Journal of Neuroimmunology 283 (2015) 11–16

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The role of laquinimod in modulation of the immune response in relapsing–remitting multiple sclerosis: Lessons from gene expression signatures R. Zilkha-Falb a,⁎,1, M. Gurevich a,1, L. Hayardeny c, A. Achiron a,b a b c

Multiple Sclerosis Center, Neurogenomic Laboratory, Sheba Medical Center, Israel Sackler School of Medicine, Tel-Aviv University, Israel Teva Pharmaceutical Industries Ltd., 5 Bazel Street, Petah Tiqva 49131, Israel

a r t i c l e

i n f o

Article history: Received 2 March 2015 Received in revised form 7 April 2015 Accepted 9 April 2015 Keywords: Multiple sclerosis Laquinimod Gene expression microarray Peripheral blood mononuclear cells

a b s t r a c t Laquinimod, is a potential oral immunomodulatory drug, for relapsing–remitting multiple sclerosis (RRMS). We analyzed the blood-transcriptional changes in RRMS patients (who participated in the ALLEGRO clinical trial) at one and six months after laquinimod treatment using gene expression microarrays. The molecular effects of laquinimod were enhanced by duration of treatment and showed down-regulation of inflammatory responses mainly via TGFb signaling, and of pro-inflammatory cytokines as well as of cellular movement, including adhesion, migration and leukocyte extravasation signaling. Our results demonstrate that laquinimod suppresses inflammation through down-regulation of inflammatory cytokines and arrest of leukocyte extravasation and thereby could attenuate disease activity in RRMS patients. © 2015 Elsevier B.V. All rights reserved.

1. Introduction Laquinimod (quinolin-3-carboxamide) is a new oral immunomodulatory agent developed as a disease-modifying treatment for relapsing– remitting multiple sclerosis (RRMS). Laquinimod is structurally related to roquinimex, but pharmacologically and chemically distinct, which results in increased potency and an improved safety profile (Varrin-Doyer et al., 2014). Laquinimod was demonstrated to inhibit the development of acute experimental autoimmune encephalomyelitis (EAE) and to reduce EAE clinical score in mice treated after disease onset (Brunmark et al., 2002; Wegner et al., 2010; Brück and Wegner, 2011; Schulze-Topphoff et al., 2012; Jolivel et al., 2013; Ruffini et al., 2013). Clinically, laquinimod demonstrated about 40% reduction in the cumulative number of gadolinium-enhanced lesions in brain MRI in 106 RRMS patients as compared to 102 placebo treated RRMS patients (Comi et al., 2008). Recently, the Assessment of Oral Laquinimod in Preventing Progression in Multiple Sclerosis in the ALLEGRO study demonstrated that laquinimod treatment modestly, but consistently across trials, decreased annualized relapse rate, slowed progression of

⁎ Corresponding author at: Multiple Sclerosis Center, Sheba Medical Center, TelHashomer 52621, Israel. E-mail address: [email protected] (R. Zilkha-Falb). 1 Equal contribution.

http://dx.doi.org/10.1016/j.jneuroim.2015.04.007 0165-5728/© 2015 Elsevier B.V. All rights reserved.

disability and prevented white and gray matter atrophy in RRMS patients treated for 24 months (Comi et al., 2008; Filippi et al., 2014). The mechanisms by which laquinimod suppresses the development of EAE involve modulation of Th1/Th2 response, interference with the migration capacity of T cells (Zou et al., 2002; Yang et al., 2004; Wegner et al., 2010; Brück and Wegner, 2011; Bruck and Vollmer, 2013), prevention of inflammation-induced synaptic alterations occurring in EAE (Ruffini et al., 2013) and down-regulation of NFκB in astrocytes which leads to down-regulation of astrocytic activation (Bruck et al., 2012). In addition, in MS patients, it has been reported that laquinimod modulates B cells and their regulatory effects on T cells (Toubi et al., 2012), and down-regulates the immunogenicity of dendritic cells (Jolivel et al., 2013). In our previous study (Gurevich et al., 2010), we characterized the molecular effects of laquinimod in-vitro in separated immune cell subtypes obtained from RRMS patients using gene expression microarrays. We demonstrated that laquinimod induced suppression of genes related to antigen presentation and corresponding inflammatory pathways involving NFκB signaling, pleiotrophin-induced inflammatory cytokines, chemokine and toll like receptor signaling, Th2 response in CD14+ macrophages and CD4+ T cells, proliferation in CD8+ T cells, and antigen presentation and adhesion in CD19+ B cells (likely via suppression of the NFκB pathway). To further elucidate the molecular mechanisms underlying the therapeutic effects of laquinimod in RRMS, we performed high throughput gene expression microarray analysis of peripheral blood mononuclear

