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• The Impact of Clinical Setting on ANA Responses in SLE: Comment on the article by Choi et al.
  David S. Pisetsky, Peter E. Lipsky
  Published on: 8 July 2022

• Published on: 8 July 2022

  The Impact of Clinical Setting on ANA Responses in SLE: Comment on the article by Choi et al.

  • David S. Pisetsky, Physician Medical Research Service, Durham VA Medical Center, Durham, USA
  • Other Contributors:
    • Peter E. Lipsky, Physician

  The Impact of Clinical Setting on ANA Responses in SLE: Comment on the article by Choi et al.
  David S. Pisetsky1 2 and Peter E. Lipsky3 4
  1 Medical Research Service, Durham VA Medical Center, Durham, North Carolina, USA
  2 Departments of Medicine and Immunology, Duke University Medical Center, Durham, North Carolina, USA
  3 RILITE Foundation, Charlottesville, Virginia, USA
  4 AMPEL BioSolutions LLC, Charlottesville, Virginia, USA

  In a recent paper in the Annals of the Rheumatic Diseases, Choi et al report data on the expression of antinuclear antibodies (ANA) in the sera of patients with systemic lupus erythematosus (SLE).(1) Using a large cohort of well characterized patients from the SLICC (Systemic Lupus International Cooperating Clinics) consortium, the authors show that ANA expression is almost invariable in SLE using three ANA assays (two immunofluorescence or IFA and one ELISA); over time, some changes can occur, with the ELISA showing a greater reduction in the frequency of positive responses than the IFA assays. In this study, patients were early in disease, with the first sample obtained on average 0.58 years after diagnosis.
  Choi et al are to be congratulated for this detailed and comprehensive study that includes longitudinal data. Most other studies on ANA expression in SLE have been cross-sectional in design or involved longitudinal data of relatively few patients.(2) Nevertheless, while consistent with data und...

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  The Impact of Clinical Setting on ANA Responses in SLE: Comment on the article by Choi et al.
  David S. Pisetsky1 2 and Peter E. Lipsky3 4
  1 Medical Research Service, Durham VA Medical Center, Durham, North Carolina, USA
  2 Departments of Medicine and Immunology, Duke University Medical Center, Durham, North Carolina, USA
  3 RILITE Foundation, Charlottesville, Virginia, USA
  4 AMPEL BioSolutions LLC, Charlottesville, Virginia, USA

  In a recent paper in the Annals of the Rheumatic Diseases, Choi et al report data on the expression of antinuclear antibodies (ANA) in the sera of patients with systemic lupus erythematosus (SLE).(1) Using a large cohort of well characterized patients from the SLICC (Systemic Lupus International Cooperating Clinics) consortium, the authors show that ANA expression is almost invariable in SLE using three ANA assays (two immunofluorescence or IFA and one ELISA); over time, some changes can occur, with the ELISA showing a greater reduction in the frequency of positive responses than the IFA assays. In this study, patients were early in disease, with the first sample obtained on average 0.58 years after diagnosis.
  Choi et al are to be congratulated for this detailed and comprehensive study that includes longitudinal data. Most other studies on ANA expression in SLE have been cross-sectional in design or involved longitudinal data of relatively few patients.(2) Nevertheless, while consistent with data underpinning the designation of a positive ANA in the EULAR-ACR classification system, the conclusions of the study pertain only to the three assays used.
  The performance characteristics of ANA testing are relevant, indeed, crucial, in two disparate settings: patient classification and assessment of eligibility of patients for clinical trials. The frequencies of ANA positivity in these two settings may be very different because of the features of the patient populations studied. Classification (or diagnosis) usually involves early disease; the clinical trial setting usually involves patients later in disease course and therefore extended periods of treatment.
  As shown most pertinently in studies with belimumab, many patients at the time of screening for trial eligibility have a high frequency of ANA negativity.(3) These studies also showed that treatment responses can vary depending on serological status, with patients who are ANA positive more likely to respond than those who are serologically negative. These findings led to the current approach for serological testing in the trial setting, with eligibility dependent on serological positivity in terms of tests for ANAs by IFA, anti-DNA and/or anti-Sm.(4, 5)
  The lower frequency of ANA positivity in patients considered for clinical trials has a number of possible explanations including the performance characteristics of the assays used. Our previous study showed that different assays can lead to widely varying frequencies of ANA positivity in cross-sectional studies of patients followed in a university setting as well as patients enrolled in a clinical trial.(6, 7) Pending more data on the results of different ANA kits in both the classification and clinical trial settings, it seems reasonable that studies involving ANA testing specify the kit used and relevant data about the frequency of responses in patients with SLE and control populations.
  Another factor that may influence the frequency of ANA positivity in any lupus population is disease duration. The study of Choi et al demonstrated a decline in the frequency of ANA positivity over time. The time-frame for this study was only 5 years, however, meaning that most patients had shorter disease duration than in the clinical trial setting. In the trial of anifrolumab, for example, the placebo population had a median time from diagnosis of 78.0 months (range 6-494) whereas the treatment group had a median time of 94.5 months (range 6-555).(8)
  The study of Choi et al indicates the persistence of ANA responses within a few years of diagnosis; this observation, however, should not obscure the equally important point that ANA levels can change significantly in response to therapy. The time course of anti-DNA expression clearly illustrates the mutability of ANA responses with treatment. The effects of belimumab are another example of the impact of treatment on ANA levels since this agent can lower autoantibody levels by up to approximately 50%.(4, 9) Other agents used to treat SLE also have effects on B cell number and function that could decrease ANA expression. These agents include cyclophosphamide, rituximab and mycophenolate among commonly used agents, although the effects of these agents can differ with respect to B cell subpopulations, plasmablasts and plasma cells.(10-13)
  In studies on the effects of various immunomodulatory therapies, it is important to note that some autoantibodies (e.g., anti-DNA) can show decreases out of proportion to the effects of total Ig levels. While other ANAs such as anti-Sm or anti-RNP can show decreases perhaps not as profound as anti-DNA, anti-Ro antibody may not be affected by belimumab, for example.(9) The maintenance of a consistent level of antibody production could suggest production by long-lived plasma cells. An intriguing study by Lindop et al showed that the anti-Ro response, while showing little change in levels over time, resulted from the emergence of new clones as indicated by variable region sequences.(14) In this case, the stability in levels of the ANA gave a false impression of an origin from long-lived plasma cells, whereas the clonal diversification implicates ongoing tick-over from memory B cells.
  Given the range of new therapies under investigation for SLE, it is important to recognize the unique immunological features of the clinical trial population (i.e., longer disease duration, history of previous immunosuppressive agents, active disease) and develop a serological profile of this patient population with quantitative assays and optimally a range of different testing kits. The study by Choi is an important step in exploring the immune landscape of SLE in the first years after disease onset. In view of advances in serological testing and future clinical trials, further exploration of this landscape in subsequent years will be both fascinating and essential.

