BACKGROUND An"autoimmune"disease is understood to be one where the target of the disease is "self"or"self antigen."There are a number of diseases that are believed to involve T cell immunity directe to self antigens, including (but not limited to) multiple sclerosis (MS), Type I diabetes, and rheumatoid arthritis (RA).

RA is a chronic inflammatory disorder characterized by joint pain. The course of the disease is variable, but can be both debilitating and mutilating. According to conservative estimates approximately 50,000,000 individuals are afflicted with RA worldwide. Those individuals are not only subjected to life-long disability and misery, but as current evidence suggests, their life expectancy is compromised as well. Unfortunately, despite considerable investigative efforts there is no cure for RA.

Established treatments of RA are designed to inhibit either final common pathways of inflammation or immunological mediators. Both approches are non-specific and, therefore, are associated with severe side effects. Corticosteroids have multiple effects on the immune system and other tissues. Their use is complicated by very high incidence of musculoskeletal, metabolic, neurologic and connective tissue side effects, as well as immunosuppression which may lead to life-threatening infections. For this reason, corticosteroids are usually avoided until all other forms of treatment have failed. See generally, R. Million et al.,"Long-Term Study of Management of Rheumatoid Arthritis,"Lancet 1: 812 (1984).

Cytotoxic and anti-metabolic drugs, such as methotrexate, azathioprine and cyclophosphamide are non-specifically affecting all rapidly dividing cells and therefore are associated with bone marrow and gastrointestinal toxicity and increased incidence of malignancy. In addition, methotrexate treatment of RA has been reporte to induce liver damage and lung disease which may be fatal. See J. A. Engelbrecht et al.,"Methotrexate Pneumonitis After Low-Dose Therapy for Rheumatoid Arthritis,"Arthritis and Rheumatism 26: 1275 (1983) and G. W. Cannon et al., "Acute Lung Disease Associated With Low-Dose

Pulse Methotrexate Therapy In Patients With Rheumatoid Arthritis."Arthritis and Rheumatism 26: 1269 (1983).

Most nonsteroidal anti-inflammatory drugs (NSAIDs) currently used are designed to non-specifically inhibit prostaglandin synthesis. NSAIDs currently in use modify or diminish -but do not arrest-the inflammatory response. Aspirin remains the most commonly used NSAID. Aspirin toxicity takes many forms, including hypersensitivity reactions. deafness, gastrointestinal and renal toxicity. See generally Simon and Mills."Nonsteroidal Antiinflammatory Drugs,"N. Eng. J. Med. 302: 1179 (1980).

Gold compound and penicillamine have also been used in the treatment of RA. They are both associated with high incidence of bone marrow, renal and mucocutaneous toxicity.

Gold treatment, in particular, is associated with nephropathy. W. Katz et al., "Proteinuria in Gold-Treated Rheumatoid Arthritis,"Ann. Int. Med. 101: 176 (1984). Penicillamine, while questionably effective. is toxic even at relatively low doses. See W. F. Kean et al.."The Toxicity Pattern Of D-Penicillamine Therapy,"Arthritis and Rheumatism 23: 158 (1980).

These problems have led to almost complete abandonment of these drugs in RA therapy.

Among the experimental therapies, cyclosporin and anti-TNFce antibodies show some promise. However. serious renal toxicity and non-specific immunosuppression limit significantly the utility of cyclosporin. Due to its ubiquitous role in many cellular functions, anti-TNF therapy may not be a safe therapeutic strategy for RA. While preliminary results indicate some promise with the anti-TNF approach, development of lupus-like disease has been noticed in some cases.

Thus, current therapies for RA are associated with high incidence of serious side effets. Furthermore although some medications may offer symptomatic relief, in many cases, they do not significantly modify the progression of joint destruction. What is needed is an effective therapeutic approach with lower toxicity such that the treatment is better tolerated and more appropriate for the treatment of RA.

SUMMARY OF THE INVENTION The present invention relates to methods and compositions for treating and diagnosing autoimmune diseases, and in particular for treating and detecting rheumatoid arthritis. The present invention contemplates a new class of anti-RA drug, namely compound that inhibit proliferation and induce apoptosis. In one embodiment, the present invention contemplates compound that are inhibitors of the sphingomyelin signal transduction pathway. For

example. the present invention contemplates a method of treating a human, comprising: a) providing: i) a human with symptoms of autoimmune disease. and ii) a preparation comprising at least one inhibitor of the sphingomyelin signal transduction pathway, and b) administering said inhibitor to said human under conditions such that said symptoms are reduced.

It is not intended that the present invention be limited to a particular autoimmune disease. In one embodiment, said human has symptoms of rheumatoid arthritis.

It is not intended that the present invention be limited to a particular route of administration. In one embodiment, said administering comprises intravenous injection. In another embodiment a mixture of inhibitor and DMSO is applied topically at the joints. In a preferred embodiment, said administering comprises intra-articular injection and said preparation further comprises a local anesthetic. Thus, the present invention specifically contemplates mixtures of inhibitors and anesthetics.

It is not intended that the present invention be limited to a particular inhibitor. As described herein, a variety of pathway inhibitors (specific for different steps in the signal transduction pathway) can be used with success, including but not limited to inhibitors of sphingosine kinase and inhibitors of Gi proteins. In this manner,"inhibitors"are defined functionally as a group (rather than structurally). A variety of sphingosine derivatives are known that are herein contemplated as inhibitors, including but not limited to those described in U. S. Patent Nos. 5,583,160,5,627,171,5,466,716,5,391,800,5,137,919,5,151.360, 5,248,824,5,260,288 and 5,331,014, all of which are hereby incorporated by reference.

Preferred derivatives are methylsphingosine, dimethylsphingosine and trimethylsphingosine.

While it is not intended that the present invention be limited by the mechanism by which successful treatment and/or protection against autoimmunity is achieved, it is believed that, although the Fas-mediated apoptosis pathway is intrinsically intact in RA lymphocytes, it is reversibly inhibited by sphingomyelin pathway products. This functional inhibition may be sufficient to allow certain subsets of activated lymphocytes to escape apoptosis and accumulate in the joints, thereby contributing to disease pathogenesis. By introducing agents that block the sphingomyelin pathway, the inhibition of lymphocyte apoptosis is reverse and activated lymphocytes are eliminated in a timely fashion.