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cells (PBMCs) from RRMS patients who participated in the Assessment of OraL Laquinimod in PrEventing ProGRession in Multiple SclerOsis (ALLEGRO) clinical trial. 2. Methods All participants gave written informed consent and the study was approved by the Sheba Medical Center IRB committee. Peripheral blood samples were obtained from RRMS patients treated with laquinimod 0.6 mg/day or placebo as an ancillary study to the ALLEGRO trial. Blood samples were obtained at baseline and after one and six months of treatment.

2.3. Verification by Western blot Protein fractions were purified from PBMCs of 5 randomly sampled patients at baseline and after six months of laquinimod treatment. Proteins were extracted from TRIZOL fractions and solubilized following the method reported by Hummon et al. (2007). Equal amounts of proteins were resolved on 10% SDS-PAGE and transferred onto nitrocellulose membranes (Invitrogen kit) for subsequent immuno-blotting with antibodies specific for TGFb, ITGB1, CXCR1 and, as control, alpha Tubulin (Santa Cruz Biotechnology, Inc., Santa Cruz, CA, USA). Blots were analyzed by standard chemi-luminescence (Supersignal Kit, Pierce, Rockford, IL, USA) and visualization was done by a ChemiDoc™ XRS System (Bio-Rad).

2.1. RNA isolation and hybridization 3. Results PBMCs were prepared from 15 ml peripheral blood, and separated by a Ficoll-Hypaque gradient. Total RNA was extracted using Trizol (Invitrogen, USA) and Phase-Lock-Gel columns (Eppendorf, Germany) including a DNase digestion step. RNA integrity was assessed by an RNA Experion automated electrophoresis system. Probe synthesis using 3 μg total RNA, hybridization, detection, and scanning were performed according to the standard Affymetrix, Inc., USA protocols; cDNA was synthesized using the Two-Cycle cDNA Synthesis Kit (Affymetrix, Inc., USA), and in-vitro transcription was performed with the GeneChip IVT Labeling Kit (Affymetrix, Inc., USA). The biotin-labeled IVT-RNA was hybridized to HG-U133A-2 arrays (Affymetrix, Inc., USA) containing 14,500 well-annotated human genes, washed in a GeneChip Fluidics Station 450 and scanned according to the manufacturer's protocol using a GeneArray™ scanner G2500A (Hewlett Packard, USA).

Samples were obtained from 25 RRMS patients, age 38.0 ± 2.0 years, female/male ratio 16/9 (similar to Allegro's overall study population). The laquinimod treatment arm consisted of 13 patients, female/male ratio 8/5, age 38.8 ± 2.3 years and the placebo arm consisted of 12 patients, female/male ratio 8/4, age 37.2 ± 3.4 years. LAQ induced differential gene expression of 354 MIGs after one month of treatment and the number of MIGs increased to 1562 after six months (Supplementary Tables 1 and 2). The majority of genes that significantly changed expression under laquinimod treatment at one and six months of treatment were down-regulated (98% and 99%, respectively). 3.1. Biological pathways associated with laquinimod treatment: down-regulation of TGFb, NFκB signaling and pro-inflammatory cytokines

2.2. Data analysis Data analysis was performed using Partek Genomics Solution software (www.partek.com). Expression values were computed from raw CEL files by applying the Robust Multi-Chip Average (RMA) background correction algorithm. RMA correction included: 1) values background correction; 2) quintile normalization; 3) log2 transformation; and 4) median polish summarization. ANOVA analysis was applied to compare PBMC gene expression after one and six months of laquinimod/ placebo treatment as compared with baseline. Age, gender and batch effects were regarded as confounders in the ANOVA model. Most informative genes (MIGs) were defined as those that differentiated between each time point and baseline with p b 0.01 by paired t-test analysis (after FDR correction) with 1.5 fold change (FC) cut off. MIGs that were related to placebo treatment with same directions as laquinimodaffected MIGs were removed from further analysis. Gene functional annotation, enrichment and pathway analyses to identify the involved biological pathways were performed using the Ingenuity Pathways Analysis (IPA) software (www.ingenuity.com). In these analyses p values were corrected for multiple testing using the False Discovery Rate (FDR) method with a cut off at p = 0.05.

