à chronic, systemic inflammatory disorder characterised by
polyarthiritis with progressive joint damage and disability,
immunological abnormalities and systemic inflammation
à genetic and environmental risk factors with a strong
autoimmune component
- Environmental risk factors include infection and
smoking
à attacks synovial joints (synovitis) + initiialy affects small
joints
à systemic autoimmune disease
• Affects 1% of the world population
• Women 3x more than men
• Onset often between 40-50 years
• à increased co-morbidity as the disease is systemic
and affects other organs including the skin
(rheumatoid nodules), lungs (fibrosis), kidneys
(amyloidosis), heart (myocardial infarction,
pericarditis, fibrosis) and blood vessels
(atherosclerosis)
Common autoantibodies to (neo antigens)
1. Antibodies to IgG with defective glycosylation
(rheumatoid factor, RF)
à 75% patients contain RF, so used as diagnostic marker
à RFs are antibodies directed to the Fc region of IgG molecules.
They are found in every immunoglobulin class (IgG, IgM, IgA,
IgE). RF of the IgG class has a self-binding capacity that can
result in the formation of very large immune complexes, which
are able to further activate the immune system
à binding between the Fab of one RF molecule and Fc of
another is promoted by defective glycosylation of Fc region,
leaving a pocket for binding of a Fab galactose residue,
increasing strength of intermolecular binding
à These are stable and pro-inflammatory complexes than can
bind and activate complement
2. Antibodies to citrullinated peptides
à Conversion of basic amino acid arginine to neutral residue
citrulline is catalysed by enzyme peptidyl arginine deiminase
(PADI)
à modification is essential for autogenicity of a number of
citrullinated proteins, including fibrin in the synovial joint
à Genetic polymorphisms in PADI4 could play a role in
citrullination of proteins in RA, and influence the development
of antibodies to citrullinated proteins
à Smoking increases citrullination of proteins and the
generation of citrullinated peptide-specific antibodies
à B-cells from synovial fluid of anti-CCP (anti-cyclic citrullinated
peptide-a standard cyclic peptide recognised by a range of RA
autoantibodies) positive RA patients, spontaneously produce
anti-CCP antibodies, but B-cells in the circulation do not,
indicating the presence of citrullinated peptides (neoantigens) in
the synovial fluid, driving the maturation of CCP-specific B-cells
at the site of inflammation
à Only patients with RA develop antibodies to citrullinated
synovial proteins
à Activated autoreactive TH cells are involved in
the pathogenesis of RA and assist B cells to
differentiate and produce pathogenic
autoantibodies
à two most characteristic autoantibodies are
rheumatoid factor (RF), an antibody (that may be
IgM, IgA or IgG), that binds to Fc portion of IgG in
circulation, and antibodies to citrullinated peptides,
(anti-CCP), in which arginine is converted to
citrulline
- Anti-CCP is specific to RA while RF is found
in 70% of RA cases but also in other
diseases
- Smoking increases the frequency of RF
à Cytokines contribute to the underlying immune
dysfunction and to immune-mediated events that
damage the target organs
à RA patients produce autoantibodies to many
autoantigens and RA can be transferred by
antibodies
Developments + selection of T cells in thymus
à normally in thymus, thymocytes develop
double positive cells, expressing CD4 + CD8 + low
levels of the αβ TCR
à undergo positive selection for weak, low
affinity, interaction with self MHC class I or class
II on cortical epithelium (cells selected for
usefulness)
à unselected/self-reactive cells undergo
apoptosis
à positive selection cells lose 1 or other of co-
receptor molecules (CD4/8)
à cells that interact with MHC class I om thymic
epithelium becomes CD8 +, whereas MHC class II
is CD4+
à mature T cell pool contains T cells able to
react with foreign proteins + react weakly to self
antigens
à major genetic risk factor for RA is in the HLA
gene coding for MHC class II and is associated
