New treatments for SLE: cell-depleting
and anti-cytokine therapies
Jennifer H. Anolik* MD, PhD
Assistant Professor of Medicine and Pathology
Martin Aringer MD
Associate Professor of Medicine
Allergy, Immunology, Rheumatology Unit, Department of Medicine,
University of Rochester School of Medicine and Dentistry, Rochester, NY 14642, USA
Department of Rheumatology, Internal Medicine III, Medical University of Vienna, Austria, Europe
Although systemic lupus erythematosus (SLE) is indeed a complex autoimmune disease, recent
advances in our understanding of lupus pathogenesis have suggested new, targeted approaches to
therapy. The purpose of this review is to discuss the underlying scientific rationale and results of
first clinical studies of new treatment approaches to SLE, with a focus on cell-depleting therapies
and cytokine blockade. It has become clear that the B lymphocyte plays a key role in disease
pathogenesis by both autoantibody-dependent and autoantibody-independent mechanisms.
Additionally, aberrant interactions between B and T cells are critical to disease emergence and
progression. New agents that directly target immune cells abnormal in SLE include the B-cell
depleting or modulating antibodies, rituximab (anti-CD20) and epratuzumab (anti-CD22) and the
anti-dsDNA tolerogen LJP394. Another promising approach has been to block co-stimulatory
interactions between Tand B cells, forexample by inhibiting the CD40-CD40 ligand pathway with
anti-CD40 ligand monoclonal antibody or the B7 pathway with CTLA-4Ig. Immune cells can also
be manipulated indirectly through cytokine effects. For B cells, anti-BAFF (B-cell activation factor
of the tumor necrosis family) provides an example of this approach. Other, more pleiotropic
cytokines can likewise be blocked in SLE. In addition to the blockade of interleukin-10 (IL-10), the
first anti-cytokine approach examined, it is mainly anti-tumor necrosis factor therapy that has
come into focus, holding promise for some patients with lupus nephritis. The majority of the
available data on these new treatment approaches stems from open-label trials, but controlled
trials are under way. Moreover, many additional cytokines, such as interleukin (IL)-6, IL-18, and
the type I interferons, represent interesting future targets.
Key words: B lymphocytes; monoclonal antibodies; receptor constructs; BAFF; B7-CTLA4;
CD20; CD22; CD40–CD40L; IL-6; IL-10; IL-18; LJP394; TNF.
Best Practice & Research Clinical Rheumatology
Vol. 19, No. 5, pp. 859–878, 2005
available online at http://www.sciencedirect.com
1521-6942/$ - see front matter Q 2005 Elsevier Ltd. All rights reserved.
*Corresponding author. Tel.: C1 585 275 1632; Fax: C1 585 442 3214.
E-mail address: email@example.com (J.H. Anolik).
Systemic lupus erythematosus (SLE) is a complex autoimmune disease with
considerable heterogeneity in clinical manifestations and disease course, charac-
terized by dysregulation in multiple arms of the immune system and the
development of anti-nuclear antibodies.1The current treatment approach includes
antimalarials, an expanding armamentarium of immunosuppressive drugs, and
steroidal and non-steroidal anti-inflammatory agents. The expanded therapeutic
options in SLE, earlier diagnosis, and improved management of disease and
treatment complications have all contributed to a dramatic improvement in
prognosis for SLE patients, with 5-year and 10-year survival rates as high as 96 and
However, significant morbidity and mortality are still
associated with the disease, to a substantial extent because of the toxicity of
standard immunosuppressive therapies. Moreover, patients with active disease
refractory to traditional therapies represent a unique management challenge. Thus,
despite improved prognosis, patients with SLE still have a 3–5-fold increased
mortality compared to the general population.3
Fortunately, advances in our understanding of disease pathogenesis and drug
development have converged toward new therapeutic strategies specifically designed
to interrupt pathways involved in disease evolution and/or tissue damage. The
pathogenesis of SLE involves a complex interplay of genetic and environmental factors
and the adaptive and innate immune systems. Abnormalities in the function, regulation,
and interactions of immune cells, with Tand B lymphocytes central, result in immune-
complex-mediated deposition and inflammatory organ damage.4With the growing
understanding of the pathogenesis of the disease and novel therapeutic agents available,
new treatment approaches have focused on interfering with defined phases of the
abnormal immune response. This chapter reviews published information regarding
strategies that target cytokine pathways and/or immune cells critical to disease
pathogenesis. Focus will be given to targets for which specific drugs exist that havebeen
studied in clinical trials in humans.
