molecules

Review
Therapeutic Potential of Targeting the Th17/Treg Axis
in Autoimmune Disorders
Patrizia Fasching, Martin Stradner, Winfried Graninger, Christian Dejaco * and Johannes Fessler
Department of Rheumatology and Immunology, Medical University of Graz, Auenbruggerplatz 15, 8036 Graz,
Austria; patriziafasching@[Link] (P.F.); [Link]@[Link] (M.S.);
[Link]@[Link] (W.G.); johannes_fessler@[Link] (J.F.)
* Correspondence: [Link]@[Link]

Academic Editor: Chun Kwok Wong

Received: 12 December 2016; Accepted: 10 January 2017; Published: 14 January 2017

Abstract: A disruption of the crucial balance between regulatory T-cells (Tregs) and Th17-cells was
recently implicated in various autoimmune disorders. Tregs are responsible for the maintenance
of self-tolerance, thus inhibiting autoimmunity, whereas pro-inflammatory Th17-cells contribute to
the induction and propagation of inflammation. Distortion of the Th17/Treg balance favoring the
pro-inflammatory Th17 side is hence suspected to contribute to exacerbation of autoimmune disorders.
This review aims to summarize recent data and advances in targeted therapeutic modification of the
Th17/Treg-balance, as well as information on the efficacy of candidate therapeutics with respect to
the treatment of autoimmune diseases.

Keywords: Th17-cells; regulatory T-cells; autoimmunity; RORγt; Foxp3

1. Introduction
Autoimmunity comprises a number of pathological conditions and disorders with distinct
appearances and characteristics, all sharing the common hallmark of impaired self-tolerance. In healthy
individuals, the mechanisms of central and peripheral tolerance ensure a proper regulation of
the immune system thus preventing autoimmunity. Regulatory T-cells (Tregs) are crucial for the
maintenance of peripheral immunological tolerance. Impairments in Treg numbers or function have
been investigated in various autoimmune diseases (AIDs) [1]. More recently, autoimmunity has been
linked to an impaired balance between Tregs and Th17-cells, an effector T-cell subset described to
promote inflammation by acting as Treg antagonists. A shift in the Th17/Treg equilibrium towards the
pro-inflammatory Th17 side has been reported in several autoimmune disorders including rheumatoid
arthritis (RA), ankylosing spondylitis (AS), psoriasis and psoriatic arthritis (PsA), multiple sclerosis
(MS), systemic lupus erythematosus (SLE), inflammatory bowel disease (IBD), as well as Crohn’s
disease (CD) [2–4]. Moreover, several drugs with the potential to modify Treg- and in particular
Th17-responses, have already shown to be effective and received approval for the treatment of some of
these disorders [5–11]. These findings have corroborated existing evidence on the involvement and
reciprocal role of Tregs and Th17-cells in autoimmune inflammation, thus highlighting the importance
of investigating new therapeutic strategies in this regard. This review aims to summarize recent data
and advances in targeted therapeutic modification of the Th17/Treg-balance, as well as on the efficacy
of candidate therapeutics with respect to the treatment of AIDs.

2. Treg-Cells
Although a wealth of regulatory immune cells [12,13] have been identified, CD4+ Tregs remain
the most extensively studied cell-type with immunosuppressive properties. Tregs can use a variety
of mechanisms to induce immunosuppression, including indirect suppression via the expression of

Molecules 2017, 22, 134; doi:10.3390/molecules22010134 [Link]/journal/molecules

Molecules 2017, 22, 134 2 of 24

inhibitory cytokines, metabolic disruption of target T-cells, cytolysis, and regulation of dendritic cell
maturation and function [14]. Tregs are divided into two different subsets, depending on their origin.
While natural Tregs (nTregs) are derived from the thymus, inducible Tregs (iTregs) develop from naïve
T-cell precursors in the periphery. Thymic development of nTregs depends on TCR-stimulation in
combination with CD28 co-stimulation. CD28 is furthermore essential for homeostatic proliferation
and survival of nTregs in the periphery [15]. In contrast, development of iTregs requires the presence
of IL-2 and transforming growth factor (TGF)-β instead of CD28 co-stimulation [16].

2.1. Transcription Factors and Surface Markers

Treg-cell lineage commitment is pivotally promoted by the expression of transcription factor
forkhead box P3 (Foxp3). Divers mutations in the human FOXP3 gene result in an allotropic syndrome
of multi-organ autoimmunity (immune dysregulation, polyendocrinopathy, enteropathy, X-linked
(IPEX) syndrome [17]) and similar effects were observed in the scurfy mouse, a murine model carrying
a mutation in Foxp3 [18]. Moreover, continued expression of Foxp3 is required to maintain function
and lineage identity of mature peripheral Tregs [19]. Transcription of FOXP3 is activated by signal
transducer and activator of transcription (STAT) 5, another transcription factor shown to influence
Treg differentiation and survival [20].
Foxp3 is one of the most specific markers to identify Tregs; however, Foxp3+ cells without
suppressive function are also present in humans. Another notable limitation of this marker is the
fact, that cells must be permeabilized in order to stain Foxp3 intracellularly. Permeabilized cells are
not viable anymore and can thus not be used for further functional testing. Other, reliable markers
expressed on the surface of Tregs are needed to identify this cell population for functional experiments.
Initially, Treg characterization was mainly based on their elevated expression of surface IL-2
receptor α-chain (CD25) until it was evident that CD25 can also be elevated in activated T-cells
lacking suppressive function. Various additional surface-markers were proposed to define Tregs
including cytotoxic T-lymphocyte associated Ag-4 (CTLA-4) [21], adhesion molecule CD62L [22],
glucocorticoid-induced tumor necrosis factor receptor (GITR) [23], programmed cell death-1 (PD-1) [24]
and many others, while CD49d, CD127, CD26 and CD6 were proposed as negative markers [25–29].
However, as none of these molecules is Treg-specific, the use of a combination of several markers is
now recommended for a reliable identification of Tregs.

2.2. Cytokines
One of the features attributed to Tregs is the secretion of cytokines exerting suppressive
function on various immune cell subsets. The major Treg-cytokines include TGF-β and interleukin
(IL)-10 [14]. TGF-β is pivotal for the maintenance of immunological tolerance through interference
with differentiation, proliferation and survival of lymphocytes and other immune cells [30]. Targeted
deletion of the TGF-βRII receptor in T-cells resulted in early-onset lethal autoimmunity in mice [30,31].
Moreover, T-cell specific TGF-βRII deficiency resulted in the emergence of a highly pathogenic T-cell
population overexpressing granzymes, perforin, death receptor ligand FasL and interferon (IFN)-γ,
which has been assumed to cause this autoimmune disease [31]. Tregs, however, are not the sole
source of TGF-β secretion, and there is a multiplicity of effects exerted by TGF-β on its target cells,
as reviewed in detail elsewhere [32,33]. IL-10, in contrast, seems to be predominantly essential for
the control of inflammation at environmental interfaces such as lungs and colon. IL-10 does not only
induce suppression of pathogenic Th17-cell responses [34–36], it is also required to maintain Treg
suppressive activity and expression of Foxp3. Besides, IL-10 was reported to interfere with Th1-cell
migration to intestinal inflammatory sites [37,38]. Apart from that, nTregs were reported to be a natural
source of IL-35, thereby triggering differentiation of naïve T-cells into a distinct iTreg-subset exerting
its suppressive function exclusively via production of IL-35 (iTr35-cells) [39]. Notably, iTr35-cells differ
from Foxp3+ Treg-subsets as they lack Foxp3 expression [39]. Presumably, IL-35 is required for maximal
suppressive function of Foxp3+ Tregs and has been suggested to contribute to the maintenance of
Molecules 2017, 22, 134 3 of 24

immune tolerance in the gut [39–41]. The exact physiological role of IL-35 in vivo, however, is under
debate and requires further investigation.
Molecules 2017, 22, 134 3 of 22
3. Th17-Cells
3. Th17‐Cells
Since their identification, Th17-cells have been extensively studied and were soon accepted
as a Since their
distinct identification,
CD4+ helper T-cellTh17‐cells
lineagehave beenAextensively
[42,43]. studied from
bulk of evidence and were soon accepted
numerous studies as
hasa
distinct CD4+ helper T‐cell lineage [42,43]. A bulk of evidence from numerous studies has
demonstrated their malicious, pro-inflammatory involvement in various autoimmune disorders [2]. demonstrated
their malicious,
However, this pro‐inflammatory
cell subset also has involvement in various
a physiologic role autoimmune
in the immunedisorders
system[2]. by
However, this
conferring
cell subset also has a physiologic role in the immune system by conferring protective function
protective function against microbial pathogens (including fungi, bacteria, and viruses) at mucosal against
microbial[44,45].
surfaces pathogens (including fungi, bacteria, and viruses) at mucosal surfaces [44,45].

3.1. Transcription Factors

Factors and
and Surface
Surface Markers
Markers
The differentiation
differentiationofofTh17-cells
Th17‐cells is directed
is directedby their master
by their transcription
master factorfactor
transcription retinoic acid-related
retinoic acid‐
orphan receptorreceptor
related orphan γt (RORγt), a specific
γt (RORγt), transcript
a specific of the RORC
transcript of thegene.
RORC Interestingly, TGF-β isTGF‐β
gene. Interestingly, initially
is
required for the development
initially required for the developmentof both,ofiTregs
both, and
iTregs Th17-cells, by triggering
and Th17‐cells, the expression
by triggering of their
the expression of
differentiating transcription
their differentiating factors,
transcription Foxp3
factors, andand
Foxp3 RORγt,
RORγt, respectively
respectively [46].
[46].InInfact,
fact,both
bothtranscription
transcription
factors are initially up-regulated
up‐regulated after after naïve
naïve CD4+
CD4+ T-cells
T‐cells encounter
encounter TGF-β
TGF‐β [47]. Whether subsequent
differentiation of the cells is skewed towards a regulatory phenotype or a pro-inflammatory pro‐inflammatory Th17
phenotype
phenotype depends
dependsmainlymainlyon onthe
thesurrounding
surroundingcytokine
cytokinemilieu.
[Link]-regulated
Up‐regulated Foxp3
Foxp3 initially binds
initially bindsto
RORγt
to RORγt thereby inhibiting
thereby the development
inhibiting the development of Th17-cells and favoring
of Th17‐cells Treg development
and favoring [48]. However,
Treg development [48].
the presence
However, theofpresence
pro-inflammatory cytokines such
of pro‐inflammatory as IL-6 such
cytokines and IL-21 can
as IL‐6 abrogate
and IL‐21 canthisabrogate
TGF-β-dependent,
this TGF‐
Foxp3-mediated inhibition of inhibition
β‐dependent, Foxp3‐mediated RORγt viaofactivation
RORγt viaofactivation
transcription factor STAT3
of transcription [46,49]
factor (Figure
STAT3 1).
[46,49]
Eventually, this leads to
(Figure 1). Eventually, the
this differentiation
leads of Th17-cells
to the differentiation and up-regulation
of Th17‐cells of the receptor
and up‐regulation IL-23R.
of the receptor
IL-23
IL‐[Link] provides
IL‐23 a positivea feedback
then provides positive loop for the
feedback maintenance,
loop expansion and
for the maintenance, properand
expansion function
proper of
Th17-cells
function of[50]. Increased
Th17‐cells surface
[50]. expression
Increased surfaceofexpression
IL-23R is characteristic for Th17-cells and
of IL‐23R is characteristic might be used
for Th17‐cells and
to identify
might this cell
be used population
to identify this [51]. Further surface
cell population markerssurface
[51]. Further suggested to serve
markers as Th17-identifiers
suggested to serve as
are chemokine receptors
Th17‐identifiers CCR6receptors
are chemokine and CCR4, CCR6bothand associated
CCR4, both with skin homing
associated with skinof cells
homing[52].ofMoreover,
cells [52].
CXCR3
Moreover, negativity
CXCR3helps to distinguish
negativity helps toCCR6+ Th17-cells
distinguish CCR6+from CXCR3+ CCR6+
Th17‐cells from CXCR3+Th1/17-cells.
CCR6+The latter
Th1/17‐
is a distinct
cells. T-cellispopulation
The latter exhibiting
a distinct T‐cell both Th1
population and Th17both
exhibiting characteristics.
Th1 and Th17 Morecharacteristics.
recently, the C-type
More
lectin CD161
recently, was reported
the C‐type to be was
lectin CD161 a useful surface
reported to bemarker forsurface
a useful Th17-cell characterization
marker for Th17‐cell given that IL-17
characterization
producing cellsproducing
given that IL‐17 originate from CD161+ from
cells originate T-cells [53]. A
CD161+ combination
T‐cells of differentofmarkers,
[53]. A combination differenthowever,
markers,
might
however,be the bestbe
might approach
the bestfor reliable Th17-cell
approach for reliableidentification (similar to the(similar
Th17‐cell identification strategytotothe identify Tregs
strategy to
as discussed
identify Tregsabove).
as discussed above).

Figure
Figure 1.
1. Development
Development and
and trans‐differentiation
trans-differentiation pathways
pathways of
of Tregs and Th17-cells.
Tregs and Th17‐cells.

3.2. Cytokines
IL‐17A (commonly referred to as IL‐17) and IL‐17F are the key effector cytokines of Th17‐cells.
During Th17‐cell differentiation, RORγt directly binds to the promoter region of IL‐17A, thereby
orchestrating its transcription [48]. IL‐17 is involved in inflammatory responses by stimulating cell
Molecules 2017, 22, 134 4 of 24

3.2. Cytokines
IL-17A (commonly referred to as IL-17) and IL-17F are the key effector cytokines of Th17-cells.
During Th17-cell differentiation, RORγt directly binds to the promoter region of IL-17A, thereby
orchestrating its transcription [48]. IL-17 is involved in inflammatory responses by stimulating cell
types of both, immune and non-immune nature. The effect of IL-17 in this context is to indirectly
promote neutrophil recruitment via induction of CXCL8 in macrophages, epithelial and endothelial
cells and fibroblasts [54]. Additionally, tumor necrosis factor (TNF)-α and granulocyte-macrophage
colony-stimulating factor (GM-CSF) secreted by Th17-cells also contribute to neutrophil recruitment,
activation and survival [55]. Furthermore, IL-17 induces CCL20 expression in various cell types found
at sites of chronic inflammation, thereby enhancing attraction of additional Th17-cells, which express
CCR6, the receptor for CCL20. Other molecules such as IL-22, IL-26 and IL-21 are also part of the
characteristic Th17-signature [47,49,56]. These cytokines feed another positive loop amplifying the
Th17 response in an autocrine manner [50,57]. IL-22 seems to be crucially involved in the pathogenesis
of psoriasis and RA [58,59] whereas IL-26 most likely contributes to the pathogenesis of intestinal
inflammation [60].

