Association between polymorphisms within the gene coding for tumor necrosis factor (TNF)-alpha with outcomes of treatment in a sample of Iraqi patients with ankylosing spondylitis taking etanercept: an observational study

Shaimaa Saleh Khudhur; Eman Saadi Saleh; Mohammed Hadi Alosami; Laith G. Shareef

doi:10.12688/f1000research.128842.1

Home Browse Association between polymorphisms within the gene coding for tumor...

ALL Metrics

-

Views

-

Downloads

Get PDF

Get XML

Export

▬

✚

Research Article

Association between polymorphisms within the gene coding for tumor necrosis factor (TNF)-alpha with outcomes of treatment in a sample of Iraqi patients with ankylosing spondylitis taking etanercept: an observational study

[version 1; peer review: awaiting peer review]

Shaimaa Saleh Khudhur¹, Eman Saadi Saleh², Mohammed Hadi Alosami³, Laith G. Shareef ⁴

PUBLISHED 23 Dec 2022

Author details Author details

¹ Department of Clinical Pharmacy, University of Baghdad, College of Pharmacy, Baghdad, 10011, Iraq
² Department of Clinical Laboratory Sciences, University of Baghdad, College of Pharmacy, Baghdad, 10011, Iraq
³ Department of Rheumatology, University of Baghdad, College of Medicine, Baghdad, 10011, Iraq
⁴ Department of Pharmacy, Al-Rasheed University College, Baghdad, 10011, Iraq

Shaimaa Saleh Khudhur
Roles: Conceptualization, Data Curation, Formal Analysis, Methodology, Project Administration, Writing – Original Draft Preparation

Eman Saadi Saleh
Roles: Conceptualization, Formal Analysis, Methodology, Supervision, Writing – Review & Editing

Mohammed Hadi Alosami
Roles: Conceptualization, Methodology, Software, Supervision, Writing – Review & Editing

Laith G. Shareef
Roles: Software, Validation, Visualization, Writing – Review & Editing

OPEN PEER REVIEW

REVIEWER STATUS AWAITING PEER REVIEW

This article is included in the Genomics and Genetics gateway.

Abstract

Background

Ankylosing spondylitis (AS) is a progressive, chronic inflammatory illness with an unclear etiology that explicitly targets the vertebral column, peripheral joints, and extraarticular tissues. The purpose of this research was to investigate if the existence of single nucleotide polymorphisms (SNPs) in the promoter region of the tumor necrosis factor-alpha (TNF-α) gene at positions -1031T/C (rs199964), -857C/T (rs1799724) and -806C/T (rs4248158) in a sample of Iraqi AS patients could influence the patients' outcomes with etanercept.

Methods

Sixty patients with established AS receiving only etanercept were selected to enroll in this study, with a mean age of 40.75±8.67 years; 51 patients were male. Patients were classed as “responders” if they obtained a Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) 50 clinical response and as "non-responders" if they did not achieve a BASDAI 50 clinical improvement after at least six months of treatment. After polymerase chain reaction (PCR) product amplification of the purified blood DNA, the promoter region of TNF-α gene SNPs was established by Sanger sequencing.

Results

This research found a significant difference in the TT genotype of rs1799964, P = 0.02, in the responder group, in contrast to the TC genotype of rs1799964, which was significantly more frequent in the non-responder group, P = 0.01. The wild TT genotype of rs1799964 seemed to enhance the probability of being a responder. Nevertheless, the heterozygote TC genotype of rs1799964 showed a negative and significant correlation for responsiveness to etanercept.

Conclusion

The TT genotype of rs1799964 is associated with a higher likelihood of responding to ETN, suggesting that it is a valuable diagnostic for predicting response in Iraqi AS patients.

Keywords

ankylosing spondylitis, genetic polymorphism, TNF-α, SNPs, etanercept

Corresponding author: Laith G. Shareef

Competing interests: No competing interests were disclosed.

Grant information: The author(s) declared that no grants were involved in supporting this work.

Copyright: © 2022 Saleh Khudhur S et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

How to cite: Saleh Khudhur S, Saadi Saleh E, Hadi Alosami M and G. Shareef L. Association between polymorphisms within the gene coding for tumor necrosis factor (TNF)-alpha with outcomes of treatment in a sample of Iraqi patients with ankylosing spondylitis taking etanercept: an observational study [version 1; peer review: awaiting peer review]. F1000Research 2022, 11:1576 (https://doi.org/10.12688/f1000research.128842.1) First published: 23 Dec 2022, 11:1576 (https://doi.org/10.12688/f1000research.128842.1) Latest published: 23 Dec 2022, 11:1576 (https://doi.org/10.12688/f1000research.128842.1)

Expression of Concern

Expression of Concern (20^th October 2023): We, the Publisher and Editor of F1000Research, are issuing an Expression of Concern for the following article:

Saleh Khudhur S, Saadi Saleh E, Hadi Alosami M and G. Shareef L. Association between polymorphisms within the gene coding for tumor necrosis factor (TNF)-alpha with outcomes of treatment in a sample of Iraqi patients with ankylosing spondylitis taking etanercept: an observational study [version 1; peer review: awaiting peer review]. F1000Research 2022, 11:1576 (https://doi.org/10.12688/f1000research.128842.1)

After publication of this article, questions about the integrity of the ethical approval were brought to the attention of the F1000 Editorial Team. We have reached out to the authors requesting that they respond to the concerns raised and provide additional information to support the integrity of the content. However, despite multiple attempts to contact the authors, and their institution, they have not responded to our queries within the requested timeframe. Therefore, as we continue to work through the issues raised, we advise readers to interpret the information presented in the article with due caution. The authors have been sent notification about this Expression of Concern.

Editorial note

Editorial Note (13^th July 2023): Since publication, concerns have been raised to the Editorial Team regarding the ethical approval for this study, as well as overlap in the sample and methods to other papers by these authors. The Editorial Team requested explanations regarding the similarities on 19^th May and 6^th June 2023, and the institution was contacted on 21^st March, 6^th April and 25^th April 2023 to verify the ethical approval. Neither the author nor institution have provided responses to our requests. The Editorial Team will update this Editorial Note as the situation progresses. Peer review activity has been suspended for this article until we receive an explanation from the authors/institution.

Introduction

Ankylosing spondylitis (AS) is a progressive, chronic inflammatory illness with an unclear etiology¹. Prolonged inflammation can cause vertebral fusion, which may result in immobility². Clinically, the sickness manifests as pain and increasing rigidity of the spine³. The hallmarks of AS are inflammation of the sacroiliac joints (SIJ) and spine⁴. AS is directly proportional to the prevalence of human leukocyte antigen (HLA)-B27 in a given population, and has been estimated to range between 0.1 and 1.4% in various parts of the world⁵. In Iraq, the estimated frequency of AS is 0.9 per 100,000, while HLA-B27 positivity was elicited in 55% of the population investigated⁶. In Arab people, between 2% and 5% of individuals are HLA-B27 positive, which is prevalent in 64% of AS patients⁷. TNF-α is a highly potent pro-inflammatory molecule and a critical component of the immune system's signaling cascade that is strongly activated in response to infection or tissue injury. Patients with AS, in particular, respond well to TNF antagonist therapy⁸. Etanercept (ETN) has been examined in various rheumatologic disorders⁹. ETN is the only soluble TNF receptor the Food and Drug Administration (FDA) has licensed for therapeutic use. It is typically administered in weekly doses of 50 mg subcutaneously (or 25 mg twice weekly), either by self-injection or by a caregiver¹⁰.