Targeting the B-cell compartment in SLE
The current experience with therapies that target the B-cell compartment includes
antibodies to B-cell surface antigens, tolerogens, blocking of co-stimulatory molecules,
and inhibition of cytokines with direct B-cell effects (Figure 1). The rationale for B-cell-
directed therapies in SLE is multi-fold, with a growing body of evidence regarding the
importance of B lymphocytes in both murine and human SLE.5,6In addition to secretion
of autoantibodies, B cells can take up and present autoantigens, via specific cell-surface
immunoglobulins, to T cells, as well as help regulate and organize inflammatory
responses through cytokine secretion and regulation of other immune cells.7–10The
importance of these latter functions has been demonstrated in murine SLE, where B
cells have been found to be critical to the development of disease even when they are
unable to secrete autoantibodies.11,12
860 J. H. Anolik and M. Aringer
Role of B cells in human SLE
Because of experimental limitations, the actual pathogenic mechanisms of B cells in
human SLE have been more difficult to elucidate. As with murine SLE, it is postulated
that autoantibodies have a direct pathogenic role in the disease process, as exemplified
by anti-double stranded DNA (anti-dsDNA) in glomerular kidney disease and
autoantibody-mediated cytopenias. Additionally, a large body of evidence indicates
that B cells are abnormal in human SLE, with an increased number of spontaneous
immunoglobulin-secreting peripheral B cells, increased calcium flux on signaling
through the B-cell receptor, and expression of high levels of co-stimulatory molecules
such as CD80, CD86, and CD40 ligand on B cells (reviewed in Ref. 13).
In concordance with data in mice, recent evidence suggests a role in human SLE for
high serum levels of B lymphocyte stimulator (BlyS; also known as BAFF or B-cell
activation factor of the tumor necrosis family), a cytokine that promotes B-cell
maturation and survival and plasma cell differentiation.14,15BLyS, along with other
cytokines and intrinsic B-cell defects, might contribute to the abnormalities in
peripheral B-cell subpopulations that have been observed in human SLE. For example,
active SLE is associated with B-cell lymphopenia, particularly of naı ¨ve B cells, as well as
Figure 1. B-cell directed therapy in SLE. (1) B-cell surface antigens: monoclonal antibodies against CD20 (e.g.
rituximab) cause death of B cells. Antibodies against other B-cell surface molecules, such as the inhibitory
receptor CD22 (e.g. epratuzumab), are alternative targets for both inhibition of B cells and induction of cell
death. (2) Targeting autoreactive B cells: B-cell tolerogens such as LJP394 extensively cross-link autoreactive
BCRs andcause B-cell anergy (functionalinactivation)ordeletion.(3) Inhibition of co-stimulation: monoclonal
antibodies against CD40L block co-stimulatory signals, thus inhibiting B-cell, but also T-cell activation. (4) An
alternative target is the CD28-B7 co-stimulatory pathway (e.g. CTLA4-Ig). (5) Indirect inhibition of B-cell
survival: monoclonal antibodies against the cytokine BLyS disrupt the survival signals through the BAFF-
New treatments for SLE861
the abnormal expansion of certain B-cell subsets in peripheral blood.13The frequency
and absolute number of early plasma cells in the peripheral blood is increased in SLE
patients with increased overall disease activity as measured by the SLEDAI.16Abnormal
expansion of a second B-cell subset with a pre-germinal center (GC) phenotype has
also been reported and may indicate either exuberant or abnormally regulated GC
reactions in SLE.
Antibodies that deplete B cells or modulate the function of B cells
Given the large body of evidence implicating abnormalities in the B-cell compartment in
both murine and human SLE, a novel and rational approach to treatment involves
depleting B cells and/or modulating their function. The two drugs that have utilized this
approach by targeting B-cell-specific antigens are the monoclonal antibodies rituximab
(anti-CD20) and epratuzumab (anti-CD22) (see Figure 1—target 1).
The development of rituximab has raised the hope of a new therapeutic approach for
autoimmune diseases such as SLE that are at least in part B cell mediated. Rituximab is a
chimeric mouse/human monoclonal antibody against the B-cell-specific antigen
CD2017, which efficiently depletes B lymphocytes in vivo from the pre-B stage in the
bone marrow (when CD20 is first expressed) to the mature B-cell stage. It was
approved by the American Food and Drug Administration (FDA) for the treatment of
relapsed or refractory B-cell lymphoma in 1997, and has since been used to treat over
300,000 patients with B-cell malignancies worldwide.18
Using rituximab to deplete B cells in SLE has several major advantages. First, there is
a large safety database in lymphoma indicating that rituximab is generally well tolerated,
with only minor effects on immunoglobulin levels and no increase in the frequency of
infections.18Second, CD20 expression is restricted to B cells so that the effects of anti-
CD20 should be directly on the B-cell compartment, with relative sparing of T cells and
plasma cells (which are CD20 negative). This approach might thus havethe advantage of
being less immunosuppressive. Third, there is accumulating positive data on the use of
rituximab in a variety of other autoimmune diseases, including IgM-antibody-associated
polyneuropathy, idiopathic thrombocytopenic purpura (ITP), and autoimmune
hemolytic anemia.13Although these were open studies, there has been a recently
reported double blind, placebo-controlled trial demonstrating the effectiveness and
safety of rituximab in rheumatoid arthritis.19
A number of open studies of rituximab in the treatment of SLE have now been
reported, and phase III randomized controlled trials are in the planning stages. The first
study began in 2000 at the University of Rochester as an open-label phase I/II trial to
determine the safety, efficacy, and dose response of rituximab added to current therapy
in the treatment of SLE.20–22Seventeen patients with clinically active disease (Systemic
Lupus Activity Measure [SLAM]O6) were treated in three dose-escalating groups:
single doses of 100 mg/m2(low) or 375 mg/m2(intermediate) or four weekly doses of
375 mg/m2(the latter high dose representing the typical lymphoma regimen).
