Autoimmune APPLICATION NOTES. MyriadRBM.com. Myriad RBM s Biomarker Testing Lab: CLIA Certified ID # 45D Supports GLP Studies

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1 I N N O V AT I V E B I O M A R K E R S O L U T I O N S Autoimmune APPLICATION NOTES Myriad RBM s Biomarker Testing Lab: CLIA Certified ID # 45D Supports GLP Studies MyriadRBM.com

2 Autoimmune diseases are chronic and debilitating disorders in which the body mounts an abnormal immune response against its own organs and tissues. With over 8 different identified disorders affecting an estimated 5 million Americans, autoimmune diseases represent an important and growing area for biomarker research 1. Myriad RBM is a leader in the field of biomarker testing, offering comprehensive, quantitative and sensitive measurement of hundreds of protein biomarkers using multi-analyte profiling (MAP ) technology. Our biomarker panels have been a key component of numerous studies covering a variety of autoimmune disorders, including Crohn s disease, rheumatoid arthritis (RA), psoriasis and systemic lupus erythematosus (SLE). Due to the chronic and heterogeneous nature of autoimmune diseases, there is considerable interest in the development of clinical response markers to guide clinicians in tailoring treatments to individual patients. A pair of recent studies on rheumatoid arthritis demonstrate the effectiveness of biomarker profiling in identifying drug responders in clinical trials 2,3. The first of these studies assessed changes in 17 biomarkers in RA patients undergoing treatment with golimumab, a human monoclonal antibody to tumor necrosis factor-alpha (TNF-α), in conjunction with the traditional treatment of methotrexate 2. The authors found multiple markers that were significantly altered after four weeks of drug treatment (Figure 1). Importantly, a subset of these proteins showed promise as biomarkers for predicting clinical response to golimumab. These markers showed a greater decrease from baseline to week 4 of the study in patients who were drug responders at week 14 as compared to non-responders. Additionally, changes from baseline to week 4 in some of the same biomarkers showed strong associations with multiple clinical measures. Similarly, a second study used HumanMAP to determine whether changes in biomarker profiles were associated with traditional measures of disease progression based on radiographic assessments of structural joint damage (van der Heijde-Sharp score) 3. The authors found that radiographic progression of the disease measured from baseline to week 28 of the study was significantly correlated with changes in a number of biomarkers during the early weeks of the trial (Figure 2). In particular, changes in two biomarkers associated with bone remodeling, EGF and CD4L, across the first 4 weeks of the study were associated with large changes in radiographic score at week 28. Together, the findings from these studies suggest that even a relatively short period of biomarker evaluation could be useful in predicting both disease progression and patient response to treatment many weeks later. Both of these RA examples underscore the tremendous value of biomarkers to predict early-stage drug responses, allowing clinicians to more effectively adjust treatments to individual patients.

3 Figure 1: Heatmap showing significant differences between biomarkers at baseline and week 4. Colors represent ranges of mean log2 transformed biomarker levels at each time point. Visvanathan et al. 21 Monocyte-Macrophage-derived chemokine (CCR-4) Lipoprotein(a) Apolipoprotein A1 Insulin Macrophage Inflammatory Protein-1α Tumor Necrosis Factor Receptor II von Willebrand Factor Cancer Antigen 125 Factor VII Leptin Intracellular Adhesion Molecule-1 Adiponectin Interleukin-18 Tissue Inhibitor of Metalloproteinase-1 Matrix Metalloproteinase-3 Monocyte Chemotactic Protein-1 Interleukin-8 Macrophage Inflammatory Protein-1β CD-4 Antigen Serum Amyloid P C-Reactive Protein Haploglobin Epithelial-Derived Neutrophil-Activating Protein 78 Ferritin Myoglobin Serum Glutamic Oxaloacetic Transaminase Vascular Endothelial Growth Factor ENRAGE (S1A12) Myeloperoxidase α-1 Antitrypsin Complement 3 Interleukin-16 Interleukin-1 Receptor Agonist Sex Hormone-Binding Globulin Plasminogen Activator Inhibitor-1 Baseline Week 4 1 mg Placebo 5 mg MTX 1 mg MTX 1 mg Placebo 5 mg MTX 1 mg MTX -2 to to -1-2 to to to.5.5 to 1 1 to to 2 Golimumab Golimumab