with the presence of autoantibodies
à Defective positive and negative selection in
the thymus
à Defects in positive selection may cause
lymphopenia (a decrease in the number of
circulating T-cells)
à Lymphopenia due to a decreased output from
the thymus is followed by a cycle of peripheral
homeostatic proliferation, or self-replication, of
naïve T-cells to restore T-cell numbers
à This process of expansion in the periphery
favours T-cells with autoreactive potential
à increases risk of developing inflammation in
the synovium in RA
A model of T-cell repertoire selection in RA Normal synovial joint:
à accelerated self-replication of peripheral T cells, which à unique synovial cavity between articulating
compensates for a premature decline in thymic output, particularly bones
in aged individuals. - Moves freely (diarthroses)
àmost patients, RA occurs at the age of 40-50, several decades à covered in hyaline cartilage, articular
after formation of the T-cell repertoire has finished and thymic cartilage
function is reduced or ceased - Reduces friction during movement
à Peripheral T-cell homeostasis maintained through positive - Absorbs shock
selection and the replication of naïve T-cells that recognise self à sleeve-live articular joint capsule
antigens. surrounding encloses synovial cavity + unites
- With peripheral selection being prominent, T-cell repertoire articulating bones
loses diversity and is biased towards autoreactivity - 2 layers, outer fibrous membrane +
- disease reflects a breakdown in tolerance to common inner synovial membrane
antigens that are preferentially recognized in the synovium à Fibrous membrane, dense collagen fibres
and clonal expansion of autoreactive T-cells. attach to bone, provides flexibility, great
- best characterised autoimmune responses in patients RA tensile strength
are directed at neoantigens - Parallel bundles, resist strain
à Autoreactive T-cells develop into potent effector cells - Ligaments
à T-cell effector functions acquired with premature senescence à connective tissue, inner synovial
are crucial in shaping the disease manifestations. membrane contains elastic fibres + fibroblast
- For example, they lose expression of CD28 and become like cells (synoviocytes)
independent of co-stimulation pathways for activation and - Secrets hyaluronic acid
function. They have increased resistance to apoptosis, - Interstitial fluid filtered from blood
increased survival and cytotoxic abilities through perforins plasma combines w/ hyaluronic acid to
and granzymes (normally found in CD8 cells). form viscous fluid called synovial fluid,
à Regulatory T-cells are a natural T-cell subset generated in which coats surfaces within articular
thymus, that regulate peripheral immune responses. capsule and acts as lubricant
- deficiency in regulatory T-cell (Treg) function, and limited à chondrocytes, no direct blood supply but
ability to suppress antigen presentation and T-cell receive O2 + nutrients via synovial fluid
activation through the immunosuppressive cytokines TGFβ à synovial fluid contains macrophages to
and IL-10. remove microbes + debris
- Depletion or functional degeneration of regulatory T-cells - Very viscous
favours inflammatory responses. - More fluid means less stress at joints
in exercise
The (a) normal and (b) inflamed synovial joint
à healthy
- Synovial membrane lines non weight bearing aspects of joint
à RA
- Synovial membrane becomes hyperplastic (increased proliferation of
synoviocytes)
- B-cell activation results in the production of antibodies including RF
- Cytokine networks are present that drive the inflammatory response
and induce self-perpetuating inflammation
- High levels of cytokines have been measured in inflamed synovium.
Include IL-1, IL-2, IL-6, IL-8, IL-10, IL-17, TNF-α, platelet-derived growth
factor (PDGF), TGFβ and are produced mainly by T-cells and
macrophages
- Naïve T-cells are activated by APC locally, in joint, and in presence of IL-6
and IL-1 or IL-21 or IL-22, differentiate into a CD4+ Th17 subset of T-
helper cells that produce IL-17.