Rituximab was safe and well-tolerated in this patient population at all three treatment
doses, with no infusion reactions. In the majority of patients with effective B-cell
depletion (11/17), the SLAM score was significantly improved at 2 and 3 months
(PZ0.0016 and 0.0022, respectively), an improvement that persisted for 12 months.22
Six patients in this study had incomplete B-cell depletion (including one of the four
862 J. H. Anolik and M. Aringer
patients in the high-dose group) and no clinical improvement. Incomplete B-cell
depletion was associated with certain Fc receptor genotypes21, African–American
ancestry, and lower serum rituximab levels22, the latter suggesting that B-cell depletion
might be more consistent if all patients are treated with high-dose rituximab.
Additionally, 6 of the 17 patients developed elevated human anti-chimeric antibodies
(HACAs), which were also associated with African–American ancestry, higher baseline
SLAM scores, and reduced B-cell depletion. This is the only reported study of rituximab
in SLE that comprehensively evaluated HACA development. The results raise the
concern that rituximab might be more immunogeneic in active SLE, although the low
doses of rituximab used in the majority of patients might have contributed to the high
frequency of HACAs.
In a subset of patients (3/11) anti-dsDNA and complement levels also normalized,
and all medications were eventually tapered and discontinued, i.e. clinical remission was
obtained (27% ‘remission’ in patients with effective B-cell depletion). However, in the
study overall the serologic response was quite variable and seemingly independent of
the clinical response.23This disconnect between B-cell depletion and reductions in
autoantibody levels is in accord with results in other autoimmune diseases and the fact
that plasma cells do not express CD20.24,25Of note, the finding that clinical responses
were rapid and preceded autoantibody decline supports the purported autoantibody-
independent role of B cells in the disease process. Moreover, the fact that long-term
reductions in autoantibody titers were variable and incomplete suggests that
autoreactive plasma cells might have heterogeneous life-spans.23
Of note, in the University of Rochester SLE study, B-cell depletion effectively
normalized a number of the disturbances in peripheral B cells characteristic of active
disease, including naı ¨ve B-cell lymphopenia, expansion of early plasma cells, and
expansion of populations of autoreactive memory B cells.23Based on their experience,
the authors conclude that rituximab is safe and promising in the treatment of SLE, but
that high-dose rituximab is necessary, possibly with the addition of other
immunosuppressive agents to ensure consistent B-cell depletion, prevent the
development of HACAs, induce serologic response, and enhance clinical efficacy.
In accord with the concept that combination therapy might be more efficacious,
Leandro et al26, at University College London, reported the treatment of six active SLE
patients with a combination of moderate dose rituximab (2!500 mg, 2 weeks apart),
high-dose glucocorticoids, and cyclophosphamide. All subjects experienced profound
B-cell depletion and a clinical improvement with a decrease in the BILAG global score
from a median of 14 at baseline to 6 at 6 months, although again with variable response
in anti-dsDNA antibodies in this first report. The University College group also
reported an additional six patients treated with a similar protocol for proliferative
nephritis.27At 3 months there was a marked improvement in the BILAG global score
(median of 19–6), and creatinine, proteinuria, C3 and anti-dsDNA were also improved.
Recently, this same group reported an extension of these earlier studies, now including
a total of 21 treated patients. The majority of patients (13/21) received full-dose
rituximab (2!1000 mg, 2 weeks apart) in combination with IV cyclophosphamide and
steroids. A total of 20/21 patients experienced effective B-cell depletion, with the
period of B-cell depletion ranging from 3 to 8 months. With the exception of one
infusion reaction, no serious adverse events were noted.
Most patients had a clinical response, with nine patients remaining off
immunosuppressive therapy at a follow-up of 12–46 months (w45% ‘remission’).28
In a subset of patients, effects on autoantibody and antimicrobial antibody profiles were
reported. Protective titers against tetanus and pneumococcus and anti-ENAs (Sm, RNP,
New treatments for SLE863
SSA) were relatively insensitive to B-cell depletion but anti-dsDNA levels decreased by
a mean of 53% at 3 months. In line with the reasoning already discussed, the authors
postulate that such heterogeneity in serum antibody responses may be due to
differences in plasma cell longevity.29
Another report of nine patients with class III and IV nephritis treated with rituximab
and a prolonged course ofmoderate-dose steroids (0.5 mg/kg for 10 weeksfollowed by
slow taper) also described good efficacy, with partial remission achieved in 80%,
complete remission in 50%, and sustained complete remission (at 12 months) in 40%.30
Interestingly, clinical response was associated with a decrease in T-helper-cell activation
based on reduced expression of CD40-ligand co-stimulatory molecule and activation
markers (CD69 and HLA-DR), again supporting an autoantibody-independent role for
B cells in promoting disease.