The present invention also contemplates methods and reagents for diagnostics. While a variety of cells from patients are comtemplated as suitable for the diagnostic assays of the present invention (e. g. synoviocytes), lymphocytes from patients with rheumatoid arthritis are

preferred for assays that detect cells displaying impaire Fas-mediated apoptosis.

Lymphocytes from such patients express higher levels of anti-apoptotic sphingolipid metabolites (such as sphingosine-1-phosphate) and the present invention contemplates testing for the presence of such metabolites by a variety of means (immunoassays, TLC. HPLC. etc.). In one embodiment, the present invention contemplates a method. comprising: a) providing: i) lymphocytes from a human with symptoms of autoimmune disease. and ii) means for detecting at least one metabolite of the sphingomyelin signal transduction pathway : and b) testing said lymphocytes with said means for detecting under conditions such that elevated levels (i. e., elevated relative to lymphocytes from controls) of said metabolite are detected. In one embodiment, said means for detecting is an antibody.

DEFINITIONS The term"apoptosis inducing agent"refers to any compound or molecule which is capable of causing (directly or indirectly) apoptosis, including but not limited to. inhibitors of the sphingomyelin signal transduction pathway. The present invention contemplates administration of apoptosis inducing agents to autoimmune patients.

The term"sphingomyelin pathway inhibitor"is used herein to refer to compound that inhibit downstream events in the sphingomyelin pathway, including but not limited to, inhibitors of sphingosine kinase and Gi proteins inhibitors. Such inhibitors are contemplated to reverse the resistance to apoptosis in RA lymphocytes. Thus, such inhibitors (and apoptosis inducing agents generally) are defined functionally. This function can be readily assessed by using the in vitro assays of the present invention (described below).

The term"subject"refers to both humans and animals.

The term"receptors"refers to structures expressed by cells and which recognize binding molecules (e. g, iigands).

The term"antagonist"refers to molecules or compound which inhibit the action of a "native"or"natural"compound. Antagonists may or may not be homologous to these natural compound in respect to conformation, charge or other characteristics. Thus, antagonists may be recognized by the same or different receptors that are recognized by the natural compound.

Thus, a kinase inhibitor is a kinase antagonist.

The term"symptoms of RA"is intended to encompass any and all symptoms. Where a symptom is said to be"reduced"it is indicated that the degree of such symptom (such as the degree of joint pain or the amount of inflammatory cells in the joints) is diminished. The

present invention is not limited to any particular quantitative level. Most importantly, the present invention is not limited to the complete elimination of symptoms.

The term"drug"as used herein, refers to any medicinal substance used in humans or other animals. Encompassed within this definition are compound analogs, naturally occurring. synthetic and recombinant pharmaceuticals.

DESCRIPTION OF THE FIGURES Figure 1 is a schematic showing various targets of the sphingomyelin pathway for RA therapy according to the teachings of the present invention.

Figure 2A is a graph showing the susceptibility of normal and RA T cells to apoptosis.

Figure 2B is a graph showing the susceptibility of EBV-transformedn normal and RA B cells to apoptosis.

Figure 2C is a graph showing the susceptibility of cells to T cell-mediated cytolysis.

Figure 3A is a graph showing anti-Fas antibody-mediated DNA fragmentation by the TLJNEL assay in EBV transformed B cell lines from normal controls and RA patients.

Figure 3B is a photograph of an agarose electrophoresis gel showing anti-Fas antibody-mediated DNA fragmentation in EBV transformed B cell lines from 4 normal controls and 4 RA patients.

Figure 3C is a graph showing DNA fragmentation by the JAM assay in EBV transformed lines from a normal control and an RA patient.

Figure 4A shows photographs of two Western blots showing inhibition of proteolytic cleavage of CPP32 and PARP in normal cells.

Figure 4B is a graph showing the susceptibility of virus-infected cells to cytolysis.

Figure 4C shows a photograph of a Western blot showing proteolytic cleavage of CPP32 by normal cells but not by RA cells.

Figure 4D shows a photograph of a Western blot showing proteolytic cleavage of PARP by normal cells but not by RA cells.

Figure 5A is a bar graph showing constitutive levels of sphingosine and SPP in normal and RA patients.

Figure SB is a bar graph showing reversa of resistance to Fas-mediated apoptosis by DMS and DHS.

Figure 5C is a graph showing reversa of resistance to T cell-mediated cytolyses in RA lymphocytes by DMS.

Figure 5D is a graph showing reversa of resistance to Fas-mediated apoptosis by pertussis toxin.

Figure 5E is a graph showing reversa of resistance to cytolysis by pertussis toxin.

Figure 6 is a bar graph showing reversa of resistance to Fas-mediated apoptosis by the MEKI inhibitor, PD098059.

Figure 7 is a bar graph showing a comparison of SK activity between normal and RA lines.

Figure 8 is a bar graph showing inhibition of SK hyperactivity in RA cells by wortmannin.

Figure 9 is a bar graph showing reversa of resistance to Fas-mediated apoptosis by wortmannin in a RA-afflicted twin.

Figure 10 is a bar graph showing a comparison of P13K activity in RA-discordant monozygotic twins.

Figure 11 is a graph showing that wrtmannin protects against adjuvant arthritis.

DESCRIPTION OF THE INVENTION The present invention relates to methods and compositions for treating autoimmune diseases, and in particular for treating rheumatoid arthritis with sphingomyelin pathway inhibitors. The description of the invention that follows discusses I) Fas-mediated Apoptosis II) Apoptosis And The Immune System, III) Reversing The Resistance to Apoptosis As A Treatment Of Autoimmule Disease, IV) Formulation of Inhibitors of the Sphingomyelin Pathway, and V) Delivery of Formulations and Intra-articular Injections.

I. Fas-Mediated Apoptosis Homeostasis of mammalian tissues is controlled not only by proliferation and differentiation of cells, but also by cell death. There are two death processes, apoptosis and necrosis. The death of cells during embryogenesis, metamorphosis, endocrine-dependent tissue atrophy, and normal tissue turnover is called programme cell death. Most of the programme cell death which occurs during mammalian development proceeds by apoptosis.

Apoptosis can be distinguished morphologically and biochemically from necrosis.

Necrosis occurs during pathological cell death as a result of injury, complement attack, severe

hypoxiat hyperthermia, lytic viral infection, and exposure to a variety of toxins. Apoptosis is accompanied by condensation and segmentation of nuclei, loss of plasma membrane microvilli, and extensive degradation of the chromosomal DNA into nucleosome units.