- T-cells are important in the regulation of autoimmune responses,
including RA
- CD4+ Th1 cells produce IFNγ and CD4+ Th2 cells produce IL-4 and IL-5
- Extensive angiogenesis brings more cells to the tissue
- develops into a pannus, which is invasive and migrates into articular
cartilage and underlying bone, and begins to destroy it.
CD4+ T-cell subsets-the new paradigm role of IL-17 in cartilage destruction
à CD4+ T-helper (Th) precursor cells are activated by the à Articular cartilage is mainly composed of
antigenic stimulation of TCR and subsequently differentiated into collagen type II and proteoglycans
different subsets of effector Th-cells to boost the immune - matrix synthesised by chondrocytes, only
response cell in the tissue. There are no blood
à Th1 and Th2 thought to be the main T-cell subsets, and vessels and chondrocytes receive oxygen
differentiate in response to IFNγ and IL-4 respectively, ie the and nutrients by diffusion.
cytokines that they go on to make. à IL-17 is a cytokine with powerful
à This Th1/Th2 paradigm has recently shifted to include Tregs inflammatory properties
and Th17 helper T-cells. - High levels are found in synovial fluid in
- stimulated to differentiate by TGFβ and Th17 T-cells are patients with RA
stimulated to differentiate in response to IL-6, plus IL-1, - IL-17 increases production of a number
IL21 or IL23. of MMPs by synoviocytes (fibroblasts
à Tregs suppress responses of activated T-cells and attenuate present in large numbers in the inflamed
immune response. Deficient in RA. synovium in RA) and chondrocytes,
à Th17 cells secrete IL-17 which is important in modulating inducing matrix degradation, and inhibits
immune inflammatory response in RA. These are increased in RA collagen and proteoglycan synthesis by
chondrocytes. Ie IL-17 inhibits cartilage
Activated T-cell;
matrix synthesis and promotes its
Th1 IFNγ, TNFα
Activation of innate degradation and is associated with
defences
CD4+
abnormal cartilage destruction
à MMPs -1,-2,-9,13 are collagenases involved
Activation of B-cell
Th2 IL-4, IL-5, IL-6
antibody production in process.
à TNFα & oncostatin M enhance cartilage
CD4+ Treg TGFβ, IL-10
Suppress activated
T-cell responses
destruction in RA joint.
à IL-17 stimulates PGE2 production by
Control of
Th17 IL-17 inflammatory chondrocytes and osteoblasts ,and PGE2
autoimmune
response contributes to the inflammatory response and
ROLE OF IL-17 in bone erosion joint destruction
à RANKL (ligand for Receptor Activator of NF-κB (RANK)
receptor) Prostaglandin synthesis and effects of PGE2 on
- Osteoclast differentiation articular cells
- Direct cell cell contact between osteoclast + osteoblast à Chondrocytes and synovial fibroblasts produce
precursors needed for RANKL effects on differentiation PGE2, 2α, and 6-keto-1α, with PGE2 being the
à IL-17 stimulates PGE2 production by osteoblasts inducing major PG synthesized
RANKL expression à synthesis increased by IL-1 and TNF-α and
à osteoblasts responsible for bone formation trauma
- Make collagen I, becomes mineralised, trapped in bone à In growth plate chondrocytes, PGE2 inhibits
matrix, become osteocytes + stop making osteoid collagen synthesis
- Decreases with age à PGE2 mediated the increase in
à osteoclasts metalloprotease (MMP) production in articular
- Formed by fusion of monocyte/macrophage cell line chondrocytes and synovial fibroblasts
- Large + mononucleated (15-20 nuclei) à PGE2 promotes IL-1 expression , amplifies local
- Activity enhance by IL-6 inflammatory process
- Release hydrogen ions through carbonic anhydrase à modulate bone resorption through through
through ruffled border into resorptive cavity, acidifying stimulation of osteoclast formation from
and aiding dissolution of the mineralized bone matrix precursor stem cells
into Ca2+, H3PO4, H2CO3, water and other substance à through NO synthesis promotes the apoptosis
- H+ pumped against high conc by proton pumps, of chondrocytes, limiting cartilage synthesis
specifically a unique vacuolar-ATPase (enzyme targeted à roles in angiogenesis and neovascularisation,