4 A Placebo MTX B Placebo MTX Change in vdh-s Score at Week Change in vdh-s Score at Week Change in EGF at Week 4 (pg/ml) Change in CD4 at Week 4 (ng/ml) Progressor Nonprogressor Figure 2: Comparison of change in van der Heijde-Sharp (vdh-s) score (baseline to week 28) with change in (A) EGF levels (baseline to week 4) and (B) CD4 Ligand levels (baseline to week 4) for structural damage progressors and nonprogressors in patients randomized to treatment with placebo MTX. Changes in EGF and CD4L levels across the first 4 weeks of the study were associated with changes in more than 1 in radiographic score at week 28. Wagner et al. 213 Myriad RBM s services have also been used to demonstrate the potential efficacy of novel therapeutic approaches to autoimmune disorders. For example, a recent study involving explanted colonic tissue from patients with Crohn s disease (CD), a form of inflammatory bowel disease (IBD), used InflammationMAP to examine the effects of a novel CD47 fusion protein on an array of pro-inflammatory cytokines and other markers of inflammation 4. Previous studies in mice had found that a CD47 fusion protein confers protection against experimentally induced colitis by suppressing the release of inflammatory cytokines 5. Baba et al. subsequently extended this study to humans. The authors found that inflamed tissue from CD patients showed a clear pro-inflammatory profile compared to controls using a panel of 47 cytokines (Figure 3A). Figure 3A shows the production of cytokines in inflamed tissue plotted against non-inflamed tissue with values above the red line indicating a pro-inflammatory profile.

5 Figure 3: CD47 fusion protein inhibits proinflammatory cytokine release by inflamed intestinal tissue from CD patients. Colonic tissue explants were cultured in the presence of CD47 fusion protein or IgG1 control. The cytokine production profile was examined in the culture supernatants. (A) Scatter plot of cytokine production in non-inflamed (x axis) versus inflamed (y axis) tissues. (B) Scatter plot of cytokine production in explant cultures expressed as the ratio of CD47 fusion protein/igg1 control for inflamed (x axis) versus non-inflamed (y axis) tissues. Values < 1 on the x axis reflect the inhibition by CD47 fusion protein in inflamed tissue. Data are presented as mean of 5 CD patients. Baba et al. 213 A Cytokines (ng or μg from 1mg) from inflamed explant culture B Ratio CD47-Var1/lgG1 control on non-inflamed explant culture Cytokines; p<.1 (Non-inflamed vs. inflamed) Cytokines (ng or μg from 1mg) from non-inflamed explant culture IFN-γ IL-1β IL Ratio CD47-Var1/lgG1 control on inflamed explant culture TNF-α IL-23 MCP-1 MIP-1β MIP-1α IL-8 IL-1 IL-18 Interestingly, exposure to the CD47 fusion protein inhibited the release of many of these cytokines by the inflamed tissue, including IL-1β, -6, -8, -23, TNF-α and IFN-γ, without affecting cytokine release in control tissue from the same patients. Figure 3B shows the effect of treatment with the CD47 fusion protein on cytokine production in non-inflamed versus inflamed tissue. The deviation from the red line but not the blue line indicates an effect of the fusion protein on cytokine release selectively in inflamed tissue only. These findings suggest that administration of the CD47 fusion protein may represent a novel therapeutic approach for CD. The comprehensive biomarker response profile that can be obtained by simultaneously screening dozens of analytes represents a powerful tool for use in both drug discovery and clinical monitoring of drug response. While a number of biomarkers associated with autoimmune diseases have been discovered, there remains a strong need for the identification and validation of blood-based biomarkers of the autoimmune disease process, with the goal of developing a minimally invasive diagnostic or prognostic to guide therapeutic intervention. A number of recent studies analyzing serum samples from patients with autoimmune disorders feature the use of HumanMAP panel in a targeted