It is believed that the apoptotic signal is induced by the binding of the Fas ligand to Fas. See generally, S. Nagata,"Fas and Fas Ligand: A Death Factor and Its Receptor," Avances in Immunology 57: 129 (1994). The cytoplasmic domain of Fas consists of 145 amino acids. About 70 amino acids in this region have significant similarity with a part of the cytoplasmic region of the type I (but not type II) TNF receptor. Indeed. analyses of point mutations in the Fas protein in this conserve region have shown that the domain is essential for the function of Fas.

The Fas ligand has been identified, isolated, and cloned. The amino acid sequence deduced from the nucleotide sequence of the cDNA indicates that the Fas ligand is a TNF- related type 11 membrane protein. However, despite the high similarity between Fas ligand and TNF (about 30% identical at the amino acid sequence level), Fas ligand does not bind to the TNF receptor.

The tissue distribution of Fas MARNA in the mouse has been examine. Fas MARNA can be detected abundantly in the thymus, heart, liver, and ovary of 8-week old mice, but not in the brain, bone marrow, and spleen. Fas is expressed in almost all populations of thymocytes. This, wide distribution of Fas is in sharp contrast to the tissue restrictive expression of Fas ligand; Fas ligand is found on the Sertoli cells of the testis, on the corneal epithelium, iris and retina, and on activated T lymphocytes.

The activation of Fas is caused by aggregation mediated by the Fas ligand (or other agonist, such as antibodies). The signal is thought to be transduced by clustering of the intracellular domain. The downstream elements of the apoptosis process are thought to be affecte by the sphingomyelin signal transduction pathway. See generally, R. N. Kolesnick et al.,"The"The Sphingomyelin Signal Transduction Pathway Mediates Apoptosis For Tumor Necrosis Factor, Fas, and Ionizing Radiation,"Biochem. Cell Biol. 72: 471 (1994). This pathway is initiated by enzymatic hydrolysis of the phosphodiester bond of sphingomyelin by a specific sphingomyelin-directed phospholipase C ("sphingomyelinase"), generating ceramide and phosphocholine.

Ceramide serves as the second messenger of the pathway, initiating signaling for several biological agents. Ultimately, ceramide activates the death signaling pathway in a Jun

kinase (JNK)-mediated pathway. See M. Verheij et al.."Requirement for ceramide-initiated SAPK/JNK signaling in stress-induced apoptosis,"Nature 380: 75 (1996).

Ceramide, however, can also be metabolized to sphingosine and sphingosine-l- phosphate (SPP) by the action of ceramidase and sphingosine kinase. respectively. See generally C. J. van Koppen et al., "Activation of a High Affinity Gj Protein-coupled Plasma Membrane Receptor by Sphingosine-1-phosphate,"J. Biol. Chem. 217: 2082 (1996). SPP has been shown to be involved in stimulating DNA synthesis and cell division, i. e., proliferation.

Importantly, SPP has been recently shown to inhibit Fas-mediated cell death. See 0.

Cuvillier et al., "Suppression of ceramide-mediated Programme Cell Death By Sphingosine- 1-phosphate,"Nature 381: 800 (1996).

II. Apoptosis And The Immune System The principal physiologic function of the immune system is the elimination of infectious organisms. The effector mechanisms that are responsible for protective immunity are also capable of injuring host tissues. In some situations, specific immune responses have little or no protective value, and the harmful consequences become dominant. The best example of this is autoimmune disease caused by pathologic immune responses against self antigens.

The immune system has evolved multiple mechanisms for controlling potentially harmful rections. Failure of these mechanisms may lead to tissue injury and disease.

Potentially harmful immune rections may be prevented either by functionally inactivating or killing the responding lymphocytes. The primary cytolytic mechanism involved in controlling lymphocyte responses is the Fas-mediated apoptotic pathway discussed above. In this manner, the immune system actively eliminates potentially harmful cells so that the host may survive. See A. Abbas,"Die and Let Live: Eliminating Dangerous Lymphocytes,"Cell 84: 655 (1996).

The mechanism by which Fas-Fas Ligand interactions maintain immunological tolerance to self-antigens is yet to be completely understood. It is believed that repeated stimulation of antigen cause T cells to express high levels of Fas and Fas Ligand, thereby killing either themselves or one another. Such a homeostatic mechanism may limit the size of lymphocyte clones responding to foreign antigens. The same mechanism may be triggered by abundant and disseminated self-antigens, which are able to interact repeatedly with specific T cells.

Abnormalities in Fas-mediated cell death pathways may result in autoimmunity even in situations in which Fas and Fas Ligand are themselves normal. For example. where apoptosis is inhibited and a proliferation pathway is stimulated, activated lymphocytes may escape elimination and cause disease. The present invention contemplates reversing the resistance to apoptosis by inhibiting downstream events of the sphingomyelin pathway. In this manner, activated lymphocytes go through the apoptosis pathway and are eliminated. It is believed that such treatment of RA patients will reduce the symptoms that are characteristic of RA.

III. Reversing The Resistance To Apoptosis As A Treatment Of Autoimmune Disease It is not intended that the present invention be limited to particular points in the sphingomvelin pathway or particular inhibitors of the sphingomyelin pathway. As noted above, SPP has been recently shown to inhibit the Fas-mediated cell death pathway. While, the present invention contemplates inhibiting SPP, thereby reversing the inhibition of Fas- mediated apoptosis, the present invention also contemplates inhibiting the sphingomyelin pathway at other points. Figure 1 is a schematic showing the broad nature of the targets contemplated for therapeutic intervention in RA.

As shown in Figure 1 (and discussed above), following Fas ligation, sphingomyelin is converted to ceramide through the activation of acid sphingomyelinase. Ceramide activates the death signaling pathway in a Jun kinase (JNK)-mediated pathway. Through its inhibitory effect on ERK 1/2, ceramide can also block proliferation, thus shifting the balance further toward apoptosis.

