ARTHRITIS & RHEUMATISM

Vol. 54, No. 9, September 2006, pp 2707–2710

DOI 10.1002/art.22062
© 2006, American College of Rheumatology

Arthritis & Rheumatism

An Official Journal of the American College of Rheumatology
www.arthritisrheum.org and www.interscience.wiley.com

EDITORIAL

Leukocyte Migration to Rheumatoid Joints: Enzymes Take Over

Gaby Palmer,1 Cem Gabay,1 and Beat A. Imhof 2

Rheumatoid arthritis (RA) is a chronic inflam-
matory disease tightly linked to leukocyte infiltration
into joints. In this issue of Arthritis & Rheumatism,
Marttila-Ichihara et al (1) describe the involvement of a
vascular molecule with ecto-oxidase activity and adhe-
sion properties in leukocyte homing to inflamed joints.
They show that leukocyte migration is blocked by a small
molecule inhibitor of this amine oxidase, known as
vascular adhesion protein 1 (VAP-1), or amine oxidase,
copper-containing 3 (AOC3). The adhesive properties
of AOC3 were initially identified using antibodies which
block rolling and firm adhesion of leukocytes on in-
flamed endothelial cells. Importantly, however, these
antibodies do not inhibit the enzymatic activity of
AOC3, suggesting that the molecule has in fact 2
functional sites operating in leukocyte migration.
The recruitment of leukocytes to inflamed tissues
is a highly regulated multistep process that includes
leukocyte rolling on the vascular endothelium, activation
of leukocytes and subsequent firm adhesion to endothe-
lial ligands, transendothelial migration from the vascular
lumen into the surrounding tissue, and migration of
inflammatory cells through the tissue in response to
chemokine gradients (2). The successive events in this
cascade are mediated by coordinated interaction of
adhesion molecules expressed by leukocytes and by the
inflamed tissue, and distinct subsets of adhesion mole-
cules are involved in the different steps of the extrava-
sation process. In particular, proteins of the selectin and
1
Gaby Palmer, PhD, Cem Gabay, MD: University of Geneva
School of Medicine and University Hospital, Geneva, Switzerland;
2
Beat A. Imhof, PhD: University of Geneva School of Medicine,
Geneva, Switzerland.
Address correspondence and reprint requests to Beat A.
Imhof, PhD, Department of Pathology and Immunology, Centre
Medical Universitaire, 1 Rue Michel-Servet, 1211 Geneva 4, Switzer-
land. E-mail: Beat.Imhof@medecine.unige.ch.
Submitted for publication March 31, 2006; accepted in revised
form May 31, 2006.
integrin families, as well as various members of the
immunoglobulin superfamily, are classically considered
to be crucial for these leukocyte–endothelial cell inter-
actions. Given the central role of leukocytes in inflam-
mation, interference with the function of adhesion mol-
ecules involved in the extravasation process represents
an interesting strategy for therapeutic intervention in
autoimmune inflammatory diseases such as RA.
Targeting adhesion molecules in arthritis
Despite accumulating evidence that leukocyte
trafficking to the inflamed synovium in RA is adhesion
molecule dependent, the mechanisms regulating recruit-
ment of leukocytes to the joint in experimental models
of inflammatory arthritis and the role of various adhe-
sion molecules in human RA are still poorly understood.
The initial capture and rolling of leukocytes on the
endothelium is mediated predominantly by the interac-
tion of selectins present both on leukocytes (L-selectin,
CD62L) and on endothelial cells (E-selectin, CD62E;
P-selectin, CD62P) with carbohydrate ligands on the
reciprocal cell membrane. Investigations in various ani-
mal models, such as rat adjuvant-induced arthritis (AIA)
and mouse antigen-induced arthritis and collagen-
induced arthritis (CIA), have provided inconsistent re-
sults concerning the importance of individual selectins in
the development of arthritis. Discrepant results have
been reported in particular depending on whether inhi-
bition of selectin function was achieved using specific
antibodies or ligands, which either partially decreased
arthritis or had no effect (3,4), or using gene knockouts,
which in some instances even aggravated the disease (5).
Altogether, the data obtained lead to the conclusion
that, in experimental arthritis models, both selectin-
dependent and -independent pathways of leukocyte re-
cruitment cooperate for joint infiltration.