Functional enrichment analysis of 354 MIGs after one month of laquinimod treatment indicated the suppression of molecules associated with different mechanisms of inflammatory response and cellular movement presented in Table 1. Furthermore, analysis of the 1562 MIGs after six months of treatment showed an overlap of 58 genes with the mechanisms identified after one month, with a growing number of genes involved with the same mechanisms. Of the significantly suppressed pathways, the TGFb superfamily signaling (Table 1) was suppressed after one (p = 3.2 ∗ 10−3), as well as after six months of laquinimod treatment (p = 4.32 ∗ 10−2). Down-regulation of the TGFb signaling pathway after one month of laquinimod treatment was evident by suppression of the TGFb and LTBP1 genes, the latter regulates secretion and activation of TGFb and thus promotes a feedback mechanism. After six months, in addition to TGFb and LTBP1, down-regulation of additional TGFb superfamily related genes, like BMP2/4/7, MIS, Type II BMP receptor, Smad14/5/6/8, TCF20, TCF2, Runx2 and the downstream ITGB1 was demonstrated (Fig. 1). In addition, laquinimod induced down-regulation of LFA-1 and VLA4 expression known to act with ITGB1 in adhesion of immune cells,

Table 1 Major biological pathways and functions affected by laquinimod treatment. After one month of treatment n = 345

After six months of treatment n = 1562

Function

Pathway

No. of genes

p-Value

Function

Pathway

No. of genes

p-Value

Inflammatory response

TGFb signaling

10

3.2 × 10−3

Inflammatory response

Cellular movement

Adhesion & migration of phagocytes Chemotaxis of neutrophils Transmigration of leukocytes

9 4 8

1.2 × 10−3 6.0 × 10−3 1.9 × 10−3

Cellular movement

TGFb signaling IL-12 signaling Invasion of cells Adhesion of cells Leukocyte extravasation signaling

14 11 120 119 29

4.3 × 10−2 3.2 × 10−3 5.6 × 10−5 2.4 × 10−5 9.4 × 10−3

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which is in accordance with published literature (Wegner et al., 2010). The suppression of the TGFb pathway after six months of laquinimod treatment was accompanied by the down-regulation of the IL-12 (including IL12p40 and IL12p70) signaling pathway (p = 6.2 ∗ 10−3 for pathway) and a wide range of other pro-inflammatory cytokines such as IL-9/11/12/20/36, TNFRSF11A/B, IFNA4/8/10/17, and also the receptors for IL-5/13/20/22 (range of p values for these genes from 3 ∗ 10−3 to 9 ∗ 10−3). The molecular signature of laquinimod after six months was also characterized by suppression of NFκB signaling as demonstrated by down-regulation of members of the NFκB signaling pathway that play a role in inflammation, including IL-1, IL-1R and IKKg (range of p values for these genes from 2.3 ∗ 10− 3 to 5.7 ∗ 10− 3) (Fig. 1). Interestingly, the down-regulation of pro-inflammatory cytokines after 6 months was accompanied by down-regulation of FGA (Fibrinogen α chain, p = 6.3 ∗ 10 − 3) and several other fibrinogen related genes, such as the fibrinogen receptor and coagulation factor 2, X, XI (p b 1.0 ∗ 10− 3). Altogether, these findings propose a mechanism of action that includes comprehensive suppression of pro-inflammatory cytokines, including the key TGFb and NFκB pathways following six months of laquinimod treatment. In view of the early down-regulation of TGFb at one month that precedes the down-regulation of additional genes encoding for pro-inflammatory cytokines, we suggest that downregulation of TGFb signaling may chronologically precede and leads either directly or indirectly to the suppression of inflammatory cytokines. Thus laquinimod may down-regulate cytokine expression via suppression of TGFb. Only five laquinimod responsive MIGs were significantly upregulated after adjustment for placebo-associated expression profiles. These included three common genes, i.e., SASH1, FUCA1 and XYLT1, both at one and six months of treatment. Although none of these genes integrate into an established canonical pathway, overexpression of SASH1 and FUCA1 has been reported as associated with the inhibition