Since increased levels of ceramide may promote programme cell death, in one embodiment, the present invention contemplates treatment of RA patients with inhibitors of ceramide catabolism. It is not intended that the present invention be limited by the nature of the inhibitor. In one embodiment, the present invention contemplates inhibiting ceramide catabolism by inhibiting its conversion to free sphingosine by ceramidase [e. g. , by using N- oleoylethanolamine, (lS, 2R)-D-erythro-2-(N-myristoylamino)-phenyl-1-propanol ("D-MAPP") or other suitable inhibitorJ. In another embodiment, the present invention contemplates inhibiting ceramide catabolism by inhibiting metabolism to glucosylceramide by glucosylceramide synthase [e. g. , by using D-threo-l-phenyl-2-decanoylamino-3-morpholino-l- propanol ("PDMP") and newer homologues or by using N-butyldeoxynojirimycin or other

suitable inhibitors]. In yet another embodiment, the present invention contemplates inhibiting ceramide catabolism by inhibiting metabolism to sphingomyelin by sphingomyelin synthase or by inhibiting metabolism to ceramide-l-phosphate by ceramide kinase. In still another embodiment, the present invention contemplates inhibiting ceramide catabolism by inhibiting metabolism to 1-O-acylceramide by ceramide transacylase (e. g. by using D-and L-erythro enantiomers of PDMP and related homologues) On the other hand, as discussed above, SPP has an antagonistic effect to that of ceramide. It is produced from sphingosine by the activity of sphingosine kinase. It has a dual, Gi-protein-dependent, anti-apoptotic effect. It blocks JNK activation on the one hand, and leads to ERK 1/2 activation on the other. Thus, the net effect of SPP is inhibition of ceramide-mediated cell death.

While it is not intended that the present invention be limited to a precise understanding of the mechanism, it is believed that resistance to Fas-mediated cell death in RA is due to a shift in the ceramide/SPP rheostat. Suppressing the pathway (e. g. by suppressing SPP synthesis with a sphingosine kinase inhibitor, or blocking its Gi-mediated effects) can both restore the susceptibility of RA lymphocytes to killing by Fas ligation.

Accordingly, targets for therapeutii ; intervention in RA include (but are not limited to) inhibition of sphingosine kinase, inhibition of Gi proteins, inhibition of MEKI, activation of JNK, or a combination of two or more of those modalities.

In one embodiment, the present invention contemplates treating RA patients with compound that inhibit sphingosine-phosphate formation. While inhibition of sphingosine kinase (e. g., with sphingosine derivatives) has been discussed, other approches to inhibiting sphingosine phosphate formation are contemplated, including inhibiting (1) synthesis of long chain bases (e. g. by use of p-chloroalanine or L-cycloserine or other suitable inhibitor), (2) inhibition of acylation of long chain bases, a critical step in eventual sphingosine formation (e. g. using fumonisin B1 or other suitable inhibitor), and (3) stimulation of sphingosine-l- phosphate phosphatase or lyase.

IV. Formulation Of Inhibitors Of The Sphingomyelin Pathway The present invention contemplates preparations comprising inhibitors of the sphingomyelin signal transduction pathway. Such formulations can be prepared either as liquid solutions or suspensions, or in solid forms. Formulations may include such normally employed additives such as binders, filles, carriers, preservatives, stabilizing agents,

emulsifiersg buffers and excipients as, for example, pharmaceutical grades of mannitol, lactose, starch, magnesium stearate, sodium saccharin, cellulose, magnesium carbonate, and the like. These compositions take the form of solutions, suspensions, tables, pills. capsules, sustained release formulations, or powders, and typically contain 1 %-95% of active ingredient. preferably 2%-70%.

The compositions are also prepared as injectables, either as liquid solutions or suspensions ; solid forms suitable for solution in, or suspension in, liquid prior to injection may also be prepared. For intra-articular injections (see below). the present invention contemplates formulations comprising one or more inhibitors of the sphingomyeline pathway along with one or more local anesthetic. It is not intended that the present invention be limited to particular anesthetics. A variety are contemplated including but not limited to prochaine or lidocaine. When injecting a bursa, tendon sheath, or periarticular region, such a mixture will give immediate relief (due to the anesthetic) followed by more lasting relief (due to the inhibitor).

Where mixtures with local anesthetics are not desired, a topical anesthetic prior to injection may be used. Such topical anethetics include but are not limited to ethyl chloride spray on the skin over the joint to be injecte. Alternatively, a local anesthetic may be given first, followed by administration of one or more of the above-described inhibitors.

V. Delivery Of Formulations And Intra-Articular Injections It is not intended that the present invention be limited to the particular route of administration. The sphingomyelin pathway inhibitors can be given orally or injecte (including but not limited to intravenous injection). The present invention specifically contemplates intra-articular injections in RA patients.

To perform an arthrocentesis, the specific area of the joint to be injecte is palpated and is then marked, e. g., with fier-n pressure by a ballpoint pen that has the inked portion retracted. This will leave an impression that will last 10 to 30 minutes. (The ballpoint pen technique can also be used with soft tissue injection.) The area to be aspirated and/or injecte should be carefully cleansed with a good antiseptic, such as one of the iodinated compound.

Then the needle can be inserted through the ballpoint pen impression.

Helpful equipment inclues the following items: alcohol sponges; iodinated solution and surgical soap; gauze dressings (2 x 2); sterile disposable 3-, 10-and 20-ml syringes; 18- and 20-gauge, 1 1/2-inch needles; 20-gauge spinal needles; 25-gage, 5/8-inch needles; plain

test tubes: heparinized tubes; clean microscope slides and coverslips: heparin to add to heparinized tubes if a large amount of inflammatory fluid is to be placed in the tube; fingernail polish to seal wet preparation; chocolate agar plates or Thayer-Martin medium; tryptic soy broth for most bacteria; anacrobic transport medium (replace periodically to keep culture media from becoming outdated); tubes with fluoride for glucose; plastic adhesive bandages: ethyl chloride; hemostat; tourniquet for drawing of simultaneous blood samples; and 1 percent lidocaine.

Knee. The knee is the easiest joint to inject. The patient should be in a supine position with the knee fully extended. The puncture mark is made just posterior to the medial portion of the pælla, and an 18-to 20-gauge, 1 1/2-inch needle directe slightly posteriorly and slightly inferiorlv. The joint space should be entered readily. On occasion thickened synovium or villous projections may occlude the opening of the needle, and it may be necessary to rotate the needle to facilitate aspiration of the knee when using the medial approach. An infrapatellar plica, a vestigal structure that is also called the ligamentum mucosum. may prevent adequate aspiration of the knee when the medial approach is used.

However, the plica should not adversely affect injections or aspirations from the lateral aspect.

