The folate antagonist methotrexate (MTX) is the 'anchor-drug' in the treatment of patients with rheumatoid arthritis (RA) . The main target of MTX in intracellular folate metabolism is dihydrofolate reductase (DHFR) but several other targets have been described (e.g. thymidylate synthase [TS] and 5-amino-imidazole-4-carboxamide ribonucleotide [AICAR]). At present the exact mechanism of action of MTX in RA still remains elusive . Despite the potent anti-rheumatic capacity of MTX many patients (at least 50%) become resistant to MTX during long-lasting therapy. However, little is known about the mechanisms of resistance against MTX in RA patients .
From the field of oncology, where MTX is used against haematological malignancies, new anti-folate drugs were developed to circumvent MTX resistance . These new folate antagonists have the following characteristics: are better transported through the reduced folate carrier, are retained intracellular more efficiently by polyglutamylation via folylpolyglutamate synthetase, and/or have other targets in the folate pathway besides DHFR (e.g. TS).
To investigate whether two new-generation anti-folate drugs, PT523 (DHFR-inhibitor) and ZD1694 (TS-inhibitor), have equal or better anti-inflammatory capacity compared with MTX based on their capacity to inhibit tumour necrosis factor alpha (TNF-α) production by activated T cells.
Whole blood from 11 RA patients and six healthy volunteers was incubated ex vivo with MTX, PT523, ZD1694 and, as a control, the DMARD sulphasalazine (SSZ) after T-cell stimulation with α-CD3/CD28. Inhibition of TNF-α production was measured after 72 hours by ELISA .
The IC-50 values (defined as the drug concentration exerting 50% inhibition of TNF-α production) are used as a value for the anti-inflammatory capacity of the drug (Table 1).
Table 1. Characteristics of drugs and mean IC-50 values (± standard deviation)
Both PT523 and D1694 turned out to inhibit TNF-α production by activated T cells much more efficiently than MTX (5–15 times). For comparison, the DMARD SSZ is effective at much higher concentration (μM range). The inhibition of TNF-α production by the anti-folate drugs does not seem to be a result of (apoptotic) cell death of T cells whereas SSZ induces apoptosis of T cells (data not shown).
In an ex vivo setting, two novel anti-folate drugs designed to circumvent MTX resistance proved to be very effective in inhibiting TNF-α production by activated T cells from RA patients and healthy volunteers. Future experiments are designed to evaluate ex vivo anti-folate sensitivity profiles for 'MTX-responders' and 'MTX-non-responders' to investigate whether these novel generation of antifolate drugs can be useful in cases of clinical failure on MTX.
This study is supported by the Dutch Arthritis Association (Grant NRF-03-I-40).
Rots MG, Pieters R, Peters GJ, van Zantwijk CH, Mauritz R, Noordhuis P, Willey JC, Hahlen K, Creutzig U, Janka-Schaub G, et al.: Circumvention of methotrexate resistance in childhood leukemia subtypes by rationally designed antifolates.