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of growth, proliferation, and invasion of cancer cells (Meng et al., 2013), indicating a need for further investigation. 3.2. Laquinimod down-regulates expression of migration, adhesion and leukocyte extravasation genes Differential expression of cellular movement pathways was observed already after one month of laquinimod treatment (p = 3.2 ∗ 10−6). These included down-regulation of genes associated with adhesion and migration of phagocytes (p = 1.2 ∗ 10−3), chemotaxis of neutrophils (p = 6 ∗ 10−3) and transmigration of leukocytes (p = 1.9 ∗ 10−3) with overlapping genes between pathways. Genes associated with cell movement and suppressed by laquinimod were P selectin, known to be involved in the initial stage of adhesion, and integrin family members like ITGB1/3/5/6/8 and ITGA8, involved in later steps of adhesion and locomotion during leukocyte extravasation (range of p values for these genes: 1.7 ∗ 10−3 to 5.5 ∗ 10−3). The suppressing effects of laquinimod on cell adhesion and integrin expression were further enhanced after six months of treatment as was evident by down-regulation of the same genes and additional genes associated with cellular movement mechanisms (range of p values for genes: 3.2 ∗ 10− 6 to 3.8 ∗ 10−3) including cell invasion (p = 5.6 ∗ 10− 5), adhesion (p = 2.4 ∗ 10−5) and leukocyte extravasation (p = 9.4 ∗ 10−3), (Table 1). Similar to the observed effects of suppressed expression of the integrin family members after one month of treatment, suppression was more strongly evident after six months of laquinimod treatment including the integrin genes ITGB/5/6/8, ITGA8, ITGB8, and ITGA2B (range of p values for these genes: 9.8 ∗ 10−4 to 1.1 ∗ 10−3). In addition, suppression of inflammatory related chemokines, such as CCL19 and chemokine receptor CXCR1/2, was also demonstrated (p = 6.8 ∗ 10−3). Moreover, laquinimod down-regulated a range of metalloproteinase family members, such as MMP16/24/26/28, and ADAM12/18/22, which play a role during extravasation (range of p values for these genes: 4.9 ∗ 10−4 to 1.3 ∗ 10−3).

Fig. 1. Laquinimod effects in RRMS patients after six months of treatment demonstrate down-regulation of multiple genes associated with TGFb and NFκB signaling, pro-inflammatory cytokines, cell adhesion and migration. Green color represents down-regulated genes and white color depicts genes with no change in their expression level.

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3.3. Verification of key genes associated with laquinimod induced molecular pathways The verification experiments performed by Western blot analysis show significant down-regulation of key gene products associated with the most significantly affected biological mechanisms of laquinimod. The TGFb protein following six months of laquinimod treatment was suppressed by 69.0% (p = 0.009) compared to baseline as could be seen from quantification of band intensities (Fig. 2A). Accordingly, Fig. 2B shows down-regulation of ITGB1, a common subunit of different integrin receptors by 40% (p = 0.03) and of CXCR1 by 24.7% (p = 0.014) (Fig. 2C). 4. Discussion In the present study, we analyzed the molecular mechanisms underlying the effects of laquinimod by high throughput gene expression microarray analysis of PBMCs from RRMS patients that participated in the ALLEGRO trial. Our results demonstrate that the most significant effect of laquinimod is suppression of inflammatory response via TGFb and NFκB pathways, as well as of cell movement processes, including adhesion, migration and leukocyte extravasation (Fig. 3). The latter was demonstrated by suppression of integrins, chemokines and metalloproteinases, as well as suppression of pro-inflammatory cytokines. These effects were observed in RRMS patients treated over a six month-period as compared with baseline. We have demonstrated that, the suppressive effects of laquinimod are already detected as early as one month after initiation of laquinimod, although to a lesser extent, suggesting a time-dependent treatment effect. The pivotal immunologic function of TGFb is mediated by induction of tolerance via regulation of lymphocyte proliferation, differentiation and survival. However, in the animal model of MS (EAE), it has been shown that in addition to its anti-inflammatory role, TGFb paradoxically can act as a pro-inflammatory factor in combination with IL-6 involved in the maintenance of TH17 cells as deletion of the TGFb gene from activated T cells, abrogates Th17 cell differentiation, resulting in almost complete protection from EAE, and suggesting TGFb pro-inflammatory potential (Gutcher et al., 2011; Lee et al., 2012; Oh and Li, 2013).