  1. Choi MY, Clarke AE, Urowitz M, et al. Longitudinal analysis of ANA in the Systemic Lupus International Collaborating Clinics (SLICC) Inception Cohort. Ann Rheum Dis 2022.
  2. Frodlund M, Wetterö J, Dahle C, et al. Longitudinal anti-nuclear antibody (ANA) seroconversion in systemic lupus erythematosus: a prospective study of Swedish cases with recent-onset disease. Clin Exp Immunol 2020;199(3):245-54.
  3. Wallace DJ, Stohl W, Furie RA, et al. A phase II, randomized, double-blind, placebo-controlled, dose-ranging study of belimumab in patients with active systemic lupus erythematosus. Arthritis Rheum 2009;61(9):1168-78.
  4. Furie R, Petri M, Zamani O, et al. A phase III, randomized, placebo-controlled study of belimumab, a monoclonal antibody that inhibits B lymphocyte stimulator, in patients with systemic lupus erythematosus. Arthritis Rheum 2011;63(12):3918-30.
  5. Pisetsky DS, Rovin BH, Lipsky PE, et al. New Perspectives in Rheumatology: biomarkers as entry criteria for clinical trials of new therapies for systemic lupus erythematosus: the example of antinuclear antibodies and anti-DNA. Arthritis Rheumatol 2017;69:487-93.
  6. Pisetsky DS, Spencer DM, Lipsky PE, et al. Assay variation in the detection of antinuclear antibodies in the sera of patients with established SLE. Ann Rheum Dis 2018;77(6):911-3.
  7. Pisetsky DS, Thompson DK, Wajdula J, et al. Variability in Antinuclear Antibody Testing to Assess Patient Eligibility for Clinical Trials of Novel Treatments for Systemic Lupus Erythematosus. Arthritis Rheumatol 2019;71(9):1534-8.
  8. Morand EF, Furie R, Tanaka Y, et al. Trial of Anifrolumab in Active Systemic Lupus Erythematosus. N Engl J Med 2020;382(3):211-21.
  9. Parodis I, Åkerström E, Sjöwall C, et al. Autoantibody and Cytokine Profiles during Treatment with Belimumab in Patients with Systemic Lupus Erythematosus. Int J Mol Sci 2020;21(10).
  10. Eickenberg S, Mickholz E, Jung E, et al. Mycophenolic acid counteracts B cell proliferation and plasmablast formation in patients with systemic lupus erythematosus. Arthritis Res Ther 2012;14(3).
  11. Heidt S, Roelen DL, Eijsink C, et al. Effects of immunosuppressive drugs on purified human B cells: evidence supporting the use of MMF and rapamycin. Transplantation 2008;86(9):1292-300.
  12. Karnell JL, Karnell FG, 3rd, Stephens GL, et al. Mycophenolic acid differentially impacts B cell function depending on the stage of differentiation. J Immunol 2011;187(7):3603-12.
  13. Fassbinder T, Saunders U, Mickholz E, et al. Differential effects of cyclophosphamide and mycophenolate mofetil on cellular and serological parameters in patients with systemic lupus erythematosus. Arthritis Res Ther 2015;17(1):92.
  14. Lindop R, Arentz G, Bastian I, et al. Long-term Ro60 humoral autoimmunity in primary Sjögren's syndrome is maintained by rapid clonal turnover. Clin Immunol 2013;148(1):27-34.

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  Conflict of Interest:
  None declared.

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