2707
2708
Chemokines trigger arrest of rolling leukocytes
and firm adhesion by activating leukocyte integrin mol-
ecules, such as lymphocyte function–associated antigen 1
(LFA-1) (␣L␤2, CD11a/CD18), Mac-1 (␣M␤2, CD11b/
CD18), and very late activation antigen 4 (VLA-4)
(␣4␤1, CD106). Leukocyte integrins interact with endo-
thelial counterreceptors of the Ig superfamily, including
intercellular adhesion molecules (ICAMs) and vascular
cell adhesion molecule 1 (VCAM-1). Again, different
requirements for individual integrins and ligands have
been reported in experimental arthritis according to the
model, time point, and cell type examined, but there is
quite some evidence for the involvement of LFA-1,
VLA-4, and ICAM-1 (CD54) in leukocyte infiltration
into the joint (3,6). Finally, platelet endothelial cell
adhesion molecule 1 (PECAM-1) (CD31) is an Ig su-
perfamily molecule involved in transendothelial migra-
tion of leukocytes. Interestingly, inhibition of PECAM-1
with specific antibodies was reported to decrease arthri-
tis, while PECAM-1–knockout mice, in contrast, dis-
played exacerbated CIA (7,8).
Increased expression of E- and P-selectins, vari-
ous integrins, and members of the Ig superfamily, such
as ICAM-1, VCAM-1, and PECAM-1, has been de-
scribed in RA synovium, and increased levels of soluble
adhesion molecules, including E-selectin, P-selectin,
ICAM-1, and VCAM, in serum and synovial fluid have
been used as markers of vascular endothelial activation
in RA (9). Many different drugs, including nonsteroidal
antiinflammatory drugs, glucocorticoids, and RA
disease–modifying agents, interfere with the expression
and/or function of cell adhesion receptors, and it has
been postulated that this effect accounts, at least in part,
for their antiinflammatory activity.
Based on these data, blocking adhesion mole-
cules that mediate the accumulation of leukocytes in
inflammation is expected to have therapeutic potential
in human RA. However, the few clinical trials performed
so far have not met expectations. For instance, efazu-
limab, a humanized monoclonal antibody against
LFA-1, did not significantly reduce arthritis in a cohort
of patients with psoriatic arthritis (10). Anti–ICAM-1
monoclonal antibodies were evaluated in a phase I/II
open-label study and had only limited effects in patients
with RA (11). Finally, a randomized, placebo-controlled
trial of an antisense oligodeoxynucleotide ICAM-1 in-
hibitor could not demonstrate clinical efficacy beyond
that of placebo in patients with active RA (12). Among
the possible explanations for this low efficacy are the
redundancy and overlapping functions of molecules that
are involved in leukocyte extravasation, due to which
PALMER ET AL
selective inhibition of single adhesion molecules might
not be sufficient to prevent leukocyte recruitment effi-
ciently.
Vascular amine oxidases and leukocyte trafficking
In addition to multiple traditional adhesion mol-
ecules present on leukocytes and endothelial cells, there
is increasing evidence that other molecules are involved
in leukocyte extravasation. For instance, several families
of membrane proteins with catalytic domains outside the
plasma membrane, so-called ectoenzymes, have been
shown to make important contributions to this process
(for review, see ref. 13).
AOC3, which is also known as VAP-1, is a
nonclassic, inflammation-inducible endothelial molecule
involved in leukocyte adhesion. AOC3 is expressed in
endothelial cells of many organs in mice and humans. Its
activity is also found in the serum, suggesting that the
enzyme may be shed from the endothelial surface.
AOC3 is an ectoenzyme belonging to the semicarbazide-
sensitive amine oxidase (SSAO) family, which catalyzes
oxidative deamination of primary amines to produce
aldehyde groups, H2O2, and ammonium. On endothelial
cells, AOC3 functions as a traditional adhesion mole-
cule, and this function can be blocked by monoclonal
antibodies. In addition, the enzymatic activity of AOC3
is also critical for its adhesive functions. It has been
suggested that leukocytes first interact with AOC3 via
adhesive epitopes and then via a leukocyte surface–
expressed substrate(s), which interacts with the catalytic
site to initiate the SSAO reaction. AOC3 may also
modify adhesion molecules on the endothelial cell
and/or leukocyte surface to modulate trafficking. Nota-
bly, the products of the SSAO enzymatic activity and, in
particular, the alteration of the redox balance by H2O2
may also regulate endothelial cell or leukocyte signals
necessary for transmigration, including expression of
adhesion molecules, chemokine receptors, or matrix
metalloproteinases (13).
