Subgroup Of Rheumatoid Arthritis Patients Research Articles

A Promising Target in Rheumatoid Arthritis Treatment: Granulocyte-Macrophage Colony-Stimulating Factor

Granulocyte-macrophage colony-stimulating factor (GM-CSF) is more familiar to clinicians as a hemopoietic growth factor. However, it also modulates functions of myeloid cells such as macrophages. Experimental work has demonstrated its significant contribution to the pathogenesis of rheumatoid arthritis (RA). It was a long-time concern that targeted therapies against this cytokine could cause severe side effects such as neutropenia or pulmonary alveolar proteinosis. Nevertheless, different compounds successfully entered clinical development for RA targeting the cytokine itself or its receptor. Currently, a monoclonal antibody against its receptor has completed phase II trials with a profound and rapid onset of response, normalization of acute phase reactants, and an overall good safety profile. The development of compounds targeting the GM-CSF pathway represents a promising approach in RA. However, the obtained ACR20 and ACR50 responses were rather similar with marketed biologic agents when added to MTX. So, it is appropriate to ask the question, whether we do really need another group of agents with a similar performance? In this context, the tumor necrosis factor (TNF)-independent mode-of action of GM-CSF blockade supports the assumption that it could be a useful alternative especially in anti-TNF-resistant patients. Furthermore, a higher efficacy with concurrent blockade of IL-17 and GM-CSF, as reported from preclinical studies, also suggests that such strategies are of interest for future approaches. Therefore, comprehensive assessment of GM-CSF blockade in anti-TNF-resistant patients and combination strategies will be of major importance. Taken together, rapid onset of action, sustained effectiveness, and shown favorable safety data from phase 2 trials warrant further evaluations of anti-GM-CSF agents in different subgroups of RA patients.

Further international adaptation and validation of the Rheumatoid Arthritis Quality of Life (RAQoL) questionnaire.

The Rheumatoid Arthritis Quality of Life (RAQoL) questionnaire was developed directly from rheumatoid arthritis (RA) patients in the United Kingdom and the Netherlands to measure quality of life (QoL). Since then, it has become widely used in clinical studies and trials and has been adapted for use in 24 languages. The objective was to develop and validate 11 additional language versions of the RAQoL in US English, Mexican Spanish, Argentinean Spanish, Belgian French, Belgian Flemish, French, Romanian, Czech, Slovakian, Polish and Russian. The language adaptation and validation required three stages: translation, cognitive debriefing interviews and validation survey. The translation process involved a dual-panel methodology (bilingual panel followed by a lay panel). The validation survey tested the psychometric properties of the new scales and included either the Nottingham Health Profile (NHP) or the Health Assessment Questionnaire (HAQ) as comparators. Internal consistency of the new language versions ranged from 0.90 to 0.97 and test-retest reliability from 0.85 to 0.99. RAQoL scores correlated as expected with the HAQ. Correlations with NHP sections were as expected: highest with energy level, pain and physical mobility and lowest with emotional reactions, sleep disturbance, and social isolation. The adaptations exhibited construct validity in their ability to distinguish subgroups of RA patients varying by perceived disease severity and general health. The new language versions of the RAQoL meet the high psychometric standards of the original UK English version. The new adaptations represent valid and reliable tools for measuring QoL in international clinical trials involving RA patients.

SAT0109 Accelerated Subclinical Atheromatosis, but not Arterial Stiffness or Hypertrophy, in Rheumatoid Arthritis Patients Free of Classical Risk Factors

BackgroundSeveral lines of evidence indicate that classical cardiovascular disease (CVD) risk factors, such as arterial hypertension, diabetes mellitus, smoking and dyslipidemia, are significantly increased in rheumatoid arthritis (RA), which, in...

SP0165 How to Evaluate Cardiovascular Risk in Patients with Inflammatory Joint Disease – A Review of the Evidence

The increased risk of cardiovascular (CV) morbidity and mortality in patients with rheumatoid arthritis (RA) has been known for decades [1]. CV disease is a major factor in the widening...

FRI0006 Mmp3 Predicts A Subgroup of Rheumatoid Patients with Structural Remission under Low-Dose Methotrexate (MTX) Monotherapy

BackgroundMethotrexate (MTX) is still a mainstay in the therapy of rheumatoid arthritis (RA) in the era of biologics therapy, and some patients do respond well without radiographic progression to MTX...

