 40,
1830–1835.
Kishimoto, T. (2006). Interleukin-6: discovery of a pleiotropic cytokine. Arthritis Res Ther
8(Suppl. 2), S2.
Kishimoto, T. (2010). IL-6: from its discovery to clinical applications. Int Immunol 22,
347–352.
Kishimoto, T., Akira, S., & Taga, T. (1992). Interleukin-6 and its receptor: a paradigm for
cytokines. Science 258, 593–597.
Kitaba, S., Murota, H., Terao, M., Azukizawa, H., Terabe, F., Shima, Y., et al. (2012). Blockade
of interleukin-6 receptor alleviates disease in mouse model of scleroderma. Am J
Pathol 180, 165–176.
Knupfer, H., & Preiss, R. (2010). Serum interleukin-6 levels in colorectal cancer patients–a
summary of published results. Int J Colorectal Dis 25, 135–140.
Korkaya, H., Kim, G. I., Davis, A., Malik, F., Henry, N. L., Ithimakin, S., et al. (2012). Activa-
tion of an IL6 inflammatory loop mediates trastuzumab resistance in HER2+ breast
cancer by expanding the cancer stem cell population. Mol Cell 47, 570–584.
Kremer, J. M., Blanco, R., Brzosko, M., Burgos-Vargas, R., Halland, A.M., Vernon, E., et al.
(2011). Tocilizumab inhibits structural joint damage in rheumatoid arthritis patients
with inadequate responses to methotrexate: results from the double-blind treatment
phase of a randomized placebo-controlled trial of tocilizumab safety and prevention
of structural joint damage at one year. Arthritis Rheum 63, 609–621.
Kudo, M., Jono, H., Shinriki, S., Yano, S., Nakamura, H., Makino, K., et al. (2009). Antitumor
effect of humanized anti-interleukin-6 receptor antibody (tocilizumab) on glioma
cell proliferation. Laboratory investigation. J Neurosurg 111, 219–225.
Kuroda, K., Nakashima, J., Kanao, K., Kikuchi, E., Miyajima, A., Horiguchi, Y., et al. (2007).
Interleukin 6 is associated with cachexia in patients with prostate cancer. Urology
69, 113–117.
Kurzrock, R., Voorhees, P. M., Casper, C., Furman, R. R., Fayad, L., Lonial, S., et al. (2013). A
phase I, open-label study of siltuximab, an anti-IL-6 monoclonal antibody, in patients
with B-cell non-Hodgkin lymphoma, multiple myeloma, or Castleman disease. Clin
Cancer Res 19, 3659–3670.
Kyrtsonis, M. C., Dedoussis, G., Zervas, C., Perifanis, V., Baxevanis, C., Stamatelou, M., et al.
(1996). Soluble interleukin-6 receptor (sIL-6R), a new prognostic factor in multiple
myeloma. Br J Haematol 93, 398–400.
Lamas, J. R., Rodriguez-Rodriguez, L., Tornero-Esteban, P., Villafuertes, E., Hoyas, J., Abasolo,
L., et al. (2013). Alternative splicing and proteolytic rupture contribute to the genera-
tion of soluble IL-6 receptors (sIL-6R) in rheumatoid arthritis. Cytokine 61, 720–723.
Lauta, V. M. (2003). A review of the cytokine network in multiple myeloma: diagnostic,
prognostic, and therapeutic implications. Cancer 97, 2440–2452.
Lee, Y. H., Lee, H. S., Choi, S. J., Ji, J.D., & Song, G. G. (2011). The association between
interleukin-6 polymorphisms and systemic lupus erythematosus: a meta-analysis.
Lupus 21, 60–67.
Lemmers, A., Gustot, T., Durnez, A., Evrard, S., Moreno, C., Quertinmont, E., et al.
(2009). An inhibitor of interleukin-6 trans-signalling, sgp130, contributes to im-
paired acute phase response in human chronic liver disease. Clin Exp Immunol
156, 518–527.
Leslie, K., Gao, S. P., Berishaj, M., Podsypanina, K., Ho, H., Ivashkiv, L., et al. (2010). Differ-
ential interleukin-6/Stat3 signaling as a function of cellular context mediates
Ras-induced transformation. Breast Cancer Res 12, R80.
Li, Y., de Haar, C., Chen, M., Deuring, J., Gerrits, M. M., Smits, R., et al. (2010).
Disease-related expression of the IL6/STAT3/SOCS3 signalling pathway in ulcerative
colitis and ulcerative colitis-related carcinogenesis. Gut 59, 227–235.