AOC3 is virtually absent from noninflamed en-
dothelium. Under inflammatory conditions, AOC3 ex-
pression is increased, and AOC3 translocates to the
luminal surface of blood vessels. AOC3-deficient ani-
mals display defective cell migration during inflamma-
tion, but appear healthy under nonchallenged condi-
tions, although they display some defects in lymphocyte
homing. AOC3-deficient mice manifest attenuated in-
flux of inflammatory cells during peritonitis and auto-
immune diabetes (13). In addition, inhibition of the
adhesive function of AOC3 using antibodies was previ-
EDITORIAL
ously demonstrated to have antiinflammatory effects in
several animal models, including peritonitis, allograft
rejection, and air-pouch inflammation (13). In humans,
increases in the levels of both plasma- and/or
membrane-associated SSAO have been reported for
many inflammation-associated diseases, including RA,
diabetes, atherosclerosis, chronic heart failure, and Alz-
heimer’s disease (14,15).
Therapeutic potential of SSAO inhibitors in arthritis
AOC3 is highly expressed on vessels of inflamed
human synovial tissue (14). In this issue of Arthritis &
Rheumatism, Marttila-Ichihara et al (1) report that
administration of a synthetic SSAO inhibitor amelio-
rates AIA in rats and anti–type II collagen antibody–
induced arthritis in mice. In arthritic rats treated with
the SSAO inhibitor, inflammatory cell infiltration into
the synovium, neovascularization, and cartilage and
bone erosion were reduced. In the more acute mouse
model, the number of infiltrated polymorphonuclear
leukocytes was decreased both in SSAO inhibitor–
treated mice and in AOC3-knockout mice. In the mouse
model, administration of the inhibitor had an even more
pronounced antiarthritic effect than the deletion of the
AOC3 gene. Based on enzymatic analyses, the authors
suggest that the higher efficacy of the inhibitor may be
related to inhibition of other closely related AOCs in
addition to AOC3. AOC1 and AOC2 are indeed also
expressed on endothelial cells in many tissues and could
mediate SSAO-catalyzed reactions in a manner similar
to AOC3. The activity of the atypical adhesion molecule
AOC3 and possibly of other closely related ecto-
oxidases thus appears to be important for leukocyte
infiltration into inflamed joints.
While inhibition of the adhesive function of
AOC3 was previously demonstrated to have antiinflam-
matory effects in various models, the study by Marttila-
Ichihara et al indicates that its enzymatic activity is also
needed for inflammation. The idea of targeting SSAO
enzymatic activity to block inflammatory responses is
interesting and promising, as also shown in a recent
report on other disease models (16). The study by
Marttila-Ichihara et al is the first to address a potential
efficacy of small molecule SSAO inhibitors in experi-
mental models of arthritis, and it provides an interesting
contribution toward a novel therapeutic concept for the
treatment of RA. This concept fits with the emerging
idea that enzymatic and/or signaling activity of adhesion
molecules, in addition to their adhesive properties, may
be important for their function, as illustrated for in-
2709
stance by the exacerbated CIA observed in E-selectin–,
P-selectin–, or PECAM-1–knockout mice (5,8). In con-
trast to classic adhesion molecules, which are generally
difficult to target using small molecule inhibitors, ec-
toenzymes are attractive candidates for the design of
new approaches to modulate leukocyte trafficking. In-
deed, the catalytic centers of enzymes are often easier to
target, and in the case of ectoenzymes, inhibitors do not
need to be cell permeable and can thus be water-soluble
molecules, which can be administered orally.
Following the proof of concept provided by
Marttila-Ichihara and colleagues, further experiments
aimed at evaluating the safety, specificity, and potency
of SSAO inhibitors for the treatment of RA are thus
eagerly awaited. Safety is obviously an important issue
when considering the inhibition of ubiquitously ex-
pressed adhesion molecules, and the benefits of down-
regulating a broad range of inflammatory processes
need to be carefully balanced against potentially delete-
rious effects on host defense against infections. Finally,
provided that further validation of their specificity and
potency can be obtained, antiadhesive therapies based
on the use of small molecule inhibitors certainly repre-
sent an economically interesting alternative to expensive
biologic treatments, such as humanized anti–adhesion
molecule antibodies, which are currently being devel-
oped for the treatment of inflammatory diseases.
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