Shoulder. Injections in the shoulder are most easily accomplished with the patient sitting and the shoulder externally rotated. A mark is made just medial to the head of the humerus and slightly inferiorly and laterally to the coracoid process. A 20-to 22-gauge, 1 1/2-inch needle is directe posteriorly and slightly superiorly and laterally. One should be able to feel the needle enter the joint space. If bone is hit, the operator should pull back and redirect the needle at a slightly different angle.

The acromioclavicular joint may be palpated as a groove at the lateral end of the clavicle just medial to the shoulder. A mark is made, and a 22-to 25-gauge, 5/8-to 1-inch needle is carefully directe inferiorly. Rarely is synovial fluid obtained.

The sternoclavicular joint is most easily entered from a point directly anterior to the joint. Caution is necessary to avoid a pneumotharax. The space is fibrocartilaginous, and rarely can fluid be aspirated.

Ánkle Joint. For injections of the inhibitors of the present invention in the ankle joints, the patient should be supine and the leg-foot angle at 90 degrees. A mark is made just medical to the tibialis anterior tendon and lateral to the medial malleolus. A 20-to 22-gauge,

1 1/2-inch needle is directe posteriorly and should enter the joint space easily without striking bone.

Subtalar Ankle Joint. Again, the patient is supine and the leg-foot angle at 90 degrees. A mark is made just inferior to the tip of the lateral mallcolus. A 20-to 22-gauge.

1 1/2-inch needle is directe perpendicular to the mark. With this joint the needle may not enter the first time, and another attempt or two may be necessary. Because of this and the associated pain, local anesthesia may be helpful.

Wrist. This is a complex joint, but fortunately most of the intercarpal spaces communicate. A mark is made just distal to the radius and just ulnar to the so-called anatomic snuff box. Usually a 24-to 26-gauge, 5/8 to 1-inch needle is adéquate and the injection is made perpendicular to the mark. If bone is hit, the needle should be pulled back and slightly redirected toward the thumb.

First Carpometacarpal Joint. Degenerative arthritis often involves this joint.

Frequently the joint space is quite narrowed, and injections may be difficult and painful. A few simple maneuvers may make the injection fairly easy, however. The thumb is flexed across the palm toward the tip of the fifth finger. A mark is made at the base of the first metacarpal bone away from the border of the snuff box. A 22-to 26-gage, 5/8 to l-inch needle is inserted at the mark and directe toward the proximal end of the fourth metacarpal.

This approach avoids hitting the radial artery.

Metacarpophalalangeal Joints and Finger Interphalangral Joints. Synovitis in these joints usually causes the synovium to bulge dorsally, and a 24-to 26-gauge, 1/2 to 5/8-inch needle can be inserted on the either side just under the extensor tendon mechanism. It is not necessary for the needle to be interpose between the articula surfaces. Some prefer having the fingers slightly flexed when injecting the metacarpophalangeal joints. It is unusual to obtain synovial fluid. When injecting, a mix of the inhibitors of the present invention with a small amount of local anesthetic is preferred.

Metatarsophalangeal Joints and Toe Interphalangeal Joints. The techniques are quite similar to those of the metacapophalangeal and finger interphalangeal joints, but many prefer to inject more dorsally and laterally to the extensor tendons. Marking the area (s) to be injecte is helpful as is gentle traction on the toe of each joint that is injecte.

Elbow. A technique preferred by many is to have the elbow flexed at 90 degrees.

The joint capsule will bulge if there is inflammation. A mark is made just below the lateral

epicondyle of the humerus. A 22-gauge, 1 to 1 1/2-inch is inserted at the mark and directe parallel to the shaft of the radius or directe perpendicular to the skin.

Hip. This is a very difficult joint to inject even when using a fluoroscope as a guide.

Rarely is the physician quite sure that the joint has been entered; synovial fluid is rarely obtained. Two approches can be used, anterior or lateral. A 20-gauge, 3 1/2-inch spinal needle should be used for both approaches.

For the anterior approach, the patient is supine and the extremity fully extended and externally rotated. A mark should be made about 2 to 3 cm below the anterior superior iliac spine and 2 to 3 cm lateral to the femoral pulse. The needle is inserted at a 60 degree angle to the skin and directe posteriorly and medially until bone is hit. The needle is withdrawn slightly. and possibly a drop or two of synovial fluid can be obtained, indicating entry into the joint space.

Many prefer the lateral approach because the needle can"follow"the femoral neck into the joint. The patient is supine, and the hips should be internally rotated-the knees apart and toes touching. A mark is made just anterior to the greater trochanter, and the needle is inserted and directe medially and sightly cephalad toward a point slightly below the middle of the inguinal ligament. One may feel the tip of the needle slide into the joint.

Temporomandibular Joint. For injections, the tempormandibular joint is palpated as a depression just below the zygomatic arch and 1 to 2 cm anterior to the tragus. The depression is more easily palpated by having the patient open and close the mouth. A mark is made and, with the patient's mouth open, a 22-gauge, 1/2 to 1-inch needle is inserted perpendicular to the skin and directe slightly posteriorly and superiorly.

EXPERIMENTAL The following examples serve to illustrate certain preferred embodiments and aspects of the present invention and are not to be construed as limiting the scope thereof.

In the experimental disclosure which follows, the following abbreviations apply: eq (equivalents); M (Molar); tM (micromolar); N (Normal); mol (moles); mmol (millimoles); pmol (micromoles); nmol (nanomoles); gm (grams); mg (milligrams);ig (micrograms); L (liters); ml (milliliters); p1 (microliters); cm (centimeters); mm (millimeters); pm (micrometers); nm (nanometers); °C (degrees Centigrade); DMS (N, N-dimethylsphingosine) ; ERK [Extra-cellularly Regulated Kinase (ERK1 for the p44maPk; ERK2 for the p42maPk; JERK3 for the p63maPk)]; MAPK (Mitogen-Activated Protein Kinase) (see generally, U. S. Patent Nos.

5, 663,313 and 5, 663,314, both of which are hereby incorporated by reference); MAPKK (MAP kinase kinase): MEK (Mitogenically Extraregulated Kinase); MEKK (ME kinase kinase); z-VAD-fmk [N-benzyloxycarbonyl-Val-Ala-Asp (O-methyl)-fluromethylketone].

In some of the examples below, the TUNEL assay was used. TdT-mediated dUTP- biotin nick end-labeling (TLJNEL) assay was performed as described [see Gorczyca. W, et al.

