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HLA-DQB1*03:01 as a Biomarker for Genetic Susceptibility to Bullous Pemphigoid Induced by DPP-4 Inhibitors

Open ArchivePublished:December 01, 2017DOI:https://doi.org/10.1016/j.jid.2017.11.023

      Abbreviations:

      BP (bullous pemphigoid), BPDAI (Bullous Pemphigoid Disease Area Index), COL17 (type XVII collagen), DPP-4i (dipeptidyl peptidase-4 inhibitor)
      To the Editor
      Dipeptidyl peptidase-4 inhibitor (DPP-4i) has been widely used to treat type 2 diabetes. DPP-4 inactivates incretins by catalyzing the cleavage of those proteins to inactive forms (
      • Drucker D.J.
      The role of gut hormones in glucose homeostasis.
      ). DPP-4i works by inhibiting the action of this enzyme and improves glycemic control (
      • Aschner P.
      • Kipnes M.
      Effect of the dipeptidyl peptidase-4 inhibitor sitagliptin as monotherapy on glycemic control in patients with type 2 diabetes.
      ). DPP-4i has been known as a safe drug; however, an increased risk of bullous pemphigoid (BP) during DPP-4i exposure has been reported in diabetic patients administered DPP-4i (
      • Béné J.
      • Moulis G.
      • Bennani I.
      • Auffret M.
      • Coupe P.
      • Babai S.
      • et al.
      Bullous pemphigoid and dipeptidyl peptidase IV inhibitors: a case-noncase study in the French Pharmacovigilance Database.
      ).
      BP is the most common autoimmune blistering disorder, and it is characterized by itchy edematous erythema and tense blisters on the whole body. It is mainly caused by autoantibodies to a major hemidesmosomal component at the dermal-epidermal junction of the skin, type XVII collagen (COL17 or BP180). The noncollagenous 16A (NC16A) domain of COL17 contains a major pathogenic epitope (
      • Giudice G.J.
      • Emery D.J.
      • Zelickson B.D.
      • Anhalt G.J.
      • Liu Z.
      • Diaz L a
      Bullous pemphigoid and herpes gestationis autoantibodies recognize a common non-collagenous site on the BP180 ectodomain.
      ). Although several factors have been reported as triggers of BP, the etiology of BP remains largely unknown.
      The exact mechanism behind the association of DPP-4i exposure and BP has yet to be elucidated. Because several studies have reported an association between HLAs and drug-induced reactions (
      • Chung W.-H.
      • Hung S.-I.
      • Hong H.-S.
      • Hsih M.
      • Yang L.-C.
      • Ho H.-C.
      • et al.
      Medical genetics: a marker for Stevens-Johnson syndrome.
      ,
      • Wang H.
      • Yan L.
      • Zhang G.
      • Chen X.
      • Yang J.
      • Li M.
      • et al.
      Association between HLA-B*1301 and Dapsone-Induced Hypersensitivity Reactions among Leprosy Patients in China.
      ), we examined HLA alleles in Japanese patients with BP who had been taking DPP-4i for type 2 diabetes for at least 3 months before BP onset (DPP-4i-BP). We recently reported that DPP-4i-BP tends to show a noninflammatory phenotype with few erythematous lesions, in sharp contrast to conventional BP unrelated to DPP-4i intake (
      • Izumi K.
      • Nishie W.
      • Mai Y.
      • Wada M.
      • Natsuga K.
      • Ujiie H.
      • et al.
      Autoantibody profile differentiates between inflammatory and noninflammatory bullous pemphigoid.
      ). We encountered 30 patients with DPP-4i-BP in the last 3 years and found that most patients (21/30) showed the noninflammatory phenotype (Figure 1a). Based on the scores for erythema/urticaria in the bullous pemphigoid disease area index (BPDAI) (
      • Murrell D.F.
      • Daniel B.S.
      • Joly P.
      • Borradori L.
      • Amagai M.
      • Hashimoto T.
      • et al.
      Definitions and outcome measures for bullous pemphigoid: recommendations by an international panel of experts.