Since the promoter region of the TNF-α gene would seem to be remarkably polymorphic, genetic variation is one of the most significant factors in the response¹¹. In contrast to numerous aspects that could potentially influence or change the ETN response, genetic manifestations do not change during a patient's lifetime¹². Consequently, polymorphism testing assists in dividing individuals with just a high response from those with an inappropriate or poor response. Accordingly, early identification of individuals who would not adhere to biological treatments allows a quicker transfer to another type of medicine, increasing the patient's likelihood of achieving therapeutic purposes more quickly¹³. The goal of pharmacogenomic and pharmacogenetic research is to use available knowledge about gene variants that influence the medication response to develop personalized treatment methods that enhance therapeutic effectiveness and safety¹⁴. Numerous single nucleotide polymorphisms (SNPs), primarily in the TNF promoter, are susceptible to rheumatoid arthritis (RA) and spondyloarthritis, and related to tumor necrosis factor inhibitor (TNFi) response. Genetic variations in cytokine genes may affect cytokine gene transcription and secretion, modulating cardiovascular disease development risk¹⁵. In addition, these promoter SNPs are thought to contribute to treatment responses by modifying TNF gene expression¹⁶. Identifying pharmacogenetic markers, enabling treatment only for those patients who will respond without the risk of unwanted effects, would considerably improve treatment efficacy and reduce expenses¹⁷. Previous studies have not examined the impact of the rs4248158C/T polymorphism on AS patients' response to ETN. No prior research has been conducted in Iraq to explore the influence of SNPs within the TNF-α promoter region upon the propensity to respond to ETN in AS patients. This current research study aimed to determine whether the presence of SNPs in the promoter region of the TNF-α gene at positions -1031T/C (rs199964), -857C/T (rs1799724), and -806C/T (rs4248158) in a sample of Iraqi AS patients could influence the patients' outcomes with ETN.

Methods

Ethical considerations

The research ethics committee approval (approval number: RECACPUB-3102020D) was obtained from the Scientific and Ethical Committee at the College of Pharmacy, Baghdad University, Iraq. This research was conducted in line with the Helsinki Declaration¹⁸. Before data collection, written consent was obtained from each of the participants.

Study design

An observational study was carried out using a suitable convenient sample of 60 Iraqi patients who were determined to have AS in accordance with the modified New York Criteria¹⁹.

Setting

The participants in this study were recruited from the Rheumatology Unit of Baghdad Teaching Hospital at Medical City in Baghdad, Iraq. From January to December 2021, all patients were evaluated and treated by a rheumatology specialist, and 76 patients with established AS were receiving only an ETN prefilled pen containing 50mg manufactured by Pfizer Company given by subcutaneous injection once a week. A total of 95 participants were selected to enroll in the study. However, only 60 subjects met the study's participation criteria, with a mean age of 40.75±8.67 years; 51 patients of them were male, and only nine patients were female.

Variables

A 50% improvement in disease activity score (Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) 50) was defined as a response to therapy²⁰; patients were classed as “responders” if they obtained a BASDAI 50 clinical response and as “non-responders” if they did not achieve a BASDAI 50 clinical improvement.

Sample size

The number of subjects was determined using the G*Power program (RRID: SCR 013726) edition 3.1.9.7. The size of the sample has to be a minimum of 59 individuals with a 95% confidence interval, 90% power, a two-tailed alpha of 0.05, and an effect size of 0.40 (f).

Eligibility criteria

Patients age 18 and above who had been diagnosed with AS using the modified New York criteria¹⁹ and had been taking ETN for at least six months, without a history of missed doses.

Exclusion criteria

Patients with coexisting other connective tissue conditions, recurring infectious diseases, cancer, hepatic or renal dysfunction, endocrine system inadequacies, hematological and cardiovascular diseases, or multiple sclerosis, any patient who has been taking ETN for less than six months, and any patient taking disease-modifying antirheumatic drugs (DMARDs) in addition to ETN. In addition, any patient with insufficient data was eliminated.

Bias

Sampling flaws may arise during the research sample selection process. This is most noticeable in retrospectively longitudinal studies, when individuals' exposures and results have already happened before they are included. Nevertheless, sampling error is much less likely since the result is unknown at the time of enrollment. The ideal study population is well-defined, easily accessible, trustworthy, and capable of producing the needed results. To avoid bias, participants were recruited so that no age group or gender was preferred over others. We considered demographics and other information about participants (and nonparticipants) to help us adjust overall conclusions.

Data collection

Demographic data (such as age, weight, height, disease duration, smoking status, family history, presence of extraarticular manifestations (such as psoriasis, inflammatory bowel disease, uveitis, and osteoporosis) and ETN side effects) were obtained through direct interviews with patients utilizing a patient records sheet specially designed for this research project. The body mass index (BMI) was computed by dividing the weight in kilograms by the square height in meters²¹.

Blood sample collection and preparation of specimens

For DNA extraction, 2 ml of the obtained blood specimen was transformed into an EDTA tube.

Clinical evaluation

A direct interview was performed with all patients in this study to evaluate disease manifestations, symptoms, medical history, and laboratory findings. In addition, the patient’s disease activity was assessed by calculating BASDAI and Bath Ankylosing Spondylitis Functional Index (BASFI).

DNA extraction

The Promega ReliaPrep™ System for Genomic DNA (Promega Corp., USA) provides a practical approach for extracting DNA from blood samples. Enzymatic amplification was accomplished using a hybrid thermal cycler and conventional polymerase chain reaction (PCR).

The primers

The DNA sequences of the TNF-α gene were obtained from the GenBank database of NCBI. Primer Premier 3 software (RRID:SCR_003139) was utilized to generate PCR primers, as shown in Table 1, with a primer length of (21to20) nucleotides and a melting temperature of (60°C). As a result, the PCR amplicon length of the TNF-α gene was (949) base pairs (bp).

Table 1. The sequences, annealing temperature, and product size (bp) of the primers.Note: F means the forward primer, and R is the reverse primer.

	Reference locus sequences (5′ - 3′)	Temperature annealing step(°C)	Size of products (bp)
Tumor necrosis factor-α-F	5`-TGTAAAACGACGGCCAGTGCTGACCAAGAGAGAAAGAAG-3`	55	949
Tumor necrosis factor-α-R	5`-CAGGAAACAGCTATGACGAGTCCTTGAGGGAGAGAAA-3`	55	949

PCR amplification

The PCR process involves three major steps: denaturation, annealing, and extension.

The first step depicts DNA denaturation at high temperatures (90–97°C). Step two is to anneal the primers to the DNA template strands in order to prime extension. Step three involves extending the annealed primers to make a complementary copy strand of DNA; the last extension step is performed as a verification stage²². As seen in Figure 1, the PCR results were segregated on 1.5% agarose gel electrophoresis stained with ethidium bromide and observed using a Gel imaging system. Macrogen Corporation, Korea, delivered the PCR products to ABI3730XL, an automated DNA sequencer, for Sanger sequencing. The data were sent to the researcher, who subsequently examined them using Geneious prime software (RRID:SCR_010519).

Figure 1. The amplification of the TNF-α gene of human samples was fractionated on 1.5% agarose gel electrophoresis stained with ethidium bromide.M:100bp ladder marker.

Lanes1-19 resemble 949bp PCR products.

The summary of chemicals and kits used in this study are summarized in Table 2.

Table 2. The sequences, annealing temperature, and product size (bp) of the primers.Note: F means the forward primer, and R is the reverse primer.

Chemical	Provider	Cat.No.	REF No.
TNF-α ELISA kit	Cusabio, China	CSB-E04740h	LOT:H25223454
hs-CRP ELISA kit	Demeditec, Germany	LOT:1110221	DE740011
Go Tag Green Master Mix	Promega, USA	M7822	NA
Agarose	Promega, USA	LOT:0000381091	V3121
Ethidium Bromide Solution (10mg/ml)	Promega, USA	LOT:0000337437	H5041
TAE 40X	Promega, USA	LOT:0000428	V4281
ReliaPrep™ Blood gDNA Miniprep System	Promega, USA	A5081	NA
100bpDNA Ladder	Promega, USA	PR-G2101	G210A
Column Wash Solution	Promega, USA	LOT:0000402367	A503B

Statistical analysis

IBM SPSS Statistics (RRID: SCR_016479) version 27 software for Microsoft Windows was used throughout the statistical analysis process. The variance or dispersion of a collection of data values was quantified by expressing continuous variables as the mean standard deviation. Presenting discrete variables by their number and percentage, the direct count revealed the percentages and frequencies of alleles and genotypes. P-values less than 0.05 were considered significant, those less than 0.01 were considered highly significant, and those less than 0.001 were considered highly significant. The Shapiro–Wilk test was used to assess the findings′ normality. To determine the significance of the difference between the means of two independent samples, an unpaired T-test was used. One-way analysis of variance (ANOVA) was used to determine the degree of difference between the groups under study .The chi-square test and the Fisher’s exact test were used to organize and analyze the data. The phi correlation coefficient (phi) was used to establish the association between each genotype and the likelihood of becoming a responder. The influence of the genotypes on the chance of becoming a responder was estimated using a binary logistic regression analysis.

