Predicting the effectiveness of methotrexate therapy based on basal expression of the AMP-activated protein kinase gene in the blood of patients with rheumatoid arthritis

Objective: to search for an association between basal expression of the AMP-activated protein kinase (adenosine monophosphate-activated protein kinase, AMPK) gene in the blood of patients with rheumatoid arthritis (RA) and disease activity, as well as joint destruction before and after 24 months of methotrexate (MT) therapy.
Patients and methods. The study included 40 patients with RA who met the 1987 ACR classification criteria, with a disease duration of not more than 2 years, with a mean age of 47.5±15.5 years. All patients received 15 mg/week of MT. The number of swollen joints (SJC) out of 44, the number of tender joints (TSC) out of 53, the duration of morning stiffness (in minutes) and RA activity were assessed using the DAS28 index. The concentration of CRP and IgM rheumatoid factor (RF), antibodies to cyclic citrullinated peptide (ACCP) were assessed. To evaluate the radiological progression of RA, the Sharp method modified by van der Heijde was used. Gene expression in peripheral blood cells was determined by reverse transcriptase reaction and real-time polymerase chain reaction.
Results and discussion. During MT therapy, there was a decrease in disease activity by DAS28 index, CRP level, duration of morning stiffness, SJC and TJC. After 2 years, there were no statistically significant changes in the number of erosions, while the number of joints with narrowing of the joint space increased by the end of the study (p=0.004). Treatment with MT resulted in a decrease in AMPK expression. At the same time, patients who achieved remission had the highest level of AMPK before therapy, as did seronegative patients compared to seropositive ones. Based on the ROC analysis, the threshold value of AMPK gene expression was determined, which makes it possible to predict a high probability of a positive effect of MT therapy.
Conclusion. AMPK gene expression is associated with disease activity. Its high initial blood level in RA patients is associated with greater efficiency of MT and, possibly, plays a protective role. With an AMPK gene expression index greater than 3.83, the probability of a positive response to MT is high.

1. Harris ED Jr. Rheumatoid Arthritis: pathophysiology and implications for therapy. N Engl J Med. 1990 May 3;322(18):1277-89. doi: 10.1056/NEJM199005033221805.

2. Firenstein GS. Evolving concepts of rheumatoid arthritis. Nature. 2003 May 15;423(6937): 356-61. doi: 10.1038/nature01661.

3. Nasonov EL, editor. Revmatologiya: Klinicheskie rekomendatsii [Rheumatology. Clinical guidelines]. Moscow: GEOTAR-Media; 2010.

4. Gossec L, Dougados M, Goupille P, et al. Prognostic factors for remission in early rheumatoid arthritis: a multiparameter prospective study. Ann Rheum Dis. 2004 Jun;63(6):675-80. doi: 10.1136/ard.2003.010611.

5. Emery P, Breedveld FC, Hall S, et al. Comparison of methotrexate monotherapy with a combination of methotrexate and etanercept in active, early, moderate to severe rheumatoid arthritis (COMET): a randomized, doubleblind, parallel treatment trial. Lancet. 2008 Aug 2;372(9636):375-82. doi: 10.1016/S0140-6736(08)61000-4. Epub 2008 Jul 16.

6. Visser H, le Cessie S, Vos K, et al. How to diagnose rheumatoid arthritis early: a prediction model for persistent (erosive) arthritis. Arthritis Rheum. 2002 Feb;46(2):357-65. doi: 10.1002/art.10117.

7. Chetina EV, Demidova NV, Karateev DE, et al. Association of gene expression in the blood of patients with rheumatoid arthritis with clinical and laboratory parameters before and after methotrexate therapy. Nauchnoprakticheskaya revmatologiya. 2016;(2): 155-63. (In Russ.).

8. Tchetina EV, Demidova NV, Markova GA, et al. Increased baseline RUNX 2, caspase 3, and p21 gene expressions in the peripheral blood of naпve rheumatoid arthritis patients are associated with improved clinical response to methotrexate therapy. Int J Rheum Dis. 2017 Oct;20(10):1468-80. doi: 10.1111/1756-185X.13131. Epub 2017 Jul 25.

9. Sharabi A, Tsokos GC. T cell metabolism: new insights in systemic lupus erythematosus pathogenesis and therapy. Nat Rev Rheumatol. 2020 Feb;16(2):100-12. doi: 10.1038/s41584-019-0356-x. Epub 2020 Jan 16.