      ), DPP-4i-BP was clearly divided into two groups, inflammatory (BPDAI: erythema/urticaria ≥ 10) and noninflammatory (BPDAI: erythema/urticaria < 10) (Figure 1b), and the clinical appearance of the patients with noninflammatory disease was distinct from that of those with conventional BP (Figure 1a). BPDAI scores for erosions/blisters showed no significant difference between DPP-4i-BP and conventional BP patients (Figure 1c). The antibody titers to full-length COL17 were similar between the two groups (Figure 1d), whereas those to the NC16A domain of COL17 were significantly lower in the noniflammatory DPP-4i-BP patients (Figure 1e). Histologically, eosinophil counts in the upper dermis of periblister lesions were significantly lower in noninflammatory DPP-4i-BP than in inflammatory DPP-4i-BP (Figure 1f). From these findings, we considered this unique noninflammatory subgroup to be distinct from inflammatory DPP-4i-BP and conventional BP, and this study focuses on this subgroup (Figure 1b red square [blue dots], and see Supplementary Tables S1 and S2 online). The collection of human samples was approved by the local ethics committee and the institutional review board of Hokkaido University and Keio University and by the research ethics committee of RIKEN. Written informed patient consent was obtained from the patients.
      Figure 1
      Figure 1DPP-4i-BP shows a unique noninflammatory phenotype with few erythematous lesions. (a) The clinical appearance of noninflammatory DPP-4i-BP, inflammatory DPP-4i-BP, and conventional BP. (b) BPDAI scores for erythema/urticaria. The dashed line indicates a BPDAI (erythema/urticaria) score of 10. The red square indicates a group of patients with noninflammatory DPP-4i-BP. The blue dots represent scores of noninflammatory DPP-4i-BP. (c) BPDAI scores for erosions/blisters. (d) Full-length COL17 ELISA index. (e) COL17 NC16A CLEIA index. (f) Histopathological findings of representative noninflammatory DPP-4i-BP and inflammatory BP. Hematoxylin and eosin staining, scale bar = 100 μm. (d) Comparison of the number of infiltrating eosinophils between noninflammatory DPP-4i-BP and inflammatory BP. Bars represent mean values. P < 0.05, ∗∗P < 0.01 using Mann-Whitney test. BP, bullous pemphigoid disease; BPDAI, Bullous Pemphigoid Disease Area Index; CLEIA, chemiluminescent enzyme immunoassay; COL17, type XVII collagen; DPP-4i, dipeptidyl peptidase-4 inhibitor; HPF, high-powered field.
      Surprisingly, 86% (18/21) of noninflammatory DPP-4i-BP patients in our sample carry HLA-DQB1*03:01 (Table 1). The frequencies of carriers of alleles HLA-DQB1*03:01, -DQA1*05:05, -DRB1*11:01, and -DRB1*12:01 were significantly higher, and those of carriers of alleles HLA-DQA1*01:03 and -DQB1*06:01 were significantly lower, in DPP-4i-BP than in Japanese general population control individuals (Table 1, and see Supplementary Tables S3–S9 online). We also compared the six HLA alleles in conventional BP patients with those in Japanese general population control individuals and found that none of those alleles was significantly different (Table 1). We next compared the six alleles in DPP-4i-BP with those in DPP-4i–tolerant patients with type 2 diabetes who were exposed to DPP-4i for at least 2 years (see Supplementary Table S10 online) and found that the frequencies of carriers of alleles HLA-DQB1*03:01 and -DRB1*12:01 were significantly higher in DPP-4i-BP (Table 1). These findings clearly show that the two alleles are significantly associated with DPP-4i-BP but not with conventional BP nor with type 2 diabetes. HLA-DQB1*03:01 was present in 19 (31%) of the 61 DPP-4i–tolerant control individuals, suggesting that this allele has 86% sensitivity and 69% specificity when we apply HLA-DQB1*03:01 as a risk predictor for noninflammatory DPP-4i-BP in the Japanese population. In addition to the allele frequencies, the two- or three-locus haplotype frequencies for HLA-DQA1, -DQB1 and -DRB1 were compared between DPP-4i-BP and control groups. HLA-DRB1*12:01-DQB1*03:01 showed the lowest P-value in 243 haplotypes (P = 2.16 × 10–8), which was greater than that of HLA-DQB1*03:01 alone (P = 5.86 × 10–11), indicating that HLA-DQB1*03:01 will be the more useful biomarker in predicting DPP-4i-BP before administration to Japanese patients (Table 1).
      Table 1Frequency of HLA alleles and haplotypes in cases and controls
      HLA AlleleDPP-4i-BP (Noninflammatory), n (%)