Recognition of new citrulline‐containing peptide epitopes by autoantibodies produced in vivo and in vitro by B cells of rheumatoid arthritis patients

Anti-citrullinated peptide/protein antibodies (ACPAs) are highly sensitive and specific markers of rheumatoid arthritis (RA). Identification of peptide epitopes that may detect different subgroups of RA patients might have diagnostic and prognostic significance. We have investigated citrulline- and arginine-containing peptide pairs derived from filaggrin, collagen or vimentin, and compared this citrulline-peptide panel with the serological assays conventionally used to detect ACPAs. Furthermore, we studied if the same citrulline-peptides identify antibody-secreting cells in in vitro cultures of RA B cells. Recognition of citrulline- and arginine-containing filaggrin, vimentin and collagen peptide epitopes were tested by Multipin ELISA system, by indirect ELISA and by a peptide-specific microarray. B cells were purified from blood by negative selection; antibody-producing cells were enumerated by ELISPOT assay. The panel composed of citrulline-peptide epitopes of filaggrin, collagen and vimentin was recognized by RA sera with a sensitivity and specificity comparable with the currently used tests. Moreover, the combined citrulline-peptide panel including the new short epitope peptide of filaggrin, fil311-315, also identified nearly one-third of RA cases that were negative for antibodies against cyclic citrullinated peptides, mutated citrullinated vimentin or for rheumatoid factor. The results with the peptide-specific microarray have shown that although most ACPAs recognizing the four citrulline peptides are IgG, some of them specifically recognizing citrulline-containing filaggrin peptides (fil311-315 and fil306-326) are IgM, and so may be produced either by newly formed activated B cells or by unswitched B memory cells. Furthermore, the citrulline-peptides of filaggrin and vimentin detect ACPA-producing cells, and so could also be applied to study the B cells of RA patients.

Identification of a Linear Epitope Recognized by a Monoclonal Antibody Directed to the Heterogeneous Nucleoriboprotein A2

Rheumatoid arthritis (RA) is a chronic autoimmune disorder, characterized by progressive joint destruction and disability. Classical autoantibodies of RA are rheumatoid factors and citrulline antibodies. Patients positive for these autoantibodies are usually associated with a progressive disease course. A subgroup of RA patients does not express citrulline antibodies, instead are approximately 35% of these anti-citrulline-negative patients reported to express autoantibodies to the heterogeneous nucleoriboprotein A2, a ribonucleoprotein involved in RNA transport and processing also referred to as RA33. In the absence of citrulline antibodies, RA33 antibodies have been suggested to be associated with a milder disease course. In this study we screened the reactivity of a monoclonal antibody to RA33-derived peptides by modified enzyme-linked immunosorbent assays (ELISA). Terminally truncated resin-bound peptides were applied for determination of the functional epitope necessary for antibody recognition. In addition, screening of substituted peptides by modified ELISA identified amino acids necessary for antibody reactivity. A potential epitope was identified in the region 71-79 (PHSIDGRVV), where the amino acids Ser, Ile and Asp were found to be essential for antibody reactivity. These amino acids were found to contribute to the antibody-antigen interface through side-chain interactions, possibly in combination with a positively charged amino acid in position 77. Moreover, the amino acids in the N-terminal end (Pro and His) were found to contribute to the interface through backbone contributions. No notable reactivity was found with RA-positive patient sera, thus screening of RA33 antibodies does not seem to be a supplementary for the diagnosis of RA.

Cardiovascular Risk in Rheumatoid Arthritis (RA): Does It Matter If RA Is Diagnosed in Early or Late Age?