Results

Demographic data and clinical characteristics variables of the research participants are expressed in Table 3 and Table 4.

Table 3. Demographic data and the disease characteristicsof the participants.

Variables		R (n=33)	NR (n=27)	p-value
Age (years)		40±7.9	41.5±9.7	0.559^a
Gender	Male n(%)	32(97%)	19(70.4%)	0.008*^b
Gender	Female n(%)	1(3%)	8(29.6%)	0.008*^b
BMI (Kg/m²)		28.4±5.6	29.7±5.3	0.340^a
Smoking status(n%)	Nonsmoker	10(30.3%)	16(59.3%)	0.077^c
	Active smoker	18(54.5%)	9(33.3%)
	Ex-smoker	5(15.2%)	2(7.4%)
Disease duration category	< 5 year n(%)	17(51.5%)	15(55.6%)	0.755^c
Disease duration category	≥ 5 year n(%)	16(48.5%)	12(44.4%)	0.755^c
Use of NSAIDs		2(6.1%)	6(22.2%)	0.124^b
Family Hx of AS		7(21.2%)	8(29.6%)	0.454^c
Presence of	Osteoporosis	9(27.3%)	5(19.2%)	0.471^c
	Uveitis	3(9.1%)	3(11.5%)	0.999^c
	IBD	0(0.0%)	2(7.7%)	0.190^c

Continuous variables presented as mean± SD; Discrete variables presented as numbers and frequencies;R=responder;NR=non-responder; n=number; BMI=body mass index with a unit of kilogram per square meter;Hx=history; IBD=inflammatory bowel disease;

^aindependent sample t-test;

^bFisher’s exact test;

^cchi-square test

*= highly significant difference between two groups.

Table 4. Clinical characteristics variables of the study groups.

Parameters	R (n=33)	NR (n=27)	p-value
TNF-α (pg/ml)	92.6±35.2	135.3±37.0	<0.001*^a
hs-CRP (mg/l)	3.4±3.0	8.5±4.0	<0.001*^a
Baseline WBC (10³/µl)	8.6±2.5	8.0±2.9	0.363^a
WBC after treatment (10³/µl)	7.7±2.0	7.4±1.8	0.512^a
Baseline ESR (mm/h)	30.1±19.7	38.1±16.8	0.104^a
ESR after treatment (mm/h)	16.8±10.9	31.2±17.5	<0.001*^a
Baseline BASDAI	4.4±0.7	4.9±1.3	0.115^a
BASDAI after treatment	2.2±0.8	4.8±1.1	<0.001*^a
BASFAI after treatment	2.5±1.3	5.0±1.4	<0.001*^a

Continuous variables presented as mean± SD; R=responder; NR=non-responder; WBC=white blood cell; BASDAI=Bath Ankylosing Spondylitis Disease Activity Index; BASFI=Bath Ankylosing Spondylitis Functional Index. * = highly significant difference between two groups; ^a: independent sample t-test.

As shown in Table 5, there was a high prevalence of CC genotype for both rs1799724 C/T and rs4248158C/T in contrast to a low proportion of mutant C allele (2%) in rs1799964T/C. At the same time, the wild T allele in rs1799964T/C was more frequent and predominant in over half of patients (73%).

Table 5. Frequency of alleles and genotypes of (-1031T/C), (-857C/T), (-806C/T) TNF-α gene in ankylosing spondylitis patients (n=60).

SNPs	Genotypes	n	%
rs1799964	TT	44	73.3
	TC	15	25
	CC	1	1.7
Allele frequency	T	103	85.8
Allele frequency	C	17	14.2
rs4248158	CC	55	91.7
rs4248158	CT	5	8.3
Allele frequency	C	115	95.8
Allele frequency	T	5	4.2
rs1799724	CC	38	63.3
rs1799724	CT	22	36.7
Allele frequency	C	98	81.7
Allele frequency	T	22	18.3

Furthermore, highlighting the disparity in genotypes frequency between responder and non-responder groups, the analysis of this study showed a significant difference in the TT genotype of rs1799964 (p-value = 0.02) in the responder group, in contrast to the TC genotype of rs1799964, which was significantly more frequent in the non-responder group (p-value = 0.01), as revealed in Table 6.

Table 6. Distribution of TNF-α gene polymorphism and individual alleles in the AS patient groups.

SNPs	Genotypes	Responder group (n=33) N(%)	Non-responder group (n=27) N (%)	p-value
rs1799964T/C	TT	28 (84.8)	16 (59.3)	0.02*
	TC	4 (12.1)	11 (40.7)	0.01*
	CC	1 (3.0)	0 (0.0)	1.00
Allele frequency	T	60 (90.9)	43 (79.6)	0.07
Allele frequency	C	6 (9.1)	11 (20.4)	0.07
rs1799724C/T	CC	20 (60.6)	18 (66.7)	0.62
rs1799724C/T	CT	13 (39.4)	9 (33.3)	0.62
Allele frequency	C	53 (80.3)	45 (83.3)	0.66
Allele frequency	T	13 (19.7)	9 (16.7)	0.06
rs4248158C/T	CC	31 (93.9)	24 (88.9)	0.48
rs4248158C/T	CT	2 (6.1)	3 (11.1)	0.64
Allele frequency	C	64 (97.0)	51 (94.4)	0.49
Allele frequency	T	2 (3.03)	3 (5.6)	0.65

* statistically significant difference between two groups.

Table 7 shows the significant and non-significant association with each studied SNP in the TNF-α promoter regain gene by binary logistic regression. The TC-rs1799964 genotype significantly reduced the tendency to be a responder to ETN (OR=0.208, 95%CI:0.057-0.762, p=0.018); this indicates that the heterozygote TC of rs1799964 is a predictor for non-responsiveness to ETN in AS patients.

Table 7. Binary logistic regression analysis of genotypes to predict the tendency of being a responder to ETN.

SNPs	OR	95% CI		p-value
SNPs	OR	Lower	Upper	p-value
rs1799964 TC CC	0.208 NA	0.057 …..	0.762 …..	0.018* 1.000
rs1799724 CT	1.204	0.404	3.586	0.739
rs4248158 CT	0.556	0.082	3.774	0.548

* significant strength of association; OR: odds ratio; CI: confidence interval; p: significance level; NA: non-applicable.

# Reference level for each SNP is the wild allele: TT for rs1799964T/C; CC for rs1799724C/T; CC for rs428158C/T.

Similarly, the phi correlation coefficient (phi) analysis was shown to verify the strength of association between each genotype and the predisposition to be a responder to ETN. For example, Table 8 shows that the homozygote wild TT genotype of rs1799964 seemed to enhance the probability of being a responder to ETN in AS patients. Nevertheless, the heterozygote TC genotype of rs1799964 showed a negative and significant correlation for responsiveness to ETN.

Table 8. Relationship between each genotype and the probability of being a responder.

SNPs		Phi-coefficient	P-value
rs1799964T/C	TT	0.288	0.025^*
	TC	−0.329	0.011^*
	CC	0.118	0.362
rs1799724C/T	CC	−0.063	0.628
rs1799724C/T	CT	0.063	0.628
Rs4248158C/T	CC	0.091	0.481
Rs4248158C/T	CT	−0.091	0.481

* statistically significant

Adverse events and associated SNPs of ETN therapy

To investigate whether SNPs in the TNF-α promoter region alter the severity of harmful effects from ETN use, we looked at the relationship between genotype and the occurrence of these adverse events: infection, injection site reaction, headache, and rash. These three SNPs were compared for each genotype between non-adverse and negative cases. Table 9 shows there was a non-significant difference between genotypes for an increased risk of developing an infection, injection site reaction, headache, and adverse rash effects.