      (n = 21)
      Conventional BP, n (%)

      (n = 72)
      Japanese General Population Control Individuals, n (%)

      (n = 873)
      DPP-4i–Tolerant Diabetes Patients, n (%)

      (n = 61)
      DPP-4i-BP (Noninflammatory) Patients Versus

      General Population Control Individuals
      Conventional BP Patients Versus

      General Population Control Individuals
      DPP-4i-BP (Noninflammatory) Versus Tolerant Control Individuals
      OR (95% CI)P-Value
      All values in this column are significant after Bonferroni correction: P < 1.27 × 10–4 (0.05/152 HLA-A, -B, -C, -DRB1, -DPB1, -DQA, -DQB1 alleles; 76 DRB1-DQA1-DQB1 haplotypes; 52 DRB1-DQA1 haplotypes; 68 DRB1-DQB1 haplotypes; and 47 DQA1-DQB1 haplotypes).
      OR (95% CI)P-ValueOR (95% CI)P-Value
      Boldface values in this column are significant after Bonferroni correction: P < 5.56 × 10–3 (0.05/6 HLA alleles, 1 DRB1-DQB1 haplotype, and 2 DQA1-DQB1 haplotypes).
      DQB1*03:0118 (86)19 (26)156 (18)19 (31)27.6 (8.0–94.8)5.86 × 10–111.6 (0.9–2.9)8.24 × 10–213.3 (3.5–50.5)2.13 × 10–5
      DQA1*05:0510 (48)10 (14)60 (7)11 (18)12.3 (5.0–30.2)8.11 × 10–72.2 (1.1–4.5)5.58 × 10–24.1 (1.4–12.1)1.79 × 10–2
      DRB1*12:0110 (48)8 (11)68 (8)7 (11)10.8 (4.4–26.2)2.34 × 10–61.5 (0.7–3.2)3.63 × 10–17.0 (2.2–22.4)1.08 × 10–3
      DQA1*01:030 (0)18 (25)368 (42)18 (30)0.0 (0.0–0.5)1.52 × 10–50.5 (0.3–0.8)4.07 × 10–30.1 (0.0–0.9)4.31 × 10–3
      DRB1*11:017 (33)6 (8)37 (4)9 (15)11.3 (4.3–29.7)2.99 × 10–52.1 (0.8–5.0)1.32 × 10–12.9 (0.9–9.1)1.07 × 10–1
      DQB1*06:010 (0)18 (25)359 (41)18 (30)0.0 (0.0–0.6)3.67 × 10–50.4 (0.3–0.8)3.45 × 10–20.1 (0.0–0.9)4.31 × 10–3
      DRB1*12:01-DQB1*03:0110 (48)6 (8)39 (4)1 (0)19.4 (7.8–48.5)2.16 × 10–81.9 (0.8–4.8)1.46 × 10–154.5 (6.3–470.1)1.56 × 10–6
      DQA1*05:05-DQB1*03:0110 (48)8 (11)58 (7)11 (18)12.8 (5.2–31.3)6.09 × 10–71.8 (0.8–3.8)1.51 × 10–14.1 (1.4–12.1)1.79 × 10–2
      DQA1*01:03-DQB1*06:010 (0)16 (22)357 (41)18 (30)0.0 (0.0–0.6)3.65 × 10–50.4 (0.2–0.7)1.62 × 10–30.0 (0.0–0.9)4.31 × 10–3
      Abbreviations: BP, bullous pemphigoid; CI, confidence interval; DPP-4i, dipeptidyl peptidase-4 inhibitor; HLA, human leukocyte antigen; OR, odds ratio.
      1 All values in this column are significant after Bonferroni correction: P < 1.27 × 10–4 (0.05/152 HLA-A, -B, -C, -DRB1, -DPB1, -DQA, -DQB1 alleles; 76 DRB1-DQA1-DQB1 haplotypes; 52 DRB1-DQA1 haplotypes; 68 DRB1-DQB1 haplotypes; and 47 DQA1-DQB1 haplotypes).
      2 Boldface values in this column are significant after Bonferroni correction: P < 5.56 × 10–3 (0.05/6 HLA alleles, 1 DRB1-DQB1 haplotype, and 2 DQA1-DQB1 haplotypes).
      Six patients with conventional BP suffered from type 2 diabetes at the onset of BP. We found that BPDAI scores for erosions/blisters were similar in those with DPP-4i-BP and conventional BP with diabetes, whereas scores for erythema/urticaria were significantly higher in those with conventional BP with diabetes (see Supplementary Figure S1 online), suggesting that the noninflammatory phenotype in DPP-4i-BP correlates with the intake of DPP-4i rather than with the existence of type 2 diabetes. Furthermore, none of the patients with conventional BP with diabetes carried HLA-DQB1*03:01.