The University of Pennsylvania is conducting an ongoing, phase I, open trial of full-
dose rituximab as monotherapy in SLE patients with active visceral disease. Results for
eight patients were reported recently31, with all but one subject achieving greater than
99% B-cell depletion. Six patients demonstrated clinical responses defined by
improvement in SLEDAI, with 2/6 having long-term remission (6–14 months) (w25%
‘remission’) and 4/6 having short-term remission (4 weeks to 6 months). Even in the
short-term responders, disease control was better post rituximab. Interestingly, as in
the University of Rochester study, serologic response in anti-dsDNA titers was
inconsistent. A number of additional smaller cohorts of SLE patients treated in an
uncontrolled fashion with rituximab have been reported recently (total of 18 additional
patients treated with heterogeneous protocols).32–34Additionally, fully humanized anti-
CD20 monoclonal antibodies are under evaluation.35,36
An open-label, pilot study of anti-CD22 in the treatment of 14 active SLE patients was
at 4 and 12 weeks) but might also function by signaling through the inhibitory CD22
membranemolecule,causingdown-modulationofB-cell receptor signaling. Thedrugwas
well tolerated, with the majority of patients experiencing a O50% improvement in the
BILAG. Limited analyses of autoantibodies revealed no consistent changes.
An approach related to B-cell depletion is specifically to target autoreactive B cells.
Tolerogens are synthetic molecules that bind to and extensively cross-link
autoantibodies, thereby causing either anergy (functional inactivation) or deletion of
B cells expressing the autoreactive B-cell receptors. LJP394 was the first such B-cell
tolerogen developed and studied in human trials (see Figure 1—target 2). It consists of
four double-stranded oligonucleotides attached to a polyethylene glycol platform and
binds avidly to anti-dsDNA antibodies. A phase II/III randomized, placebo-controlled
trial in 230 patients with a history of lupus nephritis demonstrated significant but
temporary decreases in anti-dsDNA levels (P!0.0001) but without clinical benefit.38A
post hoc analysis found a decrease in renal flare (67% fewer) and SLE flare in the patients
with high-affinity antibodies and sustained reduction in anti-dsDNA. Although titers of
anti-dsDNA antibodies were again decreased, significant clinical benefits were not
confirmed in a second study.39A phase III trial of 317 randomized patients was recently
completed (PEARL; Program Enabling Antibody Reduction in Lupus), and preliminary
864 J. H. Anolik and M. Aringer
results indicate that sustained reductions in anti-dsDNA antibodies lead to
improvement in health-related quality of life.40Overall, this novel tolerogen might
have a role for induction or maintenance therapy in the subset of SLE patients with
elevated high-affinity anti-dsDNA and active disease; additional studies are ongoing.
Inhibition of co-stimulation
As an alternative to selective B-cell depletion, there has been interest in targeting co-
stimulatory signaling pathways. CD40 binding to CD40 ligand is one of the most
important co-stimulatory signals on B cells inducing activation, proliferation, and class-
switching in germinal center reactions.41Direct inhibition of collaboration between B
and T cells through inhibition of the CD40–CD40L pathway has been demonstrated to
be effective in mouse models of lupus.42,43Two well-designed studies of anti-CD40L
antibodies in SLE have been reported44,45(see Figure 1—target 3). The first open-label
study (Biogen Hu5c9 antibody) focused on 30 patients with lupus nephritis and showed
improvement in serology and hematuria. Unfortunately, this study was halted because
of unexpected thromboembolic events.45
The second double-blind, placebo-controlled trial (IDEC 131) of 85 patients with
mild to moderate SLE failed to show clinical efficacy over placebo.44Moreover, use of
this anti-CD40L antibody in a separate study in Crohn’s disease was associated with
thrombotic events. Interestingly, two small mechanistic studies attached to the first trial
demonstrated beneficial immune effects (nZ5 for each), including a marked reduction
in autoreactive anti-dsDNA-producing B cells46and substantial reductions in abnormal
B-cell populations, including pre-GC cells and IgDC plasmacytes.47
These reports suggest that anti-CD40L can interfere with aberrant germinal center
reactions in SLE and translate into clinical benefit, if administered with the proper
pharmacokinetics for adequate co-stimulatory blockade. The latter is a critical point as
insufficient blockade could explain the lack of clinical efficacy in the second study.
Additional controlled studies would be warranted to understand the mechanism of
action of this therapy, which might take place at different points during B-cell
differentiation.48Moreover, the potential for untoward immunosuppression due to
dentritic cell (DC) expression of CD40L (see Figure 1) requires further exploration.