Liang, B., Gardner, D. B., Griswold, D. E., Bugelski, P. J., & Song, X. Y. (2006).
Anti-interleukin-6 monoclonal antibody inhibits autoimmune responses in a mu-
rine model of systemic lupus erythematosus. Immunology 119, 296–305.
Linker-Israeli, M., Deans, R. J., Wallace, D. J., Prehn, J., Ozeri-Chen, T., & Klinenberg, J. R.
(1991). Elevated levels of endogenous IL-6 in systemic lupus erythematosus. A puta-
tive role in pathogenesis. J Immunol 147, 117–123.
Loeffler, S., Fayard, B., Weis, J., & Weissenberger, J. (2005). Interleukin-6 induces transcrip-
tional activation of vascular endothelial growth factor (VEGF) in astrocytes in vivo
and regulates VEGF promoter activity in glioblastoma cells via direct interaction be-
tween STAT3 and Sp1. Int J Cancer 115, 202–213.
Lossos, I. S., Czerwinski, D. K., Alizadeh, A. A., Wechser, M.A., Tibshirani, R., Botstein, D.,
et al. (2004). Prediction of survival in diffuse large-B-cell lymphoma based on the ex-
pression of six genes. N Engl J Med 350, 1828–1837.
138 X. Yao et al. / Pharmacology & Therapeutics 141 (2014) 125–139
Lotz, M. (1995). Interleukin-6: a comprehensive review. Cancer Treat Res 80, 209–233.
Maimone, D., Gregory, S., Arnason, B. G., & Reder, A. T. (1991). Cytokine levels in the ce-
rebrospinal fluid and serum of patients with multiple sclerosis. J Neuroimmunol 32,
67–74.
Mann, M. K., Ray, A., Basu, S., Karp, C. L., & Dittel, B. N. (2012). Pathogenic and regulatory roles
for B cells in experimental autoimmune encephalomyelitis. Autoimmunity 45, 388–399.
McKeown, D. J., Brown, D. J., Kelly, A., Wallace, A.M., & McMillan, D. C. (2004). The rela-
tionship between circulating concentrations of C-reactive protein, inflammatory cy-
tokines and cytokine receptors in patients with non-small-cell lung cancer. Br J
Cancer 91, 1993–1995.
McLoughlin, R. M., Hurst, S. M., Nowell, M.A., Harris, D. A., Horiuchi, S., Morgan, L. W., et al.
(2004). Differential regulation of neutrophil-activating chemokines by IL-6 and its
soluble receptor isoforms. J Immunol 172, 5676–5683.
Mease, P., Strand, V., Shalamberidze, L., Dimic, A., Raskina, T., Xu, L. A., et al. (2012). A
phase II, double-blind, randomised, placebo-controlled study of BMS945429
(ALD518) in patients with rheumatoid arthritis with an inadequate response to
methotrexate. Ann Rheum Dis 71, 1183–1189.
Melkamu, T., Kita, H., & O'Grady, S. M. (2013). TLR3 activation evokes IL-6 secretion, au-
tocrine regulation of Stat3 signaling and TLR2 expression in human bronchial epithe-
lial cells. J Cell Commun Signal 7, 109–118.
Meng, F., Henson, R., Wehbe-Janek, H., Smith, H., Ueno, Y., & Patel, T. (2007). The
MicroRNA let-7a modulates interleukin-6-dependent STAT-3 survival signaling in
malignant human cholangiocytes. J Biol Chem 282, 8256–8264.
Mihara, M., Kasutani, K., Okazaki, M., Nakamura, A., Kawai, S., Sugimoto, M., et al. (2005).
Tocilizumab inhibits signal transduction mediated by both mIL-6R and sIL-6R, but not
by the receptors of other members of IL-6 cytokine family. Int Immunopharmacol 5,
1731–1740.
Mihara, M., Takagi, N., Takeda, Y., & Ohsugi, Y. (1998). IL-6 receptor blockage inhibits the
onset of autoimmune kidney disease in NZB/W F1 mice. Clin Exp Immunol 112,
397–402.
Miki, C., Konishi, N., Ojima, E., Hatada, T., Inoue, Y., & Kusunoki, M. (2004). C-reactive pro-
tein as a prognostic variable that reflects uncontrolled up-regulation of the IL-1-IL-6
network system in colorectal carcinoma. Dig Dis Sci 49, 970–976.