Although controversial, in other studies the Th17 cells did not show encephalitogenicity (Yang et al., 2009; Ghoreschi et al., 2010; Lee et al., 2014). As TGFb is crucial for regulatory T cell (Treg) induction and function (Horwitz et al., 2003) it is unlikely that laquinimod acts through induction of Treg. The disparate effects of TGFb on Treg versus Th17 cell fate reflect the context-dependent function of this pleiotropic cytokine (Oh and Li, 2013). Based on in vitro studies in human T lymphocytes, it was suggested that TGFb is involved in stimulation of inflammatory cell adhesion, migration and extravasation, and could promote penetration of auto-aggressive lymphocytes to the central nervous system (CNS) (Brill et al., 2001; Bartolome et al., 2003). In order to demonstrate correlation between TGFb and the adhesion or migration pathway we have performed a verification experiment. The verification results showing decreased expression of TGFb and also those of the adhesion molecule ITGB1 and the chemokine receptor CXCR1 (Fig. 2A–C), and together with previous studies (Brill et al., 2001; Bartolome et al., 2003) suggest that TGFb can regulate adhesion and migration pathways and accordingly down-regulation of the TGFb pathway could attenuate adhesion and migration. TGFb is also known to regulate the expression of IL-9 (Takami et al., 2012) and IL-22 (Sanjabi et al., 2009). In our study laquinimod induced down-regulation of these genes thereby reducing the expression of molecules associated with inflammation. TGFb itself can be both activated and inhibited by IL-1 depending on the duration of exposure to IL-1 (Luo et al., 2009). As both IL-1 and TGFb were suppressed in laquinimod gene expression signature, it is likely that IL-1 positively affects TGFb. In accordance with observations linking TGFb with the inflammatory process in EAE (Gutcher et al., 2011; Lee et al., 2012; Yoshida et al., 2014), the suppression of TGFb and members of the TGFb pathway by laquinimod could result in beneficial reduction of active inflammation in MS. The down-regulation of TGFb by laquinimod in our study is in accordance with the down-regulation of serum levels of TGFb1 four weeks after treatment of MS patients with IFN beta (Lunemann et al., 2001). The suppression of TGFb signaling and MAP3K7 (TAK1) by laquinimod corroborates with previous publications reporting that laquinimod suppresses TAK1, a strong positive regulator of cellular proliferation, and that this suppression is mediated by TGFb activation in CD14 + cells (Wan et al., 2006; Gurevich et al., 2010).

Fig. 2. Expression of TGFb, ITGB1 and CXCR1 in RRMS patients treated with laquinimod. Protein extracts were prepared from PBMC samples derived from RRMS patients before treatment (black bars) and compared to PBMC samples of the same patients after six months of laquinimod treatment (white bars). The signal intensity of protein bands were quantified by Quantity One 4.6.9 software. The resultant background-subtracted values of protein expression were normalized to those of Tubulin and then calculated as the relative protein levels for each patient before or after laquinimod treatment. The blot images in A, B and C are representative of two out of five analyzed patients showing down-regulation of TGFb, ITGB1 and CXCR1, respectively as also quantified by the densitometry of bands analyzed from five patients. Data are presented as mean ± SEM. Statistically significant differences are marked in graphs (n = 5, paired one-tailed t-test).

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Fig. 3. Laquinimod down-regulates leukocyte extravasation in RRMS patients. Laquinimod can inhibit infiltration of inflammatory cells to the CNS by direct suppression of genes associated with leukocyte extravasation or via suppression of TGFb superfamily and inflammatory cytokines.