Table 9. Distribution of studied patients according to the occurrence of infection, injection site reaction, headache, and rash as a side effect and encountered alleles.

SNPs	Genotypes	Infection		P-value
SNPs	Genotypes	Yes N (%), n=17	No N (%), n=43	P-value
rs1799964T/C	TT	13 (76.4)	31 (72.0)	1.00
	TC	4 (28.5)	11 (25.5)
	CC	0 (0.0)	1 (2.3)
rs1799724C/T	CC	10 (58.8)	28 (65.1)	0.649
rs1799724C/T	CT	7 (41.2)	15 (34.9)	0.649
rs 4248158C/T	CC	15 (88.2)	40 (93.0)	0.545
rs 4248158C/T	CT	2 (11.8)	3 (7.0)	0.545
SNPs	Genotypes	Injection site reaction		P-value
SNPs	Genotypes	Yes N (%), n=21	No N (%), n=39	P-value
rs1799964T/C	TT	17 (80.9)	27 (69.2)	0.376
	TC	4 (19.0)	11 (28.2)
	CC	0 (0.0)	1 (2.5)
rs1799724C/T	CC	14 (66.7)	24 (61.5)	0.694
rs1799724C/T	CT	7 (33.3)	15 (38.5)	0.694
rs 4248158C/T	CC	21 (100.0)	34 (87.2)	0.087
rs 4248158C/T	CT	0 (0.0)	5 (12.8)	0.087
SNPs	Genotypes	Headache		P-value
		Yes N (%), n=11	No N (%), n=49
		Yes N (%), n=11
rs1799964T/C	TT	8 (72.72)	36 (73.46)	1.00
	TC	3 (27.27)	12 (24.48)
	CC	0 (0.0)	1 (2.04)
rs1799724C/T	CC	8 (72.7)	30 (61.2)	0.474
rs1799724C/T	CT	3 (27.3)	19 (38.8)	0.474
rs 4248158C/T	CC	11 (100.0)	44 (89.8)	0.278
rs 4248158C/T	CT	0 (0.0)	5 (10.2)	0.278
SNPs	Genotypes	Rash		P-value
SNPs	Genotypes	Yes N (%), n=12	No N (%), n=48	P-value
rs1799964T/C	TT	10 (83.3)	34 (70.8)	0.485
	TC	2 (16.6)	13 (27.0)
	CC	0 (0.0)	1 (2.0)
rs1799724C/T	CC	6 (50.0)	32 (66.7)	0.284
rs1799724C/T	CT	6 (50.0)	16 (33.3)	0.284
rs 4248158C/T	CC	12 (100.0)	43 (89.6)	0.243
	CT	0 (0.0)	5 (10.4)

Discussion

AS is a chronic inflammatory condition with an unknown cause. In contrast to other systemic autoimmune diseases, the innate immune system plays a dominant role in AS, which is characterized by the aberrant activity of innate and innate-like immune cells, such as T cells, group 3 innate lymphoid cells, neutrophils, mucosal-associated invariant T cells, and mast cells, at disease-prone sites²³.

The first biological DMARDs considered second-line therapy are TNFi. Adalimumab, certolizumab pegol, ETN, golimumab, and infliximab, as well as its biosimilars, are now indicated. Anti-TNF medication is quite successful in AS, with significant improvements in disease activity and functional scores following six months of treatment²⁴. These drugs should be used according to their indications, contraindications, and patient comorbidities. No TNFi are recommended for preferred efficacy²⁵. In large, randomized, controlled clinical trials, TNF-α inhibitors have shown efficacy and are well-tolerated. However, a considerable minority of individuals do not respond to these medications, and their use may be associated with severe adverse drug reactions.

It is worth mentioning that the most reported adverse drug reactions to biological drugs in a study performed in Iraq were related to general disorders and administration site conditions, followed by skin and subcutaneous disorders, respiratory disorders, and gastrointestinal disorders²⁶. In the current research, the mean age in the responder and non-responder groups was not significantly different (p = 0.559). The study results revealed that there was a significant difference (p < 0.005) in gender distribution, in which the percentage of males in the responder group was 97%, whereas it was 70.4% in the non-responder group, while the percentage of females in the responder and non-responder groups was 3% and 29.6%, respectively; this result is consistent with various previous studies^27–29.

The serum TNF-α and high-sensitivity C-reactive protein (hs-CRP) levels were also shown to vary significantly between the responder and non-responder groups. The mean BASDAI (4.8 ± 1.1) and BASFI) 5.0 ± 1.4) of the non-responder group treated with ETN was higher than the responder group, and this difference was statistically significant (p-value < 0.001). Additionally, the mean serum level of ESR after treatment with ETN was higher in the non-responder group (31.2 ± 17.5) than the responder group (16.8 ± 10.9), and this difference was statistically significant (p-value < 0.001). This finding is close to the result of a previously performed study by Albagoa et al.³⁰.

Prior studies conducted in Iraq examined the association between genetic variants in different genes and the prevalence and severity of AS^31–33. This observational study is the first study in Iraq that has analyzed the association of SNPs in the TNF-α promoter region gene -1031T/C (rs1799964), -857C/T (rs1799724) and -806C/T (rs 4248158) with outcomes of treatment in 60 Iraqi patients with AS taking ETN.

Numerous global researchers have investigated the influence of SNPs in the different genes on the TNFi response^34–37. Regarding the frequency of the prevalence of -1031T/C (rs1799964) in all AS patients, the present study showed that the wild TT homozygote in rs1799964T/C was more frequent and predominant in over half of patients (73%), followed by heterozygote TC (25%) and a low proportion of mutant CC homozygote (2%). Moreover, the T allele was found in over 85% of patients, but the C allele was present in only about 14% of patients. There has been no previous research conducted in Iraq that closely examined -1031T/C on AS or any other disease to match it with; hence, the outcomes seemed to be equivalent to those of Han Chinese and Korean people with AS, demonstrated in previous research.

This result is consistent with the Sheng et al.³⁸ study, where the TT, TC, and CC genotypes were found in approximately 76%, 19%, and 4% of AS patients, respectively, with the proportion of T allele to C allele being 86 % and 14%, respectively. Similarly, Chung et al.³⁹. showed a higher proportion of wild TT homozygote genotype in about 59 patients, followed by 18 patients with the TC heterozygote genotype and no patients with the CC genotype. Regarding the difference in -1031T/C (rs1799964) genotypes frequency between responders and non-responders, the analysis of this study showed a significant difference in the TT genotype of -1031T/C polymorphism (rs1799964)( p-value = 0.02) in the responder group, in contrast to the TC genotype, which was significantly more frequent in the non-responder group (p-value = 0.01), while there was no significant difference in the availability of the CC genotype between responder and non-responder groups. Similar findings were seen in a study by Tong et al^.40, who observed that the TT genotype had a better treatment outcome compared with the CT and CC genotypes.

The current research findings could be attributed to the fact that the availability of the -1031TT genotype diminished TNF-α concentrations in the serum. Regarding the frequency of the prevalence of -857 C/T (rs1799724) in all AS patients, the current data show that there was a high prevalence of CC genotype, occurring in more than half the patients. Besides that, the C allele was found in over 80% of patients, but the T allele was present in only about 18% of patients.

This result was in agreement with a study by Mohammed et al.⁴¹, which covered 80 Iraqi RA patients and revealed the prevalence of the CC genotype, with the C allele found in 81.25%. In contrast, the T allele was found in only about 18% of participants. Similarly, an Italian study by Aita et al.⁴² reported a high frequency of CC genotype (60%) compared with TC and TT genotypes in AS patients. In addition, the current investigation indicated that both CC and CT genotypes were distributed equally across study patients.

There was no significant difference statistically between the respondent and non-respondent groups, and without correlation with any response to ETN. The outcome seems to agree with the result of a previous study by Mohammed et al.⁴¹. However, the current findings disagree with the Chinese Han study by Tong et al., which revealed that -857CC genotypes can predict positive prognosis responsiveness to TNF-α inhibitors⁴⁰. Indeed, a meta-analysis of a variety of ethnic groupings highlighted a relationship between the -857 C allele and the sensitivity of TNF-inhibitors in Caucasians, which was not observed in Asians³⁵. Put another way, many investigations indicate that TNF-α -857CC improves the responsiveness to treatment (ETN), despite contradictory and insignificant evidence for this relationship⁴³.