Leukemia 7,659-70 (1993)]. Briefly, cells were fixed in 1% buffered formaldehyde (pH 7.4) for 15 min on ice, washed in phosphate-buffered saline (PBS) and stored at 4 °C in 70% ethanol. Subsequently, cells were resuspended in 50 p1 of a solution containing: 5 unites of terminal deoxynucleotidyl transferase (Boehringer Mannheim, Indianapolis, IN), 2.5 mM CoC12,0.2 M potassium cacodylate, 25 mM Tris-HCI, 0.25 mg/ml bovine serum albumin, 0.5 moles biotin-16-dUTP (Boehringer Mannheim Biochemicals, Indianapolis, IN). Cells were incubated in this solution at 37 °C for 30 min, then rinsed in PBS and resuspended in 100 il of staining solution, containing 2.5 pg/ml fluorescinated avidin, 4 X concentrated saline sodium citrate buffer. 0.1 % Triton X-100, and 5% (w/v) non-fat dry milk. Cells were incubated in this solution for 30 min at room temperature in the dark. Cells were then rinsed in PBS containing 0.1 % Triton X-100 and resuspended in 1 ml in PBS containing 5tg/ml propidium iodide and 0.1% RNase (Sigma). Green (b-dUTP) and red (DNA) fluorescence of individual cells were measured with an EPICS Elite Flow Cytometer (Coulter, Hialeah, FL, USA).

In some examples below, methods were used to determine DNA fragmentation. One method involves the demonstration of DNA laddering on agarose gels. Briefly, cells were lysed in TE buffer containing 0.2% Triton X-100, pH 8. Fragmente DNA was separated from intact chromatin by microfuging for 20 min, 14,000 rmp in 4 °C. The resulting supernatant was treated with 1 mg/ml of proteinase K at 37 °C overnight, then extracted with phenol/chloroform/isoamyl alcohol (25: 24: 1) three times. DNA was precipitated by addition of three volumes of absolut ethanol, in the presence of 0.3 M sodium acetate, pH 5.2, and incubated overnight at-20 °C and then pelleted by centrifugation at 14,000 rpm at 4 °C for 20 min. The pellet was washed twice with 75% ethanol and dissolve in 30 tl of TE containing 10 pg/ml of RNase overnight at 37 C. DNA samples were separated by electrophoresis on 1.8% agarose gel in the presence of ethidium bromide.

In some examples below, Western blots were performed. For Western blot analysis, 5xlO6cells were washed and suspende in 100 ptl of lysis buffer [1% sodium dodecyl sulfate (SDS), 1 mM sodium vanadate, 10 mM Tris (pH 7.6), and boiled for 5 min. After micro-

centrifugation at 14,000 rpm for 10 min, supernatants (cell lysats) were recovered. The protein concentration of the lysates was determined with bicinchoninic acid (BCA) protein assay reagent (Pierce). For CPP32 immunoblots, cell lysates (10-20tg of protein per lane) were separated on 15% SDS-polyacrylamide gels under reducing conditions, transferred to polyvinylidene difluoride (PVDF) membranes (Millipore), and probed with mouse monoclonal anti-CPP32 (clone #!19, IgG2a, from Signal Transduction Labs, Lexington, KY) followed by sheep F'kab") 2 fragment horseradish peroxidase-conjugated, anti-mouse Ig (Amersham). For PARP immunoblots, cell lysates (10 zig of protein per lane) were separated on 7.5% SDS- polyacrylamide gels, transferred to PVDF membrane, and probed with monoclonal mouse anti-human PARP antibody C2.10 (IgG1, Enzyme Systems Products Dublin, CA). Antibody binding was detected with an ECL detection system (Amersham).

EXAMPLE 1 In this example, the susceptibility of lymphocytes to cell death is examine. As noted above, it is believed that prevention of immune-mediated self injury requires prompt elimination of activated lymphocytes at the end of an immune response. In this example, the resistance of T cells of RA patients to anti-Fas antibody-induced death is demonstrated.

Briefly, PHA T cell lymphoblasts from 6 normal controls and 6 RA patients were established by stimulating peripheral blood mononuclear cells with 0.5, ug/ml PHA for 3 days. followed by expansion in 20 U/ml of recombinant human IL-2 (Collaborative Biomedical Products, Bedford, MA). Day-10 T cell lymphoblasts were incubated with 125 ng/ml of the agonist anti-Fas monoclonal antibody CH-11 (the antbody was immobilized and 1X105 cells per well were used). In all experiments, control mouse monoclonal IgM antibody (TEPC-183, from Sigma) was used in equivalent concentrations. Cell death was determined at different time points, using a commercial MTS kit (Promega, Maison, WI). Microplate wells were read by ELISA plate reader at 490 nm.

Figure 2A shows that activated lymphocytes of the T-cell lineage from normal individuals (open squares) die rapidly after exposure to the agonist anti-Fas antibody CH-11.

In contras. T lymphocytes of RA patients (open circles) show complete resistance to killing up to 4 hours following ligation. Some susceptibility, however, can be seen in these cells at the 24 hour time point. Thus, at the critical early period, RA cells are resistant to killing by Fas-ligation.

Figure 2B shows that activated lymphocvtes of the B-cell lineage (i. e. EBV transformed B cell lines) from 4 normal individuals (open squares) also die rapidly.

However. EBV transformed B cell lines from 5 RA individuals (open circles) show resistance to anti-Fas antibody-induced death (soluble anti-Fas antibody was used and percent cell death determined as above).

Fas-mediated cell death in-vivo iS thought to be triggered, primarily, by cytotoxic T cells. Lymphocytes expressing the Vy9/V82 (Vgamma9/Vdelta2) T cell receptor have previously been found to display potent MHC-unrestricted cytolytic activity against a wide variety of targets and have been found in large numbers in the synovial fluid and peripheral blood of RA patients. The present inventors have found that RA and control B lymphoblastoid targets were equally capable of forming cell conjugates with V79/V62 T-cells (data not shown). However, susceptibility to cytolysis is markedly different between the two groups whell determined using standard 4 hour 5'Cr release assays. Figure 2C is a bar grapl showing the susceptibility to cytolysis by V79N82 T cell clones determined in EBV transformed lines from 23 normal controls, 18 patients with RA, 6 patients with pauciarticular-onset juvenile arthritis ("pJA"), and 3 patients with autoimmune thyroiditis.