3.3. Pathogenic vs. Non-Pathogenic

Although Th17-cells were first recognized due to their pathogenic involvement in autoimmune
inflammation, accumulating evidence points toward a considerable heterogeneity of the Th17-lineage.
For example, a non-pathogenic subset of Th17-cells has been identified, which has a physiologic
role in the protection of intestinal barrier function [44,45]. This led to the conclusion that Th17-cells
are not uniform in function. Further analyses revealed that Th17-cell differentiation in the presence
of TGF-β1 and IL-6 results in cells co-producing IL-17 and IL-10 [61]. These cells are assigned to
the non-pathogenic subset of the Th17-lineage, as they are incapable of promoting autoimmune
inflammation and might even act anti-inflammatory. On the other hand, differentiation of highly
pathogenic Th17-cells from naïve precursor-cells was reported to occur independently of TGF-β
signaling in presence of IL-23, IL-6 and IL-1β [62,63]. Lee et al. [64] reported that IL-23 exposure
resulted in a transcriptomic switch in differentiating Th17-cells thereby triggering Th17-pathogenicity
via induction of a set of unique transcription factors and induction of TGF-β3 production. They support
their concept by demonstrating that TGF-β3 and IL-6 were sufficient to induce differentiation of
pathogenic Th17-cells in in vitro experiments [64]. More recently, the serum/glucocorticoid regulated
kinase 1 (SGK1) was reported to be critical for the generation of pathogenic Th17-cells by deactivating
Foxo1, a direct repressor of IL-23R expression [65]. CD5L is another candidate molecule described
to regulate Th17-pathogenicity. Loss of CD5L converts non-pathogenic Th17-cells into pathogenic
ones that induce autoimmunity [66]. The mechanism by which CD5L regulated Th17-pathogenicity
is based on alterations of the cellular fatty acid composition, eventually resulting in RORγt ligand
restriction [66]. Collectively, these studies indicate that there exist various subsets of Th17-cells with
distinct function and pathogenic capacity.

4. Th17/Treg Plasticity and Balance

Shared requirement of TGF-β and the reciprocal regulation of their master transcription factors
RORγt and Foxp3 suggest a dichotomy in the generation of Th17-cells and Tregs. More importantly,
there is a reported phenotypic and functional plasticity in both populations allowing differentiated
cells to “re-”differentiate (Figure 1).
For example, IL-6 does not only enhance Th17-differentiation via STAT3 activation in naïve T-cells
but was also shown to promote re-differentiation of Tregs into Th17-cells in presence of TGF-β and
IL-1 [67]. Similar observations were published by Deknuydt et al. [68] after combined in vitro treatment
of isolated Tregs with IL-6 and IL-1β, but not with IL-6 alone . This finding is in line with the previously
reported resistance of TGF-β-induced Tregs to be skewed into the Th17-direction in a cell culture
Molecules 2017, 22, 134 5 of 24

setting with IL-6 and IL-2 [69]. This result highlights the importance of IL-1β in this re-polarization
process. A recent study by Komatsu et al. [70] reported CD25lo Foxp3+CD4+ T-cells obtained from
Foxp3hCD2 knock-in mice to preferentially loose Foxp3-expression and acquire expression of IL-17 upon
adoptive transfer into arthritic mice. These exFoxp3 Th17-cells eventually accumulate in inflamed
joints of these animals. Conversely, Gagliani et al. [71] more recently reported reprogramming of
inflammatory Th17-cells into IL-10 producing cells with regulatory functions. Clustering analysis of
Th17-relevant genes revealed that these exTh17-cells have undergone transcriptional reprogramming
and subsequently clustered together with Tr1-cells, a regulatory T-cell subset characterized by secretion
of IL-10 but lacking Foxp3 expression. Gagliani et al. referred to this subset as Tr1exTh17 . Moreover,
a complete functional trans-differentiation from Th17 into regulatory Tr1-cells was suggested as these
Tr1exTh17Molecules
cells were furthermore
2017, 22, 134 shown to prevent Th17-cell mediated colitis in the respective 5 of 22 mouse
model. Overall, these studies illustrate the ability of Th17-cells and Tregs to undergo phenotype
Moreover, a complete functional trans‐differentiation from Th17 into regulatory Tr1‐cells was
conversion. The physiological role of this phenotypic and functional adaptation of these cells to
suggested as these Tr1exTh17 cells were furthermore shown to prevent Th17‐cell mediated colitis in the
changingrespective
environmental conditions
mouse model. may
Overall, lie studies
these in maintenance of ability
illustrate the an appropriate immune-regulation
of Th17‐cells and Tregs to in
responseundergo
to the presence
phenotype of certain microbes,
conversion. cytokines
The physiological role ofand other signals
this phenotypic from innate
and functional immune cells.
adaptation
of these cells
As an imbalance between to changing environmental
Th17-cells and Tregsconditions
is observed mayin lie in maintenancethe
autoimmunity, of plasticity
an appropriate
of these cells
could be exploited in order to develop more effective therapies that will recover signals
immune‐regulation in response to the presence of certain microbes, cytokines and other immune from tolerance
innate immune cells. As an imbalance between Th17‐cells and Tregs is observed in autoimmunity,
while avoiding adverse effects that go along with therapies of systemic immunosuppression.
the plasticity of these cells could be exploited in order to develop more effective therapies that will
recover immune tolerance while avoiding adverse effects that go along with therapies of systemic
5. Therapeutic Approaches: Molecules Influencing the Th17/Treg Axis
immunosuppression.
In the past years, accumulating evidence highlighted a shift in the Th17/Treg equilibrium towards
5. Therapeutic Approaches: Molecules Influencing the Th17/Treg Axis
the pro-inflammatory Th17-program, which is assumed to contribute to the pathogenesis of chronic
In the past years, accumulating evidence highlighted a shift in the Th17/Treg equilibrium towards
inflammatory disorders such as psoriasis, PsA, RA, AS, SLE, MS, IBD and CD [2–4].
the pro‐inflammatory Th17‐program, which is assumed to contribute to the pathogenesis of chronic
Various drugs with the potential to modify Treg- and in particular Th17-responses have already
inflammatory disorders such as psoriasis, PsA, RA, AS, SLE, MS, IBD and CD [2–4].
proven efficacy anddrugs
Various received approval
with the potential for the treatment
to modify ofparticular
Treg‐ and in certain Th17‐responses
AIDs while others are currently
have already
being tested
provenin clinical trials
efficacy and (Figure
received 2). Nevertheless,
approval identification
for the treatment and while
of certain AIDs testing of additional
others candidate
are currently
moleculesbeing
is tested in clinical trials
an incessant (Figureaim.
research 2). Nevertheless,
Generally, identification
therapeutic and testing of additional
approaches candidate
are multidirectional
molecules is an incessant research aim. Generally, therapeutic approaches are multidirectional and
and comprise direct targeting of Th17-related cytokines, cytokine receptors, intracellular signaling
comprise direct targeting of Th17‐related cytokines, cytokine receptors, intracellular signaling pathways,
pathways, as well as inhibiting Th17- and enhancing Treg-specific transcription factors.
as well as inhibiting Th17‐ and enhancing Treg‐specific transcription factors.

Figure 2. Therapeutic tools targeting Th17‐cell cytokines, cytokine receptors and transcription factor
Therapeutic
Figure [Link] tools
facilitate targeting
correction Th17-cell
of the Th17/Tregcytokines, cytokine
imbalance in receptors
favor of the and transcription
Treg‐population. All Th17‐ factor
pathways facilitate
modifying correction
agents of figure
listed in this the Th17/Treg imbalance
are either approved in favorstudied
or are currently of theinTreg-population.
clinical trials. All
Th17-modifying agents listed in this figure are either approved or are currently studied in clinical trials.
5.1. Targeting Th17‐Related Cytokines and Receptors

5.1.1. IL‐17
IL‐17 is the most prominent effector cytokine of Th17‐cells and is implicated in a variety of
inflammatory diseases [3]. This led to the conclusion that neutralization of IL‐17, although not directly
inducing a re‐balance of Th17/Treg‐cell ratio can abrogate IL‐17‐mediated pathogenic effects in
autoimmune settings. Several IL‐17 neutralizing monoclonal antibodies have been developed in
Molecules 2017, 22, 134 6 of 24

5.1. Targeting Th17-Related Cytokines and Receptors

5.1.1. IL-17
IL-17 is the most prominent effector cytokine of Th17-cells and is implicated in a variety of
inflammatory diseases [3]. This led to the conclusion that neutralization of IL-17, although not
directly inducing a re-balance of Th17/Treg-cell ratio can abrogate IL-17-mediated pathogenic effects
in autoimmune settings. Several IL-17 neutralizing monoclonal antibodies have been developed in
recent years including secukinumab (AIN457), ixekizumab (LY2439821) and brodalumab (AMG827).
Multiple clinical trials yielded impressive therapeutic effects of all three molecules [5–8,72] leading
to the approval of secukinumab for psoriasis, PsA and AS, and ixekizumab for psoriasis [73–76].
Besides, ongoing clinical trials are evaluating the efficacy of ixekizumab in patients with active PsA
(NCT01695239) and AS (NCT02696785, NCT02696798, NCT02757352).
In RA patients, IL-17 neutralization yielded inconsistent results, with some studies reporting
significant clinical response and improvements in patient-reported outcomes [77–79], whereas others
failed to meet the primary efficacy end points [80–82]. Importantly, approaches of IL-17 neutralization
in CD were terminated due to high rates of serious adverse events and fungal infections, overall
resulting in a worsening of the disease while having no beneficial impact [83,84]. The explanation
for the clear failure of IL-17 neutralization in CD is most likely because of the protective role of IL-17
at mucosal surfaces where it confers host defense and contributes to the maintenance of immune
homeostasis [85].

5.1.2. IL-23
Years of research compellingly illustrated the requirement of IL-23 for expansion and maintenance
of Th17-cells and recently also for their conversion of non-pathogenic cells with a protective role
at mucosal barriers into highly pathogenic cells that promote inflammation [86,87]. IL-23 is a
heterodimeric cytokine composed of two subunits, p19 and p40. The latter subunit is shared by
the Th1-inducing cytokine IL-12 [88]. In psoriasis patients, p40 and p19 mRNA levels were higher in
affected compared to normal skin whereas mRNA of the second IL-12 subunit (p35) was decreased
in the lesions [89]. Pre-clinical psoriasis models further indicated that IL-23, but not IL-12, is able to
drive excessive growth and abnormal differentiation of keratinocytes in murine skin [89]. Moreover,
genetic abrogation of the p19 subunit of IL-23 in mice resulted in resistance to the development of
experimental autoimmune encephalomyelitis (EAE), the most commonly used experimental model
for human MS [90]. Similarly, resistance against joint inflammation was observed in p19-lacking mice
with collagen induced arthritis (CIA), a mouse model of RA [91]. In this study, IL-23-deficiency was
linked to the absence of IL-17-producing CD4+ T-cells [91]. Another mouse study reported that both,
anti-IL-12/23p40 and anti-IL-23p19 antibodies markedly lowered transcript levels of Th17-cytokines
such as IL-17 and IL-22 [92]. Blocking IL-23 and its cognate receptor IL-23R is therefore another
promising therapeutic strategy for the inhibition of Th17-responses in autoimmunity.
Several antibodies for the application in humans have been developed so far, including the
anti-IL-12/23p40 antibodies ustekinumab and briakinumab.
Due to its favorable efficacy, ustekinumab has already been approved for the treatment of
psoriasis [93,94], PsA [95–98] and CD (NCT01369329, NCT01369342). Additional clinical trials
are underway assessing the effectiveness of ustekinumab in UC (NCT02407236; phase 3), SpA
(NCT02437162, NCT02438787, NCT02407223; phase 3), RA (NCT01645280; phase 2) and type 1 diabetes
(T1D) (NCT02117765; phase 1 & 2). Notably, ustekinumab did not reduce disease activity of MS patients,
hence no further studies are planned in this area [99]. Briakinumab was associated with an increased
risk of major adverse cardiovascular events [100], and its application for marketing approval was
therefore withdrawn in 2011.
Several anti-IL-23p19 antibodies (tildrakizumab, guselkumab, BI-655066, AMG 139, LY3074828)
have been in clinical development. These antibodies enable specific targeting of IL-23 without the
Molecules 2017, 22, 134 7 of 24

cross-reactive effect on IL-12. Tildrakizumab and guselkumab are currently under investigation in
phase 3 clinical trials (Tildra: NCT01722331, NCT01729754; Guselku: VOYAGE 1 & 2) for psoriasis and
in a phase 2 study for PsA (Guselku: NCT02319759). BI-655066 induced rapid and durable clinical
improvements in psoriasis patients [101] while LY3074828 and AMG139 are still in early stages of
studies for psoriasis, CD and UC.

5.1.3. IL-6 & IL-6R

A substantial role for IL-6 in modulating the Th17/Treg ratio has become increasingly
evident because IL-6 is essential for Th17-cell differentiation and also inhibits TGF-β-induced
Treg-development [46,49].
Tocilizumab and sarilumab are monoclonal antibodies targeting the human IL-6R. In RA, clinical
studies have demonstrated a significant reduction in Th17-cells in tocilizumab-treated patients
compared to pre-treatment levels, while at the same time an increase in Tregs was seen [102–104].
Similarly, Tada et al. [105] reported the Foxp3/RORγt ratio to rise upon tocilizumab treatment in RA
patients. An earlier study by Pesce et al. did not observe a significant effect of tocilizumab on Th17
frequencies, whereas Treg numbers increased [106]. Cytokine levels of IL-17A were not affected in
tocilizumab-treated RA patients in a recent study by Lee et al. [107]; however, higher baseline IL-17A
levels were associated with a worse responsiveness to the treatment. A tempting approach to achieve
better treatment outcomes might thus be a combined therapy with IL-17A blockers (e.g., secukinumab)
and IL-6-inhibitors such as tocilizumab. This approach, however, has yet to be addressed.
Tocilizumab is meanwhile not only approved for the treatment of RA, but also for polyarticular
and systemic JIA due to its favorable results in numerous clinical trials [10,11]. In addition, sarilumab
was demonstrated to significantly improve various disease-aspects in RA patients [108–110] but its
potential approval for RA is still pending. Notably, sarilumab [111] and tocilizumab (NCT01209702,
NCT01209689) both failed to achieve significant benefits in AS patients.
Sirukumab, olokizumab and clazakizumab are therapeutic tools that also interfere with IL-6
signaling, but directly target IL-6 and inhibit its interaction with the IL-6R. Several phase 3 clinical
trials are currently assessing sirukumab (NCT02019472, NCT01604343, NCT01606761, NCT01856309,
NCT02019472) and olokizumab (NCT02760368, NCT02760433 and NCT02760407) as therapeutic
alternatives in RA. Clazakizumab already proved efficacy in phase 2 trials of RA [112] and PsA [113]
and it may be expected that this drug becomes approved for the treatment of both diseases if its efficacy
can be confirmed in phase 3 trials.

