Systemic Lupus Erythematosus: Are there triggers and association to a mixed connective tissue disease?

By

Edward L. Treadwell, MDProfessor of MedicineRheumatology/ImmunologyBrody School of Medicine at East Carolina UniversityEmail: treadwelle@ecu.eduPhone: (252) 744-2533

Systemic Lupus Erythematosus

Immunologic Associations• B and T cell dysfunction• Antinuclear autoantibodies (ds or native-

DNA, Sm, nRNP, SS-A(Ro), SS-B (La), Su)

• Immune complexes (IgG and IgM)• Antiphospholipid antibodies, lupus

anticoagulants, positive syphilis test

Criteria for the Classification of Systemic Lupus Erythematosus

1. Malar rash2. Discoid rash3. Photosensitivity4. Oral ulcers5. Arthritis6. Serositis7. Renal disorder8. Neurologic disorder9. Hematologic disorder10. Immunologic disorder11. Antinuclear antibody

4 of 11 criteria required for diagnosis of systemic lupus erythematosus (criteria revised 1997; Primer on the Rheumatic Diseases; 13th

edition. Arthritis Foundation, Atlanta, GA, 2009).

Mixed Connective Tissue DiseasesClinical Clues• Fatigue• Fever of unknown origin• Symmetrical joint pain/swelling/warmth• Morning stiffness• Skin rashes/alopecia• Muscle weakness• Raynaud’s• Sclerodactyly• Dysphagia/motility dysfunction• Headaches/neuropathies/altered mental status• Ulcers – chronic• Elevated immunoglobulins (polyclonal elevation)• Cryoglobulins• Rheumatoid factors• Antinuclear antibodies• T-cells with abnormal numbers• Increase creatinine phosphokinase (CPKs). Serum aldolase, and other muscle

enzymes

Table 5Characteristics of 34 Patients with Mixed Connective Disease

Characteristic Number PercentageRaynaud’s phenomenon 31 91Polyarthritis 29 85Swollen hands or sclerodactyly 29 85Pulmonary disease 29 85Inflammatory myositis 27 79Esophageal hypomotility 25 74Lymphadenopathy 17 50Alopecia 13 41Pleuritis 12 35Malar rash 10 29Renal disease 9 26Cardiac disease 9 26Anemia 8 24Leukopenia 7 21Diffuse scleroderma 7 21Sjogren’s syndrome 4 12Trigeminal neuropathy 2 6Positive antinuclear antibody 34 100Positive ribonucleoprotein antibody 34 100Positive rheumatoid agglutinins 20 59Hypergammaglobulinemia 18 53Hypocomplementemia 11 32Positive LE cell test 6 18

(From Sullivan, W.D.k et al; Medicine 63:92-107, 1984)

Table 1

Mortality rate in patients who have mixed connective tissue diseaseFirst author, year No. of Disease No. of deaths

patients duration (y) (mortality rate in %)_______________________________________________________________________________

______Sharp, 1976 100 6 4 (4)Singsen, 1977 15 6.8 4 (27)Nimelstein, 1980 22 12 8 (36)Bennett, 1980 20 5 (follow-up) 4 (20)Grant, 1981 23 8.3 (follow-up) 5 (22)Sullivan, 1984 34 11 4 (12)Piirainen, 1990 23 17 5 (22)Michels, 1997 33 7.6 2 (6)Burdt, 1999 47 15 (follow-up) 11 (23)

Total 317 47 (15)

Modified from - Lundberg IE: Rheum Dis Clin N Am. 31:538, 2005

Systemic Lupus ErythematosusPossible Triggers

Genetic SusceptibilityCytoChrome P450 EnzymesCYP19, CYP1A2, CYP3A4

Tumor necrosis factor N-Acetyl Transferase

(NAT)

Nutritional Susceptibilityantioxidantsfatty acidsdietary fat

Hormonal Exposures•age at menarche•menstrual cycle patterns •medications (hormone replacement •oral contraceptives, fertility drugs)•endogenous estrogen, androgen•prolactin levels

Environmental Exposures

•silica dust •solvents•smoking•environmental

endocrine modulators(dioxin, pesticides)

Infectious Exposures

•herpetoviral (Epstein Barr,cytomegalovirus, herpes zoster)

•retrovial (endogenous or infectious)

HORMONAL MODULATORS AND CONNECTIVE TISSUE DISEASES

Pesticides (Alkyl Halides)• Organochlorine (Estrogens)• Organophosphate (Estrogens)• DDE (1, 1-dichlorophenyl) ethane

- metabolite of DDT or 1, 1 – trichloro-2, 2-bis (p-chlorophenyl) ethane (anti-androgenic)

HORMONAL METABOLIC PATHWAYS ASSOCIATED WITH CONNECTIVE TISSUE DISEASES

• Cytochrome P450 – Sex Steroid Hormones from Cholesterol

• Cyp 19 Gene – Codes for Aromatase (microsomal enzyme)(Converts androstenedione to estrone and testosterone to estradiol)

• CyP1A2 – P450 enzyme causes C2 hydroxylation• Cyp3A4 – P450 enzyme causes C16 hydroxylation

Carolina Lupus Study 1995-1999 ( 245 Lupus Patients)

Demographics

• Involved 60 contiguous counties in Eastern and Central North and South Carolina (4 million adults; 18 years and older, 30% African American)

ENVIRONMENTAL FACTORS AND INCREASE RISK OF SLE

• Sulfa Allergies• Tobacco Use (Smoking)• Infrequent Breast Feeding• Early Menopause• Quartz Silica Exposure• Dark hair dyes______________________________________