      Eight patients with conventional BP had noninflammatory disease, and 37.5% (3/8) of those patients carried HLA-DQB1*03:01. This frequency is similar to that for patients with inflammatory conventional BP (16/64 [25%]) and inflammatory DPP-4i-BP (4/9 [44%]) and lower than that for those with noninflammatory DPP-4i-BP (18/21 [86%]), suggesting that HLA-DQB1*03:01 is associated with noninflammatory DPP-4i-BP rather than with noninflammatory conventional BP or inflammatory DPP-4i-BP.
      To our knowledge, the association of HLA-DQB1*03:01 with noninflammatory DPP-4i-BP is the strongest association that has been described between a class II HLA and a drug-related autoimmune disease. HLA-DQB1*03:01, also reported to be associated with mucous membrane pemphigoid in Caucasian patients (
      • Ahmed A.R.
      • Foster S.
      • Zaltas M.
      • Notani G.
      • Awdeh Z.
      • Alper C.A.
      • et al.
      Association of DQw7 (DQB1*0301) with ocular cicatricial pemphigoid.
      ,
      • Delgado J.C.
      • Turbay D.
      • Yunis E.J.
      • Yunis J.J.
      • Morton E.D.
      • Bhol K.
      • et al.
      A common major histocompatibility complex class II allele HLA-DQB1* 0301 is present in clinical variants of pemphigoid.
      ), seems to be a risk factor for DPP-4i-BP in Japanese. To confirm this, the incidence of DPP-4i-BP among diabetic patients carrying HLA-DQB1*03:01 should be investigated. In addition, to determine whether the noninflammatory phenotype is a distinctive feature of DPP-4i-BP or just a mild form of BP, further investigations are required. The findings of this study give us important clues about the breakdown of self-tolerance that results from the interaction of genetic background and drug intake.

      Conflict of Interest

      The authors state no conflict of interest.

      Acknowledgments

      We thank Jun Yamagami and Yuichi Kurihara of the Keio University Department of Dermatology for collecting the DPP-4i-BP samples and Shingo Yanagiya and Yuka Kameda of the Hokkaido University Department of Rheumatology, Endocrinology, and Nephrology for collecting the DPP-4i–tolerant control samples. We also thank Miyuki Kasegai of the Hokkaido University Hospital Clinical Research and Medical Innovation Center for technical assistance. This work was supported by the Research on Measures for Intractable Diseases Project: Matching Fund Subsidy (H26-069 to HS) from the Ministry of Health, Labor, and Welfare of Japan and the Tailor-Made Medical Treatment Program (BioBank Japan Project) funded by the Ministry of Education, Culture, Sports, Science, and Technology of Japan. We thank the Midosuji Rotary Clubs and other Rotary Clubs for cooperation in this study.

      Supplementary Material

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