6 approach to biomarker discovery 6,7. In one such study, the authors compared serum samples from 26 Systemic Lupus Erythematosus (SLE) patients with samples from healthy controls, finding significantly higher circulating levels of β2-microglobulin (β2mg) in samples from individuals diagnosed with SLE 6. In addition, β2mg levels correlated with a composite measure of disease activity known as the SLE Disease Activity Index (SLEDAI). The SLEDAI is a weighted cumulative index that has been well established as a reliable measure of disease activity in lupus 8. β2mg levels were also correlated with circulating levels of a variety of proteins that are thought to be involved in disease progression, including complement C3, IL-6, -8, -1, -18 and TNF-α (Figure 4). As the course of SLE is highly variable and unpredictable, the identification of serum biomarkers that reliably track disease activity offers tremendous clinical potential. A 25 B 25 Beta-2 Microglobulin (mg/l) Beta-2 Microglobulin (mg/l) SLEDAI C3 (g/l) Figure 4: Scatter plot of serum levels of β2mg and disease activity measured as (A) SLEDAI and (B) Complement C3 in 26 patients with SLE. Correlation: (A) R =.68, p <.1, (B) R = -.52, p =.7. Hermansen et al. 212 All together, these studies highlight the effectiveness of using Myriad RBM s multiplexed immunoassays for the quantitative measurement of a large number of analytes within an individual study. Further characterization of the biomarker profiles related to the progression and treatment of autoimmune diseases promises to make significant contributions to diagnosis and therapeutics. Myriad RBM strives to be a leading provider of biomarker assays for research on autoimmune disorders.

7 1. The Cost Burden of Autoimmune Disease: The Latest Front in the War on Healthcare Spending. American Autoimmune Related Diseases Association (AARDA) and the National Coalition of Autoimmune Patient Groups (NCAPG). (211). 2. Visvanathan S, Rahman MU, Keystone E, Genovese M, Klareskog L, Hsia E, Mack M, Buchanan J, Elashoff M, Wagner C. Association of serum markers with improvements in clinical response measures after treatment with golimumab in patients with active rheumatoid arthritis despite receiving methotrexate: results from the GO-FORWARD study. Arthritis Res Ther. (21) 12(6):R Wagner C, Chen D, Fan H, Hsia EC, Mack M, Emery P, Fleischmann RM. Evaluation of serum biomarkers associated with radiographic progression in methotrexate-naïve rheumatoid arthritis patients treated with methotrexate or golimumab. J Rheumatol. (213) 4(5): Baba N, Van VQ, Wakahara K, Rubio M, Fortin G, Panzini B, Soucy G, Wassef R, Richard C, Tamaz R, Lahaie R, Bernard EJ, Caussignac Y, Leduc R, Lougnarath R, Bergeron C, Racicot MA, Bergeron F, Panzini MA, Demetter P, Franchimont D, Schakel K, Weckbecker G, Kolbinger F, Heusser C, Huber T, Welzenbach K, Sarfati M. CD47 fusion protein targets CD172a cells in Crohn s disease and dampens the production of IL-1β and TNF. J Exp Med. (213) 21(6): Fortin G, Raymond M, Van VQ, Rubio M, Gautier P, Sarfati M, Franchimont D. A role for CD47 in the development of experimental colitis mediated by SIRPαCD13- dendritic cells. Journal of Experimental Medicine. (29) 26(9): Hermansen ML, Hummelshoj L, Lundsgaard D, Hornum L, Keller P, Fleckner J, Fox B, Poulsen LK, Jacobsen S. Increased serum β2-microglobulin is associated with clinical and immunological markers of disease activity in systemic lupus erythematosus patients. Lupus. (212) 21(1): Suarez-Farinas M, Li K, Fuentes-Duculan J, Hayden K, Brodmerkel C, Kreuger J. Expanding the psoriasis disease profile: interrogation of the skin and serum of patients with moderate-to-severe psoriasis. J Invest Dermatol. (212) 132(11): Bombardier C, Gladman DD, Urowitz MB, Caron D, Chang CH. Derivation of the SLEDAI. A disease activity index for lupus patients. The Committee on Prognosis Studies in SLE. Arthritis Rheum. (1992) 35(6):63-4.

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