Mitsunaga, S., Ikeda, M., Shimizu, S., Ohno, I., Furuse, J., Inagaki, M., et al. (2013). Serum
levels of IL-6 and IL-1beta can predict the efficacy of gemcitabine in patients with ad-
vanced pancreatic cancer. Br J Cancer 108, 2063–2069.
Miyazawa, K., Mori, A., & Okudaira, H. (1999). IL-6 synthesis by rheumatoid synoviocytes
is autonomously upregulated at the transcriptional level. J Allergy Clin Immunol 103,
S437–S444.
Mizutani, Y., Bonavida, B., Koishihara, Y., Akamatsu, K., Ohsugi, Y., & Yoshida, O. (1995). Sen-
sitization of human renal cell carcinoma cells to cis-diamminedichloroplatinum(II) by
anti-interleukin 6 monoclonal antibody or anti-interleukin 6 receptor monoclonal anti-
body. Cancer Res 55, 590–596.
Moreau, P., Harousseau, J. L., Wijdenes, J., Morineau, N., Milpied, N., & Bataille, R. (2000). A
combination of anti-interleukin 6 murine monoclonal antibody with dexamethasone
and high-dose melphalan induces high complete response rates in advanced multiple
myeloma. Br J Haematol 109, 661–664.
Mouawad, R., Rixe, O., Meric, J. B., Khayat, D., & Soubrane, C. (2002). Serum interleukin-6
concentrations as predictive factor of time to progression in metastatic malignant
melanoma patients treated by biochemotherapy: a retrospective study. Cytokines
Cell Mol Ther 7, 151–156.
Mouawad, R., Soubrane, C., Rixe, O., Khayat, D., & Spano, J. P. (2006). An unexpected inverse
correlation between soluble epidermal growth factor receptor and interleukin-6 in
metastatic malignant melanoma patients. Melanoma Res 16, 335–340.
Muangchan, C., & Pope, J. E. (2012). Interleukin 6 in systemic sclerosis and potential im-
plications for targeted therapy. J Rheumatol 39, 1120–1124.
Mullberg, J., Oberthur, W., Lottspeich, F., Mehl, E., Dittrich, E., Graeve, L., et al. (1994). The
soluble human IL-6 receptor. Mutational characterization of the proteolytic cleavage
site. J Immunol 152, 4958–4968.
Nakahara, H., Song, J., Sugimoto, M., Hagihara, K., Kishimoto, T., Yoshizaki, K., et al. (2003).
Anti-interleukin-6 receptor antibody therapy reduces vascular endothelial growth
factor production in rheumatoid arthritis. Arthritis Rheum 48, 1521–1529.
Nanki, T., Onoue, I., Nagasaka, K., Takayasu, A., Ebisawa, M., Hosoya, T., et al. (2013).
Suppression of elevations in serum C reactive protein levels by anti-IL-6 autoan-
tibodies in two patients with severe bacterial infections. Ann Rheum Dis 72,
1100–1102.
Narazaki, M., Yasukawa, K., Saito, T., Ohsugi, Y., Fukui, H., Koishihara, Y., et al. (1993). Sol-
uble forms of the interleukin-6 signal-transducing receptor component gp130 in
human serum possessing a potential to inhibit signals through membrane-anchored
gp130. Blood 82, 1120–1126.
Naugler, W. E., & Karin, M. (2008). The wolf in sheep's clothing: the role of interleukin-6
in immunity, inflammation and cancer. Trends Mol Med 14, 109–119.
Negrier, S., Perol, D., Menetrier-Caux, C., Escudier, B., Pallardy, M., Ravaud, A., et al. (2004).
Interleukin-6, interleukin-10, and vascular endothelial growth factor in metastatic
renal cell carcinoma: prognostic value of interleukin-6–from the Groupe Francais
d'Immunotherapie. J Clin Oncol 22, 2371–2378.
Neurath, M. F., & Finotto, S. (2011). IL-6 signaling in autoimmunity, chronic inflammation
and inflammation-associated cancer. Cytokine Growth Factor Rev 22, 83–89.
Neveu, W. A., Allard, J. B., Dienz, O., Wargo, M. J., Ciliberto, G., Whittaker, L. A., et al. (2009).
IL-6 is required for airway mucus production induced by inhaled fungal allergens. J
Immunol 183, 1732–1738.
Nilsson, M. B., Langley, R. R., & Fidler, I. J. (2005). Interleukin-6, secreted by human ovarian
carcinoma cells, is a potent proangiogenic cytokine. Cancer Res 65, 10794–10800.
