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To the Editor:

A recent report by Damjanov et al (1) described nonsignificant therapeutic effects of a selective p38 MAPK inhibitor in patients with rheumatoid arthritis (RA), and a recent editorial by Genovese (2) discussed the disappointing outcomes of several clinical trials of p38 inhibitors in RA and in other chronic inflammatory diseases. Blockade of this signaling pathway has consistently had little or no clinical benefit and has resulted in only transient suppression of markers of inflammation. It has been argued that the lack of efficacy of p38 inhibitors “must lie in one or more biologic adaptations that allow escape from this pathway” (2). Therefore, “to best understand the failure of this class of therapies, we need to better understand this biologic adaptation” (2).

MAPK p38 inhibitors were first discovered using simple in vitro screens for compounds that blocked production of tumor necrosis factor (TNF) and interleukin-1 (IL-1) in myeloid cells stimulated with lipopolysaccharide (LPS). Since that initial identification of p38 as a promising therapeutic target, many increasingly potent and specific inhibitors have been generated. Together with genetic and molecular approaches, these compounds have been used in investigations to determine exactly what p38 does, and how. It was soon recognized that p38 not only promotes expression of proinflammatory cytokines but is also activated by them. This potential feed-forward loop creates the danger of self-amplifying, runaway inflammatory responses. Such an outcome is prevented, in part, by p38-dependent antiinflammatory mechanisms. For example, the p38 pathway controls the expression of important antiinflammatory factors that limit inflammation and contribute to its resolution; consequently, long-term blockade of the pathway may have little net benefit. It also participates in crosstalk that constrains the activity of other proinflammatory pathways, with the result that p38 inhibitors may enhance other proinflammatory processes. To use a crude metaphor, p38 has one foot on the gas and one foot on the brake. An awareness of this characteristic may help us to understand the disappointing outcomes of clinical trials of p38 inhibitors.

Inflammatory stimuli (e.g., IL-1, TNF, or ligands of the Toll-like receptors) engage their diverse receptors, and all promote activation of the transforming growth factor β–activated kinase 1 (TAK1) signaling complex (Figure 1). TAK1 then activates MKKs and IKK, which is responsible for the activation of the transcription factor NF-κB. The MKKs phosphorylate and activate both p38 and JNK, another member of the MAPK family. (There are 4 isoforms of p38: α, β, γ, and δ. Herein we generally refer to p38α, the major ubiquitous isoform and the most important regulator of inflammatory responses. Most, although not all, inhibitors are active against p38α and p38β.) Once phosphorylated and activated, p38 phosphorylates its own substrates, which include downstream kinases such as MAPKAPK2 (MK2).

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Figure 1. Activation by p38 MAPK of 4 negative feedback loops that limit the inflammatory response. Expression of the antiinflammatory cytokine interleukin-10 (IL-10) is acutely dependent on p38 (4, 5). The coupling of IL-10 and tumor necrosis factor (TNF) biosynthesis may provide an autocrine or paracrine mechanism to limit inflammatory responses (A). The mRNA destabilizing factor tristetraprolin (TTP) binds to AUUUA motifs in the 3′ untranslated regions of mRNA encoding several mediators of inflammation, including those for TNF, IL-1α, cyclooxygenase 2, and IL-6, and targets the transcripts for rapid degradation (3). The p38 pathway causes transient stabilization of these mRNA via phosphorylation and inactivation of TTP by the downstream kinase MAPKAPK2 (MK2). At the same time, p38 is required for the expression of TTP (6, 7). Therefore inflammatory stimuli cause the accumulation of TTP in a dormant, phosphorylated form, which is then poised to become active and drive the degradation of mRNA encoding mediators of inflammation when p38 MAPK activity declines. Long-term blockade of p38 activity interrupts this important pro-resolution mechanism (B). Proinflammatory stimuli induce expression of MAPK phosphatase 1 (MKP-1) in a p38-dependent manner (5, 8, 9). MKP-1 dephosphorylates and inactivates both p38 MAPK and JNK. Its expression forms a negative feedback loop that controls the duration and strength of proinflammatory signaling. MKP-1–knockout mice are hyperresponsive to inflammatory stimuli, including the experimental induction of arthritis (10) (C). MAPK p38 phosphorylates regulatory subunits of the TAK1 (transforming growth factor β–activated kinase 1) complex, inhibiting signaling via p38, JNK, and IKK pathways (11) (D). Broken lines show negative feedback mechanisms. LPS = lipopolysaccharide.

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Together, the NF-κB, JNK, and p38 pathways regulate the expression of inflammation mediators, including cytokines and chemokines, cyclooxygenase 2, and many other proteins. Both transcriptional and posttranscriptional effects of p38 are critical to this coordinated response. Many inflammatory effectors are encoded by messenger RNA (mRNA) that contain destabilizing AUUUA motifs. The RNA binding protein tristetraprolin (TTP) recognizes these sequence motifs and directs mRNA for rapid degradation (3). The antiinflammatory function of TTP is well illustrated by the erosive arthritis found in TTP−/− mice, which is largely caused by overexpression of TNF. When activated by p38, MK2 phosphorylates and inactivates TTP, allowing accumulation and translation of mRNA for TNF and other inflammatory cytokines.