10. Finlay DK. N-myristoylation of AMPK controls T cell inflammatory function. Nat Immunol. 2019 Mar;20(3):252-4. doi: 10.1038/s41590-019-0322-4.

11. Shi M, Wang J, Xiao Y, et al. Glycogen Metabolism and Rheumatoid Arthritis: The Role of Glycogen Synthase 1 in Regulation of Synovial Inflammation via Blocking AMP-Activated Protein Kinase Activation. Front Immunol. 2018 Jul 27;9:1714. doi: 10.3389/fimmu.2018.01714.eCollection 2018.

12. Terkeltaub R, Yang B, Lotz M, et al. Chondrocyte AMP-activated protein kinase activity suppresses matrix degradation responses to proinflammatory cytokines interleukin-1 and tumor necrosis factor. Arthritis Rheum.2011 Jul;63(7):1928-37. doi: 10.1002/art.30333.

13. Wen Z, Jin K, Shen Y, et al. N-myristoyltransferase deficiency impairs activation of kinase AMPK and promotes synovial tissue inflammation. Nat Immunol. 2019 Mar;20(3): 313-25. doi: 10.1038/s41590-018-0296-7. Epub 2019 Feb 4.

14. Thornton CC, Al-Rashed F, Calay D, et al. Methotrexate-mediated activation of an AMPK-CREB-dependent pathway: a novel mechanism for vascular protection in chronic systemic inflammation. Ann Rheum Dis. 2016 Feb;75(2):439-48. doi: 10.1136/annrheumdis-2014-206305. Epub 2015 Jan 9.

15. Arnett FC, Edworthy SM, Bloch DA, et al. The American Rheumatism Association 1987 revised criteria for the classification of rheumatoid arthritis. Arthritis Rheum. 1988 Mar; 31(3):315-24. doi: 10.1002/art.1780310302.

16. Van der Heijde D. How to read radiographs according to the Sharp/van der Heijde method. J Rheumatol. 1999 Mar;26(3):743-5.

17. Steinberg GR, Kemp BE. AMPK in health and disease. Physiol Rev. 2009 Jul; 89(3):1025-78. doi: 10.1152/physrev.00011.2008.

18. Hardie DG, Ross FA, Hawley SA. AMPactivated protein kinase: a target for drugs both ancient and modern. Chem Biol. 2012 Oct 26;19(10):1222-36. doi: 10.1016/j.chembiol.2012.08.019.

19. Faubert B, Boily G, Izreig S, et al. AMPK Is a negative regulator of the Warburg effect and suppresses tumor growth in vivo. Cell Metab. 2013 Jan 8;17(1):113-24. doi: 10.1016/j.cmet.2012.12.001. Epub 2012 Dec 27.

20. Salt IP, Palmer TM. Exploiting the antiinflammatory effects of AMP-activated protein kinase activation. Expert Opin Investig Drugs. 2012 Aug;21(8):1155-67. doi: 10.1517/13543784.2012.696609. Epub 2012 Jun 14.

21. Sag D, Carling D, Stout RD, et al. Adenosine 5'-monophosphate-activated protein kinase promotes macrophage polarization to an anti-inflammatory functional phenotype.J Immunol. 2008 Dec 15;181(12):8633-41. doi: 10.4049/jimmunol.181.12.8633.

22. Yang Z, Shi H, Xue BZ. Macrophage {alpha}1-AMP-activated protein kinase ({alpha}1AMPK) antagonizes fatty acid-induced inflammation through SIRT1. J Biol Chem. 2010 Jun 18;285(25):19051-9. doi: 10.1074/jbc.M110.123620. Epub 2010 Apr 26.

23. Agrawal S, Misra R, Aggarwal A. Autoantibodies in rheumatoid arthritis: association with severity of disease in established RA. Clin Rheumatol. 2007 Feb;26(2):201-4. doi: 10.1007/s10067-006-0275-5. Epub 2006 Mar 30.

24. Ermakova YuA, Karateev DE, Luchikhina EL, Demidova NV. The influence of ADC- and RF-positivity on the formation of outcomes of early rheumatoid arthritis in the long term. Saratovskii nauchno-meditsinskii zhurnal. 2015; 11(2):135-41. (In Russ.).