Rheumatoid arthritis (RA) is a complex autoimmune disorder with heterogeneous clinical presentations, including age at disease onset. Indeed, RA can be diagnosed at any age. Although the peak age of onset is between 50 and 75 years, the prevalence of RA in females over age 65 is up to 5%1. Given the prevalence of RA is about 1% in whites2, there is a substantial subgroup of RA patients who are elderly (over age 65) at disease onset. There are over 50 countries with current life expectancies of 75 years or older3. Hence, the risk of morbidity and mortality even in the subgroup of elderly-onset RA patients is of clinical relevance. The approximately 2 to 3-fold increased risk of cardiovascular disease (CVD) in RA is well-established4,5,6. It is suggested that both traditional CV risk factors as well as RA-specific disease mechanisms (e.g., systemic inflammation, immune dysregulation, and premature immunosenescence) contribute to the overall CV risk in RA. However, few studies have examined the risks and determinants of CVD in subgroups of RA patients depending on their age at diagnosis. In a previous population-based study6, it was shown that the 10-year absolute cardiovascular (CV) risk in given age groups varied substantially according to the presence of CV risk factors; among 60 to 69-year-old RA patients with no risk factors, the absolute CV risk was only 16.8%, but rose to 60.4% if CV risk factors of smoking, hypertension (HTN), dyslipidemia, diabetes, and obesity were present. A recent study by Ajeganova and colleagues in this issue of The Journal 7 complements these findings by examining the effect of early RA disease factors on CV risk, stratified by age at RA disease onset. Their study sought to examine the associations of … Address correspondence to Dr. Liang, University of Pittsburgh, Division of Rheumatology, 3500 Terrace St., BST S723, Pittsburgh, PA 15261, USA. E-mail: liangkp{at}upmc.edu

AB0027 Impact of additional genetic markers of rheumatoid arthritis on pattern of functional stress responses

BackgroundGrowing evidence supports the hypothesis that alteration of the stress response and interactions between the autonomic nervous system, the hypothalamus-pituitary-adrenal axis and the immune system contributes to the pathogenesis of...

SAT0005 Human C-Type Lectin Domain Family 4, Member C Gene Expression Level Helps Predict Future Clinical Response to Tabalumab Blockade of Baff in Rheumatoid Arthritis

BackgroundPatients with rheumatoid arthritis (RA) exhibit substantial variability in both the magnitude and duration of their clinical response to treatment. Despite considerable research, no biomarker has reproducibly been shown to...

Lack of Association BetweenTLR4rs4986790 Polymorphism and Risk of Cardiovascular Disease in Patients with Rheumatoid Arthritis

Rheumatoid arthritis (RA) is a chronic inflammatory disease associated with increased cardiovascular (CV) mortality. Toll-like receptor-4 (TLR4) activates the innate immune response via NF-kB pathway and mitogen-activated protein kinase signaling, leading to expression of proinflammatory cytokines and chemokines. The G allele of TLR4 rs4986790 (+896A>G, Asp299Gly) gene polymorphism has been implicated in reduction of risk of atherosclerosis. In this study, 1481 RA patients fulfilling the 1987 American College of Rheumatology (ACR) criteria were genotyped for the rs4986790 TLR4 variant to determine the influence of this variant in the risk of CV events in these patients. Also, HLA-DRB1 status was determined using molecular based methods. Moreover, potential influence of rs4986790 variant in the development of subclinical atherosclerosis was assessed in a subgroup of RA patients with no history of CV events by the measurement of surrogate markers of subclinical atherosclerosis. No statistically significant differences in allele or genotype frequencies for the rs4986790 variant between RA patients who experienced CV events or not were found. Likewise, no significant association between this gene variant and any of the surrogate markers of subclinical atherosclerosis was found. In summary, results in our study do not support the hypothesis that the rs4986790 (+896A>G, Asp299Gly) TLR4 variant may influence predisposition for subclinical atherosclerosis and clinically evident CV disease in RA patients.

Validation of a multiplex chip-based assay for the detection of autoantibodies against citrullinated peptides

IntroductionAutoantibodies directed against citrullinated proteins/peptides (ACPAs) are highly specific and predictive for the development of rheumatoid arthritis (RA). Different subgroups of RA patients, which have different prognoses and may require different treatments, are characterized by different autoantibody profiles. The objective of this study was to develop a microarray for the detection of multiple RA-associated autoantibodies, initially focusing on responses against citrullinated epitopes on candidate autoantigens in RA.MethodsThe microarray is based on Phadia's ImmunoCAP ISAC system, with which reactivity to more than 100 antigens can be analyzed simultaneously, by using minute serum volumes (< 10 μl). Twelve citrullinated peptides, and the corresponding native arginine-containing control peptides, were immobilized in an arrayed fashion onto a chemically modified glass slide, allowing a three-dimensional layer with high binding capacity. The assay was optimized concerning serum dilution and glass surface, whereas each individual antigen was optimized concerning coupling chemistry, antigen concentration, and selection of spotting buffer. The performance of each peptide in the ImmunoCAP ISAC system was compared with the performance in enzyme-linked immunosorbent assays (ELISAs). Serum from 927 RA patients and 461 healthy controls from a matched case-control study were applied onto reaction sites on glass slides, followed by fluorescent-labeled anti-human immunoglobulin G (IgG) antibody. Fluorescence intensities were detected with a laser scanner, and the results analyzed by using image-analysis software.ResultsStrong correlations between the ImmunoCAP ISAC system and ELISA results were found for individual citrullinated peptides (Spearman ρ typically between 0.75 and 0.90). Reactivity of RA sera with the peptides was seen mainly in the anticyclic citrullinated peptide 2 (CCP2)-positive subset, but some additional reactivity with single citrullinated peptides was seen in the anti-CCP2-negative subset. Adjusting for reactivity against arginine-containing control peptides did not uniformly change the diagnostic performance for antibodies against the individual citrullinated peptides.ConclusionsThe multiplexed array, for detection of autoantibodies against multiple citrullinated epitopes on candidate RA autoantigens, will be of benefit in studies of RA pathogenesis, diagnosis, and potentially as a guide to individualized treatment.