5.2. Targeting Transcription Factors

5.2.1. RORγt
The ROR family of nuclear hormone receptors generally comprises three different members:
RORα, RORβ and RORγ. While RORγ mRNA is present in various peripheral tissues, expression of its
isoform RORγt is restricted to lymphoid tissues and certain types of lymphoid cells [114]. After RORγt
was recognized as master transcription factor of the Th17-lineage, there has been a major research
interest in potential inhibitors of the RORγt/Th17 axis.
The small molecule digoxin has been well established for decades in cardiology. Later it was
reported also to inhibit the transcriptional activity of RORγt [115]. Digoxin suppressed differentiation
of murine Th17-cells without affecting other T-cell lineages [116] and inhibited IL-17 production of
T-cells from EAE mice [115]. Consistently, digoxin was effective in attenuating EAE [116] as well as in
reducing the incidence of arthritis and joint inflammation in CIA mice, where it significantly reduced
Th17-cells and increased Treg numbers [117].
Another study in the CIA mouse model identified the herbal medicine compound ursolic acid (UA)
to effectively inhibit RORγt function and to decrease IL-17 expression in developing and differentiated
Th17-cells [118]. In the spleens of these animals, UA decreased the frequency of Th17-cells while Treg
Molecules 2017, 22, 134 8 of 24

numbers were increased [118]. Clinically UA treatment resulted in a reduction of disease activity of
CIA mice [118].
TMP778 and TMP920 were identified as inverse agonists of RORγt [119]. Both molecules were
shown to potently suppress Th17-cell generation and IL-17 secretion by differentiated Th17-cells
in vitro [119]. TMP778 moreover inhibited human Th17 signature gene expression in vitro as well
as murine Th17-cell differentiation in vivo [120,121]. Two independent murine studies reported
TMP778 administration to reduce imiquimod-induced cutaneous inflammation (a murine model of
psoriasis) and the severity of EAE [119,121]. Unfortunately, high doses of digoxin, TMP778 and
TMP920 are most likely toxic for a variety of non-immune tissues and cells. Lately, Takaishi et al. [122]
described attenuation of psoriasis-like lesions in two independent psoriasis mouse models after oral
administration of the novel RORγt antagonist A213. They suggested that this effect was based on
neutralization of IL-17-producing cells [122], however, A213 also led to a systemic attenuation of Tregs.
The underlying mechanism for this effect remained unclear [122]. Smith et al. [123] described the
RORγt inverse agonist GSK2981278 to significantly inhibit production of Th17 signature cytokines
(IL-17A, IL-17F, IL-22 and IL-23) in multiple in vitro and human tissue-based assays, including topical
delivery of the compound via the sRICA assay and psoriatic lesional explants. Assuming that tissue
cytokine production is one of the main drivers of inflammation in plaque psoriasis, this study suggests
that topical treatment with GSK2981278 might improve clinical outcomes of psoriasis patients [123].
Results from a recent phase 1 proof-of-concept study (NCT02548052) will shed more light on the
potential benefit of topical GSK2981278 application in psoriasis patients. Another inverse agonist,
VTP-43742 [124], is already in a phase II clinical trial (NCT02555709).
Given that RORγt and RORγ share a similar ligand binding domain (LBD) but differ by a
variation in their N-terminal region [114], current small molecule antagonists and inverse agonist
targeting RORγt bear the risk of an inadvertent impact on non-immune tissues via binding of
RORγ. The mechanisms of post-translational modification of RORγt, including acetylation and
ubiquitinylation, are therefore subject of ongoing investigations with the goal to develop therapeutic
RORγt modulators with greater specificity, selectivity and safety.
The fact that acetylation and ubiquitination processes often compete for the same lysine residues
led to speculations about the exact consequences of these modifications in Th17-cells. One hypothesis is
that acetylation prevents the respective protein from ubiquitination-induced proteasomal degradation.
For instance, histone acetyltransferase (HAT) p300 was shown to stabilize RORγt via acetylation of its
K81 residue. Knockdown of p300 in HEK293 T-cells resulted in down-regulation of RORγt protein
levels [125]. However, there is also evidence that this acetylation occurs within the DNA-binding region
of RORγt consequently impairing interaction of the transcription factor with its target genes [126].
Using mass spectrometry, Lim et al. [126] reported that all three acetylated lysine residues (K69, K81,
K99) located within the DNA-binding domain of RORγt become deacetylated in presence of the protein
deacetylase SIRT1. Hence, SIRT1 increased transcriptional activity of RORγt and enhanced Th17-cell
development and function [126]. SIRT-inhibition in EAE mice not only delayed disease onset, but also
ameliorated disease severity. This observation supports the concept of a pro-inflammatory role of
SIRT1 in autoimmunity [126].
Apart from acetylation, the complex area of ubiqitination-mediated RORγt-regulation was
recently addressed. Several reports identified a number of E3 ubiquitin ligases (e.g., Itch, UBR5
and TRAF5) that seem to be involved in Th17-regulation by ubiquitination of RORγt [127–129]. E3
ligases are known to mediate the last step in the ubiquitination cascade, whereas deubiquitnating
enzymes (e.g., USP15, USP17, DUBA) counteract this mechanism. Itch was identified to target RORγt
for ubiquitination, resulting in decreased IL-17 expression and preventing colonic inflammation [129].
He et al. [130] recently reported that deubiquitination of K446 by ubiquitin-specific protease USP15
enhanced the recruitment of steroid receptor coactivator 1 (SRC1), thereby stimulating RORγt activity.
Moreover, USP17 seems to acts as a positive regulator of RORγt [131]. Its knockdown in Th17-cells
decreased RORγt protein levels and expression of Th17-related genes [131]. Paradoxically, TRAF5
Molecules 2017, 22, 134 9 of 24

mediated ubiquitination stabilizes RORγt protein levels and might thus aggravate inflammatory
responses [127]. Consistent with this observation, elevated TRAF5 mRNA levels were found in
CD4+ T-cells from SLE-patients [127]. Another surprising observation is the stabilization of ubiquitin
ligase UBR5 upon accumulation of deubiqitinase DUBA in activated T-cells. In response to TGF-β
singaling, UBR5 could then ubiquitinate the RORγ protein and act as cell-intrinsic suppressor of IL-17
production [128].
In summary, post-translational modification of RORγt is a tightly regulated, highly complex
mechanism. Extensive investigational effort is needed in order to identify a safe target for novel
pharmacologic interventions in AIDs.

5.2.2. STAT3
Differentiation of Th17-cells is triggered by an intracellular signaling cascade involving
IL-6-dependent phosphorylation and activation of STAT3 [67,132]. More precisely, binding of IL-6 to its
receptor IL-6R results in homodimerization of the signal-transducing β-receptor gp130 [133]. This leads
to STAT3 phosphorylation via activation of gp130-associated janus kinases (JAKs), in particular
Jak1 [132]. STAT3 is a latent transcription factor that upon phosphorylation translocates into the nucleus
to induce transcription of IL-6-responsive genes [132]. As previously mentioned, IL-6-dependent STAT3
activation downregulates TGF-β-induced Foxp3-expression and promotes differentiation of naïve
CD4+ T-cells into Th17-cells with simultaneous suppression of Treg development [67]. Therapeutic
approaches aimed at the modulation of IL-6 signaling are thus not limited to direct targeting of IL-6
and its receptor IL-6R, but also comprise inhibition of the JAK/STAT pathway.
Tofacitinib is a targeted synthetic small molecule that competitively binds to the ATP-binding
pocket of JAKs, thus inhibiting their catalytic activity in a reversible manner [134]. Tofacitinib
potently inhibited IL-6 induced phosphorylation of STAT1 and STAT3 in human whole blood cellular
studies [135] and in synovial tissue extracts from RA patients [136]. Importantly, reduced levels of
pSTAT1 and pSTAT3 in synovial biopsies were highly correlated with clinical improvement of RA,
indicating that JAK1-mediated signaling of IFNs and IL-6 is involved in the synovial response to JAK
blockade [136]. Moreover, tofacitinib potently suppressed the generation of pathogenic Th17-cells
with an IL-23/STAT3 signature by abrogating IL-21, IL-22 but also IL-23R expression [137]. Tofacitinib
is approved for RA in numerous countries [9], and it is under investigation as a possible treatment
option for other inflammatory disorders , including psoriasis [138–140], PsA [141] and IBD [142,143].
The STAT3 inhibitor STA-21 is another compound that interferes with STAT3 signaling leading to an
improvement of the clinical course of arthritis in IL-1Ra–KO mice. STA-21 enhanced Treg function and
numbers while acting suppressive on Th17-cells and osteoclast formation [144]. SHR0302—another
JAK inhibitor—binding JAK1 with strong affinity—reduced Th17 function along with total B-cell
numbers via inhibition of JAK1-STAT3 phosphorylation in a study with adjuvant-induced arthritis
rats [145]. Human clinical trials for SHR0302 have recently been started with three studies evaluating
pharmacokinetics, safety and tolerability in healthy individuals (NCT02892370, NCT02423538) and RA
patients (NCT02665910).
Several other biological and synthetic compounds were shown in animal models to skew the
Th17/Treg balance towards the regulatory direction by blocking STAT3 phosphorylation. These
compounds include the green tea-derived component epigallocatechin-3-gallate (EGCG) [146], the
herbal compound celastrol [147], grape seed proanthocyanidin extract (GSPE) [148], the gastrointestinal
protective drug rebamipide [149], halofuginone [150] and the antidiabetic drug metformin [151].
Among these, GSPE and metformin were also reported to increase the phosphorylation of STAT5 thus
additionally enhancing Treg development [148,151].

5.2.3. Foxp3
Targeting the bona fide Treg marker Foxp3 is a reasonable choice to influence the Th17/Treg
equilibrium and thus, numerous studies investigated the effect of Foxp3 modulation. Several animal
Molecules 2017, 22, 134 10 of 24

studies for example demonstrated that ectopic expression of Foxp3 in conventional T-cells by retroviral
gene transfer resulted in a Treg-like phenotype and function and that these Foxp3-transduced T-cells
were able to suppress arthritis in a murine host [152–154].
In the absence of IL-6, TGF-β stimulates a transcriptional program in naive T-cells with
up-regulation of Foxp3 and inhibition of nuclear receptor RORγt, finally resulting in the evolvement
of iTregs. Inhibition of RORγt by Foxp3, however, is abolished under the influence of TGF-β plus
IL-6, leading to the generation of Th17-cells [155]. Consequently, tocilizumab treatment was shown to
increase the Foxp3/RORγt ratio in patients with RA [105]. A similar effect was observed in studies
evaluating the effect of TNF-α blockade on Foxp3. Etanercept treatment induced transcriptional
levels of Foxp3, STAT3 and STAT4 mRNA in responding psoriasis patients [156] and increased the
Foxp3/RORγt ratio in RA patients [157]. In the latter study, the Treg/Th17 ratio negatively correlated
with TGF-β, but positively correlated with IL-6. More recently, adalimumab was reported to expand
functional Foxp3+ Tregs via binding monocyte membrane TNF, and it unexpectedly enhanced the
expression of TNF-RII on Treg-cells [158].
Abatacept, a CTLA-4 fusion protein, is clinically effective in RA and was recently effective in
delaying the decline of beta-cell function in recent-onset T1D [159,160]. Tregs stimulated via CTLA-4
showed increased suppressive capacity in vitro, whereas activity of non-regulatory T-cells was reduced
upon CTLA-4 ligation [161]. Moreover, abatacept therapy decreased the Foxp3/RORγt ratio [105].
In accordance with this finding, Bonelli et al. [162] observed an increase in Foxp3+ Tregs following
initiation of CTLA-4Ig treatment. Tregs isolated from these abatacept-treated patients, however,
revealed diminished in vitro suppression of responder cell proliferation [162].
In the early phase of B-cell depletion with rituximab, mRNA levels of Foxp3 were significantly
increased in patients with active SLE. During follow-up, patients in clinical remission revealed
persistently elevated Foxp3 mRNA levels, whereas this marker decreased in patients with active
disease [163]. This finding is potentially explained by a simultaneous rise in mRNA levels of TGF-β,
a cytokine contributing to Treg induction.
Apart from the aforementioned factors, epigenetic modifications contribute to the regulation of
Foxp3 expression. A critical factor in Foxp3 protein stability is the methylation status of CpG sites
within the proximal promoter region of the FOXP3 gene [164]. In vitro experiments showed that
TGF-β favors de-methylation, whereas the addition of IL-6 increases methylation, the latter resulting
in reduced Foxp3 expression [165]. More recently, Cribbs et al. [166] reported that methotrexate
was able to increase expression of Foxp3 and restored suppressive function of initially defective
Tregs in RA patients. Bisulfite sequencing PCR of methotrexate-treated Tregs revealed a significant
reduction in methylation of the FOXP3 upstream enhancer region [166]. Similarly, treatment with the
combination rapamycin/IL-2 was shown to augment the frequency and function of Tregs in vitro [167].
The suppressive activity of these Tregs was further increased by all trans retinoic acid, leading to a
lower methylation status of the FOXP3 gene [168].
These findings led to the hypothesis that inhibition of DNA methyltransferases (DNMTs) might
be a treatment option in autoimmunity. In vitro studies demonstrated the emergence of a stable Foxp3+
Treg population in the presence of TGF-β and the DNMT inhibitor 5-aza-20- deoxycytidine [165].
Another method to increase Foxp3 expression in Tregs is the inhibition of histone deacetylases (HDACs).
HDACs are normally recruited by methylated DNA and mediate compact nucleosome formation.
A study in mice showed that trichostatin A therapy down-regulating HDACs led to increased
prevalence and suppressive function of Foxp3+ Tregs [169]. Accordingly, impaired Treg function
was observed upon inhibition of acetyltransferase p300, since p300—despite increasing stability of
RORγt [125]— hyperacetylates Foxp3 [170]. Besides, deletion of HDAC6, HDAC9, or Sirt1 increased
expression of the gene encoding Foxp3, and enhanced suppressive function of Tregs [171–173]. On the
other hand, Tregs of HDAC5−/− mice showed reduced suppressive function in vitro and in vivo.
CD4+ T-cells lacking HDAC5 convert poorly into Tregs despite appropriate polarizing conditions [174].
Molecules 2017, 22, 134 11 of 24

Therefore, there is a need for subsequent studies and a more sophisticated inhibition of HDACs seems
necessary to ensure stable Treg induction.

5.2.4. FoxO1
Recently, FoxO1 was reported to be a negative regulator of the Th17 transcriptional program [175].
Expression of FoxO1 in T-cells resulted in a distinct reduction in Th17 generation as well as in a
lower transcription of IL-17 and IL-23R genes in vitro. At the molecular level, FoxO1 binds RORγt
via its DNA binding domain thereby inhibiting the activity of this gene. As outlined above, RA
patients treated with the anti-IL-6R antibody tocilizumab yielded a marked reduction of circulating
Th17-cells and simultaneously an increase of peripheral Tregs [102]. The effect of IL-6 is related, at
least partly, to FoxO1. Ichiyama et al. [176] showed that IL-6 induces a microRNA-183-96-182 cluster
in Th17-cells. This cluster directly represses FoxO1 which in turn inhibits the expression of IL-1R1
resulting in enhanced pathogenic cytokine production [176]. Another study reported that microRNA
182 inhibits Treg differentiation in a FoxO1 dependent manner [177]. Accumulating evidence suggests
that anti-TNF-α therapy may support immunomodulation by Tregs via the influence of this therapy
on FoxO1. While TNF-α induced the activation of FoxO1 in human fibroblasts [178], the TNF-α
antagonist etanercept was reported to re-activate FoxO1 in patients suffering from psoriasis [179].
Liao et al. [180] reported that TNF-α promotes microRNA-705 expression, which in turn represses
FoxO1 via post-transcriptional regulation. Consistently, elevated numbers of Tregs [181] as well as
reduced frequencies of Th17-cells [182,183] were described following anti-TNF-α treatment in patients
with RA.
FoxO1 is also modulated by environmental factors. Wu et al. reported for example that a modest
increase in salt concentration induces SGK1 expression thus deactivating FoxO1 and promoting
IL-23R expression and Th17-cell differentiation in mice in vitro and in vivo [65]. Besides, in vitro
high-salt activation of human Tregs resulted in the loss of suppressive function that was mediated by
FoxO1-dependent alterations in Foxp3 stability [184]. Luo et al. recently reported that differentiation
of activated Tregs was associated with repression of FoxO1-dependent gene transcription, along with
a reduced FoxO1 expression [185]. This finding indicates that the role of FoxO1 is not fully understood
and requires further investigation.