Lymphoblastoid target lines from all 23 normal controls tested were efficiently killed by Vy9/V82 clones, while none of the lines from 18 RA patients were susceptible. This resistance was disease-specific, since lines from 5 of 6 patients with another form of autoimmune arthritis (pauciarticular-onset juvenile arthritis), as well as lines from three patients with autoimmune thyroiditis, were all susceptible.

EXAMPLE 2 The experiments in this example show that resistance of RA lymphocytes to killing is due to failed apoptosis. Briefly, anti-Fas antibody-mediated DNA fragmentation by the TUNEL assay was performed in EBV transformed B cell lines from 6 normal controls (Figure 3A, open bars) and 5 RA patients (Figure 3B, dashed bars). Cells were incubated with either the agonist anti-Fas antibody, CH-11, or with isotype-matched control antibody, TEPC-183 before analysis of DNA fragmentation.

Fas ligation resulted in DNA fragmentation in control lymphocytes, but not in RA lymphocytes.

Anti-Fas antibody-mediated DNA fragmentation was also analyzed in EBV transforrned B cell lines from 4 normal controls (Figure 3B, left) and 4 RA patients (Figure

3B, right) by agarose electrophoresis. Again, cells were incubated with either the agonist anti-Fas antibody, CH-11, or with isotype-matched control antibody, TEPC-183 before analysis of DNA fragmentation. Again, Fas ligation resulted in DNA fragmentation of control cells, but not RA lymphocytes.

DNA fragmentation by the JAM assay was also performed in EBV transformed lines (Figure 3C3 from a normal control (#) and an RA patient (o), subjected to yb T cell- mediated killing. Lack of DNA fragmentation in RA target cells was also observe during Vy9/V62 T cell-mediated killing.

While the present invention is not limited to any theory, it is believed that RA lymphocytes are not innately resistant to programme cell deathF as they display some susceptibility to Fas-mediated cell death at the late time points, and more importantly ! T-cells from both patients and controls are equally susceptible to apoptosis induced by IL-2 withdrawal (data not shown).

Resistance to anti-Fas antibody-mediated apoptosis in RA lymphocytes is not attributable to reduced surface expression of the Fas receptor, since equivalent levels of Fas receptor expression could be found on lymphocytes of both the T and B cell lineage from normal individuals and RA patients. No differences in surface expression of CD4* CD8 or CD45RO could be detected between normal and RA T cells. Similarly, B cell lines from controls and RA patients expressed equivalent levels of CD30 and CD40 on their cell surface (data not shown).

EXAMPLE 3 The above results suggest that an intracellular defect may be responsible for the observe resistance to apoptosis. The Fas-mediated signaling cascade is initiated by oligomerization of the intracytoplasmic death domain and assembly of a death signaling complex. Those events lead to activation of caspases such as YamalCPP32 (caspase 3), that in turn cleave death substrates, including poly (ADP-ribose) polymerase (PARP) to a signature apoptotic form. Thus, examination of downstream proteolytic events following Fas ligation reports on the integrity of this pathway.

In this example, it is demonstrated that activation of caspases is essential for Fas- mediated apoptosis. Briefly, cells were preincubated for 1 hr in the presence or absence of 40 zip of Z-VAD-fmk, and subsequently incubated with 100 ng/ml of the anti-Fas antibody CH- 11. At different time points thereafter, cells were collecte, lysed and a Western blot analysis

performed with the relevant antibodies. The results show that the inhibitor Z-VAD-fmk blocks proteolytic processing of CPP32 (Figure 4A, upper panel). cleavage of PARP (Figure 4A, lower panel), and subsequent cell death.

The resistance of MCF7 targets transfected with crmA cDNA to killing by Vy9/V62 T cell clones was also tested. The results show that caspases are also essential for apoptotic killing mediated by cytolytic Vy9/VS2 T cell clones, since MCF7 target cells expressing the cowpox virus crama are resistant to cytolysis (Figure 4B).

The Fas pathway in RA lymphocytes was also examine for impaire activation of caspases. Briefly, cells were incubated with 100 ng/ml of the anti-Fas antibody. CH-11, over a time course and Western blot analysis performed with the relevant antibodies. Examination of the Fas pathway in RA lymphocytes revealed impaire activation of caspases. In 4 of 4 normal lymphoblastoid B cell lines, but in none of 4 RA lines tested, proteolytic cleavage of CPP32 could be seen within 2 hours following Fas ligation (Fig. 4C). Similarly cleavage of PARP was detected in normal lines within 1-4 hours, but was undetectable in lines from RA patients (Fig. 4D). Cleavage of CPP32 and PARP could be seen in RA lymphocytes at later time points (data not shown), suggesting that Fas-mediated signals are being transduced, albeit inefficiently.

EXAMPLE 4 To investigate the possibility that Fas-mediated signals are being modulated by an exogenous inhibitor, the sphingomyelin pathway was studied, which has been previously shown to regulate Fas-mediated apoptosis. No significant differences in either ceramide levels or sphingomyelinase activity could be found between control and RA lymphocytes (data not shown). However, when sphingosine and SPP levels were quantitatively measured by the conversion of SPP to tritiated N-acetyl-sphingosine-1-phosphate by acetylation with 3H acetic anhydride, intracellular levels of these 2 ceramide metabolites were found to be significantly higher in RA lymphocytes. Figure 5A shows the constitutive levels of sphingosine (left) and SPP (right) in EBV transformed B cell lines from eight normal controls (open bar) and five RA patients (hatched bars).

SPP, a potent derivative of sphingosine, has been recently shown to activate a pertussis toxin-sensitive G protein and to inhibit Fas-mediated cell death. Therefore, the ability of SPP to inhibit apoptosis in RA lymphocytes was investigated. Apoptosis induced by 8 hr stimulation with the anti-Fas antibody CH-11 (100 ng/ml) was determined in EBV

transformed target cells in the presence (Figure 5B, dashed bars) or absence (Figure 5B, open bars) of 2. 5 µM DMS in serum-free RPMI 1640 medium supplemented with insulin and transferrin. At the end of incubation, cells were washed and DNA strand breaks were determined using the TUNEL assay. As can be seen, resistance of RA targets to apoptosis by anti-Fas antibodies could be effectively reverse by prior incubation of target cells with the sphingosine kinase inhibitors, N, N dimethylsphingosine (DMS) or DL-threo- dihydrosphingosine (DHS).