for osteoporosis) to supply oxygen and nutrients to the developing
- hydrolytic enzymes, such as members of the cathepsin pannus
and matrix metalloprotease(MMP) groups, are released à induces the synthesis of angiogenic cytokines
to digest the organic components of the matrix (VEGF,) and induces endothelial proliferation and
- enzymes are released into compartment by lysosomes reduces endothelial apoptosis
COX inhibitors Therapeutic approaches:
à NSAIDs reduce symptoms of RA but don’t slow or à DMARDs relieve symptoms, (the number of swollen and
reverse disease painful joints and levels of rheumatoid factor) and may halt
à COX 1 or reverse the disease process
- Expressed in all cells - May take months, reduces effects of NSAIDs +
- Inhibitors associated with unwanted side corticosteroids
effects in gut à Sulfasalazine; First choice DMARD
- PGs present throughout the GI tract ( controls à combination of sulfonamide and a salicylate that can
acid secretion, bicarbonate secretion, mucous produce remission in RA
production, and mucosal blood flow) à broken down in the gut to release 5-amino salicylic acid,
à COX 2 which can scavenge reactive free radicals produced by
- Aim is inhibit cox 2, reduces PGE2 synthesis neutrophils that contribute to tissue damage
- Inhibition reduces vasodilation, oedema and à Gold compounds, such as sodium aurothiomalate
pain (intramuscular) and auranofin (oral) accumulate in synovial
- both chondrocytes and osteoblasts are cells in inflamed joints and in other tissues and are thought
activated by IL-17 to release PGE2, which to inhibit cytokine synthesis
increases the damage to cartilage and bone à Penicillamine, a metal chelator, decreases immune
and limits the repair process response and IL-1 synthesis. Effective in 75% of patients
- cardiovascular side effects + increased à Hydroxychloroquine, an anti-malarial, last choice for
number of heart attacks therapy (Multiple effects, inhibits T and B-cell activation,
- celecoxib (Cox-2:COX-1 = 300:1). Effective in and restores Treg/Th17 balance)
RA but some concerns over prothrombotic à Immunosuppressants; Methotrexate is a folic acid
cardiovascular side effects. Rofecoxib (Cox- antagonist with cytotoxic and immunosuppressant activity.
2:COX-1 = 1000:1), also known as Vioxx, was Inhibits purine and DNA synthesis and T-cell proliferation
withdrawn in 2004 - act during the induction of the immune response,
and inhibit IL-2 synthesis and T-cell proliferation
Anti-inflammatory effects of corticosteroids –
effects on gene transcription
include ciclosporin and tacrolimus, and steroids
Increased transcription of anti-inflammatory proteins:
- inhibit cytokine synthesis by other cells
Lipocortin-1;
b2-adrenoreceptor;
phospholipase A2 inhibitor (corticosteroids) and have anti-inflammatory effects
bronchorelaxation
Secretory leukocyte protease inhibitor;
protease inhibitor à Azathioprine interferes with purine synthesis and is
IL-1 receptor antagonist; blocks binding of IL-1 to its receptor
IL-1R2; decoy for IL-1, no functional effects cytotoxic to dividing cells, and inhibits T-cell proliferation
IkB-a;
IL-10;
inhibitor of NF-kB
anti-inflammatory cytokine
during induction of immune response
Decreased transcription of pro-inflammatory proteins:
Cytokines; IL-1, IL-2, IL-3, IL-4, IL-5, IL-6, IL-11,
à Leflunomide has specific inhibitory effects on activated
IL-12, IL-13, TNFa , GM-CSF T-cells
Chemokines; IL-8, RANTES,MIP-1a, MCP-3,eotaxin
Enzymes; iNOS, COX-2,cytoplasmic PLA2 à Corticosteroids are used to treat RA and other diseases
Endothelin-1;
NK1, NK2-receptors;
fibroblastmitogen
mediate mucus secretion, vasodilation characterised by T-cell mediated inflammation and
Adhesion molecules; ICAM-1, V-CAM, E-selectin accumulation of eosinophils, such as asthma. They do not
work well in diseases characterised by neutrophilic
Activation of pro-inflammatory genes by transcription factors
inflammation, such as cystic fibrosis or COPD
mRNA
transcription
Nuclear transcription factors; CBP/co-activators RNA polymeraseII
AP-1, NF-kB, CREB, Sp1