5.3. Targeting Intracellular Signaling Pathways

5.3.1. ROCK Inhibition

Rho associated kinase 2 (ROCK2) was shown to be activated in murine T-cells under Th17-
conditions and is thought to influence Th17-generation via phosphorylation of IRF4, a transcription
factor involved in the development of Th17-cells [186,187]. Notably, ROCK activity was found to be
increased in SLE and RA patients [188,189]. In studies on human T-cells, ROCK2 was reported to
control IL-21 and IL-17 secretion via mechanisms that involve regulation through STAT3, IRF4, and
RORγt [190,191]. As reported by Biswas et al. [187] ROCK inhibition diminished production of
IL-17 and IL-21 and ameliorated disease signs in Def6trap/trap DO11.10 mice, a murine model of
RA-like arthritis. Fasudil derivative FaD-1, a ROCK inhibitor, was reported to ameliorate neurological
defects and disease severity in EAE mice, in part via downregulation of the Th17-response in the
spinal cord [192]. WAR-5, another ROCK inhibitor described to selectively inhibit ROCK2 led to the
attenuation of myelin damage, reduction of CNS inflammation and alleviation of clinical symptoms
in EAE mice [193]. WAR-5 treatment further reduced levels of IFN-γ and IL-17 while increasing
IL-10. This might thus skew the imbalance between Th1/Th17-cells and Tregs in many autoimmune
diseases toward immune regulation [193]. Zanin-Zhorov et al. [190] investigated KD025, a selective
ROCK2 inhibitor, to modulate inflammation by decreasing STAT3 activation, enhancing STAT5
phosphorylation and increasing the suppressive function of Tregs. Overall, KD025 induced a beneficial
shift in the Th17/Treg balance [190]. Two phase 2 clinical trials (NCT02317627 and NCT02106195)
Molecules 2017, 22, 134 12 of 24

investigating the efficacy of KD025 for the treatment of psoriasis have recently been completed, the
results of these trials will be available soon. Another study with a similar objective (NCT02852967) has
just started recruitment and will presumably be completed in 2018.

5.3.2. MAPK Inhibition

In contrast to effector T-cells, Tregs constitutively express GITR at a high level [23]. Interestingly,
ligation of GITR with its cognate ligand GITRL can abrogate suppressive function of Tregs [194].
The differentiation of naïve CD4+ T-cells was skewed toward the Th17-lineage when cultured with
GITRL protein. Besides, the administration of recombinant GITRL resulted in enhanced Th17-cell
generation and exacerbation of arthritis in CIA mice [195].
Tang et al. [196] have proposed the molecular mechanism underlying GITRL modulation of
Th17-cells to be based on enhanced phosphorylation of p38 MAPK and subsequent phosphorylation
of STAT3. Elevated levels of p38 MAPK phosphorylation in RA CD4+ T-cells correlated with
increased serum autoantibody levels in these patients [196]. More recently, Li et al. [197] reported that
elevated concentrations of GITRL were found in RA synovial fluid and serum, and that GITRL levels
correlated with autoantibody production. Notably, administration of a p38 MAPK inhibitor resulted in
suppression of GITRL-induced Th17-differentiation and ameliorated disease activity in CIA mice [196].
Unfortunately, several specific pharmacologic inhibitors of p38 MAPK inhibitors were found to be
ineffective in clinical studies of RA [198].

6. Conclusions
A bulk of evidence has highlighted a shift of the Th17/Treg equilibrium towards the
pro-inflammatory Th17-program in several autoimmune disorders, contributing to their progression
and recurrent clinical exacerbation. Substantial progress in understanding the development, function
and reciprocal regulation of Th17 cells and Tregs yielded a high therapeutic potential for targeting
these cell populations. The pathophysiology of autoimmunity however, is complex, explaining
the observations that certain therapeutic strategies are effective in some AIDs (e.g., IL-6R blockade
in RA [10]), while exhibiting no benefit in others (e.g., IL-6R blockade in AS [111]). Attention
must furthermore be drawn to the physiologic role of Th17-cells and -cytokines. For example,
IL-17 confers host defense and, in addition to other Th17-cytokines like IL-22, participates in
the maintenance of immune homeostasis at mucosal surfaces, especially in the gut [85]. IL-17
neutralization was accompanied by high rates of serious adverse events and fungal infections in
CD patients [83,84], despite being highly effective in the treatment of psoriasis [5–8,72]. Recently, it was
shown that Th17 is not a uniform subset but rather consists of a non-pathogenic and a pathogenic cell
population [61–66]. Targeting pathogenic Th17-cells alone might therefore be the next step to ameliorate
Th17/Treg-targeted therapies. Moreover, little is known about the consequences of long-term inhibition
of the IL-17 pathway. Various novel candidate molecules to beneficially re-shape the Th17/Treg
imbalance have recently shown promising results in animal models [116,118,120,122]. The application
of these substances still poses safety issues in humans and requires further evaluation before it can be
tested in clinical trials in humans.
In summary, there are still multiple challenges to identify, develop and implement the “ideal”
Th17/Treg-targeted interventional strategy with respect to the treatment of autoimmunity.

Author Contributions: P.F. and J.F. wrote the article. M.S., W.G. and C.D. provided intellectual input and critically
reviewed the manuscript.
Conflicts of Interest: The authors declare no conflicts of interest.
Molecules 2017, 22, 134 13 of 24

References
1. Grant, C.R.; Liberal, R.; Mieli-Vergani, G.; Vergani, D.; Longhi, M.S. Regulatory T-cells in autoimmune
diseases: Challenges, controversies and—Yet—Unanswered questions. Autoimmun. Rev. 2015, 14, 105–116.
[CrossRef] [PubMed]
2. Han, L.; Yang, J.; Wang, X.; Li, D.; Lv, L.; Li, B. Th17 cells in autoimmune diseases. Front. Med. 2015, 9, 10–19.
[CrossRef] [PubMed]
3. Beringer, A.; Noack, M.; Miossec, P. IL-17 in Chronic Inflammation: From Discovery to Targeting.
Trends Mol. Med. 2016, 22, 230–241. [CrossRef] [PubMed]
4. Waite, J.C.; Skokos, D. Th17 response and inflammatory autoimmune diseases. Int. J. Inflam. 2012, 2012,
819467. [CrossRef] [PubMed]
5. Hueber, W.; Patel, D.D.; Dryja, T.; Wright, A.M.; Koroleva, I.; Bruin, G.; Antoni, C.; Draelos, Z.; Gold, M.H.;
Group, P.S.; et al. Effects of AIN457, a fully human antibody to interleukin-17A, on psoriasis, rheumatoid
arthritis, and uveitis. Sci. Transl. Med. 2010, 2, 52ra72. [CrossRef] [PubMed]
6. Papp, K.A.; Langley, R.G.; Sigurgeirsson, B.; Abe, M.; Baker, D.R.; Konno, P.; Haemmerle, S.; Thurston, H.J.;
Papavassilis, C.; Richards, H.B. Efficacy and safety of secukinumab in the treatment of moderate-to-severe
plaque psoriasis: A randomized, double-blind, placebo-controlled phase II dose-ranging study. Br. J. Dermatol.
2013, 168, 412–421. [CrossRef] [PubMed]
7. Langley, R.G.; Elewski, B.E.; Lebwohl, M.; Reich, K.; Griffiths, C.E.M.; Papp, K.; Puig, L.; Nakagawa, H.;
Spelman, L.; Sigurgeirsson, B.; et al. Secukinumab in plaque psoriasis—Results of two phase 3 trials. N. Engl.
J. Med. 2014, 371, 326–338. [CrossRef] [PubMed]
8. Blauvelt, A.; Prinz, J.C.; Gottlieb, A.B.; Kingo, K.; Sofen, H.; Ruer-Mulard, M.; Singh, V.; Pathan, R.;
Papavassilis, C.; Cooper, S. Secukinumab administration by pre-filled syringe: Efficacy, safety and usability
results from a randomized controlled trial in psoriasis (FEATURE). Br. J. Dermatol. 2015, 172, 484–493.
[CrossRef] [PubMed]
9. Wu, P.; Nielsen, T.E.; Clausen, M.H. FDA-approved small-molecule kinase inhibitors. Trends Pharmacol. Sci.
2015, 36, 422–439. [CrossRef] [PubMed]
10. Teitsma, X.M.; Marijnissen, A.K.A.; Bijlsma, J.W.J.; Lafeber, F.P.J.; Jacobs, J.W.G. Tocilizumab as monotherapy
or combination therapy for treating active rheumatoid arthritis: A meta-analysis of efficacy and safety
reported in randomized controlled trials. Arthritis Res. Ther. 2016, 18, 211. [CrossRef] [PubMed]
11. Turnier, J.L.; Brunner, H.I. Tocilizumab for treating juvenile idiopathic arthritis. Expert Opin. Biol. Ther. 2016,
16, 559–566. [CrossRef] [PubMed]
12. Han, J.; Sun, L.; Fan, X.; Wang, Z.; Cheng, Y.; Zhu, J.; Jin, T. Role of regulatory B cells in neuroimmunologic
disorders. J. Neurosci. Res. 2016, 94, 693–701. [CrossRef] [PubMed]
13. Cosmi, L.; Liotta, F.; Lazzeri, E.; Francalanci, M.; Angeli, R.; Mazzinghi, B.; Santarlasci, V.; Manetti, R.;
Vanini, V.; Romagnani, P.; et al. Human CD8+CD25+ thymocytes share phenotypic and functional features
with CD4+CD25+ regulatory thymocytes. Blood 2003, 102, 4107–4115. [CrossRef] [PubMed]
14. Vignali, D.A.A.; Collison, L.W.; Workman, C.J. How regulatory T cells work. Nat. Rev. Immunol. 2009, 8,
523–532. [CrossRef] [PubMed]
15. Bluestone, J.A.; Abbas, A.K. Natural versus adaptive regulatory T cells. Nat. Rev. Immunol. 2003, 3, 253–257.
[CrossRef] [PubMed]
16. Piccirillo, C.A.; Letterio, J.J.; Thornton, A.M.; McHugh, R.S.; Mamura, M.; Mizuhara, H.; Shevach, E.M.
CD4+CD25+ Regulatory T Cells Can Mediate Suppressor Function in the Absence of Transforming Growth
Factor β1 Production and Responsiveness. J. Exp. Med. 2002, 196, 237–245. [CrossRef] [PubMed]
17. Bacchetta, R.; Barzaghi, F.; Roncarolo, M.-G. From IPEX syndrome to FOXP3 mutation: A lesson on immune
dysregulation. Ann. N. Y. Acad. Sci. 2016. [CrossRef] [PubMed]
18. Godfrey, V.L.; Wilkinson, J.E.; Russell, L.B. X-linked lymphoreticular disease in the scurfy (sf) mutant mouse.
Am. J. Pathol. 1991, 138, 1379–1387. [PubMed]
19. Williams, L.M.; Rudensky, A.Y. Maintenance of the Foxp3-dependent developmental program in mature
regulatory T cells requires continued expression of Foxp3. Nat. Immunol. 2007, 8, 277–284. [CrossRef]
[PubMed]
20. Mahmud, S.A.; Manlove, L.S.; Farrar, M.A. Interleukin-2 and STAT5 in regulatory T cell development and
function. JAK-STAT 2013, 2, e23154. [CrossRef] [PubMed]
Molecules 2017, 22, 134 14 of 24