Nishimoto, N., Kanakura, Y., Aozasa, K., Johkoh, T., Nakamura, M., Nakano, S., et al. (2005).
Humanized anti-interleukin-6 receptor antibody treatment of multicentric Castleman
disease. Blood 106, 2627–2632.
Nishimoto, N., Sasai, M., Shima, Y., Nakagawa, M., Matsumoto, T., Shirai, T., et al. (2000).
Improvement in Castleman's disease by humanized anti-interleukin-6 receptor anti-
body therapy. Blood 95, 56–61.
Nishimoto, N., Terao, K., Mima, T., Nakahara, H., Takagi, N., & Kakehi, T. (2008). Mech-
anisms and pathologic significances in increase in serum interleukin-6 (IL-6) and
soluble IL-6 receptor after administration of an anti-IL-6 receptor antibody, toci-
lizumab, in patients with rheumatoid arthritis and Castleman disease. Blood 112,
3959–3964.
Ogata, A., & Tanaka, T. (2012). Tocilizumab for the treatment of rheumatoid arthritis and
other systemic autoimmune diseases: current perspectives and future directions. Int J
Rheumatol 2012, 946048.
Okada, S., Okusaka, T., Ishii, H., Kyogoku, A., Yoshimori, M., Kajimura, N., et al. (1998). El-
evated serum interleukin-6 levels in patients with pancreatic cancer. Jpn J Clin Oncol
28, 12–15.
O'Reilly, S., Ciechomska, M., Cant, R., Hugle, T., & van Laar, J. M. (2012). Interleukin-6, its
role in fibrosing conditions. Cytokine Growth Factor Rev 23, 99–107.
Palmqvist, P., Persson, E., Conaway, H. H., & Lerner, U. H. (2002). IL-6, leukemia inhibitory
factor, and oncostatin M stimulate bone resorption and regulate the expression of re-
ceptor activator of NF-kappa B ligand, osteoprotegerin, and receptor activator of
NF-kappa B in mouse calvariae. J Immunol 169, 3353–3362.
Peranzoni, E., Zilio, S., Marigo, I., Dolcetti, L., Zanovello, P., Mandruzzato, S., et al. (2010).
Myeloid-derived suppressor cell heterogeneity and subset definition. Curr Opin
Immunol 22, 238–244.
Pollard, J. W. (2004). Tumour-educated macrophages promote tumour progression and
metastasis. Nat Rev Cancer 4, 71–78.
Pu, Y. S., Hour, T. C., Chuang, S. E., Cheng, A. L., Lai, M. K., & Kuo, M. L. (2004). Interleukin-6
is responsible for drug resistance and anti-apoptotic effects in prostatic cancer cells.
Prostate 60, 120–129.
Quintas-Cardama, A., Manshouri, T., Estrov, Z., Harris, D., Zhang, Y., Gaikwad, A., et al.
(2010). Preclinical characterization of atiprimod, a novel JAK2 AND JAK3 inhibitor.
Invest New Drugs 29, 818–826.
Rabinovich, A., Medina, L., Piura, B., Segal, S., & Huleihel, M. (2007). Regulation of ovarian
carcinoma SKOV-3 cell proliferation and secretion of MMPs by autocrine IL-6.
Anticancer Res 27, 267–272.
Ravishankaran, P., & Karunanithi, R. (2011). Clinical significance of preoperative serum
interleukin-6 and C-reactive protein level in breast cancer patients. World J Surg
Oncol 9, 18.
Rhodes, B., Furnrohr, B. G., & Vyse, T. J. (2011). C-reactive protein in rheumatology: biol-
ogy and genetics. Nat Rev Rheumatol 7, 282–289.
Rincon, M. (2012). Interleukin-6: from an inflammatory marker to a target for inflamma-
tory diseases. Trends Immunol 33, 571–577.
Rincon, M., & Irvin, C. G. (2012). Role of IL-6 in asthma and other inflammatory pulmo-
nary diseases. Int J Biol Sci 8, 1281–1290.
Rose-John, S., Scheller, J., Elson, G., & Jones, S. A. (2006). Interleukin-6 biology is coordinat-
ed by membrane-bound and soluble receptors: role in inflammation and cancer. J
Leukoc Biol 80, 227–236.
Rossi, J. F., Fegueux, N., Lu, Z. Y., Legouffe, E., Exbrayat, C., Bozonnat, M. C., et al. (2005).
Optimizing the use of anti-interleukin-6 monoclonal antibody with dexamethasone
and 140 mg/m2 of melphalan in multiple myeloma: results of a pilot study including
biological aspects. Bone Marrow Transplant 36, 771–779.