This disparity in results comparing the current study to earlier research can be associated with the rarity of the T allele in patients with AS in Iraq who participated in the current research and may be because of genetic heterogeneity and different environmental factors in different populations. In the instance of -806C/T genotypes, the results of this investigation demonstrated that the CC genotype was widespread, in more than 90% of patients, followed by the CT genotype in about 8% of participants. More than 95% of patients carried the C allele, while just 4% carried the T allele.

This is the first study to examine the genotyping of -806C/T in AS patients from Iraq. Nevertheless, the results were equivalent to those from investigational research on the hazards of intracranial aneurysms among Chinese people⁴⁴. Furthermore, addressing the distinction in genotype frequency between the study groups, an analysis of this study showed a non-significant difference in CC and CT genotypes between the two groups. Similarly, while the CC genotype showed a positive relationship and the CT genotype showed a negative relationship, neither of them reached the statistical significance level. It is noteworthy that ours is the first study to investigate the association between the TNF-α -806C/T polymorphism and response to ETN in patients with AS. To investigate whether SNPs in the promoter region of the TNF-α gene alter the severity of harmful effects from ETN use, we looked at the relationship between genotype and the occurrence of these adverse events: infection, injection site reaction, headache, and rash.

These three SNPs were compared for each genotype between non-adverse and adverse events cases. The most frequently reported side effects were injection site reaction (21 patients, 35%), followed by infection (28.3%), then headache and rash, with an incidence of about 38%. The incidence of short-term and long-term adverse effects linked with TNF-blocker medication in Chinese Han patients with AS was investigated by Tong et al.⁴⁵, and they discovered that disease duration, ESR, and CRP levels in the serum were related to an increase in side effects when using TNF-blockers. Chronic therapy with infliximab correlated with more side effects than rhTNFR-Fc.

Moreover, Chou et al.⁴⁶ found no severe adverse events in a prospective, open-label trial of ETN, involving 46 patients with AS from 60 Taiwan medical centers. However, SNPs investigated in this study cannot effectively predict the occurrence of drug-related adverse events. There are significant limits to the generalizability of our study's findings. First, the limited sample size is a drawback of this study. Specifically, even though ETN is a highly effective treatment for AS, its expense and stringent inclusion criteria are frequently the primary reasons why published observations in AS patients, as well as our study, typically have a small sample size. Next, the present research was conducted at one institute, and, while our institute serves Iraqi people from many cities, we recommend that further studies may be necessary prior to expressing the results among all Iraqi AS individuals.. Lastly, a tiny proportion of cases solely received ETN because of inadequate budget and resources. Regardless, it would be intriguing to increase the sample size to validate the result. Indeed, the small sample size and differences in genetic background amongst ethnic populations may explain the few contradictory findings.

Conclusion

The presence of the TT genotype of rs1799964 is associated with a higher likelihood of responding to ETN, suggesting that it is a useful diagnostic for predicting response in Iraqi AS patients. In contrast, the TC genotype of rs1799964 greatly increases the risk of becoming an ETN non-responder. These results suggest that the TC genotype of rs1799964 should be investigated in AS patients prior to delivery of ETN.

Ethical approval

Ethical approval was obtained from the Scientific and Ethical Committee at the College of Pharmacy, Baghdad University, Iraq (approval number: RECACPUB-3102020D). This research was conducted in line with the Helsinki Declaration¹⁸.

Consent

Before data collection, written consent was obtained from each of the participants.

Data availability

Underlying data

Zenodo: Association between polymorphisms within gene coding for tumor necrosis factor (TNF)-alpha with outcomes of treatment in sample of Iraqi patients with Ankylosing Spondylitis taking Etanercept. https://doi.org/10.5281/zenodo.7339117⁴⁷.

This project contains the following underlying data:

- Article data.xlsx (Demographic data, disease characteristics, and laboratory findings.)

Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0).