21. Takahashi, T.; Tagami, T.; Yamazaki, S.; Uede, T.; Shimizu, J.; Sakaguchi, N.; Mak, T.W.; Sakaguchi, S.
Immunologic self-tolerance maintained by CD25(+)CD4(+) regulatory T cells constitutively expressing
cytotoxic T lymphocyte-associated antigen 4. J. Exp. Med. 2000, 192, 303–309. [CrossRef] [PubMed]
22. Hamann, A.; Klugewitz, K.; Austrup, F.; Jablonski-Westrich, D. Activation induces rapid and profound
alterations in the trafficking of T cells. Eur. J. Immunol. 2000, 30, 3207–3218. [CrossRef]
23. De Boer, O.J.; van der Loos, C.M.; Teeling, P.; van der Wal, A.C.; Teunissen, M.B. Immunohistochemical
Analysis of Regulatory T Cell Markers FOXP3 and GITR on CD4+CD25+ T Cells in Normal Skin and
Inflammatory Dermatoses. J. Histochem. Cytochem. 2007, 55, 891–898. [CrossRef] [PubMed]
24. Raimondi, G.; Shufesky, W.J.; Tokita, D.; Morelli, A.E.; Thomson, A.W.; Raimondi, G.; Shufesky, W.J.;
Tokita, D.; Morelli, A.E.; Thomson, A.W. Regulated compartmentalization of programmed cell death-1
discriminates CD4+CD25+ resting regulatory T cells from activated T cells. J. Immunol. 2006, 176, 2808–2816.
[CrossRef] [PubMed]
25. Garcia Santana, C.A.; Tung, J.W.; Gulnik, S. Human Treg cells are characterized by low/negative CD6
expression. Cytom. A 2014, 85, 901–908. [CrossRef] [PubMed]
26. Salgado, F.J.; Pérez-Díaz, A.; Villanueva, N.M.; Lamas, O.; Arias, P.; Nogueira, M. CD26: A negative selection
marker for human Treg cells. Cytom. A 2012, 81, 843–855. [CrossRef] [PubMed]
27. Kleinewietfeld, M.; Starke, M.; Di Mitri, D.; Borsellino, G.; Battistini, L.; Rötzschke, O.; Falk, K. CD49d
provides access to “untouched” human Foxp3+ Treg free of contaminating effector cells. Blood 2009, 113,
827–836. [CrossRef] [PubMed]
28. Shen, L.S.; Wang, J.; Shen, D.F.; Yuan, X.L.; Dong, P.; Li, M.X.; Xue, J.; Zhang, F.M.; Ge, H.L.; Xu, D.
CD4+CD25+CD127low/- regulatory T cells express Foxp3 and suppress effector T cell proliferation and
contribute to gastric cancers progression. Clin. Immunol. 2009, 131, 109–118. [CrossRef] [PubMed]
29. Hartigan-O’Connor, D.J.; Poon, C.; Sinclair, E.; McCune, J.M. Human CD4+ regulatory T cells express lower
levels of the IL-7 receptor alpha chain (CD127), allowing consistent identification and sorting of live cells.
J. Immunol. Methods 2007, 319, 41–52. [CrossRef] [PubMed]
30. Li, M.O.; Sanjabi, S.; Flavell, R.A. Transforming Growth Factor-β Controls Development, Homeostasis, and
Tolerance of T Cells by Regulatory T Cell-Dependent and -Independent Mechanisms. Immunity 2006, 25,
455–471. [CrossRef] [PubMed]
31. Marie, J.C.; Liggitt, D.; Rudensky, A.Y. Cellular Mechanisms of Fatal Early-Onset Autoimmunity in Mice
with the T Cell-Specific Targeting of Transforming Growth Factor-β Receptor. Immunity 2006, 25, 441–454.
[CrossRef] [PubMed]
32. Li, M.O.; Flavell, R.A. Contextual Regulation of Inflammation: A Duet by Transforming Growth Factor-β
and Interleukin-10. Immunity 2008, 28, 468–476. [CrossRef] [PubMed]
33. Li, M.O.; Flavell, R.A. TGF-β: A Master of All T Cell Trades. Cell 2008, 134, 392–404. [CrossRef]
34. Rubtsov, Y.P.; Rasmussen, J.P.; Chi, E.Y.; Fontenot, J.; Castelli, L.; Ye, X.; Treuting, P.; Siewe, L.; Roers, A.;
Henderson, W.R.; et al. Regulatory T Cell-Derived Interleukin-10 Limits Inflammation at Environmental
Interfaces. Immunity 2008, 28, 546–558. [CrossRef] [PubMed]
35. Chaudhry, A.; Samstein, R.M.; Treuting, P.; Liang, Y.; Pils, M.C.; Heinrich, J.M.; Jack, R.S.; Wunderlich, F.T.;
Brüning, J.C.; Müller, W.; et al. Interleukin-10 Signaling in Regulatory T Cells Is Required for Suppression of
Th17 Cell-Mediated Inflammation. Immunity 2011, 34, 566–578. [CrossRef] [PubMed]
36. Huber, S.; Gagliani, N.; Esplugues, E.; O’Connor, W.; Huber, F.J.; Chaudhry, A.; Kamanaka, M.; Kobayashi, Y.;
Booth, C.J.; Rudensky, A.Y.; et al. Th17 Cells Express Interleukin-10 Receptor and Are Controlled by Foxp3-
and Foxp3+ Regulatory CD4+ T Cells in an Interleukin-10-Dependent Manner. Immunity 2011, 34, 554–565.
[CrossRef] [PubMed]
37. Wadwa, M.; Klopfleisch, R.; Adamczyk, A.; Frede, A.; Pastille, E.; Mahnke, K.; Hansen, W.; Geffers, R.;
Lang, K.S.; Buer, J.; et al. IL-10 downregulates CXCR3 expression on Th1 cells and interferes with their
migration to intestinal inflammatory sites. Mucosal Immunol. 2016, 9, 1263–1277. [CrossRef] [PubMed]
38. Murai, M.; Turovskaya, O.; Kim, G.; Madan, R.; Karp, C.L.; Kronenberg, M. Interleukin 10 acts on regulatory
T cells to maintain expression of the transcription factor Foxp3 and suppressive function in mice with colitis.
Nat. Immunol. 2009, 10, 1178–1184. [CrossRef] [PubMed]
39. Collison, L.W.; Chaturvedi, V.; Henderson, A.L.; Giacomin, P.R.; Guy, C.; Bankoti, J.; Finkelstein, D.; Forbes, K.;
Workman, C.J.; Brown, S.A.; et al. IL-35-mediated induction of a potent regulatory T cell population.
Nat. Immunol. 2010, 11, 1093–1101. [CrossRef] [PubMed]
Molecules 2017, 22, 134 15 of 24

40. Collison, L.W.; Workman, C.J.; Kuo, T.T.; Boyd, K.; Wang, Y.; Vignali, K.M.; Cross, R.; Sehy, D.; Blumberg, R.S.;
Vignali, D.A.A. The inhibitory cytokine IL-35 contributes to regulatory T-cell function. Nature 2007, 450,
566–569. [CrossRef] [PubMed]
41. Wirtz, S.; Billmeier, U.; Mcheldlidze, T.; Blumberg, R.S.; Neurath, M.F. Interleukin-35 Mediates Mucosal
Immune Responses That Protect Against T-Cell–Dependent Colitis. Gastroenterology 2011, 141, 1875–1886.
[CrossRef] [PubMed]
42. Harrington, L.E.; Hatton, R.D.; Mangan, P.R.; Turner, H.; Murphy, T.L.; Murphy, K.M.; Weaver, C.T.
Interleukin 17–producing CD4+ effector T cells develop via a lineage distinct from the T helper type 1
and 2 lineages. Nat. Immunol. 2005, 6, 1123–1132. [CrossRef] [PubMed]
43. Park, H.; Li, Z.; Yang, X.O.; Chang, S.H.; Nurieva, R.; Wang, Y.; Wang, Y.; Hood, L.; Zhu, Z.; Tian, Q.; et al.
A distinct lineage of CD4 T cells regulates tissue inflammation by producing interleukin 17. Nat. Immunol.
2005, 6, 1133–1141. [CrossRef] [PubMed]
44. Bettelli, E.; Korn, T.; Oukka, M.; Kuchroo, V.K. Induction and effector functions of T(H)17 cells. Nature 2008,
453, 1051–1057. [CrossRef] [PubMed]
45. Torchinsky, M.B.; Blander, J.M. T helper 17 cells: Discovery, function, and physiological trigger. Cell. Mol.
Life Sci. 2010, 67, 1407–1421. [CrossRef] [PubMed]
46. Bettelli, E.; Carrier, Y.; Gao, W.; Korn, T.; Strom, T.B.; Oukka, M.; Weiner, H.L.; Kuchroo, V.K. Reciprocal
developmental pathways for the generation of pathogenic effector TH17 and regulatory T cells. Nature 2006,
441, 235–238. [CrossRef] [PubMed]
47. Manel, N.; Unutmaz, D.; Littman, D.R. The differentiation of human Th-17 cells requires transforming
growth factor-β and induction of the nuclear receptor RORγT. Nat. Immunol. 2008, 9, 641–649. [CrossRef]
[PubMed]
48. Ichiyama, K.; Yoshida, H.; Wakabayashi, Y.; Chinen, T.; Saeki, K.; Nakaya, M.; Takaesu, G.; Hori, S.;
Yoshimura, A.; Kobayashi, T. Foxp3 Inhibits RORγt-mediated IL-17A mRNA Transcription through Direct
Interaction with RORγt. J. Biol. Chem. 2008, 283, 17003–17008. [CrossRef] [PubMed]
49. Korn, T.; Bettelli, E.; Gao, W.; Awasthi, A.; Jager, A.; Strom, T.B.; Oukka, M.; Kuchroo, V.K. IL-21 initiates
an alternative pathway to induce proinflammatory T(H)17 cells. Nature 2007, 448, 484–487. [CrossRef]
[PubMed]
50. Ivanov, I.I.; Zhou, L.; Littman, D.R. Transcriptional regulation of Th17 cell differentiation. Semin. Immunol.
2007, 19, 409–417. [CrossRef] [PubMed]
51. Wilson, N.J.; Boniface, K.; Chan, J.R.; McKenzie, B.S.; Blumenschein, W.M.; Mattson, J.D.; Basham, B.;
Smith, K.; Chen, T.; Morel, F.; et al. Development, cytokine profile and function of human interleukin
17-producing helper T cells. Nat. Immunol. 2007, 8, 950–957. [CrossRef] [PubMed]
52. Acosta-Rodriguez, E.V.; Rivino, L.; Geginat, J.; Jarrossay, D.; Gattorno, M.; Lanzavecchia, A.; Sallusto, F.;
Napolitani, G. Surface phenotype and antigenic specificity of human interleukin 17-producing T helper
memory cells. Nat. Immunol. 2007, 8, 639–646. [CrossRef] [PubMed]
53. Maggi, L.; Santarlasci, V.; Capone, M.; Peired, A.; Frosali, F.; Crome, S.Q.; Querci, V.; Fambrini, M.; Liotta, F.;
Levings, M.K.; et al. CD161 is a marker of all human IL-17-producing T-cell subsets and is induced by RORC.
Eur. J. Immunol. 2010, 40, 2174–2181. [CrossRef] [PubMed]
54. Annunziato, F.; Cosmi, L.; Liotta, F.; Maggi, E.; Romagnani, S. Defining the human T helper 17 cell phenotype.
Trends Immunol. 2012, 33, 505–512. [CrossRef] [PubMed]
55. Pelletier, M.; Maggi, L.; Micheletti, A.; Lazzeri, E.; Tamassia, N.; Cosmi, L.; Lunardi, C.; Annunziato, F.;
Romagnani, S.; Marco, A.; et al. Evidence for a cross-talk between human neutrophils and Th17 cells
Evidence for a cross-talk between human neutrophils and Th17 cells. Blood 2010, 115, 335–343. [CrossRef]
[PubMed]
56. Yang, L.; Anderson, D.E.; Baecher-Allan, C.; Hastings, W.D.; Bettelli, E.; Oukka, M.; Kuchroo, V.K.;
Hafler, D.A. IL-21 and TGF-β are required for differentiation of human TH17 cells. Nature 2008, 454,
350–352. [CrossRef] [PubMed]
57. Nurieva, R.; Yang, X.O.; Martinez, G.; Zhang, Y.; Panopoulos, A.D.; Ma, L.; Schluns, K.; Tian, Q.;
Watowich, S.S.; Jetten, A.M.; et al. Essential autocrine regulation by IL-21 in the generation of inflammatory
T cells. Nature 2007, 448, 480–483. [CrossRef] [PubMed]
58. Rutz, S.; Eidenschenk, C.; Ouyang, W. IL-22, not simply a Th17 cytokine. Immunol. Rev. 2013, 252, 116–132.
[CrossRef] [PubMed]
Molecules 2017, 22, 134 16 of 24

59. Xie, Q.; Wang, S.C.; Li, J. Interleukin 22, a potential therapeutic target for rheumatoid arthritis. J. Rheumatol.
2012, 39, 2220–2221. [CrossRef] [PubMed]
60. Stephen-Victor, E.; Fickenscher, H.; Bayry, J. IL-26: An Emerging Proinflammatory Member of the IL-10
Cytokine Family with Multifaceted Actions in Antiviral, Antimicrobial, and Autoimmune Responses.
PLoS Pathog. 2016, 12, 4–9. [CrossRef] [PubMed]
61. McGeachy, M.J.; Bak-Jensen, K.S.; Chen, Y.; Tato, C.M.; Blumenschein, W.; McClanahan, T.; Cua, D.J. TGF-beta
and IL-6 drive the production of IL-17 and IL-10 by T cells and restrain Th-17 cell-mediated pathology.
Nat. Immunol. 2007, 8, 1390–1397. [CrossRef] [PubMed]
62. Ghoreschi, K.; Laurence, A.; Yang, X.; Tato, C.M.; Mandy, J.; Konkel, J.; Ramos, H.L.; Wei, L.; Davidson, T.;
Grainger, J.; et al. Generation of Pathogenic Th17 Cells in the Absence of TGF-β Signaling. Nature 2010, 467,
967–971. [CrossRef] [PubMed]
63. Chung, Y.; Chang, S.H.; Martinez, G.J.; Yang, X.O.; Kang, H.S.; Ma, L.; Watowich, S.S.; Jetten, A.; Tian, Q.;
Dong, C. Critical regulation of early Th17 cell differentiation by IL-1 signaling. Immunity 2009, 30, 576–587.
[CrossRef] [PubMed]
64. Lee, Y.; Awasthi, A.; Yosef, N.; Quintana, F.J.; Xiao, S. Induction and molecular signature of pathogenic TH17
cells. Nat. Immunol. 2012, 13, 991–999. [CrossRef] [PubMed]
65. Wu, C.; Yosef, N.; Thalhamer, T.; Zhu, C.; Xiao, S.; Regev, A.; Kuchroo, V. Induction of pathogenic TH17 cells
by inducible salt-sensing kinase SGK1. Nature 2013, 496, 513–517. [CrossRef] [PubMed]
66. Wang, C.; Yosef, N.; Gaublomme, J.; Wu, C.; Lee, Y.; Clish, C.B.; Kaminski, J.; Xiao, S.; Zu Horste, G.M.;
Pawlak, M.; et al. CD5L/AIM Regulates Lipid Biosynthesis and Restrains Th17 Cell Pathogenicity. Cell 2015,
163, 1413–1427. [CrossRef] [PubMed]
67. Yang, X.O.; Nurieva, R.; Martinez, G.J.; Kang, H.S.; Pappu, B.P.; Shah, B.; Chang, S.H.; Schluns, K.S.;
Watowich, S.S.; Feng, X.; et al. Molecular antagonism and plasticity of regulatory and inflammatory T cell
programs. Immunity 2008, 29, 44–56. [CrossRef] [PubMed]
68. Deknuydt, F.; Bioley, G.; Valmori, D.; Ayyoub, M. IL-1β and IL-2 convert human Treg into TH17 cells.
Clin. Immunol. 2009, 131, 298–307. [CrossRef] [PubMed]
69. Zheng, S.G.; Wang, J.; Horwitz, D.A. Cutting Edge: Foxp3+CD4+CD25+ Regulatory T Cells Induced by IL-2
and TGF-β Are Resistant to Th17 Conversion by IL-6. J. Immunol. 2008, 180, 7112–7116. [CrossRef] [PubMed]
70. Komatsu, N.; Okamoto, K.; Sawa, S.; Nakashima, T.; Oh-hora, M.; Kodama, T.; Tanaka, S.; Bluestone, J.A.;
Takayanagi, H. Pathogenic conversion of Foxp3+ T cells into TH17 cells in autoimmune arthritis. Nat. Med.
2014, 20, 62–68. [CrossRef] [PubMed]
71. Gagliani, N.; Vesely, M.C.A.; Iseppon, A.; Brockmann, L.; Xu, H.; Palm, N.W.; de Zoete, M.R.;
Licona-Limón, P.; Paiva, R.S.; Ching, T.; et al. Th17 cells transdifferentiate into regulatory T cells during
resolution of inflammation. Nature 2015, 523, 221–225. [CrossRef] [PubMed]
72. Farahnik, B.; Beroukhim, K.; Abrouk, M.; Nakamura, M.; Zhu, T.H.; Singh, R.; Lee, K.; Bhutani, T.; Koo, J.
Brodalumab for the Treatment of Psoriasis: A Review of Phase III Trials. Dermatol. Ther. (Heidelb.) 2016, 6,
111–124. [CrossRef] [PubMed]
73. McInnes, I.B.; Mease, P.J.; Kirkham, B.; Kavanaugh, A.; Ritchlin, C.T.; Rahman, P.; Van Der Heijde, D.;
Landewe, R.; Conaghan, P.G.; Gottlieb, A.B.; et al. Secukinumab, a human anti-interleukin-17A monoclonal
antibody, in patients with psoriatic arthritis (FUTURE 2): A randomised, double-blind, placebo-controlled,
phase 3 trial. Lancet 2015, 386, 1137–1146. [CrossRef]
74. Mease, P.J.; McInnes, I.B.; Kirkham, B.; Kavanaugh, A.; Rahman, P.; van der Heijde, D.; Landewé, R.; Nash, P.;
Pricop, L.; Yuan, J.; et al. Secukinumab Inhibition of Interleukin-17A in Patients with Psoriatic Arthritis.
N. Engl. J. Med. 2015, 373, 1329–1339. [CrossRef] [PubMed]
75. Baeten, D.; Sieper, J.; Braun, J.; Baraliakos, X.; Dougados, M.; Emery, P.; Deodhar, A.; Porter, B.; Martin, R.;
Andersson, M.; et al. Secukinumab, an Interleukin-17A Inhibitor, in Ankylosing Spondylitis. N. Engl. J. Med.
2015, 373, 2534–2548. [CrossRef] [PubMed]
76. Baeten, D.; Baraliakos, X.; Braun, J.; Sieper, J.; Emery, P.; van der Heijde, D.; McInnes, I.; van Laar, J.M.;
Landewé, R.; Wordsworth, P.; et al. Anti-interleukin-17A monoclonal antibody secukinumab in treatment of
ankylosing spondylitis: A randomised, double-blind, placebo-controlled trial. Lancet 2013, 382, 1705–1713.
[CrossRef]
Molecules 2017, 22, 134 17 of 24

