An Immunological Toolkit for Clinical Application

Patients with rheumatoid arthritis (RA) suffer with joint pain and stiffness, and joint damage which leads to a reduced ability to carry out everyday tasks. Although these are the most obvious features of the disease, the root cause of the disease lies within the human immune system. At the moment we don?t fully understand the immune abnormalities that lead to RA but, if we did, this should help us to manage the disease better. It would become easier to make a diagnosis, as well as to determine whether a patient?s RA is likely to damage their joints in the future. Perhaps most importantly it would help us to design better drugs to combat the disease, and to better use the drugs that already exist. Something that we would really like to be able to do is to decide the most appropriate drug for each patient and a better understanding of the immune abnormalities would also help here.
Therefore our plans are to study, in detail, the immune system of patients with RA. This will involve taking blood from patients and running a panel of advanced laboratory tests on their white blood cells. We will compare the results we obtain with the immune changes in healthy individuals responding to a vaccine ? expecting some to be the same and some to be different. Our work is in three phases and, during the phases, we plan to slowly ?home in? on simple laboratory tests that will allow us to measure what is happening to the immune system in patients with RA. An exciting aspect of the work is that what is relevant to RA may also relate to other diseases (diabetes, multiple sclerosis, asthma) and to patients with an organ transplant. Therefore our results could have wide-ranging influence beyond improving the care of patients with RA

Current management of rheumatoid arthritis (RA) is based upon measurement of inflammation and tissue damage. However these are downstream consequences of immune dysregulation, and sub-optimal guides for managing patients and designing disease-modifying drugs. Our aim is to identify the key immune abnormalities that define RA and to develop an immunological toolkit: a set of functional and flow cytometry-based assays to study and monitor the dysfunctional immune system. A UK-wide collaboration of academic and industrial scientists will develop the toolkit, using regular discussions and workshops. Although current theory suggests that key immune abnormalities in RA should reside within T- or B- lymphocytes, lessons from other diseases suggest a discovery approach to be most appropriate, encompassing deep immunophenotyping of major peripheral blood immune and inflammatory cell subsets. Therefore in phase I purified CD4+ and CD8+ T-cells, B-cells, monocytes, NK cells and neutrophils will undergo: multiparameter flow cytometry for cell surface phenotype, intracellular cytokine and lineage transcription factor expression, and signalling pathways; transcriptional analysis using Affymetrix U219 microarrays; and small RNA sequencing. A well-defined subset (n=30) will subsequently undergo ultra-deep RNA sequencing, providing a complete picture of the RA transcriptome. We will study three sets of individuals: 30 healthy controls during an evolving vaccination response; 200 established RA patients, stratified for disease activity and disease duration; and 30 RA patients receiving abatacept (costimulation blockade). Hypothesis-generating phase I will provide a detailed signature of cells and pathways that characterise the RA immune system, and inform the design of customised, low-density array(s) (LDA), alongside the initial development of relevant in vitro immune function assays. In phase II these will be applied to 100 patients with recent onset inflammatory arthritis, sampled longitudinally, alongside a refined panel of flow cytometry protocols. Signals that are consistent between phases I and II will lead to further refinement of the in vitro assays ready for phase III, which encompasses proof-of-concept studies with novel therapeutic compounds, provided by industrial partners. Here the final immune toolkit will be ?road tested?, providing a secondary outcome measure that predicts conventional efficacy parameters. Success in this challenging programme will provide a novel portfolio of immune function assays, potentially applicable to RA but also other immunopathologies. Their widespread adoption and application across diseases will reinforce the successful image of UK translational immunological research. Intellectual property generated by the work will be protected for future exploitation as appropriate.