Figure 1 illustrates antiinflammatory mechanisms that are controlled by the p38 pathway. First, the expression of IL-10, a powerful antiinflammatory cytokine with an important role in the resolution of inflammation, is strongly dependent on p38 (4, 5). Ironically, p38 inhibitors could have also been identified by screening for compounds that blocked IL-10 expression. Second, blockade of p38 signaling can reduce expression of TTP and interrupt the normal “off” phase of inflammatory gene expression that involves the degradation of mRNA encoding mediators of inflammation (6, 7). Third, inhibiting p38 may augment JNK activity by reducing the expression of MAPK phosphatase 1. This enzyme dephosphorylates and inactivates both p38 and JNK, and hence restrains inflammatory responses (8–10). Finally, in a similar way, p38 inhibitors can prevent the negative feedback control of TAK1 activity and thus enhance activity of JNK and NF-κB pathways (11).

In clinical trials, “escape” from, or lack of, antiinflammatory effects may involve disruption of one or more of these antiinflammatory mechanisms. It is likely that therapeutic targeting of kinase pathways will often run the risk of perturbing negative feedback and crosstalk mechanisms, whose function is to constrain cellular responses. It might be worth considering whether the endogenous feedback mechanisms are disturbed in chronic diseases such as RA, in which mediators of inflammation continue to be expressed in the absence of a recognizable stimulus. If the breakdown of negative feedback loops contributes to chronicity, it may be possible to exert antiinflammatory effects by repairing or reinforcing these natural “off” mechanisms, rather than by simply blocking the p38 pathway.

  • 1
    Damjanov N, Kauffman RS, Spencer-Green GT. Efficacy, pharmacodynamics, and safety of VX-702, a novel p38 MAPK inhibitor, in rheumatoid arthritis: results of two randomized, double-blind, placebo-controlled clinical studies. Arthritis Rheum 2009; 60: 123241.
  • 2
    Genovese MC. Inhibition of p38: has the fat lady sung? [editorial]. Arthritis Rheum 2009; 60: 31720.
  • 3
    Carrick DM, Lai WS, Blackshear PJ. The tandem CCCH zinc finger protein tristetraprolin and its relevance to cytokine mRNA turnover and arthritis. Arthritis Res Ther 2004; 6: 24864.
  • 4
    Koprak S, Staruch MJ, Dumont FJ. A specific inhibitor of the p38 mitogen activated protein kinase affects differentially the production of various cytokines by activated human T cells: dependence on CD28 signaling and preferential inhibition of IL-10 production. Cell Immunol 1999; 192: 8795.
  • 5
    Ananieva O, Darragh J, Johansen C, Carr JM, McIlrath J, Park JM, et al. The kinases MSK1 and MSK2 act as negative regulators of Toll-like receptor signaling. Nat Immunol 2008; 9: 102836.
  • 6
    Brook M, Tchen CR, Santalucia T, McIlrath J, Arthur JS, Saklatvala J, et al. Posttranslational regulation of tristetraprolin subcellular localization and protein stability by p38 mitogen-activated protein kinase and extracellular signal-regulated kinase pathways. Mol Cell Biol 2006; 26: 240818.
  • 7
    Hitti E, Iakovleva T, Brook M, Deppenmeier S, Gruber AD, Radzioch D, et al. Mitogen-activated protein kinase-activated protein kinase 2 regulates tumor necrosis factor mRNA stability and translation mainly by altering tristetraprolin expression, stability, and binding to adenine/uridine-rich element. Mol Cell Biol 2006; 26: 2399407.
  • 8
    Breitwieser W, Lyons S, Flenniken AM, Ashton G, Bruder G, Willington M, et al. Feedback regulation of p38 activity via ATF2 is essential for survival of embryonic liver cells. Genes Dev 2007; 21: 206982.
  • 9
    Hu JH, Chen T, Zhuang ZH, Kong L, Yu MC, Liu Y, et al. Feedback control of MKP-1 expression by p38. Cell Signal 2007; 19: 393400.
  • 10
    Abraham SM, Clark AR. Dual-specificity phosphatase 1: a critical regulator of innate immune responses. Biochem Soc Trans 2006; 34: 101823.
  • 11
    Mendoza H, Campbell DG, Burness K, Hastie J, Ronkina N, Shim JH, et al. Roles for TAB1 in regulating the IL-1-dependent phosphorylation of the TAB3 regulatory subunit and activity of the TAK1 complex. Biochem J 2008; 409: 71122.

Andrew R. Clark PhD*, Jonathan L. E. Dean PhD*, Jeremy Saklatvala MD, PhD*, * Imperial College London London, UK.