Unfortunately, such studies will probably be hampered by the thromboembolic side
effects described. However, alternative approaches to blocking the CD40–CD40L
pathway merit investigation.
Alternative co-stimulatory targets in SLE includes the CD28 and CTLA4 receptors
and their B-cell co-ligands B7-1 and B7-2 (see Figure 1—target 4). Blockade of B7
stimulation on B cells with a fusion protein of the extracellular domain of CTLA and
immunoglobulin constant regions (abatacept) has yielded promising results in murine
SLE4242,49, and demonstrated safety in human clinical trialsin RA and psoriasis.50,51This
drug has yet to be used in human SLE, but clinical trials are in the planning stages.
The alternative to directly targeting immune cells is to interfere with their messengers.
Immune cells exert many of their effector and immunoregulatory functions by cytokine
New treatments for SLE 865
release (Figure 2). In fact, most cytokines investigated have been found to be
dysregulated in SLE. Although there are still many controversial issues regarding
cytokine regulation and cytokine effects in SLE, the consecutive development of a
variety of anti-cytokine agents has made insight into this regulatory process much more
relevant. These medications could also be useful in SLE, and at least two approaches
have been tested in SLE patients and found successful. We will therefore concentrate
on: (i) what is known currently regarding anti-cytokine therapy in patients with SLE; and
(ii) the potential therapeutic effects of anti-cytokine drugs, developed forotherdiseases
and not yet used in SLE patients, on the autoimmunity and organ manifestations of SLE.
Inhibition of cytokines with B-cell effects
BLyS or BAFF is a secreted cytokine of the TNF family that binds to three different
membrane receptors (BCMA, BAFFR, and TACI) expressed on B cells (see Figure 1—
target 5). It has profound effects on B-cell survival, stimulates plasma-cell
differentiation, and might have differential effects on autoreactive B cells, which show
greater dependence on BAFF signaling in mouse models.52Mice over-expressing BAFF
develop an SLE-like phenotype.53Moreover, lupus-prone mice have elevated levels of
Figure 2. Overview on targeted therapies in SLE. In addition to cell-directed therapies targeting B cells via
antibodies to surface molecules (1) or tolerogens (2) and co-stimulation blockade by antibodies to CD40L (3)
or by CTLA4-Ig (4), cytokines are major therapeutic targets. In addition to B-cell directed cytokines (5), a
variety of other pro-inflammatory and/or immunoregulatory cytokines (6) derived from monocytes/macro-
phages (MF), dendritic cells (DC), or lymphocytes, could likewise be blocked by antibodies, receptor
constructs, or receptor antagonists. These include TNF, both type I and type II interferons and several
interleukins, such as IL-1, IL-6, IL-10, IL-15, or IL-18.
866 J. H. Anolik and M. Aringer
circulating BAFF and administration of soluble BAFF receptors ameliorates disease
progression and improves survival.54Finally, elevated BAFF levels are evident in the
serum of SLE patients and positively correlated with serum IgG and autoantibody
Lympho-Stat-B is a fully human monoclonal antibody that specifically binds to and
neutralizes soluble human BAFF. A phase I dose-escalation trial in mild to moderate SLE
(nZ70) demonstrated safety and biological activity with significant reductions
(12–47%) in peripheral blood B cells. In this short-term study, there was no change
in anti-dsDNA levels or disease activity.56A phase II double-blind, placebo-controlled
trial of the safety and efficacy of three different doses administered in addition to
standard therapy is underway (nZ350). Alternative approaches to inhibiting BAFF,
including use of BAFFR-Ig and TACI-Ig, are also under development.