The increasing disease duration of patients at the time of orthopaedic surgery for rheumatoid arthritis

In recent years, disease-modifying antirheumatic drugs (DMARDs), including biological agents, have been used to inhibit or halt the underlying immune process and prevent long-term damage in rheumatoid arthritis (RA). The introduction of biological DMARDs has increased treatment options for RA, and clinical remission is now considered to be the primary goal of RA treatment. Despite the availability of such aggressive therapies, ongoing progressive destruction of joints occurs in a subgroup of RA patients, who eventually require joint surgery [1]. Orthopaedic procedures can substantially improve the overall function and quality of life in such patients. However, some reports have suggested that improvements in medical treatment might partially explain the reduction in the incidence of orthopaedic joint surgery, resulting in a worldwide trend towards better long-term outcomes [2–5]. In this study, we investigated the disease duration at the time of orthopaedic surgery among RA patients who participated in a large observational cohort study established by our institute (IORRA) [4]. Outpatients who fulWlled the American College of Rheumatology criteria for RA and/or 2010 rheumatoid arthritis classiWcation criteria were registered in this cohort study [6, 7]. An average of 4,990 outpatients with RA were seen each month from 2003 to 2009. Patient information was collected biannually (April/May and October/November) when the patients visited the outpatient unit of the Institute of Rheumatology, Tokyo Women’s Medical University [8]. Figure 1a shows the average RA disease activity from 2003 to 2009. As previously reported, disease activity decreased during this period [9]. Figure 1b shows the disease duration trend at the time of surgery. Surprisingly, the disease duration of patients who underwent total knee arthroplasty (TKA) gradually increased during this period. In addition, the disease duration of patients who underwent any type of surgery, including TKA, total hip arthroplasty, wrist and Wnger joint surgeries, and foot surgeries, was also increased. The reason for the observed increase in disease duration at the time of RA-associated surgery may be related to the decreased number of synovectomies and suppression of disease activity that has resulted from the use of methotrexate (MTX) and biological agents [9]. MTX was approved for the treatment for RA by the Japanese Ministry of Health, Labor and Welfare in 1999, while inXiximab was approved in 2003, etanercept was approved in 2005, adalimumab and tocilizumab were approved in 2008, and abatacept was approved in 2009. In addition, the use and dosage of MTX and the number of use of biological agents have been increasing every year [9]. Conversely, disease activity score (CDAI: clinical disease activity index, SDAI: simpliWed disease activity index) has been decreasing. Therefore, the recent implementation of medical therapy in RA patients may have suppressed and delayed the progression of destruction in arthritic joints, thereby resulting in postponement of surgery. We believe that these clinical results also provide evidence that these recently introduced medical therapies result in better long-term outcomes for RA patients. However, further studies, including analyses of RA databases that collect long-term data on a variety of surgical interventions, are required to conWrm this hypothesis. S. Momohara (&) · K. Ikari · K. Kawakami · T. Iwamoto · E. Inoue · K. Yano · Y. Sakuma · R. Hiroshima · A. Tokita · A. Taniguchi · H. Yamanaka Institute of Rheumatology, Tokyo Women’s Medical University, 10-22 Kawada, Shinjuku, Tokyo 162-0054, Japan e-mail: smomohara@ior.twmu.ac.jp

HETEROGENEITY OF EARLY RHEUMATOID ARTHRITIS PATIENTS ACCORDING TO BLOOD GENE EXPRESSION: THEORETICAL BASES OF A DIFFERENTIAL THERAPY APPROACH

Система комплексной поддержки и сопровождения научного журнала Elpub позволяет запустить двуязычный сайт журнала со встроенной системой электронной редакции в соответствии с лучшими издательскими практиками, а так же предусматривает техническую и методическую поддержку со стороны специалистов НЭИКОН.