HAT
p50 p65

-
- Ac
Ac- Ac- Ac
-
Ac
Ac- Ac- Ac-

Repressive chromatin-DNA highly Active chromatin- acetylation of

condensed on histone core histone leads to unwinding of the DNA

àsecond-messenger systems are up-regulated

leading to activation of different nuclear
transcription factors
à Binding of factors to recognition sequences on
DNA leads to binding of CBP (CREB binding protein)
and other co-activators to different promoters and
acetylation of specific lysine groups on the histones
by intrinsic histone acetyl transferase (HAT) activity
à Mediator proteins bind RNA polymerase II and
activate gene transcription
Inhibition of pro-inflammatory genes by glucocorticosteroids Activation of anti-inflammatory genes by high dose corticosteroids
cell membrane

GCS
GCS
Active
GR nuclear membrane Active
GR
GR
mRNA
transcription c GR
Histone
Hsp90 deacetylase
y
CBP/co-activators RNA polymeraseII t
o
mRNA
HAT
p
Hsp90 RNA polymeraseII transcription
l CBP/co-activators
p65 a
p50 -
s
Ac
Ac-
-
Ac m HAT histone core
- Ac
- Ac - Ac -
Ac
-
Ac
+Ve - Ac
- Ac
Ac
GCS binding to GR stimulatestransrepression of gene transcription GRE
-

à major action of glucocorticoids is to Ac

-
Ac

switch off multiple activated Active GR binds to + ve GRE and stimulates transactivation of gene transcription
GRE; glucocorticoid response element
inflammatory genes that encode for
à high doses of glucocorticosteroids, glucocorticoid receptors
cytokines, chemokines, adhesion
homodimerize and bind to glucocorticoid response elements (GRE) in
molecules inflammatory enzymes and
the promoter region of glucocorticoid-responsive genes and this
receptors
interaction switches on gene transcription of anti-inflammatory genes
à genes are switched on in airways by
à Activation of glucocorticoid-responsive genes occurs via an
pro-inflammatory transcription factors,
interaction between the DNA-bound GR and transcriptional co-activator
such as nuclear factor-kB (NF-kB) and
molecules such as CREB-binding protein, which have intrinsic histone
activator protein-1 (AP-1), both of
acetyltransferase activity and cause acetylation of core histones (tags
which are usually activated at sites of
histones to recruit RNA polymerase II) results in gene activation
inflammation in asthma and COPD,
à Genes that are switched on by glucocorticoids include genes encoding
resulting in switching on of multiple
beta2-adrenergic receptors and the anti-inflammatory proteins
inflammatory genes
secretory leukoprotease inhibitor and IL-10. May contribute to the anti-
à genes are activated through
inflammatory actions of glucocorticoids.
interactions with transcriptional co-
à Side effects of corticosteroids
activator molecules in a similar manner
- GR interaction with negative GREs, or to GREs that cross
to that described for GR-mediated gene
transcriptional start site, may suppress gene transcription and
transcription
this may be important in mediating many of the side effects of
à Activated GR interact with co-
glucocorticoids, such as inhibition of osteocalcin that is required
repressor molecules to attenuate NF-
for bone synthesis
kB-associated co-activator activity, thus
- long term corticosteroids include osteoporosis, cataracts and
reducing histone acetylation,
steroid myopathy, contributing to the weakness of respiratory
chromatin remodelling and RNA
muscles
polymerase II actions
à Reduction of histone acetylation Biologics; inhibitors of TNF-α, the new DMARDs
occurs through the specific recruitment à infliximab (Remicade), which is a chimeric human/mouse mab, having
of histone deacetylase-2 (HDAC2) to mouse Fab (mouse anti-human TNFα) and human Fc regions
à Adalimumab
activated inflammatory gene complex
à third biologic, is a fusion protein of the extracellular domain of the TNF α
by activated GR, thereby resulting in
receptor with the constant Fc domains of human IgG
effective suppression of activated
à all have the ability to neutralise soluble TNFα and have significant positive
inflammatory genes within the nucleus therapeutic effect
à relatively safe, because genes other à Monoclonal antibodies are typically made by fusing myeloma cells
than those that encode inflammatory (immortal cancer cells) with the antibody-producing spleen cells from a
proteins are not affected mouse that has been immunized with the desired human antigen
à COPD there is reduced expression à major problem for the therapeutic use of monoclonal antibodies in
and activity of histone deacetylase -2, a medicine was that initial methods used to produce them yielded mouse, not
critical enzyme, which is required by human antibodies
corticosteroids to switch off activated - structurally similar, differences between two were sufficient to
pro-inflammatory genes. Thus, COPD is invoke immune response when mouse mabs injected into humans
relatively resistant to the anti- and resulted in rapid removal from the blood, systemic inflammatory
inflammatory effects of corticosteroids effects, and production of human anti-mouse mabs.
à Anakinra is an IL-1 receptor à recombinant DNA have been explored
antagonist, a competitive inhibitor of IL-1 à mouse DNA encoding the binding portion of a monoclonal antibody was
binding to its receptor, preventing IL-1 merged with human antibody-producing DNA in living cells, and the
mediated inflammation. Biologics are expression of this chimeric DNA
given together with DMARDs