Rossi, J. F., Negrier, S., James, N. D., Kocak, I., Hawkins, R., Davis, H., et al. (2010). A phase
I/II study of siltuximab (CNTO 328), an anti-interleukin-6 monoclonal antibody, in
metastatic renal cell cancer. Br J Cancer 103, 1154–1162.
Ruff, K. R., Puetter, A., & Levy, L. S. (2007). Growth regulation of simian and human
AIDS-related non-Hodgkin's lymphoma cell lines by TGF-beta1 and IL-6. BMC Cancer
7, 35.
Ruiz-Irastorza, G., Khamashta, M.A., Castellino, G., & Hughes, G. R. (2001). Systemic lupus
erythematosus. Lancet 357, 1027–1032.
Salgado, R., Junius, S., Benoy, I., Van Dam, P., Vermeulen, P., Van Marck, E., et al. (2003).
Circulating interleukin-6 predicts survival in patients with metastatic breast cancer.
Int J Cancer 103, 642–646.
Samson, M., Audia, S., Janikashvili, N., Ciudad, M., Trad, M., Fraszczak, J., et al. (2012). Brief
report: inhibition of interleukin-6 function corrects Th17/Treg cell imbalance in pa-
tients with rheumatoid arthritis. Arthritis Rheum 64, 2499–2503.
Sanchez-Correa, B., Bergua, J. M., Campos, C., Gayoso, I., Arcos, M. J., Banas, H., et al.
(2013). Cytokine profiles in acute myeloid leukemia patients at diagnosis: surviv-
al is inversely correlated with IL-6 and directly correlated with IL-10 levels.
Cytokine 61, 885–891.
Sansone, P., Storci, G., Tavolari, S., Guarnieri, T., Giovannini, C., Taffurelli, M., et al. (2007).
IL-6 triggers malignant features in mammospheres from human ductal breast carci-
noma and normal mammary gland. J Clin Invest 117, 3988–4002.
Santer, F. R., Malinowska, K., Culig, Z., & Cavarretta, I. T. (2010). Interleukin-6 trans-signalling
differentially regulates proliferation, migration, adhesion and maspin expression in
human prostate cancer cells. Endocr Relat Cancer 17, 241–253.
Sato, K., Tsuchiya, M., Saldanha, J., Koishihara, Y., Ohsugi, Y., Kishimoto, T., et al. (1993).
Reshaping a human antibody to inhibit the interleukin 6-dependent tumor cell
growth. Cancer Res 53, 851–856.
Schneider, A., Long, S. A., Cerosaletti, K., Ni, C. T., Samuels, P., Kita, M., et al. (2013). In ac-
tive relapsing-remitting multiple sclerosis, effector T cell resistance to adaptive
T(regs) involves IL-6-mediated signaling. Sci Transl Med 5, 170ra115.
Scott, H. R., McMillan, D. C., Crilly, A., McArdle, C. S., & Milroy, R. (1996). The relationship be-
tween weight loss and interleukin 6 in non-small-cell lung cancer. Br J Cancer 73,
1560–1562.
Seavey, M. M., Lu, L. D., Stump, K. L., Wallace, N. H., Hockeimer, W., O'Kane, T. M., et al.
(2012). Therapeutic efficacy of CEP-33779, a novel selective JAK2 inhibitor, in a
mouse model of colitis-induced colorectal cancer. Mol Cancer Ther 11, 984–993.
 X. Yao et al. / Pharmacology & Therapeutics 141 (2014) 125–139
Serada, S., Fujimoto, M., Mihara, M., Koike, N., Ohsugi, Y., Nomura, S., et al. (2008). IL-6 block-
ade inhibits the induction of myelin antigen-specific Th17 cells and Th1 cells in experi-
mental autoimmune encephalomyelitis. Proc Natl Acad Sci U S A 105, 9041–9046.
Shima, Y., Kuwahara, Y., Murota, H., Kitaba, S., Kawai, M., Hirano, T., et al. (2010). The skin
of patients with systemic sclerosis softened during the treatment with anti-IL-6 re-
ceptor antibody tocilizumab. Rheumatology (Oxford) 49, 2408–2412.
Shimazaki, J., Goto, Y., Nishida, K., Tabuchi, T., Motohashi, G., & Ubukata, H. (2013). In pa-
tients with colorectal cancer, preoperative serum interleukin-6 level and
granulocyte/lymphocyte ratio are clinically relevant biomarkers of long-term cancer
progression. Oncology 84, 356–361.