Our results showed not only down-regulation of TGFb but also of the latent TGFb (LTBP1) that can be bound by fibrinogen in the context of CNS inflammation and thereby converted to active TGFb (Schachtrup et al., 2010). Fibrinogen plays a causative role in nervous system disease as a regulator of inflammation (Akassoglou et al., 2004; Adams et al., 2007a,b; Akassoglou, 2015), remyelination (Akassoglou et al., 2002), and neurodegeneration (Schachtrup et al., 2007). Fibrin, the final product of the coagulation cascade, is a result of thrombin-mediated conversion of fibrinogen to an insoluble fibrin network (Akassoglou, 2015). Accumulating evidences suggest a detrimental role for the components of the coagulation cascade in EAE/MS (Gveric et al., 2003; East et al., 2008; Davalos and Akassoglou, 2012). Strikingly, a recent study reported that increased thrombin activity begins early and increases with progression of EAE, and is specifically detected within local demyelinating lesions with prominent microglial activation and axonal damage (Davalos et al., 2014). Although accumulating evidence indicates that fibrin mediates, controls, and sometimes triggers immune activation, the specific roles and relative contributions of upstream components of the coagulation cascade in disease pathogenesis warrant a more detailed investigation. The down-regulation of fibrinogen and other coagulation factors following laquinimod treatment are in line with a protective role of tissue plasminogen activator (tPA) in the mouse model of MS (Gveric et al., 2003; East et al., 2008). Strikingly, an extensive fibrinogen deposition with diffuse and focal abnormalities and microglial activation in MS lesions was demonstrated in a postmortem MRI study (Vos et al., 2005). In our study the down-regulation of fibrinogen after six months of laquinimod treatment supports the potential immunomodulation and neuroprotective effects of laquinimod in reducing expression of fibrinogen related genes. Our results challenge previous data reporting a mild induction of fibrinogen in blood occurring after the first month of treatment with laquinimod that returned to baseline at the sixth month [Vollmer TL et al., 2014 published as ePoster at the Joint ECTRIMS–ACTRIMS 2014; (Gasperini et al., 2010)]. The ability of laquinimod to suppress immune trafficking was demonstrated by suppressed expression of a large number of 268 genes related to cell adhesion and cell movement known to be involved in different stages of leukocyte extravasation. The ability of inflammatory cells to move from the periphery to the CNS is a crucial multistep process in the pathology of MS. Laquinimod down-regulated several important components of rolling, activation, adhesion, locomotion, protrusion and transmigration of immune cells during extravasation to the CNS

including Selectin P and IL-8R (CXCR1/2), that mediate rolling and the initial leukocyte–endothelial interactions; VLA-4, LFA-1, ITGA2/8, and ITGB1-6, integrins that mediate leukocyte adhesion and transmigration; chemokines and chemokine receptors for integrin activation, including CCL19, responsible for leukocyte arrest and transmigration, and the IL8 receptor (CXCR1/2). Taken together, our findings suggest that laquinimod acts through inhibition of immune cell movement, adhesion and transmigration, thereby reducing the migratory capacity of active inflammatory cells through the blood brain barrier (Fig. 3). The suppression of cell migration corroborates with the known effects of laquinimod to induce down-regulation of pro-inflammatory cytokines and integrins such as IL-12, IL-13, IL-17, IFNg, TNFa and VLA-4 integrin-mediated adhesiveness resulting in interfered migratory capacity of T cells (Wegner et al., 2010; Brück and Wegner, 2011; Jadidi-Niaragh and Mirshafiey, 2011). Similarly, in MS patients, we previously demonstrated that laquinimod down-regulated IL-1, IL-1R, IL-12 and IKKg genes associated with the pro-inflammatory NFκB pathway. The suppression of the NFκB pathway by laquinimod was also demonstrated in our in-vitro study on PBMCs obtained from untreated MS patients (Gurevich et al., 2010) and in astrocytes following laquinimod treatment in the cuprizone-induced demyelination model (Bruck et al., 2012). NFκB signaling mediates IL12 activation in macrophages (Murphy et al., 1995) and therefore it is conceivable that laquinimod suppresses both IL-1 and IL-12 dependent inflammation via down-regulation of NFκB signaling. Apparently, the transcriptional signature of laquinimod in the present study is characterized by robust down-regulation of genes, while only 5 genes were significantly up-regulated. Three of these up-regulated genes could be detected already after one month of treatment with a sustained effect at six months; SASH1 and FUCA1 are involved in suppression of proliferation, and XYLT catalyzes the biosynthesis of glycosaminoglycan and its high activity was reported in the blood of systemic sclerosis patients and the cerebrospinal fluid of patients with an impaired blood brain barrier (Ponighaus et al., 2007). After six months of treatment, another growth inhibitor gene PID1 was found to be overexpressed, supporting prior data on suppression of proliferation of CD8 + cells by laquinimod (Gurevich et al., 2010). In view of the reported functions of these up-regulated genes it is likely that their up-regulation could suppress the proliferation of active inflammatory cells. In summary, our study characterized laquinimod-induced transcriptional profile in treated RRMS patients demonstrating suppression of

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The role of laquinimod in modulation of the immune response in relapsing-remitting multiple sclerosis: Lessons from gene expression signatures.

Laquinimod, is a potential oral immunomodulatory drug, for relapsing-remitting multiple sclerosis (RRMS). We analyzed the blood-transcriptional change...
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