Interleukin-10 (IL-10) and anti-IL-10 therapy
Although this therapeutic approach is still being hampered by the absence of a
therapeutic agent suitable for long-time application in human patients, IL-10 was the
first cytokine successfully blocked in SLE.57IL-10 is over-produced by the B cells and
monocytes of patients with SLE58–60, increased in SLE sera60,61, and associated with
disease activity.62,63However, the specificity of these findings is unclear, as increased
numbers of IL-10-producing cells were also found in first degree relatives as well as
These findings would, in addition to environmental factors, suggest a combination
between genetic and disease-induced events. In fact, IL-10 genotypes were linked to
SLE66and an IL-10 promoter polymorphism has been described and linked to IL-10
over-production65, although a larger study including patient family members with
increased IL-10 production64has not confirmed this association.67
In line with the association between IL-10 and disease activity, immune complexes
from SLE sera, as well as monoclonal anti-dsDNA antibodies, induced IL-10 production
in healthy monocytes68,69and the probable removal of such immune complexes by
immunoadsorption reduced the number of IL-10 producing cells.70B-cell secretion of
IL-10 might regulate DC- and T-cell function, promoting Th2 deviation of the immune
response.10In turn, IL-10 might contribute to a number of the earlier described
peripheral B-cell abnormalities in SLE, including plasma cell expansion16(reviewed in
Murine models of SLE are characterized by IL-10 over-production71and
continuous early-onset therapy with an anti-IL-10 antibody delayed autoimmunity in
NZB/W mice.72Moreover, the continuous administration of recombinant IL-10
increased disease activity, while being well tolerated in normal mice.72It is interesting
that the protective effect of anti-IL-10 antibodies was abolished by the concomitant
administration of blocking anti-TNF antibodies72, suggesting that in the NZB/W
mouse an immunoregulatory balance exists between these two cytokines. A
neutralizing anti-IL-10 antibody also reduced serum immunoglobulin and renal
immune complex deposition in SCID mice implanted with a hybridoma secreting a
pathogenic anti-dsDNA antibody, but was not very effective in reducing proteinuria in
In the absence of a human or humanized antibody to IL-10, an anti-IL-10 murine
monoclonal antibody (MoAb) was administered daily (20 mg IV) to six SLE patients for
a total of 21 days.57All patients had skin and joint involvement and constitutional
New treatments for SLE867
symptoms despite corticosteroid therapy and therapy with chloroquine, azathioprine,
or methotrexate. As was to be expected, all patients developed antibodies against
the murine MoAb. Nevertheless, this therapy was well tolerated and rapid clinical
improvement was seen in all six patients. Despite the cessation of therapy after 3
weeks, therapeutic benefits were stable at the end of observation (6 months).
Although this was a small, uncontrolled, open-label study in patients with relatively
mild disease, these findings suggest that anti-IL-10 therapy with an agent suitable for
use in humans would probably benefit some patients with SLE. Such an agent might
soon be available.
Tumor necrosis factor (TNF) and anti-TNF therapy
In contrast to the situation with regard to IL-10, therapeutic agents blocking TNF are
readily available and widely used in other rheumatic diseases. However, TNF is a
pleiotropic cytokine that exerts several functions in the immune system and can either
promote or relieve autoimmunity.74,75
An example of the protective function of TNF in autoimmunity is provided by the
NZB/W murine model of SLE.76NZB/W mice produce much less TNF than other
mice, a defect that stems from the NZW parent and fosters lupus-like autoimmunity,
and the development of lupus nephritis can be delayed by TNF administration in these
mice.76In line with this finding, NZB mice rendered TNF-deficient showed a phenotype
similar to NZB/W.77However, low TNF is not required for the induction of lupus in
NZB/W mice, since the same mice without the TNF defect still get severe disease,
albeit later78, and the administration of TNF to NZB/W mice does not prevent
development of the disease.76,79Nevertheless, from this murine model of SLE it is clear
that TNF has an important immunoregulatory function.
Given these immunoregulatory properties, it is perhaps not surprising that
therapeutic TNF blockade in patients with autoimmune diseases, such as rheumatoid
arthritis (RA) or Crohn’s disease, is associated with the development of ANA, anti-
dsDNA, and anti-cardiolipin antibodies, as well as with rare cases of drug-induced
lupus like syndromes, all of which disappeared after therapy was stopped (reviewed in
Proinflammatory TNF effects in SLE
Although one might thus argue that TNF is beneficial in SLE and that, accordingly, TNF
blockade in SLE would be detrimental, in vivo data from SLE patients speak to the
contrary. TNF concentrations are actually increased in sera of SLE patients and closely
associated with disease activity (reviewed in Ref. 81). As both soluble TNF receptors
are likewise increased and correlate with disease activity82–84, it was postulated that
they would block the biological activity of the increased serum TNF. In fact, however,
the increased TNF in SLE sera is bioactive85, suggesting that these receptors might
dilute the local concentration of TNF but not remove it.
Moreover, TNF was found in the inflamed kidneys of patients with lupus
glomerulonephritis and correlated with histological disease activity (reviewed in Ref.
86). This iswellexplained by the fact thatTNF, like IL-10, can beinduced by anti-dsDNA
antibodies and by immune complexes69,87, (and our unpublished data), the deposition
of which is a major pathogenic event in lupus nephritis. In addition, renal cells express
TNF receptors88and might therefore bind some of the abundant circulating TNF.
868 J. H. Anolik and M. Aringer
As TNF is well-known for its pro-inflammatory properties75,89, these findings therefore
argue for a pathogenic role in the local inflammatory disease processes in SLE (see
Similar findings that support the local proinflammatory role of TNF in SLE kidney
disease were also made in lupus mouse models (reviewed in Refs. 74,81). Sera as well as
inflamed kidney tissue samples from MRL/lpr lupus mice contain significant amounts of
TNF, again associated with disease activity. Moreover, even NZB/W inflamed kidney
samples contained increased levels of TNF, and the additional administration of
recombinant TNF later in life accelerated the nephritis of NZB/W mice. Finally,
inhibition or blockade of TNF improved organ disease in several murine models of SLE
(reviewed in Ref. 81).