Shinriki, S., Jono, H., Ota, K., Ueda, M., Kudo, M., Ota, T., et al. (2009). Humanized
anti-interleukin-6 receptor antibody suppresses tumor angiogenesis and in vivo
growth of human oral squamous cell carcinoma. Clin Cancer Res 15, 5426–5434.
Shinriki, S., Jono, H., Ueda, M., Ota, K., Ota, T., Sueyoshi, T., et al. (2011). Interleukin-6 signal-
ling regulates vascular endothelial growth factor-C synthesis and lymphangiogenesis in
human oral squamous cell carcinoma. J Pathol 225, 142–150.
Shirota, Y., Yarboro, C., Fischer, R., Pham, T. H., Lipsky, P., & Illei, G. G. (2012). Impact of
anti-interleukin-6 receptor blockade on circulating T and B cell subsets in patients
with systemic lupus erythematosus. Ann Rheum Dis 72, 118–128.
Slattery, M. L., Wolff, R. K., Herrick, J. S., Caan, B. J., & Potter, J.D. (2007). IL6 genotypes and
colon and rectal cancer. Cancer Causes Control 18, 1095–1105.
Smith, K. C., Bateman, A.C., Fussell, H. M., & Howell, W. M. (2004). Cytokine gene polymor-
phisms and breast cancer susceptibility and prognosis. Eur J Immunogenet 31, 167–173.
Smolen, J. S., Aletaha, D., Koeller, M., Weisman, M. H., & Emery, P. (2007). New therapies
for treatment of rheumatoid arthritis. Lancet 370, 1861–1874.
Smolen, J. S., Beaulieu, A., Rubbert-Roth, A., Ramos-Remus, C., Rovensky, J., Alecock, E.,
et al. (2008). Effect of interleukin-6 receptor inhibition with tocilizumab in patients
with rheumatoid arthritis (OPTION study): a double-blind, placebo-controlled,
randomised trial. Lancet 371, 987–997.
Solary, E., Guiguet, M., Zeller, V., Casasnovas, R. O., Caillot, D., Chavanet, P., et al. (1992).
Radioimmunoassay for the measurement of serum IL-6 and its correlation with tu-
mour cell mass parameters in multiple myeloma. Am J Hematol 39, 163–171.
Song, L., Rawal, B., Nemeth, J. A., & Haura, E. B. (2011). JAK1 activates STAT3 activity in
non-small-cell lung cancer cells and IL-6 neutralizing antibodies can suppress
JAK1–STAT3 signaling. Mol Cancer Ther 10, 481–494.
Stahl, E. A., Raychaudhuri, S., Remmers, E. F., Xie, G., Eyre, S., Thomson, B. P., et al. (2010).
Genome-wide association study meta-analysis identifies seven new rheumatoid ar-
thritis risk loci. Nat Genet 42, 508–514.
Steiner, H., Cavarretta, I. T., Moser, P. L., Berger, A. P., Bektic, J., Dietrich, H., et al. (2006).
Regulation of growth of prostate cancer cells selected in the presence of
interleukin-6 by the anti-interleukin-6 antibody CNTO 328. Prostate 66, 1744–1752.
Suchi, K., Fujiwara, H., Okamura, S., Okamura, H., Umehara, S., Todo, M., et al. (2011).
Overexpression of Interleukin-6 suppresses cisplatin-induced cytotoxicity in esopha-
geal squamous cell carcinoma cells. Anticancer Res 31, 67–75.
Takagi, N., Mihara, M., Moriya, Y., Nishimoto, N., Yoshizaki, K., Kishimoto, T., et al.
(1998). Blockage of interleukin-6 receptor ameliorates joint disease in murine
collagen-induced arthritis. Arthritis Rheum 41, 2117–2121.
Tanaka, T., & Kishimoto, T. (2012). Immunotherapeutic implication of IL-6 blockade.
Immunotherapy 4, 87–105.
Tanaka, T., Narazaki, M., & Kishimoto, T. (2011). Anti-interleukin-6 receptor antibody,
tocilizumab, for the treatment of autoimmune diseases. FEBS Lett 585, 3699–3709.
Tang, R. F., Wang, S. X., Zhang, F. R., Peng, L., Xiao, Y., & Zhang, M. (2005). Interleukin-1alpha,
6 regulate the secretion of vascular endothelial growth factor A, C in pancreatic cancer.
Hepatobiliary Pancreat Dis Int 4, 460–463.
