Atherosclerosis in Rheumatoid Arthritis and Lupus: Restoring Cholesterol Balance

Conditions:Arthritis, Rheumatoid Arthritis, Cardiology
Therapuetic Areas:Cardiology / Vascular Diseases, Rheumatology
Age Range:18 - 65
Start Date:September 2008
End Date:December 2018
Contact:Allison B Reiss, MD

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Atherosclerosis in RA and Lupus: Restoring Cholesterol Balance

Hypothesis: SLE and RA increase risk of myocardial infarction (MI, heart attack). Immune
reactants in the circulation of SLE patients downregulate cholesterol efflux proteins
27-hydroxylase and ABCA1 and upregulate scavenger receptor CD36, thus encouraging cholesterol
accumulation. Adenosine A2A receptor agonist or statin treatment of cells exposed to SLE
plasma (or immune complexes or cytokine-enriched plasma fractions from SLE patients) may
ameliorate inflammatory properties of their plasma, lessening its atherogenic potency.

Rationale: SLE and RA plasma contain components not present in significant levels in normal
plasma that could, individually or acting together, affect 27-hydroxylase, ABCA1 and CD36
expression. Candidate components include autoantibodies, immune complexes, and various
cytokines. Statins reduce major cardiovascular events and death. Modulation of adenosine
signaling participates in regulation of 27-hydroxylase and ABCA1. As a potential preventative
and therapeutic approach to atherosclerotic cardiovascular disease, the investigators
evaluate the effect of A2A receptor agonists and statins on atherogenic parameters in SLE and
RA plasma.

Experimental Plan: Quantitate 27-hydroxylase and several other proteins involved in cellular
cholesterol uptake and excretion in THP-1 monocytes/macrophages and HAEC after exposure to
plasma and plasma components from SLE patients (and controls) ± lipid loading with acetylated
LDL with/without addition of A2AR agonist, statin, or both. Determine relative impact of
immune complexes and cytokines on expression of proteins involved in cholesterol flux.
Determine levels of proteins involved in cellular cholesterol influx/efflux in peripheral
blood mononuclear cells isolated from RA, SLE and psoriatic arthritis patients and normal
controls at baseline, then following incubation in culture media alone or with statin,
adenosine A2A agonist or both statin + A2AR agonist.

Atherosclerotic cardiovascular disease (ASCVD) is a major cause of morbidity and mortality,
especially in patients with autoimmune disorders such as systemic lupus erythematosus (lupus)
and rheumatoid arthritis (RA). We have found that immune and inflammatory mediators promote
atherosclerosis by disabling mechanisms that prevent cells of the artery wall from being
overloaded with cholesterol, leading to formation of lipid laden foam cells. This proposal
seeks to identify which specific components in the blood of patients with lupus and RA make
them vulnerable to ASCVD and to explore potential novel therapeutic approaches utilizing our
finding that the naturally occurring anti-inflammatory molecule adenosine can restore normal
cholesterol outflow to cells that line the artery wall.

1. A 40 cc blood sample will be taken from each subject by venipuncture. The plasma will be
added to cell culture media (25 and 50% vol/vol) and used for incubation with THP-1
monocytic leukemia cells and/or human monocyte-derived macrophages and/or human aortic
endothelial cells so that the effect of exposure to various disease and control plasma
on cholesterol homeostatic protein expression by the cultured cells can be assessed.
PBMC will be isolated from a portion of the sample by Ficoll hypaque gradient

Subject Inclusion & Exclusion Criteria

1. Normal Controls Normal healthy volunteers, age 18-65, not on corticosteroids or any
other immune-modifying medications. Because SLE is a disease with >90% female
prevalence and RA has a similar gender bias towards the female sex, our data in men
will be exploratory only and we will not be able to examine sex differences in
effects on our outcome measures (1, 2).

2. Rheumatoid Arthritis Patients Patients age 18-65 who satisfy at least 4 of the 7
revised criteria (1987) for the classification of rheumatoid arthritis (3).

3. Active SLE patients Patients, age 18-65, must fulfill the 1982 revised criteria of
the American College of Rheumatology (formerly the American Rheumatism Association)
for classification of SLE (4). SLE activity status will be designated using the
SLEDAI disease activity index (5). Patients with previous documentation of a
diagnosis of a connective tissue disorder other than SLE will be excluded. Patients
will have had no statin treatment in the prior three months.

4. Psoriatic Arthritis Patients Diagnosed according to criteria described by McGonacle
et al (6). Defined as an inflammatory arthritis associated with psoriasis

40 patients will be recruited for each group. Anti-C1q antibodies will be measured
in all subjects by a solid-phase enzyme-linked immunosorbent assay.

2. Protection of Human Subjects- Informed consent will be obtained from all subjects and
patient confidentiality will be maintained at all times. The protocol and consent form
will be approved by the Winthrop University Hospital IRB. We are not using a case study
approach so all data will be pooled and anonymity will be preserved. To further ensure
anonymity, all records and blood specimens will be numerically coded, and the
translation table will be accessible only to the PI. Patients will be asked by their
physicians during routine visits to participate in the study.

3. Sources of research material- Blood sample (40 cc) drawn during routine outpatient
visits to the faculty practices offices of Winthrop University Hospital Academic
Rheumatologists. Patient charts will be utilized to obtain information on disease
activity status, medication regimen, age, sex and cardiovascular disease history. All
such information is collected in the patient chart as part of standard medical

4. Potential Risk to Subjects The studies proposed only require the donation of blood
samples (40 cc each) by the subjects and impose only the minimal risk to the subjects of
blood drawing. These risks include hematoma formation and, very rarely, infection at the
puncture site. No interventions or special measures are involved. Furthermore, as
patients with the diagnoses of SLE and RA require frequent monitoring of blood
parameters, whether in relation to their disease activity or for monitoring the side
effects of the treatments they receive, the acquisition of the blood samples for the
study impose no additional discomfort to them than what they would experience in their
routine medical care. The course of treatment for the subjects will not be changed in
any way by participation in this project. All blood specimens will be handled carefully
and with full blood precautions.

5. The Risks of this Study are no more than those involved in any routine blood drawing.
Donating blood may occasionally cause pain, bruising, fainting or a small infection at
the puncture site.

6. Potential Benefits of the Proposed Research to the Subjects and Others At this time,
there is no direct benefit for enrolled subjects. However, we hope to gather information
that may help people in the future by reducing morbidity and mortality from
cardiovascular disease.

7. The Importance of the Knowledge to Be Gained Although the patients will see no direct
personal benefit, the knowledge to be gained has immense potential to benefit SLE and RA
patients because it may eventually lead us to an understanding of the role of
immunological mechanisms in the pathogenesis of premature cardiovascular disease. This
understanding will pave the way for the development of life-prolonging preventive and
therapeutic interventions.

Inclusion Criteria:

- Males and females age 18-65

Exclusion Criteria:

- No methotrexate or statin therapy in prior 3 months.

- Not on biological therapies.
We found this trial at
259 1st St
Mineola, New York 11501
(516) 663-0333
Principal Investigator: Allison B Reiss, MD
Phone: 516-663-4751
Winthrop University Hospital Founded in 1896 by a group of local physicians and concerned citizens,...
Mineola, NY
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