77. Burmester, G.R.; Durez, P.; Shestakova, G.; Genovese, M.C.; Schulze-Koops, H.; Li, Y.; Wang, Y.A.;
Lewitzky, S.; Koroleva, I.; Berneis, A.A.; et al. Association of HLA-DRB1 alleles with clinical responses to the
anti-interleukin-17A monoclonal antibody secukinumab in active rheumatoid arthritis. Rheumatology 2016,
55, 49–55. [CrossRef] [PubMed]
78. Genovese, M.C.; Durez, P.; Richards, H.B.; Supronik, J.; Dokoupilova, E.; Aelion, J.A.; Lee, S.-H.;
Codding, C.E.; Kellner, H.; Ikawa, T.; et al. One-year Efficacy and Safety Results of Secukinumab in
Patients With Rheumatoid Arthritis: Phase II, Dose-finding, Double-blind, Randomized, Placebo-controlled
Study. J. Rheumatol. 2014, 41, 414–421. [CrossRef] [PubMed]
79. Genovese, M.C.; Greenwald, M.; Cho, C.-S.; Berman, A.; Jin, L.; Cameron, G.S.; Benichou, O.; Xie, L.;
Braun, D.; Berclaz, P.-Y.; et al. A Phase II Randomized Study of Subcutaneous Ixekizumab, an
Anti-Interleukin-17 Monoclonal Antibody, in Rheumatoid Arthritis Patients Who Were Naive to Biologic
Agents or Had an Inadequate Response to Tumor Necrosis Factor Inhibitors. Arthritis Rheumatol. 2014, 66,
1693–1704. [CrossRef] [PubMed]
80. Martin, D.A.; Churchill, M.; Flores-Suarez, L.; Cardiel, M.H.; Wallace, D.; Martin, R.; Phillips, K.; Kaine, J.L.;
Dong, H.; Salinger, D.; et al. A phase Ib multiple ascending dose study evaluating safety, pharmacokinetics,
and early clinical response of brodalumab, a human anti-IL-17R antibody, in methotrexate-resistant
rheumatoid arthritis. Arthritis Res. Ther. 2013, 15, R164. [CrossRef] [PubMed]
81. Genovese, M.C.; Durez, P.; Richards, H.B.; Supronik, J.; Dokoupilova, E.; Mazurov, V.; Aelion, J.A.; Lee, S.-H.;
Codding, C.E.; Kellner, H.; et al. Efficacy and safety of secukinumab in patients with rheumatoid arthritis:
A phase II, dose-finding, double-blind, randomised, placebo controlled study. Ann. Rheum. Dis. 2013, 72,
863–869. [CrossRef] [PubMed]
82. Pavelka, K.; Chon, Y.; Newmark, R.; Lin, S.-L.; Baumgartner, S.; Erondu, N. A Study to Evaluate the Safety,
Tolerability, and Efficacy of Brodalumab in Subjects with Rheumatoid Arthritis and an Inadequate Response
to Methotrexate. J. Rheumatol. 2015, 42, 912–919. [CrossRef] [PubMed]
83. Targan, S.R.; Feagan, B.G.; Vermeire, S.; Panaccione, R.; Melmed, G.Y.; Blosch, C.; Newmark, R.; Zhang, N.;
Chon, Y.; Lin, S.-L.; et al. A randomized, double-blind, placebo-controlled study to evaluate the safety,
tolerability, and efficacy of AMG 827 in subjects with moderate to severe crohn’s disease. Gastroenterology
2012, 143, e26. [CrossRef]
84. Hueber, W.; Sands, B.E.; Lewitzky, S.; Vandemeulebroecke, M.; Reinisch, W.; Higgins, P.D.R.; Wehkamp, J.;
Feagan, B.G.; Yao, M.D.; Karczewski, M.; et al. Secukinumab, a human anti-IL-17A monoclonal antibody, for
moderate to severe Crohn’s disease: Unexpected results of a randomised, double-blind placebo-controlled
trial. Gut 2012, 61, 1693–1700. [CrossRef] [PubMed]
85. O’Connor, W., Jr.; Zenewicz, L.A.; Flavell, R.A. The dual nature of T(H)17 cells: Shifting the focus to function.
Nat. Immunol. 2010, 11, 471–476. [CrossRef] [PubMed]
86. Langrish, C.L.; Chen, Y.; Blumenschein, W.M.; Mattson, J.; Basham, B.; Sedgwick, J.D.; McClanahan, T.;
Kastelein, R.A.; Cua, D.J. IL-23 drives a pathogenic T cell population that induces autoimmune inflammation.
J. Exp. Med. 2005, 201, 233–240. [CrossRef] [PubMed]
87. Lee, Y.; Kuchroo, V. Defining the functional states of Th17 cells. F1000Research 2015, 4, 1–7. [CrossRef]
[PubMed]
88. Fitch, E.; Harper, E.; Skorcheva, I.; Kurtz, S.E.; Blauvelt, A. Pathophysiology of psoriasis: Recent advances on
IL-23 and Th17 cytokines. Curr. Rheumatol. Rep. 2010, 9, 461–467. [CrossRef]
89. Lee, E.; Trepicchio, W.L.; Oestreicher, J.L.; Pittman, D.; Wang, F.; Chamian, F.; Dhodapkar, M.; Krueger, J.G.
Increased expression of interleukin 23 p19 and p40 in lesional skin of patients with psoriasis vulgaris.
J. Exp. Med. 2004, 199, 125–130. [CrossRef] [PubMed]
90. Cua, D.J.; Sherlock, J.; Chen, Y.; Murphy, C.A.; Joyce, B.; Seymour, B.; Lucian, L.; To, W.; Kwan, S.;
Churakova, T.; et al. Interleukin-23 rather than interleukin-12 is the critical cytokine for autoimmune
inflammation of the brain. Nature 2003, 421, 744–748. [CrossRef] [PubMed]
91. Murphy, C.A.; Langrish, C.L.; Chen, Y.; Blumenschein, W.; McClanahan, T.; Kastelein, R.A.; Sedgwick, J.D.;
Cua, D.J. Divergent pro- and antiinflammatory roles for IL-23 and IL-12 in joint autoimmune inflammation.
J. Exp. Med. 2003, 198, 1951–1957. [CrossRef] [PubMed]
92. Nakajima, K.; Kanda, T.; Takaishi, M.; Shiga, T.; Miyoshi, K.; Nakajima, H.; Kamijima, R.; Tarutani, M.;
Benson, J.M.; Elloso, M.M.; et al. Distinct roles of IL-23 and IL-17 in the development of psoriasis-like lesions
in a mouse model. J. Immunol. Res. 2011, 186, 4481–4489.
Molecules 2017, 22, 134 18 of 24

93. Leonardi, C.L.; Kimball, A.B.; Papp, K.A.; Yeilding, N.; Guzzo, C.; Wang, Y.; Li, S.; Dooley, L.T.; Gordon, K.B.
Efficacy and safety of ustekinumab, a human interleukin-12/23 monoclonal antibody, in patients with
psoriasis: 76-week results from a randomised, double-blind, placebo-controlled trial (PHOENIX 1). Lancet
2008, 371, 1665–1674. [CrossRef]
94. Papp, K.A.; Langley, R.G.; Lebwohl, M.; Krueger, G.G.; Szapary, P.; Yeilding, N.; Guzzo, C.; Hsu, M. Efficacy
and safety of ustekinumab, a human interleukin-12/23 monoclonal antibody, in patients with psoriasis:
52-week results from a randomised, double-blind, placebo-controlled trial (PHOENIX 2). Lancet 2008, 371,
1675–1684. [CrossRef]
95. Mcinnes, I.B.; Kavanaugh, A.; Gottlieb, A.B.; Puig, L.; Rahman, P.; Ritchlin, C.; Brodmerkel, C.; Li, S.; Wang, Y.
Efficacy and safety of ustekinumab in patients with active psoriatic arthritis: 1 year results of the phase 3,
multicentre, double-blind, placebo-controlled PSUMMIT 1 trial. Lancet 2013, 382, 780–789. [CrossRef]
96. Kavanaugh, A.; Ritchlin, C.; Rahman, P.; Puig, L.; Gottlieb, A.B.; Li, S.; Wang, Y.; Noonan, L.; Brodmerkel, C.;
Song, M.; et al. Ustekinumab, an anti-IL-12/23 p40 monoclonal antibody, inhibits radiographic progression
in patients with active psoriatic arthritis: Results of an integrated analysis of radiographic data from the
phase 3, multicentre, randomised, double-blind, placebo-c. Ann. Rheum. Dis. 2014, 73, 1000–1006. [CrossRef]
[PubMed]
97. Kavanaugh, A.; Puig, L.; Gottlieb, A.B.; Ritchlin, C.; You, Y.; Li, S.; Song, M.; Randazzo, B.; Rahman, P.;
Mcinnes, I.B. Efficacy and safety of ustekinumab in psoriatic arthritis patients with peripheral arthritis
and physician-reported spondylitis: Post-hoc analyses from two phase III, multicentre, double-blind,
placebo-controlled studies (PSUMMIT-1/PSUMMIT-2). Ann. Rheum. Dis. 2016, 75, 1984–1988. [CrossRef]
[PubMed]
98. Ritchlin, C.; Rahman, P.; Kavanaugh, A.; Mcinnes, I.B.; Puig, L.; Li, S.; Wang, Y.; Shen, Y.; Doyle, M.K.;
Mendelsohn, A.M.; et al. Efficacy and safety of the anti-IL-12/23 p40 monoclonal antibody, ustekinumab,
in patients with active psoriatic arthritis despite conventional non-biological and biological anti-tumour
necrosis factor therapy: 6-month and 1-year results of the controlled. Ann. Rheum. Dis. 2014, 73, 990–999.
[CrossRef] [PubMed]
99. Segal, B.M.; Constantinescu, C.S.; Raychaudhuri, A.; Kim, L.; Fidelus-Gort, R.; Kasper, L.H.
Repeated subcutaneous injections of IL12/23 p40 neutralising antibody, ustekinumab, in patients
with relapsing-remitting multiple sclerosis: A phase II, double-blind, placebo-controlled, randomised,
dose-ranging study. Lancet 2008, 7, 796–804. [CrossRef]
100. Gordon, K.B.; Langley, R.G.; Gottlieb, A.B.; Papp, K.A.; Krueger, G.G.; Strober, B.E.; Williams, D.A.; Gu, Y.;
Valdes, J.M. A phase III, randomized, controlled trial of the fully human IL-12/23 mAb briakinumab in
moderate-to-severe psoriasis. J. Investig. Dermatol. 2012, 132, 304–314. [CrossRef] [PubMed]
101. Krueger, J.G.; Ferris, L.K.; Menter, A.; Wagner, F.; White, A.; Visvanathan, S.; Lalovic, B.; Aslanyan, S.;
Wang, E.E.L.; Hall, D.; et al. Anti-IL-23A mAb BI 655066 for treatment of moderate-to-severe psoriasis:
Safety, efficacy, pharmacokinetics, and biomarker results of a single-rising-dose, randomized, double-blind,
placebo-controlled trial. J. Allergy Clin. Immunol. 2015, 136, 116–124. [CrossRef] [PubMed]
102. Samson, M.; Audia, S.; Janikashvili, N.; Ciudad, M.; Trad, M.; Fraszczak, J.; Ornetti, P.; Maillefert, J.F.;
Miossec, P.; Bonnotte, B. Brief report: Inhibition of interleukin-6 function corrects Th17/Treg cell imbalance
in patients with rheumatoid arthritis. Arthritis Rheum. 2012, 64, 2499–2503. [CrossRef] [PubMed]
103. Kikuchi, J.; Hashizume, M.; Kaneko, Y.; Yoshimoto, K.; Nishina, N.; Takeuchi, T. Peripheral blood
CD4+CD25+CD127low regulatory T cells are significantly increased by tocilizumab treatment in patients
with rheumatoid arthritis: Increase in regulatory T cells correlates with clinical response. Arthritis Res. Ther.
2015, 17, 1–10. [CrossRef] [PubMed]
104. Li, S.; Wu, Z.; Li, L.; Liu, X. Interleukin-6 (IL-6) Receptor Antagonist Protects Against Rheumatoid Arthritis.
Med. Sci. Monit. 2016, 22, 2113–2118. [CrossRef] [PubMed]
105. Tada, Y.; Ono, N.; Suematsu, R.; Tashiro, S.; Sadanaga, Y.; Tokuda, Y.; Ono, Y.; Nakao, Y.; Maruyama, A.;
Ohta, A.; et al. The balance between Foxp3 and Ror-γt expression in peripheral blood is altered by
tocilizumab and abatacept in patients with rheumatoid arthritis. BMC Musculoskelet. Disord. 2016, 17,
290. [CrossRef] [PubMed]
Molecules 2017, 22, 134 19 of 24