Therapeutic TNF blockade in SLE patients
This background provided the rationale for using anti-TNF in SLE patients.81,90,91In an
open-label safety trial of infliximab in patients with mild to moderate SLE, a total of four
infusions (300 mg each) were administered to patients with refractory lupus nephritis
or lupus arthritis, on an immunosuppressive background medication of azathioprine or
methotrexate and low-dose corticosteroids.80It is important that infections were
limited to urinary tract infections and non-specific viral disease, and that no infusion
reactions occurred under this protocol. In contrast, in the absence of azathioprine or
methotrexate, others commonly found severe infusion reactions92, suggesting that the
combination with immmunomodulators is essential.
Both major findings of this trial are in accord with the background outlined above.
Two-thirds of the patients experienced an increase in anti-dsDNA antibodies.
Interestingly, in contrast to the situation in infliximab-treated RA or Crohn’s disease93,
all of these antibodies were of the IgG isotype.80However, the increase in
autoantibodies proved to be transient and did not lead to a fall in serum complement
or to any lupus flares. By contrast, the inflammatory organ disease improved rapidly in
all patients.80Lupus arthritis remitted within days and only relapsed 8–11 weeks after
the last infusion. Even more exciting, a significant renal response was observed.
Specifically, the one patient with overt nephrotic syndrome experienced complete
resolution of peripheral edema within days of starting infliximab. Moreover, proteinuria
decreased to less than 50% within weeks in all fourof the nephritic patients treated, and
remained at this low level for at least 1 year thereafter.
Similarly, other groups found beneficial effects of TNF blockers with regard to lupus
arthritis and refractory skin disease.94,95Taken together, these clinical results suggest
that a limited time period of TNF blockade, when combined with azathioprine or
methotrexate, might be safe and effective in a subset of SLE patients, particularly those
with lupus nephritis. It is imperative now to study TNF blockade in SLE in a double-
blind, placebo-controlled fashion in order to appropriately evaluate the role of anti-
TNF agents in SLE therapy.
IL-1 can both be increased by TNF and by autoantibodies to dsDNA.69,96In SLE
glomerulonephritis, IL-1 (both a and b) was clearly detectable.97Likewise, following the
onset of nephritis, kidneys of MRL/lpr and NZB/W mice over-express IL-198–100, and
low-dose IL-1 administration accelerated renal disease.99Moreover, in vitro treatment
New treatments for SLE 869
of MRL/lpr B cells with recombinant IL-1 receptor antagonist (IL-1Ra) reduced
autoantibody production. In addition, IL-1 activity was also found increased in
cerebrospinal fluids of patients with CNS lupus.101
In vivo, established MRL/lpr nephritis did not respond to therapy with the IL-1
receptor antagonist102but an alternative IL-1 targeted approach using recombinant IL-1
receptor was successful.103Recently, in a first open trial of anakinra (IL-1Ra) in four
patients with SLE and severe lupus polyarthritis, anakinra therapy appeared safe and
improved arthritis in all four patients.104This therapeutic effect ceased in two of the
four patients after 6 weeks and 8 months, respectively, despite ongoing therapy, and a
potential effect on lupus nephritis has not yet been investigated.
IL-18 is a pro-inflammatory cytokine closely related to IL-1 and, like IL-1, activated by
interleukin-1b converting enzyme (ICE). Several groups found increased serum levels of
IL-18 in SLE, and most saw an association with disease activity.105–109However, in
rheumatoid arthritis patients, IL-18 was found to act secondary to TNF.110Apparently,
the same is true for patients with SLE.109The latterdata suggest that the level of IL-18 is
in fact associated with the TNF level rather than with disease activity itself.109
Although no data on the expression in human lupus glomerulonephritis have been
published so far, IL-18 is over-expressed in the nephritic kidneys of MRL/lpr mice.111
Moreover, MRL/lpr animals also benefited from targeting IL-18.112So far,IL-18 blockade
has not been reported in SLE patients but agents suitable for this purpose are currently
being tested in other rheumatic diseases.
IL-6 is another pro-inflammatory cytokine secreted predominantly by macrophages and
T cells and found to be increased in SLE sera (reviewed in Refs. 81,113). In concert with
type I interferons, it has been shown to activate B cells and drive plasma-cell
differentiation.114IL-6 is induced by anti-dsDNA antibodies, as well as multiple
cytokines including TNF, IL-1, and interferon-g.69,96,115
IL-6 is also highly expressed in SLE glomerulonephritis (reviewed in Ref. 86).
Moreover, in NZB/W mice, IL-6 promotes disease, and anti-IL-6 therapy delays lupus
nephritis116,117, suggesting that IL-6 blockade might also be beneficial in SLE patients. In
fact, an open label trial of IL-6 blockade reportedly is under way.113
Therapeutic agents against IL-15 are currently being tested in other autoimmune
diseases. IL-15 is found increased in sera of SLE patients and associated with immune
abnormalities of the disease, such as the increased percentage of CD25C
lymphocytes.107,118However, more severe nephrotoxic serum nephritis in IL-15K/K
mice119would demand caution with regard to SLE renal disease.