Tassone, P., Galea, E., Forciniti, S., Tagliaferri, P., & Venuta, S. (2002). The IL-6 receptor
super-antagonist Sant7 enhances antiproliferative and apoptotic effects induced by
dexamethasone and zoledronic acid on multiple myeloma cells. Int J Oncol 21,
867–873.
Tchirkov, A., Khalil, T., Chautard, E., Mokhtari, K., Veronese, L., Irthum, B., et al. (2007).
Interleukin-6 gene amplification and shortened survival in glioblastoma patients. Br
J Cancer 96, 474–476.
Tisi, M. C., Bozzoli, V., Giachelia, M., Massini, G., Ricerca, B.M., Maiolo, E., et al. (2013). Ane-
mia in diffuse large B cell non-Hodgkin lymphoma: the role of IL-6, hepcidin and
erythropoietin. Leuk Lymphoma, May 6 (Epub ahead of print).
Trikha, M., Corringham, R., Klein, B., & Rossi, J. F. (2003). Targeted anti-interleukin-6
monoclonal antibody therapy for cancer: a review of the rationale and clinical evi-
dence. Clin Cancer Res 9, 4653–4665.
Tsuboi, I., Tanaka, H., Nakao, M., Shichijo, S., & Itoh, K. (1995). Nonsteroidal anti-inflammatory
drugs differentially regulate cytokine production in human lymphocytes: up-regulation
of TNF, IFN-gamma and IL-2, in contrast to down-regulation of IL-6 production. Cytokine
7, 372–379.
van Rhee, F., Fayad, L., Voorhees, P., Furman, R., Lonial, S., Borghaei, H., et al. (2010).
Siltuximab, a novel anti-interleukin-6 monoclonal antibody, for Castleman's disease.
J Clin Oncol 28, 3701–3708.
139
Vasilopoulos, Y., Sourli, F., Zafiriou, E., Klimi, E., Ioannou, M., Mamuris, Z., et al. (2013).
High serum levels of HIF-1alpha in psoriatic patients correlate with an
over-expression of IL-6. Cytokine 62, 38–39.
Veldhoen, M., Hocking, R. J., Atkins, C. J., Locksley, R. M., & Stockinger, B. (2006). TGFbeta
in the context of an inflammatory cytokine milieu supports de novo differentiation of
IL-17-producing T cells. Immunity 24, 179–189.
Voorhees, P.M., Chen, Q., Kuhn, D. J., Small, G. W., Hunsucker, S. A., Strader, J. S., et al.
(2007). Inhibition of interleukin-6 signaling with CNTO 328 enhances the activity of
bortezomib in preclinical models of multiple myeloma. Clin Cancer Res 13, 6469–6478.
Voorhees, P.M., Chen, Q., Small, G. W., Kuhn, D. J., Hunsucker, S. A., Nemeth, J. A., et al.
(2009). Targeted inhibition of interleukin-6 with CNTO 328 sensitizes pre-clinical
models of multiple myeloma to dexamethasone-mediated cell death. Br J Haematol
145, 481–490.
Voorhees, P.M., Manges, R. F., Sonneveld, P., Jagannath, S., Somlo, G., Krishnan, A., et al.
(2013). A phase 2 multicentre study of siltuximab, an anti-interleukin-6 monoclonal
antibody, in patients with relapsed or refractory multiple myeloma. Br J Haematol
161, 357–366.
Waage, A., Slupphaug, G., & Shalaby, R. (1990). Glucocorticoids inhibit the production of
IL6 from monocytes, endothelial cells and fibroblasts. Eur J Immunol 20, 2439–2443.
Wallner, L., Dai, J., Escara-Wilke, J., Zhang, J., Yao, Z., Lu, Y., et al. (2006). Inhibition of
interleukin-6 with CNTO328, an anti-interleukin-6 monoclonal antibody, inhibits
conversion of androgen-dependent prostate cancer to an androgen-independent
phenotype in orchiectomized mice. Cancer Res 66, 3087–3095.
Watson, J. M., Sensintaffar, J. L., Berek, J. S., & Martinez-Maza, O. (1990). Constitutive pro-
duction of interleukin 6 by ovarian cancer cell lines and by primary ovarian tumor
cultures. Cancer Res 50, 6959–6965.
Weissglas, M., Schamhart, D., Lowik, C., Papapoulos, S., Vos, P., & Kurth, K. H. (1995). Hy-
percalcemia and cosecretion of interleukin-6 and parathyroid hormone related pep-
tide by a human renal cell carcinoma implanted into nude mice. J Urol 153, 854–857.