Inhibition of Fas-mediated death signaling by SPP was also examine using y8 T cell clones. Cytolysis of EBV transformed target cells by Vy9/V62 T cells was determined by 4 <BR> <BR> <BR> <BR> hr 5'Cr release assay (Figure 5C) in the presence (I) or absence (o) of 2.5 HUM DMS. At the<BR> <BR> <BR> <BR> <BR> <BR> <BR> end of incubation, targets were washed and susceptibility to killing by y6 T cells was assessed. A representative expriment with one RA target, out of five tested, is shown in Figure 5C. As can be seen, resistance of RA targets to apoptosis by yA T cells could be effectively reverse by prior incubation of target cells with the sphingosine kinase inhibitors, N,N-dimethylsphingosine (DMS) or DL-threo-dihydrosphingosine (DHS).

Additionally, pre-incubating RA targets with pertussis toxin reverse their resistance to Fas-mediated and y8 T cell-mediated killing (Figures 5D and 5E). For assessing Fas- mediated killing, EBV transformed B cell lines from eight normal controls (Figure 5D, left) and six RA patients (Figure 5E, right) were preincubated with (6) or without (o) pertussis toxin, 1 µg/ml for 1 hr. At the end of incubation, target cells were washed and stimulated with 100 ng/ml of the anti-Fas antibody CH-11 over a time course. Cell death was determined using the commercial MTS kit (Promega, Maison, WI). For assessing yA T cell-mediated killing (Figure 5E), EBV transformed B cell targets were incubated for 1 hr with (6) or without (o) 1 pg/ml pertussis toxin as above. At the end of incubation, targets were washed <BR> <BR> <BR> and susceptibility to y6 T cell killing was determined using a 4 hr 5'Cr-release assay.<BR> <BR> <BR> <BR> <BR> <BR> <BR> <BR> <BR> <BR> <BR> <BR> <BR> <BR> <P> EXAMPLE 5 As noted above, it is not intended that the present invention be limited to any one inhibitor. In this example, resistance to Fas-mediated cell killing is shown to be reverse by preincubation of target cells with a MEKI inhibitor. Apoptosis of RA EBV transformed target cells was induced by 16 hr stimulation with anti-Fas antibody CH-11 (200 ng/ml) in the presence (Figure 6, black bars) or absence (Figure 6, open bars) of 100 uM of the MEKI inhibitor 2- (2'-amino3-methoxyphenyl-oxanaphthalen-4-one) (PD098059).

EXAMPLE 6 In this example, inhibitors are tested in an animal model. RA-like disease is inducible in certain strains of rats (e. g., Lewis rats) by immunization with Mycobacterium tuberculosis ("MT") in oil or CFA. See C. Jacob et al., "Heterogeneous Effects of IFN in Adjuvant Arthritis"J. Immunol. 142: 1500 (1989). The disease is characterized by a self-limited, subacute polyarthritis and has been propose as a model for human RA.

Rats are inoculated intradermally at the base of the tail with 0.1 ml CFA containing 10 mg/ml of heat killed MT in IFA (Difco Laboratories, Detroit, Michigan). Sphingosine derivatives (methylsphingosine, dimethylsphingosine and trimethyl-sphingosine in separate rats) are used as inhibitors of the sphingomyelin signal transduction pathway. The derivatives are prepared in a mixture containing a local anesthetic and injecte intra-articularly. MT- reactive T cells from the joints are compare pre-and post-injection to assure that symptoms are reduced due to the administration of the inhibitor.

EXAMPLE 7 As discussed above, elevated cellular levels of sphingosine-l-phosphate (SPP) cause resistance to apoptosis in rheumatoid arthritis (RA) cells. In order to further define the rnechanism controlling SPP levels in RA, we have determined the enzymatic activity of sphingosine kinase (SK), the enzyme which converts sphingosine to SPP. As can be seen in Figure 7, mean SK activity in nine RA cell lines was more than twice higher than the measured enzymatic activity in 11 normal control lines (p<0.02).

EXAMPLE 8 Previous studies have determined that SK enzymatic activity is inducible by serum growth factors, including platelet derived growth factor (PDGF). The mechanism by which growth factors induce S1 (activity has not been determined to date. Since one of the key downstream effector molecules in the PDGF receptor pathway and other growth factor- mediated pathways is phosphatidylinositol 3 kinase (PI3K), we have undertaken to assess the involvement of this enzyme in the observe hyperactivity of SK in RA cells. To that end, we first determined whether SK activity is regulated by PI3K by using a potent PI3K inhibitor, wortmannin, SK activity was determined in cells pre-treated with or without wortmannin. As Figure 8 shows, pre-incubation of RA cells with 20 nM of wortmannin resulted in a mean SK inhibition of 40.0+-10.0% in seven RA cells, but only 1.4+-11.6% SK inhibition was found in

nine normal cell lines (p<0.05, Figure 8). Thus, elevated SK enzyme activity in Ra cells is attributable to PI3K activation. Additionally, these results suggest that PI3K is positioned upstream to SK in this pathway.

EXAMPLE 9 This example describes measuring PI3K enzymatic activity in cell lines. In order to minimize inter-individual variations, we have elected to compare pairs of RA disease- discordant monozygotic twins. Those individuals differ in the presence or absence of RA. but are genetically identical. Figure 9 depicts PI3K activity in one pair RA-discordant monozygotic twins. As can be seen, untreated cells of the RA twin were resisitant to Fas- . nediated killing, while the cells from the healthy twin were susceptible. Treatment of the resistant tin's cells with wortmannin reverse their resistance. Additionally, PI3K enzymatic activity in the RA twin was 3-fold higher than that of the healthy co-twin. (Figure 10). Thus, resistance to Fas-mediated apoptosis in RA is due to increased enzymatic activity of P13K. which induce higher activity of SK with resultant higher SPP levels.

EXAMPLE 10 In order to assess the practical utility of the observations mentioned above, we have tested the therapeutic efficacy of wortmannin in adjuvant arthritis (AA) in rats, an experimental model of RA. As shown in Figure 11, pre-treatment of rats with intra peritoneal injections of wortmannin markedly decreased the severity of AA.

Taken together, the results reporte here further implicate the propose pathway in the pathogenesis of RA. We have substantiated the role of the sphyngomyelin pathway in RA and identifie an important upstream regulatory mechanism controlling the hyperactivation of this pathway in the disease. Thus, the invention presented here provides multiple potential targets for the therapeutic intervention in RA.