Inflammatory biomarker analysis confirms reduced disease severity in heterozygous patients with familial Mediterranean fever

Abstract

Introduction: Familial Mediterranean fever (FMF) is a genetic disease leading to recurrent episodes of inflammation. Two pathogenic variants are required for classical disease, but the disease can occur in heterozygous patients. Patients are treated continuously with colchicine to prevent amyloid A (AA) amyloidosis, including heterozygous patients who display a moderate form of FMF and rarely develop AA amyloidosis. The need for lifelong colchicine treatment in heterozygous FMF is therefore controversial. We aimed to characterise genotype-specific levels of inflammatory biomarkers, and to focus on heterozygous patients who discontinued colchicine.

Methods: All patients with FMF from the European databases AIDnet and JIRcohort who received colchicine during follow-up were included. Demographics, C reactive protein (CRP), serum amyloid A (SAA), S100A8/A9 and S100A12 levels, leucocyte and neutrophil counts were extracted. Visits were classified as active, subclinical or inactive according to symptoms, CRP and SAA levels.

Results: Data from 747 patients were extracted (233 homozygous, 201 compound heterozygous, 224 heterozygous patients, 49 heterozygous with one class III variant and 40 compound heterozygous with two class III variants). During active visits, all biomarker levels were higher compared with inactive visits (p<0.001). Heterozygous patients showed lower levels of CRP, SAA, S100A8/A9 and S100A12 during inactive and subclinical visits than patients with two class IV-V variants. Colchicine was discontinued in 52 heterozygous patients and reintroduced in 23 of them (44%).

Conclusion: S100A8/A9 and S100A12 proteins are biomarkers that can be used to assess disease activity. Heterozygous patients have lower levels of inflammatory biomarkers and some of them can sustainably discontinue colchicine treatment.

Keywords: Child; Familial Mediterranean Fever; Inflammation.

Figure 1. Characteristics of included patients according to database. (A) Flow chart of included patients and corresponding mutation status. (B) Dot plot of included patients according to genotype and database (one patient is represented by one dot). WT, wild type; III, class III variant.

Figure 2. S100 proteins levels measured during inactive visits levels according to genotype. (A) Decimal logarithm conversion (10ⁿ) of median S100A8/A9 levels in patients with class III variants, heterozygous, compound heterozygous and homozygous patients. (B) Decimal logarithm conversion (10ⁿ) of median S100A12 levels in patients with class III variants, heterozygous, compound heterozygous and homozygous patients.