Faculty Opinions recommended

References

1. Kasper D, Fauci A, Hauser S, et al.: Harrison's principles of internal medicine. 19e: Mcgraw-hill New York, NY, USA; 2015. Reference Source
2. Greene RJ, Harris ND: Pathology and Therapeutics for Pharmacists. Pharmaceutical Press; 2020. Reference Source
3. Papadakis MA, McPhee SJ, Rabow MC: Medical Diagnosis & Treatment. Mc Graw Hill: San Francisco, CA, USA; 2019.
4. Braun J, Sieper J: Ankylosing spondylitis. Lancet. 2007; 369(9570): 1379–90. PubMed Abstract | Publisher Full Text
5. Dougados M, Baeten D: Spondyloarthritis. Lancet. 2011; 377(9783): 2127–37. PubMed Abstract | Publisher Full Text
6. Al-Bedri KZM: Prevalence, clinical features, and radiological features of Iraqi patients with ankylosing spondylitis. J Nat Appl Sci. 2014; 4(24). Reference Source
7. Mustafa KN, Hammoudeh M, Khan MA: HLA-B27 prevalence in Arab populations and among patients with ankylosing spondylitis. J Rheumatol. 2012; 39(8): 1675–7. PubMed Abstract | Publisher Full Text
8. Zambrano-Zaragoza JF, Agraz-Cibrian JM, González-Reyes C, et al.: Ankylosing spondylitis: from cells to genes. Int J Inflam. 2013; 2013: 501653. PubMed Abstract | Publisher Full Text | Free Full Text
9. Parnham MJ, Bruinvels J: Milestones in Drug Therapy MDT. 2006. Reference Source
10. DiPiro JT, Talbert RL, Yee GC, et al.: Pharmacotherapy: A Pathophysiologic Approach. ed. Connecticut: Appleton and Lange, 2014; 4: 141–2. Reference Source
11. Baseggio L, Bartholin L, Chantome A, et al.: Allele-specific binding to the -308 single nucleotide polymorphism site in the tumour necrosis factor-alpha promoter. Eur J Immunogenet. 2004; 31(1): 15–9. PubMed Abstract | Publisher Full Text
12. Bergman MJ, Kivitz AJ, Pappas DA, et al.: Clinical utility and cost savings in predicting inadequate response to anti-TNF therapies in rheumatoid arthritis. Rheumatol Ther. 2020; 7(4): 775–92. PubMed Abstract | Publisher Full Text | Free Full Text
13. Ma MHY, Defranoux N, Li W, et al.: A multi-biomarker disease activity score can predict sustained remission in rheumatoid arthritis. Arthritis Res Ther. 2020; 22(1): 158. PubMed Abstract | Publisher Full Text | Free Full Text
14. Ventola CL: Role of pharmacogenomic biomarkers in predicting and improving drug response: part 1: the clinical significance of pharmacogenetic variants. P T. 2013; 38(9): 545–60. PubMed Abstract | Free Full Text
15. Rao M, Wong C, Kanetsky P, et al.: Cytokine gene polymorphism and progression of renal and cardiovascular diseases. Kidney Int. 2007; 72(5): 549–56. PubMed Abstract | Publisher Full Text
16. Wu X, Sheng X, Sheng R, et al.: Genetic and clinical markers for predicting treatment responsiveness in rheumatoid arthritis. Front Med. 2019; 13(4): 411–9. PubMed Abstract | Publisher Full Text
17. Prieto-Pérez R, Cabaleiro T, Daudén E, et al.: Gene polymorphisms that can predict response to anti-TNF therapy in patients with psoriasis and related autoimmune diseases. Pharmacogenomics J. 2013; 13(4): 297–305. PubMed Abstract | Publisher Full Text
18. General Assembly of the World Medical Association: World Medical Association Declaration of Helsinki: ethical principles for medical research involving human subjects. J Am Coll Dent. 2014; 81(3): 14–8. PubMed Abstract
19. van der Linden S, Valkenburg HA, Cats A: Evaluation of diagnostic criteria for ankylosing spondylitis. A proposal for modification of the New York criteria. Arthritis Rheum. 1984; 27(4): 361–8. PubMed Abstract | Publisher Full Text
20. Rudwaleit M, Listing J, Brandt J, et al.: Prediction of a major clinical response (BASDAI 50) to tumour necrosis factor α blockers in ankylosing spondylitis. Ann Rheum Dis. 2004; 63(6): 665–70. PubMed Abstract | Publisher Full Text | Free Full Text
21. Markowitz JS: Body mass index (BMI). Mortality and Its Risk Factors Among Professional Athletes: Springer; 2018; 39–49.
22. Joshi M, Deshpande JD: Polymerase chain reaction: methods, principles and application. Int J Biomed Res. 2010; 2(1): 81–97. Publisher Full Text
23. Mauro D, Thomas R, Guggino G, et al.: Ankylosing spondylitis: an autoimmune or autoinflammatory disease? Nat Rev Rheumatol. 2021; 17(7): 387–404. PubMed Abstract | Publisher Full Text
24. Hyrich KL, Watson KD, Silman AJ, et al.: Predictors of response to anti-TNF-α therapy among patients with rheumatoid arthritis: results from the British Society for Rheumatology Biologics Register. Rheumatology (Oxford). 2006; 45(12): 1558–65. PubMed Abstract | Publisher Full Text
25. van der Heijde D, Ramiro S, Landewé R, et al.: 2016 update of the ASAS-EULAR management recommendations for axial spondyloarthritis. Ann Rheum Dis. 2017; 76(6): 978–91. PubMed Abstract | Publisher Full Text
26. Hassan EF, Kadhim DJ, Younus MM: Safety profile of biological drugs in clinical practice: a retrospective pharmacovigilance study. Iraqi Journal of Pharmaceutical Sciences. 2022; 31(1): 32–42. Publisher Full Text
27. Al-Osami MH, Gorial FI, Albeer MR, et al.: Etanercept is effective and relatively safe in a sample of Iraqi patients with ankylosing spondylitis. JNSR. 2013; 3(14): 124–30. Reference Source
28. Al Hafidh AH: Clinical and epidemiological aspects of ankylosing spondylitis patients in a single center in Baghdad. Journal of Techniques. 2022; 4(1): 62–6. Reference Source
29. Al-Shaibani SAR, Jassim NA, Al-Bayati AAK: Raised inflammatory markers as predictors of response to anti-tumor necrosis factor drugs (etanercept and infliximab) in a sample of Iraqi patients with ankylosing spondylitis. Medical Journal of Babylon. 2021; 18(3): 241–244. Reference Source
30. Albagoa ZR, Thanoon IA, Abdulla FI, et al.: Etanercept in patients with ankylosing spondylitis: effectiveness and rate of response. MMSL. 2022; 91(4): 266–273. Publisher Full Text
31. Al-Taee MM, Jassim HM, Alosami MH: Genetic polymorphism in endoplasmic reticulum aminopeptidase-l (erap1) gene in Iraqi patients with ankylosing spondylitis. World J Pharm Res. 2016; 5(6): 321–32. Reference Source
32. Daekh NA, Mohammed KA, Ali NH: Polymorphism of HLA-B27 among ankylosing spondylitis patients in Basrah, Iraq. Sci J Med Res. 2020; 4(13): 12–6. Reference Source
33. Al-Tarboolee AYK, Al-Taee MM, Kadir OKAAL: MHC Class I polypeptiderelated sequence A (MICA) polymorphism association with ankylosing spondylitis in Iraqi patients. Indian Journal of Forensic Medicine & Toxicology. 2020; 50(4): 356–361. Reference Source
34. Reich K, Hüffmeier U, König IR, et al.: TNF polymorphisms in psoriasis: association of psoriatic arthritis with the promoter polymorphism TNF*-857 independent of the PSORS1 risk allele. Arthritis Rheum. 2007; 56(6): 2056–64. PubMed Abstract | Publisher Full Text
35. Song GG, Seo YH, Kim JH, et al.: Association between TNF-α (-308 A/G, -238 A/G, -857 C/T) polymorphisms and responsiveness to TNF-α blockers in spondyloarthropathy, psoriasis and Crohn's disease: a meta-analysis. Pharmacogenomics. 2015; 16(12): 1427–37. PubMed Abstract | Publisher Full Text
36. Tong Q, Zhao L, Qian XD, et al.: Association of TNF-α polymorphism with prediction of response to TNF blockers in spondyloarthritis and inflammatory bowel disease: a meta-analysis. Pharmacogenomics. 2013; 14(14): 1691–700. PubMed Abstract | Publisher Full Text
37. Fabris M, Quartuccio L, Fabro C, et al.: The -308 TNFα and the -174 IL-6 promoter polymorphisms associate with effective anti-TNFα treatment in seronegative spondyloarthritis. Pharmacogenomics J. 2016; 16(3): 238–42. PubMed Abstract | Publisher Full Text
38. Sheng N, Gao Y, Li H, et al.: The associations of rs1799724 and rs361525 with the risk of ankylosing spondylitis are dependent on HLA-B27 status in a Chinese Han Population. Front Immunol. 2022; 13: 852326. PubMed Abstract | Publisher Full Text | Free Full Text
39. Chung WT, Choe JY, Jang WC, et al.: Polymorphisms of tumor necrosis factor-α promoter region for susceptibility to HLA-B27-positive ankylosing spondylitis in Korean population. Rheumatol Int. 2011; 31(9): 1167–75. PubMed Abstract | Publisher Full Text
40. Tong Q, Zhao DB, Bajracharya P, et al.: TNF-α -857 and -1031 polymorphisms predict good therapeutic response to TNF-α blockers in Chinese Han patients with ankylosing spondylitis. Pharmacogenomics. 2012; 13(13): 1459–67. PubMed Abstract | Publisher Full Text
41. Mohammed S, Zalzala M, Gorial F: Association of tumor necrosis factor-alpha promoter region gene polymorphism at positions -308G/A, -857C/T, and -863C/A with etanercept response in Iraqi rheumatoid arthritis patients. Arch Rheumatol. 2022; 37(4): 613–625. Publisher Full Text
42. Aita A, Basso D, Ramonda R, et al.: Genetics in TNF-TNFR pathway: A complex network causing spondyloarthritis and conditioning response to anti-TNFα therapy. PLoS One. 2018; 13(3): e0194693. PubMed Abstract | Publisher Full Text | Free Full Text
43. Murdaca G, Negrini S, Magnani O, et al.: Impact of pharmacogenomics upon the therapeutic response to etanercept in psoriasis and psoriatic arthritis. Expert Opin Drug Saf. 2017; 16(10): 1173–9. PubMed Abstract | Publisher Full Text
44. Hu J, Luo J, Wang H, et al.: Association of TNF-α-3959T/C Gene Polymorphisms in the Chinese Population with Intracranial Aneurysms. J Mol Neurosci. 2017; 63(3–4): 349–54. PubMed Abstract | Publisher Full Text
45. Tong Q, Cai Q, de Mooij T, et al.: Adverse events of anti-tumor necrosis factor α therapy in ankylosing spondylitis. PLoS One. 2015; 10(3): e0119897. PubMed Abstract | Publisher Full Text | Free Full Text
46. Chou CT, Tsai CY, Liang TH, et al.: Better short-term clinical response to etanercept in Chinese than Caucasian patients with active ankylosing spondylitis. Mod Rheumatol. 2010; 20(6): 580–7. PubMed Abstract | Publisher Full Text
47. Shareef LG: Demographic data, disease characteristics, and laboratory findings for Association between polymorphisms within gene coding for tumor necrosis factor (TNF)-alpha with outcomes of treatment in sample of Iraqi patients with Ankylosing Spondylitis taking Etanercept. 2022. http://www.doi.org/10.5281/zenodo.7339117

Comments on this article Comments (0)

Version 1

VERSION 1 PUBLISHED 23 Dec 2022

Author details Author details

¹ Department of Clinical Pharmacy, University of Baghdad, College of Pharmacy, Baghdad, 10011, Iraq
² Department of Clinical Laboratory Sciences, University of Baghdad, College of Pharmacy, Baghdad, 10011, Iraq
³ Department of Rheumatology, University of Baghdad, College of Medicine, Baghdad, 10011, Iraq
⁴ Department of Pharmacy, Al-Rasheed University College, Baghdad, 10011, Iraq

Shaimaa Saleh Khudhur
Roles: Conceptualization, Data Curation, Formal Analysis, Methodology, Project Administration, Writing – Original Draft Preparation

Eman Saadi Saleh
Roles: Conceptualization, Formal Analysis, Methodology, Supervision, Writing – Review & Editing

Mohammed Hadi Alosami
Roles: Conceptualization, Methodology, Software, Supervision, Writing – Review & Editing

Laith G. Shareef
Roles: Software, Validation, Visualization, Writing – Review & Editing

Competing interests

No competing interests were disclosed.