A multiplex microarray for the detection of rheumatoid arthritis-associated autoantibodies

Background and objectivesAutoantibodies, for example, directed against citrullinated proteins/peptides (ACPA) are highly specific and predictive of development of rheumatoid arthritis (RA). Different subgroups of RA patients have different autoantibody specificities...

Association of the response to tumor necrosis factor antagonists with plasma type I interferon activity and interferon‐β/α ratios in rheumatoid arthritis patients: A post hoc analysis of a predominantly Hispanic cohort

AbstractObjectiveDespite the substantial clinical efficacy of tumor necrosis factor α (TNFα) antagonist therapy in patients with rheumatoid arthritis (RA), some patients respond poorly to such agents. Since an interferon (IFN) signature is variably expressed among RA patients, we investigated whether plasma type I IFN activity might predict the response to TNF antagonist therapy.MethodsRA patients (n = 35), the majority of whom were Hispanic, from a single center were evaluated before and after initiation of TNF antagonist therapy. As controls, 12 RA patients from the same center who were not treated with a TNF antagonist were studied. Plasma type I IFN activity was measured using a reporter cell assay, and disease status was assessed using the Disease Activity Score in 28 joints (DAS28). Levels of interleukin‐1 receptor antagonist (IL‐1Ra) were determined in baseline plasma samples using a commercial enzyme‐linked immunosorbent assay. The clinical response was classified according to the European League Against Rheumatism criteria for improvement in RA.ResultsPlasma type I IFN activity at baseline was significantly associated with clinical response (odds ratio 1.36 [95% confidence interval 1.05–1.76], P = 0.020), with high baseline IFN activity associated with a good response. Changes in DAS28 scores were greater among patients with a baseline plasma IFNβ/α ratio &gt;0.8 (indicating elevated plasma IFNβ levels). Consistent with the capacity of IFNβ to induce IL‐1Ra, elevated baseline IL‐1Ra levels were associated with better therapeutic outcomes (odds ratio 1.82 [95% confidence interval 1.1–3.29], P = 0.027).ConclusionThe plasma type I IFN activity, the IFNβ/α ratio, and the IL‐1Ra level were predictive of the therapeutic response in TNF antagonist–treated RA patients, indicating that these parameters might define clinically meaningful subgroups of RA patients with distinct responses to therapeutic agents.

Confirmation of STAT4, IL2/IL21, and CTLA4 polymorphisms in rheumatoid arthritis

Recent advances have led to novel identification of genetic polymorphisms that are associated with susceptibility to rheumatoid arthritis (RA). Currently, 5 loci (HLA, PTPN22, TRAF1/C5, TNFAIP3, and STAT4) have been consistently reported, whereas others have been observed less systematically. The aim of the present study was to independently replicate 3 recently described RA susceptibility loci, STAT4, IL2/IL21, and CTLA4, in a large Dutch case-control cohort, and to perform a meta-analysis of all published studies to date and investigate the relevance of the findings in clinically well-defined subgroups of RA patients with or without autoantibodies. The STAT4, IL2/IL21, and CTLA4 gene polymorphisms (rs7574865, rs6822844, and rs3087243, respectively) were genotyped in 877 RA patients and 866 healthy individuals. A meta-analysis of all published studies of disease association with these polymorphisms was performed using the Mantel-Haenszel fixed-effects method. An association of STAT4, IL2/IL21, and CTLA4 with RA was detected in Dutch patients (odds ratio [OR] 1.19 [P=0.031], OR 0.84 [P=0.051], and OR 0.87 [P=0.041], respectively). Results from the meta-analysis confirmed an association of all 3 polymorphisms with RA in Caucasians (OR 1.24 [P=1.66x10(-11)], OR 0.78 [P=5.6x10(-5)], and OR 0.91 [P=1.8x10(-3)], respectively). The meta-analysis also revealed that STAT4 predisposed to disease development equally in patients with autoantibodies and those without autoantibodies, and that CTLA4 enhanced the development of anti-citrullinated protein antibody (ACPA)-positive RA as compared with ACPA-negative RA. Our results replicate and firmly establish the association of STAT4 and CTLA4 with RA and provide highly suggestive evidence for IL2/IL21 loci as a risk factor for RA. Given the strong statistical power of our meta-analysis to confirm a true-positive association, these findings provide considerable support for the involvement of CTLA4 in distinct subsets of RA patients.