106. Pesce, B.; Soto, L.; Sabugo, F.; Wurmann, P.; Cuchacovich, M.; López, M.N.; Sotelo, P.H.; Molina, M.C.;
Aguillón, J.C.; Catalán, D. Effect of interleukin-6 receptor blockade on the balance between regulatory T cells
and T helper type 17 cells in rheumatoid arthritis patients. Clin. Exp. Immunol. 2013, 171, 237–242. [CrossRef]
[PubMed]
107. Lee, S.J.; Park, W.; Park, S.H.; Shim, S.C.; Baek, H.J.; Yoo, D.H.; Kim, H.A.; Lee, S.K.; Leee, Y.J.; Park, Y.E.; et al.
Low baseline interleukin-17A levels are associated with better treatment response at 12 weeks to tocilizumab
therapy in rheumatoid arthritis patients. J. Immunol. Res. 2015, 2015, 487230. [CrossRef] [PubMed]
108. Strand, V.; Kosinski, M.; Chen, C.; Joseph, G.; Rendas-baum, R.; Graham, N.M.H.; Van Hoogstraten, H.;
Bayliss, M.; Fan, C.; Huizinga, T.; et al. Sarilumab plus methotrexate improves patient-reported outcomes in
patients with active rheumatoid arthritis and inadequate responses to methotrexate: Results of a phase III
trial. Arthritis Res. Ther. 2016, 18, 1–10. [CrossRef] [PubMed]
109. Genovese, M.C.; Fleischmann, R.; Kivitz, A.J.; Rell-Bakalarska, M.; Martincova, R.; Fiore, S.; Rohane, P.;
Van Hoogstraten, H.; Garg, A.; Fan, C.; et al. Sarilumab Plus Methotrexate in Patients with Active Rheumatoid
Arthritis and Inadequate Response to Methotrexate. Results of a Phase III Study. Arthritis Rheumatol. 2015,
67, 1424–1437. [CrossRef] [PubMed]
110. Boyapati, A.; Msihid, J.; Fiore, S.; van Adelsberg, J.; Graham, N.M.H.; Hamilton, J.D. Sarilumab plus
methotrexate suppresses circulating biomarkers of bone resorption and synovial damage in patients
with rheumatoid arthritis and inadequate response to methotrexate: A biomarker study of MOBILITY.
Arthritis Res. Ther. 2016, 18, 225. [CrossRef] [PubMed]
111. Sieper, J.; Braun, J.; Kay, J.; Badalamenti, S.; Radin, A.R.; Jiao, L.; Fiore, S.; Momtahen, T.; Yancopoulos, G.D.;
Stahl, N.; et al. Sarilumab for the treatment of ankylosing spondylitis: Results of a Phase II, randomised,
double-blind, placebo-controlled study (ALIGN). Ann. Rheum. Dis. 2015, 74, 1051–1057. [CrossRef]
[PubMed]
112. Weinblatt, M.E.; Mease, P.; Mysler, E.; Takeuchi, T.; Drescher, E.; Berman, A.; Xing, J.; Zilberstein, M.;
Banerjee, S.; Emery, P. The Efficacy and Safety of Subcutaneous Clazakizumab in Patients with
Moderate-to-Severe Rheumatoid Arthritis and an Inadequate Response to Methotrexate. Arthritis Rheumatol.
2015, 67, 2591–2600. [CrossRef] [PubMed]
113. Mease, P.J.; Gottlieb, A.B.; Berman, A.; Drescher, E.; Xing, J.; Wong, R.; Banerjee, S. The Efficacy and Safety
of Clazakizumab, an Anti-Interleukin-6 Monoclonal Antibody, in a Phase IIb Study of Adults With Active
Psoriatic Arthritis. Arthritis Rheumatol. 2016, 68, 2163–2173. [CrossRef] [PubMed]
114. Cook, D.N.; Kang, H.S.; Jetten, A.M. Retinoic acid orphan receptors (RORs): Regulatory functions in
immunity, development, circadian rhythm and metabolism. Nucl. Recept. Res. 2015, 2, 101185. [CrossRef]
[PubMed]
115. Fujita-Sato, S.; Ito, S.; Isobe, T.; Ohyama, T.; Wakabayashi, K.; Morishita, K.; Ando, O.; Isono, F. Structural
basis of digoxin that antagonizes RORγt receptor activity and suppresses Th17 cell differentiation and
interleukin (IL)-17 production. J. Biol. Chem. 2011, 286, 31409–31417. [CrossRef] [PubMed]
116. Huh, J.R.; Leung, M.W.L.; Huang, P.; Ryan, D.A.; Michael, R.; Malapaka, R.R.V.; Chow, J.; Manel, N.;
Ciofani, M.; Kim, S.V.; et al. Digoxin and its derivatives suppress Th17 cell differentiation by antagonizing
RORγt activity. Nature 2011, 472, 486–490. [CrossRef] [PubMed]
117. Lee, J.; Baek, S.; Lee, J.; Lee, J.; Lee, D.; Park, M.; Cho, M.; Park, S.; Kwok, S. Digoxin ameliorates autoimmune
arthritis via suppression of Th17 differentiation. Int. Immunopharmacol. 2015, 26, 103–111. [CrossRef]
[PubMed]
118. Baek, S.-Y.; Lee, J.J.; Lee, D.-G.; Park, M.-K.; Lee, J.J.; Kwok, S.-K.; Cho, M.; Park, S.-H. Ursolic acid ameliorates
autoimmune arthritis via suppression of Th17 and B cell differentiation. Acta Pharmacol. Sin. 2014, 35, 1–11.
[CrossRef] [PubMed]
119. Xiao, S.; Yosef, N.; Yang, J.; Wang, Y.; Zhou, L.; Zhu, C.; Wu, C.; Baloglu, E.; Schmidt, D.; Ramesh, R.; et al.
Small-molecule RORγt antagonists inhibit T helper 17 cell transcriptional network by divergent mechanisms.
Immunity 2014, 40, 477–489. [CrossRef] [PubMed]
120. Skepner, J.; Trocha, M.; Ramesh, R.; Qu, X.A.; Schmidt, D.; Baloglu, E.; Lobera, M.; Davis, S.; Nolan, M.A.;
Thaddeus, J.; et al. In vivo regulation of gene expression and T helper type 17 differentiation by RORγt
inverse agonists. Immunology 2014, 145, 347–356. [CrossRef] [PubMed]
Molecules 2017, 22, 134 20 of 24

121. Skepner, J.; Ramesh, R.; Trocha, M.; Schmidt, D.; Baloglu, E.; Lobera, M.; Carlson, T.; Hill, J.;
Orband-Miller, L.A.; Barnes, A.; et al. Pharmacologic Inhibition of RORγt Regulates Th17 Signature Gene
Expression and Suppresses Cutaneous Inflammation In Vivo. J. Immunol. 2014, 192, 2564–2575. [CrossRef]
[PubMed]
122. Takaishi, M.; Ishizaki, M.; Suzuki, K.; Isobe, T.; Shimozato, T.; Sano, S. Oral administration of a novel RORγt
antagonist attenuates psoriasis-like skin lesion of two independent mouse models through neutralization of
IL-17. J. Dermatol. Sci. 2016. [CrossRef] [PubMed]
123. Smith, S.H.; Peredo, C.E.; Takeda, Y.; Bui, T.; Neil, J.; Rickard, D.; Millerman, E.; Therrien, J.P.; Nicodeme, E.;
Brusq, J.M.; et al. Development of a topical treatment for psoriasis targeting RORγ: From bench to skin.
PLoS ONE 2016, 11, e0147979. [CrossRef] [PubMed]
124. Gege, C. Retinoid-related orphan receptor gamma t (RORγt) inhibitors from Vitae Pharmaceuticals
(WO2015116904) and structure proposal for their Phase I candidate VTP-43742. Expert Opin. Ther. Pat. 2016,
26, 737–744. [CrossRef] [PubMed]
125. Wu, Q.; Nie, J.; Gao, Y.; Xu, P.; Sun, Q.; Yang, J.; Han, L. Reciprocal regulation of RORγt acetylation and
function by p300 and HDAC1. Sci. Rep. 2015, 5, 16355. [CrossRef] [PubMed]
126. Lim, H.W.; Kang, S.G.; Ryu, J.K.; Schilling, B.; Fei, M.; Lee, I.S.; Kehasse, A.; Shirakawa, K.; Yokoyama, M.;
Schnolzer, M.; et al. SIRT1 deacetylates RORγt and enhances Th17 cell generation. J. Exp. Med. 2015, 212,
607–617. [CrossRef] [PubMed]
127. Wang, X.; Yang, J.; Han, L.; Zhao, K.; Wu, Q.; Bao, L.; Li, Z.; Lv, L.; Li, B. TRAF5-mediated Lys-63-linked
polyubiquitination plays an essential role in positive regulation of RORγt in promoting IL-17A expression.
J. Biol. Chem. 2015, 290, 29086–29094. [CrossRef] [PubMed]
128. Rutz, S.; Kayagaki, N.; Phung, Q.T.; Eidenschenk, C.; Noubade, R.; Wang, X.; Lesch, J.; Lu, R.; Newton, K.;
Huang, O.W.; et al. Deubiquitinase DUBA is a post-translational brake on interleukin-17 production in
T cells. Nature 2015, 518, 417–421. [CrossRef] [PubMed]
129. Kathania, M.; Khare, P.; Zeng, M.; Cantarel, B.; Zhang, H.; Ueno, H.; Venuprasad, K. Itch inhibits
IL-17-mediated colon inflammation and tumorigenesis by ROR-γt ubiquitination. Nat. Immunol. 2016,
17, 997–1004. [CrossRef] [PubMed]
130. He, Z.; Wang, F.; Ma, J.; Sen, S.; Zhang, J.; Gwack, Y.; Zhou, Y.; Sun, Z. Ubiquitination of RORγt at Lysine
446 Limits Th17 Differentiation by Controlling Coactivator Recruitment. J. Immunol. 2016, 197, 1148–1158.
[CrossRef] [PubMed]
131. Han, L.; Yang, J.; Wang, X.; Wu, Q.; Yin, S.; Li, Z.; Zhang, J.; Xing, Y.; Chen, Z.; Tsun, A.; et al. The E3
deubiquitinase USP17 is a positive regulator of retinoic acid-related orphan nuclear receptor γt (RORγt) in
Th17 cells. J. Biol. Chem. 2014, 289, 25546–25555. [CrossRef] [PubMed]
132. Babon, J.J.; Varghese, L.N.; Nicola, N.A. Inhibition of IL-6 family cytokines by SOCS3. Semin. Immunol. 2014,
26, 13–19. [CrossRef] [PubMed]
133. Wolf, J.; Rose-John, S.; Garbers, C. Interleukin-6 and its receptors: A highly regulated and dynamic system.
Cytokine 2014, 70, 11–20. [CrossRef] [PubMed]
134. Hodge, J.A.; Kawabata, T.T.; Krishnaswami, S.; Clark, J.D.; Telliez, J.; Dowty, M.E.; Menon, S.; Lamba, M.;
Zwillich, S.; Hodge, J.A.; et al. The mechanism of action of tofacitinib—An oral Janus kinase inhibitor for the
treatment of rheumatoid arthritis. Clin. Exp. Rheumatol. 2016, 34, 318–328. [PubMed]
135. Meyer, D.M.; Jesson, M.I.; Li, X.; Elrick, M.M.; Funckes-shippy, C.L.; Warner, J.D.; Gross, C.J.; Dowty, M.E.;
Ramaiah, S.K.; Hirsch, J.L.; et al. Anti-inflammatory activity and neutrophil reductions mediated by the
JAK1/JAK3 inhibitor, CP-690,550, in rat adjuvant-induced arthritis. J. Inflamm. 2010, 7, 41. [CrossRef]
[PubMed]
136. Boyle, D.L.; Soma, K.; Hodge, J.; Kavanaugh, A.; Mandel, D.; Mease, P.; Shurmur, R.; Singhal, A.K.; Wei, N.;
Rosengren, S.; et al. The JAK inhibitor tofacitinib suppresses synovial JAK1-STAT signalling in rheumatoid
arthritis. Ann. Rheum. Dis. 2015, 74, 1311–1316. [CrossRef] [PubMed]
137. Ghoreschi, K.; Jesson, M.I.; Li, X.; Jamie, L.; Ghosh, S.; Alsup, J.W.; Warner, J.D.; Tanaka, M.;
Steward-tharp, S.M.; Gadina, M.; et al. Modulation of Innate and Adaptive Immune Responses by Tofacitinib
(CP-690,550). J. Immunol. 2011, 186, 4234–4243. [CrossRef] [PubMed]
138. Bachelez, H.; van de Kerkhof, P.C.M.; Strohal, R.; Kubanov, A.; Valenzuela, F.; Lee, J.; Yakusevich, V.
Tofacitinib versus etanercept or placebo in moderate-to-severe chronic plaque psoriasis: A phase 3
randomised non-inferiority trial. Lancet 2015, 386, 552–561. [CrossRef]
Molecules 2017, 22, 134 21 of 24

139. Valenzuela, F.; Paul, C.; Mallbris, L.; Tan, H.; Papacharalambous, J.; Valdez, H.; Mamolo, C. Tofacitinib
versus etanercept or placebo in patients with moderate to severe chronic plaque psoriasis: Patient-reported
outcomes from a Phase 3 study. JEADV 2016, 30, 1753–1759. [CrossRef] [PubMed]
140. Papp, K.A.; Krueger, J.G.; Feldman, S.R. Tofacitinib, an oral Janus kinase inhibitor, for the treatment of
chronic plaque psoriasis: Long-term efficacy and safety results from 2 randomized phase-III studies and 1
open-label long-term extension study. J. Am. Acad. Dermatol. 2016, 74, 841–850. [CrossRef] [PubMed]
141. Gao, W.; McGarry, T.; Orr, C.; McCormick, J.; Veale, D.J.; Fearon, U. Tofacitinib regulates synovial
inflammation in psoriatic arthritis, inhibiting STAT activation and induction of negative feedback inhibitors.
Ann. Rheum. Dis. 2016, 75, 311–315. [CrossRef] [PubMed]
142. Izzo, R.; Bevivino, G.; Monteleone, G. Tofacitinib for the treatment of ulcerative colitis. Expert Opin.
Investig. Drugs 2016, 8, 991–997. [CrossRef] [PubMed]
143. Danese, S.; Grisham, M.; Hodge, J.; Telliez, J. JAK inhibition using tofacitinib for inflammatory bowel disease
treatment: A hub for multiple inflammatory cytokines. Am. J. Physiol. Gastrointest. Liver Physiol. 2016, 310,
G155–G162. [CrossRef] [PubMed]
144. Park, J.S.; Kwok, S.K.; Lim, M.A.; Kim, E.K.; Ryu, J.G.; Kim, S.M.; Oh, H.J.; Ju, J.H.; Park, S.H.; Kim, H.Y.;
et al. La STA-21, a promising STAT-3 inhibitor that reciprocally regulates Th17 and Treg cells, inhibits
osteoclastogenesis in mice and humans and alleviates autoimmune inflammation in an experimental model
of rheumatoid arthritis. Arthritis Rheumatol. 2014, 66, 918–929. [CrossRef] [PubMed]
145. Wu, H.; Yan, S.; Chen, J.; Luo, X.; Li, P. JAK1-STAT3 blockade by JAK inhibitor SHR0302 attenuates
inflammatory responses of adjuvant-induced arthritis rats and decreases Th17 and total B cells. Jt. Bone Spine
2016, 83, 525–532. [CrossRef] [PubMed]
146. Yang, E.J.; Lee, J.; Lee, S.Y.; Kim, E.K.; Moon, Y.M.; Jung, Y.O.; Park, S.H.; Cho, M.L. EGCG attenuates
autoimmune arthritis by inhibition of STAT3 and HIF-1α pathway with Th17/Treg control. PLoS ONE 2014,
9, e86062.
147. Astry, B.; Venkatesha, S.H.; Laurence, A.; Christensen-Quick, A.; Garzino-demo, A.; Frieman, M.B.;
O’Shea, J.J.; Moudgil, K.D. Celastrol, a Chinese herbal compound, controls autoimmune inflammation
by altering the balance of pathogenic and regulatory T cells in the target organ. Clin. Immunol. 2015, 157,
228–238. [CrossRef] [PubMed]
148. Jhun, J.Y.; Moon, S.J.; Yoon, B.Y.; Byun, J.K.; Kim, E.K.; Yang, E.J.; Ju, J.H.; Hong, Y.S.; Min, J.K.; Park, S.H.; et al.
La Grape seed proanthocyanidin extract-mediated regulation of STAT3 proteins contributes to Treg
differentiation and attenuates inflammation in a murine model of obesity-associated arthritis. PLoS ONE
2013, 8, e78843. [CrossRef] [PubMed]
149. Moon, S.J.; Park, J.S.; Woo, Y.J.; Lim, M.A.; Kim, S.M.; Lee, S.Y.; Kim, E.K.; Lee, H.J.; Lee, W.S.;
Park, S.H.; et al. Rebamipide suppresses collagen-induced arthritis through reciprocal regulation of
Th17/Treg cell differentiation and heme oxygenase 1 induction. Arthritis Rheumatol. 2014, 66, 874–885.
[CrossRef] [PubMed]
150. Park, M.K.; Park, J.S.; Park, E.M.; Lim, M.A.; Kim, S.M.; Lee, D.G.; Baek, S.Y.; Yang, E.J.; Woo, J.W.; Lee, J.; et al.
Halofuginone ameliorates autoimmune arthritis in mice by regulating the balance between Th17 and treg
cells and inhibiting osteoclastogenesis. Arthritis Rheumatol. 2014, 66, 1195–1207. [CrossRef] [PubMed]
151. Sun, Y.; Tian, T.; Gao, J.; Liu, X.; Hou, H.; Cao, R.; Li, B.; Quan, M.; Guo, L. Metformin ameliorates the
development of experimental autoimmune encephalomyelitis by regulating T helper 17 and regulatory
T cells in mice. J. Neuroimmunol. 2016, 292, 58–67. [CrossRef] [PubMed]
152. Fontenot, J.D.; Gavin, M.A.; Rudensky, A.Y. Foxp3 programs the development and function of CD4+CD25+
regulatory T cells. Nat. Immunol. 2003, 4, 330–336. [CrossRef] [PubMed]
153. Hori, S.; Nomura, T. Saka Control of Regulatory T Cell Development by the Transcription Factor Foxp3.
Science 2003, 299, 1057–1061. [CrossRef] [PubMed]
154. Ohata, J.; Miura, T.; Johnson, T.A.; Hori, S.; Ziegler, S.F.; Kohsaka, H. Enhanced efficacy of regulatory
T cell transfer against increasing resistance, by elevated Foxp3 expression induced in arthritic murine hosts.
Arthritis Rheum. 2007, 56, 2947–2956. [CrossRef] [PubMed]
155. Zhou, L.; Lopes, J.E.; Chong, M.M.W.; Ivanov, I.I.; Min, R.; Victora, G.D.; Shen, Y.; Du, J.; Rubtsov, Y.P.;
Rudensky, A.Y.; et al. TGF-β-induced Foxp3 inhibits Th17 cell differentiation by antagonizing RORγt
function. Nature 2008, 453, 236–241. [CrossRef] [PubMed]
Molecules 2017, 22, 134 22 of 24