Grant information

The author(s) declared that no grants were involved in supporting this work.

Article Versions (1)

version 1

Published: 23 Dec 2022, 11:1576

https://doi.org/10.12688/f1000research.128842.1

Copyright

© 2022 Saleh Khudhur S et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Download

Export To

metrics

	Views	Downloads
F1000Research	-	-
PubMed Central Data from PMC are received and updated monthly.	-	-

Citations

0

SEE MORE DETAILS

CITE

how to cite this article

Saleh Khudhur S, Saadi Saleh E, Hadi Alosami M and G. Shareef L. Association between polymorphisms within the gene coding for tumor necrosis factor (TNF)-alpha with outcomes of treatment in a sample of Iraqi patients with ankylosing spondylitis taking etanercept: an observational study [version 1; peer review: awaiting peer review]. F1000Research 2022, 11:1576 (https://doi.org/10.12688/f1000research.128842.1)

NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article.

track

receive updates on this article

Track an article to receive email alerts on any updates to this article.

Open Peer Review

Comments on this article Comments (0)

Version 1

VERSION 1 PUBLISHED 23 Dec 2022

Open Peer Review

Reviewer Status

AWAITING PEER REVIEW

Comments on this article

All Comments(0)

Add a comment

Sign up for content alerts

Browse by related subjects

[1] 1. Kasper D, Fauci A, Hauser S, et al.: Harrison's principles of internal medicine. 19e: Mcgraw-hill New York, NY, USA; 2015. Reference Source

[2] 2. Greene RJ, Harris ND: Pathology and Therapeutics for Pharmacists. Pharmaceutical Press; 2020. Reference Source

[3] 3. Papadakis MA, McPhee SJ, Rabow MC: Medical Diagnosis & Treatment. Mc Graw Hill: San Francisco, CA, USA; 2019.

[4] 4. Braun J, Sieper J: Ankylosing spondylitis. Lancet. 2007; 369(9570): 1379–90. PubMed Abstract | Publisher Full Text

[5] 5. Dougados M, Baeten D: Spondyloarthritis. Lancet. 2011; 377(9783): 2127–37. PubMed Abstract | Publisher Full Text

[6] 6. Al-Bedri KZM: Prevalence, clinical features, and radiological features of Iraqi patients with ankylosing spondylitis. J Nat Appl Sci. 2014; 4(24). Reference Source

[7] 7. Mustafa KN, Hammoudeh M, Khan MA: HLA-B27 prevalence in Arab populations and among patients with ankylosing spondylitis. J Rheumatol. 2012; 39(8): 1675–7. PubMed Abstract | Publisher Full Text

[8] 8. Zambrano-Zaragoza JF, Agraz-Cibrian JM, González-Reyes C, et al.: Ankylosing spondylitis: from cells to genes. Int J Inflam. 2013; 2013: 501653. PubMed Abstract | Publisher Full Text | Free Full Text

[9] 9. Parnham MJ, Bruinvels J: Milestones in Drug Therapy MDT. 2006. Reference Source

[10] 10. DiPiro JT, Talbert RL, Yee GC, et al.: Pharmacotherapy: A Pathophysiologic Approach. ed. Connecticut: Appleton and Lange, 2014; 4: 141–2. Reference Source

[11] 11. Baseggio L, Bartholin L, Chantome A, et al.: Allele-specific binding to the -308 single nucleotide polymorphism site in the tumour necrosis factor-alpha promoter. Eur J Immunogenet. 2004; 31(1): 15–9. PubMed Abstract | Publisher Full Text

[12] 12. Bergman MJ, Kivitz AJ, Pappas DA, et al.: Clinical utility and cost savings in predicting inadequate response to anti-TNF therapies in rheumatoid arthritis. Rheumatol Ther. 2020; 7(4): 775–92. PubMed Abstract | Publisher Full Text | Free Full Text

[13] 13. Ma MHY, Defranoux N, Li W, et al.: A multi-biomarker disease activity score can predict sustained remission in rheumatoid arthritis. Arthritis Res Ther. 2020; 22(1): 158. PubMed Abstract | Publisher Full Text | Free Full Text

[14] 14. Ventola CL: Role of pharmacogenomic biomarkers in predicting and improving drug response: part 1: the clinical significance of pharmacogenetic variants. P T. 2013; 38(9): 545–60. PubMed Abstract | Free Full Text

[15] 15. Rao M, Wong C, Kanetsky P, et al.: Cytokine gene polymorphism and progression of renal and cardiovascular diseases. Kidney Int. 2007; 72(5): 549–56. PubMed Abstract | Publisher Full Text

[16] 16. Wu X, Sheng X, Sheng R, et al.: Genetic and clinical markers for predicting treatment responsiveness in rheumatoid arthritis. Front Med. 2019; 13(4): 411–9. PubMed Abstract | Publisher Full Text

[17] 17. Prieto-Pérez R, Cabaleiro T, Daudén E, et al.: Gene polymorphisms that can predict response to anti-TNF therapy in patients with psoriasis and related autoimmune diseases. Pharmacogenomics J. 2013; 13(4): 297–305. PubMed Abstract | Publisher Full Text

[18] 18. General Assembly of the World Medical Association: World Medical Association Declaration of Helsinki: ethical principles for medical research involving human subjects. J Am Coll Dent. 2014; 81(3): 14–8. PubMed Abstract

[19] 19. van der Linden S, Valkenburg HA, Cats A: Evaluation of diagnostic criteria for ankylosing spondylitis. A proposal for modification of the New York criteria. Arthritis Rheum. 1984; 27(4): 361–8. PubMed Abstract | Publisher Full Text

[20] 20. Rudwaleit M, Listing J, Brandt J, et al.: Prediction of a major clinical response (BASDAI 50) to tumour necrosis factor α blockers in ankylosing spondylitis. Ann Rheum Dis. 2004; 63(6): 665–70. PubMed Abstract | Publisher Full Text | Free Full Text

[21] 21. Markowitz JS: Body mass index (BMI). Mortality and Its Risk Factors Among Professional Athletes: Springer; 2018; 39–49.

[22] 22. Joshi M, Deshpande JD: Polymerase chain reaction: methods, principles and application. Int J Biomed Res. 2010; 2(1): 81–97. Publisher Full Text

[23] 23. Mauro D, Thomas R, Guggino G, et al.: Ankylosing spondylitis: an autoimmune or autoinflammatory disease? Nat Rev Rheumatol. 2021; 17(7): 387–404. PubMed Abstract | Publisher Full Text

[24] 24. Hyrich KL, Watson KD, Silman AJ, et al.: Predictors of response to anti-TNF-α therapy among patients with rheumatoid arthritis: results from the British Society for Rheumatology Biologics Register. Rheumatology (Oxford). 2006; 45(12): 1558–65. PubMed Abstract | Publisher Full Text

[25] 25. van der Heijde D, Ramiro S, Landewé R, et al.: 2016 update of the ASAS-EULAR management recommendations for axial spondyloarthritis. Ann Rheum Dis. 2017; 76(6): 978–91. PubMed Abstract | Publisher Full Text

[26] 26. Hassan EF, Kadhim DJ, Younus MM: Safety profile of biological drugs in clinical practice: a retrospective pharmacovigilance study. Iraqi Journal of Pharmaceutical Sciences. 2022; 31(1): 32–42. Publisher Full Text