Xu, Z., Bouman-Thio, E., Comisar, C., Frederick, B., Van Hartingsveldt, B., Marini, J. C., et al.
(2011). Pharmacokinetics, pharmacodynamics and safety of a human anti-IL-6
monoclonal antibody (sirukumab) in healthy subjects in a first-in-human study. Br
J Clin Pharmacol 72, 270–281.
Yamamoto, M., Yoshizaki, K., Kishimoto, T., & Ito, H. (2000). IL-6 is required for the devel-
opment of Th1 cell-mediated murine colitis. J Immunol 164, 4878–4882.
Yanbaeva, D.G., Dentener, M.A., Spruit, M.A., Houwing-Duistermaat, J. J., Kotz, D., Passos,
V. L., et al. (2009). IL6 and CRP haplotypes are associated with COPD risk and systemic
inflammation: a case-control study. BMC Med Genet 10, 23.
Yao, Z., Fenoglio, S., Gao, D. C., Camiolo, M., Stiles, B., Lindsted, T., et al. (2010). TGF-beta
IL-6 axis mediates selective and adaptive mechanisms of resistance to molecular
targeted therapy in lung cancer. Proc Natl Acad Sci U S A 107, 15535–15540.
Yokota, S., Imagawa, T., Mori, M., Miyamae, T., Aihara, Y., Takei, S., et al. (2008). Efficacy and
safety of tocilizumab in patients with systemic-onset juvenile idiopathic arthritis: a
randomised, double-blind, placebo-controlled, withdrawal phase III trial. Lancet 371,
998–1006.
Yokota, S., & Kishimoto, T. (2010). Tocilizumab: molecular intervention therapy in chil-
dren with systemic juvenile idiopathic arthritis. Expert Rev Clin Immunol 6, 735–743.
Yokoyama, A., Kohno, N., Fujino, S., Hamada, H., Inoue, Y., Fujioka, S., et al. (1995). Circu-
lating interleukin-6 levels in patients with bronchial asthma. Am J Respir Crit Care Med
151, 1354–1358.
Yoshida, N., Ikemoto, S., Narita, K., Sugimura, K., Wada, S., Yasumoto, R., et al. (2002). In-
terleukin-6, tumour necrosis factor alpha and interleukin-1beta in patients with renal
cell carcinoma. Br J Cancer 86, 1396–1400.
Yoshio-Hoshino, N., Adachi, Y., Aoki, C., Pereboev, A., Curiel, D. T., & Nishimoto, N. (2007).
Establishment of a new interleukin-6 (IL-6) receptor inhibitor applicable to the gene
therapy for IL-6-dependent tumor. Cancer Res 67, 871–875.
Yoshizaki, K., Matsuda, T., Nishimoto, N., Kuritani, T., Taeho, L., Aozasa, K., et al. (1989).
Pathogenic significance of interleukin-6 (IL-6/BSF-2) in Castleman's disease. Blood
74, 1360–1367.
Yu, H., Pardoll, D., & Jove, R. (2009). STATs in cancer inflammation and immunity: a lead-
ing role for STAT3. Nat Rev Cancer 9, 798–809.
Yu, C. C., Tsai, L. L., Wang, M. L., Yu, C. H., Lo, W. L., Chang, Y. C., et al. (2013). miR145 tar-
gets the SOX9/ADAM17 axis to inhibit tumor-initiating cells and IL-6-mediated para-
crine effects in head and neck cancer. Cancer Res 73, 3425–3440.
Zhang, Y., Wang, X., Zhong, M., Zhang, M., Suo, Q., & Lv, K. (2013). MicroRNA let-7a ame-
liorates con A-induced hepatitis by inhibiting IL-6-dependent Th17 cell differentia-
tion. J Clin Immunol 33, 630–639.
Zhang, J., Xie, S., Ma, W., Teng, Y., Tian, Y., Huang, X., et al. (2013). A newly identified
microRNA, mmu-miR-7578, functions as a negative regulator on inflammatory cyto-
kines tumor necrosis factor-alpha and interleukin-6 via targeting Egr1 in vivo. J Biol
Chem 288, 4310–4320.
Zhuang, Y., Xu, Z., de Vries, D. E., Wang, Q., Shishido, A., Comisar, C., et al. (2013). Pharma-
cokinetics and safety of sirukumab following a single subcutaneous administration to
healthy Japanese and Caucasian subjects. Int J Clin Pharmacol Ther 51, 187–199.