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Extended report
Incomplete response of inflammatory arthritis to TNFα blockade is associated with the Th17 pathway
  1. Saba Alzabin1,
  2. Sonya M Abraham2,
  3. Taher E Taher3,
  4. Andrew Palfreeman1,
  5. Dobrina Hull1,
  6. Kay McNamee1,
  7. Ali Jawad3,
  8. Ejaz Pathan1,
  9. Anne Kinderlerer4,
  10. Peter C Taylor1,
  11. Richard Williams1,
  12. Rizgar Mageed3
  1. 1Kennedy Institute of Rheumatology, University of Oxford, London, UK
  2. 2Division of Immunology and Inflammation, Imperial College London, London, UK
  3. 3Queen Mary Hospital, Barts and The London School of Medicine and Dentistry, London, UK
  4. 4St Mary's Hospital, Imperial College NHS Trust, London, UK
  1. Correspondence to Saba Alzabin, University of Oxford, Kennedy Institute of Rheumatology, London W6 8LH, UK; s.alzabin{at}


Objectives To establish if changes in Th1/Th17 cell populations previously reported in experimental arthritis occur in patients with rheumatoid arthritis (RA) treated with anti-tumour necrosis factor α (TNFα) agents, and whether the therapeutic response to anti-TNFα is compromised in patients and mice because of elevated Th17/IL-17 levels. Finally, to assess the efficacy of combined blockade of anti-TNFα and anti-IL-17 in experimental arthritis.

Methods A longitudinal study of two independent cohorts (cohort 1, n=24; cohort 2, n=19) of patients with RA treated with anti-TNFα biological agents was carried out to assess their Th17/IL-17 levels before and after the start of anti-TNFα therapy. IL-12/23p40 production was assessed in plasma Peripheral blood lymphocytes (PBLs) and monocytes. Mice with collagen-induced arthritis (CIA) were treated with anti-TNFα alone, anti-IL17 alone or a combination of the two. Efficacy of treatment and response was assessed from changes in Disease Activity Score 28–erythrocyte sedimentation rate scores in patients, and in clinical scores and histological analysis in CIA.

Results Significant increases in circulating Th17 cells were observed in patients after anti-TNFα therapy and this was accompanied by increased production of IL-12/23p40. There was an inverse relationship between baseline Th17 levels and the subsequent response of patients with RA to anti-TNFα therapy. In addition, PBLs from non-responder patients showed evidence of increased IL-17 production. Similarly, in anti-TNFα-treated mice, there was a strong correlation between IL-17 production and clinical score. Finally combined blockade of TNFα and IL-17 in CIA was more effective than monotherapy, particularly with respect to the duration of the therapeutic effect.

Conclusions These findings, which need to be confirmed in a larger cohort, suggest that a Th17-targeted therapeutic approach may be useful for anti-TNFα non-responder patients or as an adjunct to anti-TNFα therapy, provided that safety concerns can be addressed.

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