[27] 27. Al-Osami MH, Gorial FI, Albeer MR, et al.: Etanercept is effective and relatively safe in a sample of Iraqi patients with ankylosing spondylitis. JNSR. 2013; 3(14): 124–30. Reference Source

[28] 28. Al Hafidh AH: Clinical and epidemiological aspects of ankylosing spondylitis patients in a single center in Baghdad. Journal of Techniques. 2022; 4(1): 62–6. Reference Source

[29] 29. Al-Shaibani SAR, Jassim NA, Al-Bayati AAK: Raised inflammatory markers as predictors of response to anti-tumor necrosis factor drugs (etanercept and infliximab) in a sample of Iraqi patients with ankylosing spondylitis. Medical Journal of Babylon. 2021; 18(3): 241–244. Reference Source

[30] 30. Albagoa ZR, Thanoon IA, Abdulla FI, et al.: Etanercept in patients with ankylosing spondylitis: effectiveness and rate of response. MMSL. 2022; 91(4): 266–273. Publisher Full Text

[31] 31. Al-Taee MM, Jassim HM, Alosami MH: Genetic polymorphism in endoplasmic reticulum aminopeptidase-l (erap1) gene in Iraqi patients with ankylosing spondylitis. World J Pharm Res. 2016; 5(6): 321–32. Reference Source

[32] 32. Daekh NA, Mohammed KA, Ali NH: Polymorphism of HLA-B27 among ankylosing spondylitis patients in Basrah, Iraq. Sci J Med Res. 2020; 4(13): 12–6. Reference Source

[33] 33. Al-Tarboolee AYK, Al-Taee MM, Kadir OKAAL: MHC Class I polypeptiderelated sequence A (MICA) polymorphism association with ankylosing spondylitis in Iraqi patients. Indian Journal of Forensic Medicine & Toxicology. 2020; 50(4): 356–361. Reference Source

[34] 34. Reich K, Hüffmeier U, König IR, et al.: TNF polymorphisms in psoriasis: association of psoriatic arthritis with the promoter polymorphism TNF*-857 independent of the PSORS1 risk allele. Arthritis Rheum. 2007; 56(6): 2056–64. PubMed Abstract | Publisher Full Text

[35] 35. Song GG, Seo YH, Kim JH, et al.: Association between TNF-α (-308 A/G, -238 A/G, -857 C/T) polymorphisms and responsiveness to TNF-α blockers in spondyloarthropathy, psoriasis and Crohn's disease: a meta-analysis. Pharmacogenomics. 2015; 16(12): 1427–37. PubMed Abstract | Publisher Full Text

[36] 36. Tong Q, Zhao L, Qian XD, et al.: Association of TNF-α polymorphism with prediction of response to TNF blockers in spondyloarthritis and inflammatory bowel disease: a meta-analysis. Pharmacogenomics. 2013; 14(14): 1691–700. PubMed Abstract | Publisher Full Text

[37] 37. Fabris M, Quartuccio L, Fabro C, et al.: The -308 TNFα and the -174 IL-6 promoter polymorphisms associate with effective anti-TNFα treatment in seronegative spondyloarthritis. Pharmacogenomics J. 2016; 16(3): 238–42. PubMed Abstract | Publisher Full Text

[38] 38. Sheng N, Gao Y, Li H, et al.: The associations of rs1799724 and rs361525 with the risk of ankylosing spondylitis are dependent on HLA-B27 status in a Chinese Han Population. Front Immunol. 2022; 13: 852326. PubMed Abstract | Publisher Full Text | Free Full Text

[39] 39. Chung WT, Choe JY, Jang WC, et al.: Polymorphisms of tumor necrosis factor-α promoter region for susceptibility to HLA-B27-positive ankylosing spondylitis in Korean population. Rheumatol Int. 2011; 31(9): 1167–75. PubMed Abstract | Publisher Full Text

[40] 40. Tong Q, Zhao DB, Bajracharya P, et al.: TNF-α -857 and -1031 polymorphisms predict good therapeutic response to TNF-α blockers in Chinese Han patients with ankylosing spondylitis. Pharmacogenomics. 2012; 13(13): 1459–67. PubMed Abstract | Publisher Full Text

[41] 41. Mohammed S, Zalzala M, Gorial F: Association of tumor necrosis factor-alpha promoter region gene polymorphism at positions -308G/A, -857C/T, and -863C/A with etanercept response in Iraqi rheumatoid arthritis patients. Arch Rheumatol. 2022; 37(4): 613–625. Publisher Full Text

[42] 42. Aita A, Basso D, Ramonda R, et al.: Genetics in TNF-TNFR pathway: A complex network causing spondyloarthritis and conditioning response to anti-TNFα therapy. PLoS One. 2018; 13(3): e0194693. PubMed Abstract | Publisher Full Text | Free Full Text

[43] 43. Murdaca G, Negrini S, Magnani O, et al.: Impact of pharmacogenomics upon the therapeutic response to etanercept in psoriasis and psoriatic arthritis. Expert Opin Drug Saf. 2017; 16(10): 1173–9. PubMed Abstract | Publisher Full Text

[44] 44. Hu J, Luo J, Wang H, et al.: Association of TNF-α-3959T/C Gene Polymorphisms in the Chinese Population with Intracranial Aneurysms. J Mol Neurosci. 2017; 63(3–4): 349–54. PubMed Abstract | Publisher Full Text

[45] 45. Tong Q, Cai Q, de Mooij T, et al.: Adverse events of anti-tumor necrosis factor α therapy in ankylosing spondylitis. PLoS One. 2015; 10(3): e0119897. PubMed Abstract | Publisher Full Text | Free Full Text

[46] 46. Chou CT, Tsai CY, Liang TH, et al.: Better short-term clinical response to etanercept in Chinese than Caucasian patients with active ankylosing spondylitis. Mod Rheumatol. 2010; 20(6): 580–7. PubMed Abstract | Publisher Full Text

[47] 47. Shareef LG: Demographic data, disease characteristics, and laboratory findings for Association between polymorphisms within gene coding for tumor necrosis factor (TNF)-alpha with outcomes of treatment in sample of Iraqi patients with Ankylosing Spondylitis taking Etanercept. 2022. http://www.doi.org/10.5281/zenodo.7339117

Association between polymorphisms within the gene coding for tumor necrosis factor (TNF)-alpha with outcomes of treatment in a sample of Iraqi patients with ankylosing spondylitis taking etanercept: an observational study

Abstract

Background

Methods

Results

Conclusion

Keywords

Expression of Concern

Editorial note

Introduction

Methods

Ethical considerations

Study design

Setting

Variables

Sample size

Eligibility criteria

Exclusion criteria

Bias

Data collection

Blood sample collection and preparation of specimens

Clinical evaluation

DNA extraction

The primers

Table 1. The sequences, annealing temperature, and product size (bp) of the primers.Note: F means the forward primer, and R is the reverse primer.

PCR amplification

Figure 1. The amplification of the TNF-α gene of human samples was fractionated on 1.5% agarose gel electrophoresis stained with ethidium bromide.M:100bp ladder marker.

Table 2. The sequences, annealing temperature, and product size (bp) of the primers.Note: F means the forward primer, and R is the reverse primer.

Statistical analysis

Results

Table 3. Demographic data and the disease characteristicsof the participants.

Table 4. Clinical characteristics variables of the study groups.

Table 5. Frequency of alleles and genotypes of (-1031T/C), (-857C/T), (-806C/T) TNF-α gene in ankylosing spondylitis patients (n=60).

Table 6. Distribution of TNF-α gene polymorphism and individual alleles in the AS patient groups.

Table 7. Binary logistic regression analysis of genotypes to predict the tendency of being a responder to ETN.

Table 8. Relationship between each genotype and the probability of being a responder.

Adverse events and associated SNPs of ETN therapy

Table 9. Distribution of studied patients according to the occurrence of infection, injection site reaction, headache, and rash as a side effect and encountered alleles.

Discussion

Conclusion

Ethical approval

Consent

Data availability

Underlying data

References

Comments on this article Comments (0)

Open Peer Review

Comments on this article Comments (0)

Open Peer Review

Reviewer Status

Comments on this article

Browse by related subjects

Competing Interests Policy

Stay Updated