Recent data suggest that unabated activation of type I interferon might play a role in
driving the autoimmune process in SLE. As reviewed in detail recently114,120, critical
870J. H. Anolik and M. Aringer
observations include the early finding of elevated serum levels of IFN-a in SLE
patients, the more recent demonstration of a striking IFN-a signature on gene
expression profiling of SLE PBMCs, and the fact that SLE serum is able to induce
maturation of DCs in an immunogenic and IFN-a dependent fashion. In addition to
dendritic cell activation, IFN-a has been associated with B-cell lymphopenia, germinal
center differentiation, and generation of plasma cells, findings of obvious relevance to
the peripheral B-cell subpopulation abnormalities characteristic of SLE. Although the
precise role of IFN-a in the autoimmune process remains to be fully elucidated, the
abundant evidence that IFN-a contributes to disease pathogenesis has made it an
attractive therapeutic target. This concept is supported by the development of lupus-
like illness in patients treated with IFN-a121. Work is ongoing to define the best
means of inhibiting the IFN-a pathway, and humanized antibodies are likely to be
available in the near future.
A combination of different biologic agents could potentially provide even better efficacy
by modulating distinct effector mechanisms.6For example, based on our understanding
of how germinal center B cells and long-lived memory and plasmacytes are generated,
co-stimulatory blockade with anti-CD40L or CTLA-4Ig has the potential for synergy
with rituximab. Alternatively, rituximab could be complemented with newer biologic
interventions that might block B-cell differentiation and survival, such as inhibition of
cytokines like BAFF, IL-6, IL-10 or IFN-a. Likewise, interventions targeting B cells might
also be combined with drugs blocking proinflammatory mediators, and TNF in
In summary, new approaches that target both immune cells and cytokine pathways
important in SLE show great promise. Several open clinical trials suggest that B-cell
depletion with rituximab treatment can improve clinical manifestations of SLE,
indicating that B cells are crucial not only for the development of SLE but also for
continued activity of established disease. Although much smaller patient numbers
were treated, the published anti-TNF experience with infliximab (and etanercept)
suggests significant benefit for rapidly reducing inflammation and possible long-term
effects on proteinuria, despite the transient occurrence of autoantibodies. Several
other cytokines, including IL-6 and IL-18, might be targeted in the near future
(Figure 2). Combination therapy with different biologic agents could potentially
provide even better efficacy by synergistically targeting different arms of the immune
system that are dysregulated in SLE. One more compelling argument for the
continued development of biologics in SLE is the potential for induction of long-term
remissions. The impact of these emerging targeted therapies on patient survival is
likely to be dramatic, and studies on the immune system of patients in upcoming
clinical trials should continue to provide invaluable insight into the pathogenesis of
human SLE .
New treatments for SLE871
Dr Anolik is supported by NIH-NIAMS K08AR048303 and the Lupus Foundation of
America. The phase I/II clinical trial at the University of Rochester was supported in
part by grants from Genentech (South San Francisco, CA) and IDEC Pharmaceuticals
(San Diego, CA). Dr Aringer received grant support from Centocor for immunological
studies related to open-label infliximab therapy in SLE patients. The authors wish to
apologize to all groups whose work could not be cited directly because of space
† so far, none of the biological response modifiers is approved for use in SLE
† currently, all data are based on open-label experience
B-cell targeted therapies, e.g. rituximab:
† rituximab is the best studied B-cell depletion therapy and was well tolerated in
SLE when administered with pre-medication (prednisone 40 mg or hydrocor-
tisone 100 mg, benadryl, and tylenol)
† rituximab can be efficacious in refractory patients with prolonged remissions in
some cases in uncontrolled studies
† high-dose rituximab is necessary for consistent B-cell depletion (typical
lymphoma dosing or alternative administration of similar total dosages)
† serologic responses are inconsistent perhaps because of the presence of long-
lived autoreactive plasma cells
Anti-cytokine therapies, e.g. infliximab:
† TNF blockade with infliximab in combination with azathioprine or
methotrexate was safe in small, open-label trials and single cases
† infliximab therapy rapidly improved inflammatory lupus organ disease and
apparently had long-lasting effect on lupus nephritis
† autoantibodies to nuclear material and cardiolipin increased during infliximab
therapy, but this increase was transient and not associated with disease flares
† multi-center, randomized, controlled trials of anti-B-cell therapies, including
rituximab, in SLE are needed to confirm the preliminary results of open studies
† determination of the optimal dosing of rituximab and the role of combination
† multi-center, randomized, controlled trials of infliximab, and possibly other
anti-TNF agents, are needed to confirm the open-label results
† open-label trials with other cytokine-directed biological response modifiers
† investigations into the frequency, consequences, and means of prevention of
† mechanistic studies of patients treated with rituximab, infliximab, and other
agents, to define the basis of clinical and serologic responses and their
872 J. H. Anolik and M. Aringer
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