Personalized medicine in rheumatology: the paradigm of serum autoantibodies

Abstract

The sequencing of the human genome is now well recognized as the starting point of personalized medicine. Nonetheless, everyone is unique and can develop different phenotypes of the same disease, despite identical genotypes, as well illustrated by discordant monozygotic twins. To recognize these differences, one of the easiest and most familiar examples of biomarkers capable of identifying and predicting the outcome of patients is represented by serum autoantibodies. In this review, we will describe the concept of personalized medicine and discuss the predictive, prognostic and preventive role of antinuclear antibodies (ANA), anti-citrullinated peptide antibodies (ACPA), rare autoantibodies and anti-drug antibodies (ADA), to evaluate how these can help to identify different disease immune phenotypes and to choose the best option for treating and monitoring rheumatic patients in everyday practice. The importance of ANA resides in the prediction of clinical manifestations in systemic sclerosis and systemic lupus erythematosus and their association with malignancies. ACPA have a predictive role in rheumatoid arthritis, they are associated with the development of a more aggressive disease, extra-articular manifestations and premature mortality in RA patients; moreover, they are capable of predicting therapeutic response. Rare autoantibodies are associated with different disease manifestations and also with a greater incidence of cancer. The determination of ADA levels may be useful in patients where the clinical efficacy of TNF-α inhibitor has dropped, for the assessment of a right management. The resulting scenario supports serum autoantibodies as the cornerstone of personalized medicine in autoimmune diseases.

Keywords: Anti-citrullinated peptide antibodies; Anti-drug antibodies; Antinuclear antibodies; Precision medicine; Rare autoantibodies; Tolerance breakdown; Twins.

Fig. 1

ANA reflex test, modified from Tonutti et al. [31]

Fig. 2

Features of ACPA-positive RA. Modified from Malmstrom et al. [, –114]

Fig. 3

Proposed algorithm in patients with a rheumatic disease and anti-TNF-α treatment failure. Modified from Steenholdt et al. [80]