____Arthritis Rheum 46:1830, 2002; J. ClinicalEpidemiology 55:982, 2002; Arthritis Rheum46:1840, 2002.

PRISTANE (IMMUNOLOGICAL AND CLINICAL EFFECTS)

• Causes plasmacytomas (inhibited by indomethacin)• Induction of anti-native DNA, Sm, Su, Ribosomal P autoantibodies • Arthritis in rats and mice• Immune complex glomerulonephritis in mice• Effects partially influenced by presence of IL-6

(S.Silva et al – Am J. Path 151:689, 1997) – Absence Decreases PlasmacytomasH.B. Richards, M. Satoh, et al – Clin Exp Immunol 115:547, 1999 –Influences DNA and Chromatin Antibodies

• Dependent on CD4+ T-cells for arthritis in mice • Decreases delayed hypersensitivity to Type II Collagen

Pristane = 2, 6, 10, 14 - Tetramethylpentadecane

Mean antibody responses by antigen capture enzyme-linked immunoassay in eight BALB/c mice injected with

pristane 0-127 days.

0.454

0.496

0.612

0.675

0.7990.775

0.719

0.773

0.235

0.275 0.288

0.773

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

30 days 61 days 89 days 127 days

Days Tested

OD

405n

m

Sm

RNP

Su

Systemic Lupus Erythematosus (SLE)

Genetic Deficiency AssociationsGene Defect Clinical Effect1. C1 SLE-95%2. C4 – complete SLE-75%3. C4A SLE nephritis4. C2 SLE5. Mannose-binding protein SLE6. FcγRIIA SLE; nephritis7. FcγRIIIA-158F SLE whites

Revised: K. Sullivan: Rheumatic Disease Clinics North America26:2000, p 235.

Objectives: SLE Therapies

Review • Standard and alternative therapies for SLE• T and B cell products (cytokines and

costimulatory molecules) that are possible new therapeutic targets in the management of SLE

• Hormonal associations with SLE disease

Lupus Therapy: Standard• Acetaminophen • Salicylates/nonsteroidal anti-inflammatory drugs• Corticosteroids• Antimalarials (hydroxychloroquine)• Azathioprine• Cyclophosphamide• Chlorambucil

CellCept (mycophenolate mofetil)

• Used in Cytoxan (cyclophosphamide resistant lupus nephritis (mice and humans

• Improves serological parameters (dosage 250-2000 mg/d)

• Adverse effects - mild (nausea and diarrhea)

• Potential use with cyclophosphamide and azathioprine in lupus nephritis

Cytokines Expression in Systemic Lupus Erythematosus

Increased Levels-Tumor necrosis factor-alpha, B-lymphocyte stimulator (BlyS) on B cells-Interleukin-10 (IL-10), IL-6, IL-18-Interferon – γ-Bcl-2 (Apoptosis protein regulator)-Fas-ligand (Apoptosis protein regulator)of IgG1- inhibits T-cell activation

Cytokines Expression in Systemic Lupus Erythematosus

- CD40 ligand (costimulatory molecule for T-cell dependent B-cells)

- CTLA4-Ig fusion protein: from the extracellular domain of cytotoxic T-lymphocyte antigen 4 and Fc portion Increased Levels

Monoclonal Antibodies• Most successful in mice• Used for multi-organ disease• Anti-CD20 B-cell receptor (rituximab), Anti-

CD40L, LJP 394, B-lymphocyte stimulator (BlyS), IL-6, IL-10, IL-18, interferon (IFN) inhibitors (tumor necrosis factor alpha or TNF-α), and ICAM

• Usually given as IV bolus or injection

Monoclonal Antibodies: Potential Therapies in SLE

• Rituximab (anti-CD 20 B cell receptor)- chimeric monoclonal antibody

- approved for non-Hodgkin’s lymphoma- Used in small studies in resistant SLE

nephritis, central nervous system disease, and other organ systems with positive results

- Dosage 100 – 375 mg/m² (Rheum Dis Clinics NA, Ginzler(ed); Ahmed S, Anolik JH, 2010 36: and

Looney et al. 2006 32: 201-215)

Monoclonal Antibodies: Potential Therapies

• Anti-B lymphocyte Stimulator (anti-BlyS)- A member of the tumor necrosis family;

present on B cells- Phase I trials - reduced B cells in 84-105 days without affecting SLE activity (Furie et al., Arthritis Rheum 2003 48:S377)

- Other trials ongoing

Monoclonal Antibodies: Potential Therapies For SLE

• LJP 394 (abetimus sodium (Riquent) -Synthetic compound composed of 4

deoxyribonucleotide sequences bound to triethylene glycol

-Designed to prevent renal flares-Decreased protein excretion by 50% -Decreased anti-dsDNA titers

references: Strand V et al., Lupus 2003 12:677-86; Anolik JH, Campbell et al., Arthritis Rheum

46:S717

Biologicals (Immunoglobulins andAntibodies)

• Immunoglobulin's - intravenous (IVIG)– for thrombocytopenia purpura– resistant lupus disease– hypogammaglobulinemia– given 0.4-0.8 g/kg once or twice monthly;

or 0.4 g/kg for 5 consecutive days over 6 -24 months

Hormonal TherapiesANDROGENS

• Dehydroepiandrosterone (DHEA)-Inhibits cytokine production-Dose = 50 - 200 mg/day-Decreased lupus activity and flares (fatigue,

rash, arthritis), over 3-6 months in separate studies of 120 female lupus patients

-Stabilized osteoporosis in 351 patient trial with 200mg/day dose (multi-center trial Petri et al., May 2004 SLE International Congress, New York) (Chang et al., Arthritis Rheum 2002 46:2924-7)