Tratamiento de situaciones clínicas difíciles en pacientes con artritis reumatoide: cáncer

Rheumatoid arthritis (RA) patients have a higher risk of developing some types of cancer, such as lymphoma or lung cancer. The severity of the disease is associated with a higher risk of developing lymphoma. Anti-TNF-α agents do not increase the incidence of neoplasm, but could trigger the onset of lymphoma in a subgroup of RA patients. Anti-TNF-α agents have been associated with a higher frequency of non-melanoma skin cancer. Although methotrexate does not increase the overall incidence of lymphoma or solid neoplasm, its use is sporadically associated with the development of lymphoma. These methotrexate-induced lymphomas occasionally disappear after withdrawal of the drug.

Association of the −1082 G/A promoter polymorphism of interleukin-10 gene with the autoantibodies production in patients with rheumatoid arthritis

Interleukin-10 (IL-10) is an immunoregulatory cytokine, usually considered to mediate the downregulation of the inflammatory response in rheumatoid arthritis (RA). Some effects of IL-10 are not anti-inflammatory; for example, the activation of B cells to promote autoantibody production. Allelic polymorphisms located in the promoter region of the IL-10 gene may contribute to the regulation of autoantibodies production. To examine the putative association between the -1082 G/A polymorphism in the promoter region of the IL-10 gene and the susceptibility to disease onset and severity of RA, a total of 144 patients with RA diagnosed according to the revised criteria of the American College of Rheumatology for RA were consecutively recruited into the study. Radiographic progression of RA was scored according to the Sharp/van der Heijde method. Serum levels of rheumatoid factors (RFs) were measured by enzyme-linked immunosorbent assay. Polymerase chain reaction amplification was used for the analysis of the promoter polymorphism of the IL-10 gene. We observed significant differences in genotype distribution of the -1082 G/A polymorphism between IgM RF, IgA RF, and IgG RF positive/negative subgroups of RA patients, with higher prevalence of the GG genotype within IgM RF (Pg = 0.006), IgA RF (Pg = 0.05), and IgG RF (Pg = 0.007) negative RA patients. Results obtained in this study provide the evidence of an association between the -1082 G/A polymorphism in the IL-10 gene promoter and the production of RFs in RA patients.

Efficient suppression of murine arthritis by combined anticytokine small interfering RNA lipoplexes

Blocking tumor necrosis factor (TNF) effectively inhibits inflammation and joint damage in rheumatoid arthritis (RA), but 40% of RA patients respond only transiently or not at all to the current anti-TNF biotherapies. The purpose of this study was to develop an alternative targeted therapy for this subgroup of RA patients. As proof of concept, we tested the efficiency of an RNA interference (RNAi)-based intervention that targets proinflammatory cytokines in suppressing murine collagen-induced arthritis (CIA). Two synthetic short interfering RNA (siRNA) sequences were designed for each of the proinflammatory cytokines interleukin-1 (IL-1), IL-6, and IL-18. Their silencing specificity was assessed according to lipopolysaccharide-induced messenger RNA expression in J774.1 mouse macrophages as compared with control siRNA. For in vivo administration, siRNA were formulated as lipoplexes with the RPR209120/DOPE liposome and a carrier DNA and were injected intravenously (0.5 mg/kg) into DBA/1 mice with CIA. Weekly injections of anti-IL-1, anti-IL-6, or anti-IL-18 siRNA-based lipoplexes significantly reduced the incidence and severity of arthritis, abrogating joint swelling and destruction of cartilage and bone, both in the preventative and the curative settings. The most striking therapeutic effect was observed when the 3 siRNA were delivered in combination. The siRNA lipoplex cocktail reduced all pathologic features of RA, including inflammation, joint destruction, and the Th1 response, and overall parameters of RA were improved as compared with anti-TNF siRNA lipoplex-based treatment. Our results present a novel option for in vivo RNAi-based antiinflammatory immunotherapy. Our findings indicate that intravenous administration of a lipoplex cocktail containing several anticytokine siRNA is a promising novel antiinflammatory therapy for RA, as well as a useful and simple tool for understanding the pathophysiology of RA and for evaluating new therapeutic candidates.