156. Quaglino, P.; Bergallo, M.; Ponti, R.; Barberio, E.; Cicchelli, S.; Buffa, E.; Comessatti, A.; Costa, C.;
Terlizzi, M.E.; Astegiano, S.; et al. Th1, Th2, Th17 and regulatory T cell pattern in psoriatic patients:
Modulation of cytokines and gene targets induced by etanercept treatment and correlation with clinical
response. Dermatology 2011, 223, 57–67. [CrossRef] [PubMed]
157. Lina, C.; Conghua, W.; Nan, L.; Ping, Z. Combined treatment of etanercept and MTX reverses Th1/Th2,
Th17/Treg imbalance in patients with rheumatoid arthritis. J. Clin. Immunol. 2011, 31, 596–605. [CrossRef]
[PubMed]
158. Nguyen, Q.D.; Merrill, P.T.; Jaffe, G.J.; Dick, A.D.; Kurup, S.K.; Sheppard, J.; Schlaen, A.; Pavesio, C.;
Cimino, L.; van Calster, J.; et al. Adalimumab for prevention of uveitic flare in patients with inactive
non-infectious uveitis controlled by corticosteroids (VISUAL II): A multicentre, double-masked, randomised,
placebo-controlled phase 3 trial. Lancet 2016, 6736, 1–10. [CrossRef]
159. Orban, T.; Bundy, B.; Becker, D.J.; DiMeglio, L.A.; Gitelman, S.E.; Goland, R.; Gottlieb, P.A.; Greenbaum, C.J.;
Marks, J.B.; Monzavi, R.; et al. Co-stimulation modulation with abatacept in patients with recent-onset type
1 diabetes: A randomised, double-blind, placebo-controlled trial. Lancet 2011, 378, 412–419. [CrossRef]
160. Emery, P. Optimizing outcomes in patients with rheumatoid arthritis and an inadequate response to anti-TNF
treatment. Rheumatology 2012, 51, 22–30. [CrossRef] [PubMed]
161. Sansom, D.M.; Walker, L.S.K. The role of CD28 and cytotoxic T-lymphocyte antigen-4 (CTLA-4) in regulatory
T-cell biology. Immunol. Rev. 2006, 212, 131–148. [CrossRef] [PubMed]
162. Bonelli, M.; Göschl, L.; Blüml, S.; Karonitsch, T.; Hirahara, K.; Ferner, E.; Steiner, C.W.; Steiner, G.; Smolen, J.S.;
Scheinecker, C. Abatacept (CTLA-4Ig) treatment reduces T cell apoptosis and regulatory T cell suppression
in patients with rheumatoid arthritis. Rheumatology 2016, 55, 710–720. [CrossRef] [PubMed]
163. Sfikakis, P.P.; Souliotis, V.L.; Fragiadaki, K.G.; Moutsopoulos, H.M.; Boletis, J.N.; Theofilopoulos, A.N.
Increased expression of the FoxP3 functional marker of regulatory T cells following B cell depletion with
rituximab in patients with lupus nephritis. Clin. Immunol. 2007, 123, 66–73. [CrossRef] [PubMed]
164. Floess, S.; Freyer, J.; Siewert, C.; Baron, U.; Olek, S.; Polansky, J.; Schlawe, K.; Chang, H.D.; Bopp, T.;
Schmitt, E.; et al. Epigenetic control of the foxp3 locus in regulatory T cells. PLoS Biol. 2007, 5, 169–178.
[CrossRef] [PubMed]
165. Lal, G.; Zhang, N.; van der Touw, W.; Ding, Y.; Ju, W.; Bottinger, E.P.; Reid, S.P.; Levy, D.E.; Bromberg, J.S.
Epigenetic regulation of Foxp3 expression in regulatory T cells by DNA methylation. J. Immunol. 2009, 182,
259–273. [CrossRef] [PubMed]
166. Cribbs, A.P.; Kennedy, A.; Penn, H.; Amjadi, P.; Green, P.; Read, J.E.; Brennan, F.; Gregory, B.; Williams, R.O.
Methotrexate restores regulatory T cell function through demethylation of the FoxP3 upstream enhancer in
patients with rheumatoid arthritis. Arthritis Rheumatol. 2015, 67, 1182–1192. [CrossRef] [PubMed]
167. Shin, H.-J.; Baker, J.; Leveson-Gower, D.B.; Smith, A.T.; Sega, E.I.; Negrin, R.S. Rapamycin and IL-2 reduce
lethal acute graft-versus-host disease associated with increased expansion of donor type CD4+CD25+Foxp3+
regulatory T cells. Blood 2011, 118, 2342–2350. [CrossRef] [PubMed]
168. Golovina, T.N.; Mikheeva, T.; Brusko, T.M.; Blazar, B.R.; Bluestone, J.A.; Riley, J.L. Retinoic acid and
rapamycin differentially affect and synergistically promote the ex vivo expansion of natural human T
regulatory cells. PLoS ONE 2011, 6, e15868. [CrossRef] [PubMed]
169. Wang, L.; Tao, R.; Hancock, W.W. Using histone deacetylase inhibitors to enhance Foxp3(+) regulatory T-cell
function and induce allograft tolerance. Immunol. Cell Biol. 2009, 87, 195–202. [CrossRef] [PubMed]
170. Liu, Y.; Wang, L.; Predina, J.; Han, R.; Beier, U.H.; Wang, L.C.; Kapoor, V.; Bhatti, T.R.; Akimova, T.;
Singhal, S.; et al. Inhibition of p300 impairs Foxp3+ T regulatory cell function and promotes antitumor
immunity. Nat. Med. 2013, 19, 1173–1177. [CrossRef] [PubMed]
171. Tao, R.; de Zoeten, E.F.; Ozkaynak, E.; Chen, C.; Wang, L.; Porrett, P.M.; Li, B.; Turka, L.A.; Olson, E.N.;
Greene, M.I.; et al. Deacetylase inhibition promotes the generation and function of regulatory T cells.
Nat. Med. 2007, 13, 1299–1307. [CrossRef] [PubMed]
172. De Zoeten, E.F.; Wang, L.; Butler, K.; Beier, U.H.; Akimova, T.; Sai, H.; Bradner, J.E.; Mazitschek, R.;
Kozikowski, A.P.; Matthias, P.; et al. Histone deacetylase 6 and heat shock protein 90 control the functions of
Foxp3+ T-regulatory cells. Mol. Cell. Biol. 2011, 31, 2066–2078. [CrossRef] [PubMed]
173. Beier, U.H.; Akimova, T.; Liu, Y.; Wang, L.; Hancock, W.W. Histone/protein deacetylases control Foxp3
expression and the heat shock response of T-regulatory cells. Curr. Opin. Immunol. 2011, 23, 670–678.
[CrossRef] [PubMed]
Molecules 2017, 22, 134 23 of 24

174. Xiao, H.; Jiao, J.; Wang, L.; O’Brien, S.; Newick, K.; Wang, L.C.S.; Falkensammer, E.; Liu, Y.; Han, R.;
Kapoor, V.; et al. HDAC5 controls the functions of Foxp3+ T-regulatory and CD8+ T cells. Int. J. Cancer 2016,
138, 2477–2486. [CrossRef] [PubMed]
175. Lainé, A.; Martin, B.; Luka, M.; Mir, L.; Auffray, C.; Lucas, B.; Bismuth, G. Foxo1 Is a T Cell−Intrinsic
Inhibitor of the RORγt-Th17 Program. J. Immunol. 2015, 195, 1791–1803. [CrossRef] [PubMed]
176. Ichiyama, K.; Gonzalez-Martin, A.; Kim, B.; Jin, H.; Jin, W.; Xu, W.; Sabouri-Ghomi, M.; Xu, S.; Zheng, P.;
Xiao, C.; et al. The MicroRNA-183–96–182 Cluster Promotes T Helper 17 Cell Pathogenicity by Negatively
Regulating Transcription Factor Foxo1 Expression. Immunity 2016, 44, 1284–1298. [CrossRef] [PubMed]
177. Wan, C.; Ping, C.; Shang, X.; Tian, J.; Zhao, S.; Li, L.; Fang, S.; Sun, W.; Zhao, Y.; Li, Z.; et al. MicroRNA
182 inhibits CD4+CD25+Foxp3+ Treg differentiation in experimental autoimmune encephalomyelitis.
Clin. Immunol. 2016, 173, 109–116. [CrossRef] [PubMed]
178. Wang, X.; Yu, Y.; Gu, L. Dehydroabietic acid reverses TNF-α-induced the activation of FOXO1 and
suppression of TGF-β1/Smad signaling in human adult dermal fibroblasts. Int. J. Clin. Exp. Pathol.
2014, 7, 8616–8626. [PubMed]
179. Liu, Y.; Luo, W.; Chen, S. Comparison of gene expression profiles reveals aberrant expression of FOXO1,
Aurora A/B and EZH2 in lesional psoriatic skins. Mol. Biol. Rep. 2011, 38, 4219–4224. [CrossRef] [PubMed]
180. Liao, L.; Su, X.; Yang, X.; Hu, C.; Li, B.; Lv, Y.; Shuai, Y.; Jing, H.; Deng, Z.; Jin, Y. TNF-α Inhibits FoxO1 by
Upregulating miR-705 to Aggravate Oxidative Damage in Bone Marrow- Derived Mesenchymal Stem Cells
during Osteoporosis. Stem Cells 2016, 34, 1054–1067. [CrossRef] [PubMed]
181. Ehrenstein, M.R.; Evans, J.G.; Singh, A.; Moore, S.; Warnes, G.; Isenberg, D.A.; Mauri, C.; Wca, L.
Compromised Function of Regulatory T Cells in Rheumatoid Arthritis and Reversal by Anti-TNFα Therapy.
J. Exp. Med. 2004, 200, 277–285. [CrossRef] [PubMed]
182. Shen, H.; Xia, L.; Lu, J.; Xiao, W. Infliximab Reduces the Frequency of Interleukin 17-Producing Cells and
the Amounts of Interleukin 17 in Patients With Rheumatoid Arthritis. J. Investig. Med. 2010, 58, 905–908.
[CrossRef] [PubMed]
183. Aravena, O.; Pesce, B.; Soto, L.; Orrego, N.; Sabugo, F.; Wurmann, P.; Molina, M.C.; Alfaro, J.; Cuchacovich, M.;
Aguillón, J.C.; et al. Anti-TNF therapy in patients with rheumatoid arthritis decreases Th1 and Th17 cell
populations and expands IFN-γ-producing NK cell and regulatory T cell subsets. Immunobiology 2011, 216,
1256–1263. [CrossRef] [PubMed]
184. Hernandez, A.L.; Kitz, A.; Wu, C.; Lowther, D.E.; Rodriguez, D.M.; Vudattu, N.; Deng, S.; Herold, K.C.;
Kuchroo, V.K.; Kleinewietfeld, M.; et al. Sodium chloride inhibits the suppressive function of FOXP3+
regulatory T cells. J. Clin. Investig. 2015, 125, 4212–4222. [CrossRef] [PubMed]
185. Luo, C.T.; Liao, W.; Dadi, S.; Toure, A.; Li, M.O. Graded Foxo1 activity in Treg cells differentiates tumour
immunity from spontaneous autoimmunity. Nature 2016, 529, 532–536. [CrossRef] [PubMed]
186. Ciofani, M.; Madar, A.; Galan, C.; Sellars, M.; Mace, K.; Pauli, F.; Agarwal, A.; Huang, W.; Parkhurst, C.N.;
Newberry, K.M.; et al. A validated regulatory network for Th17 cell specification. Cell 2012, 151, 289–303.
[CrossRef] [PubMed]
187. Biswas, P.S.; Gupta, S.; Chang, E.; Song, L.; Stirzaker, R.A.; Liao, J.K.; Bhagat, G.; Pernis, A.B. Phosphorylation
of IRF4 by ROCK2 regulates IL-17 and IL-21 production and the development of autoimmunity in mice.
J. Clin. Investig. 2010, 120, 3280–3295. [CrossRef] [PubMed]
188. He, Y.; Xu, H.; Liang, L.; Zhan, Z.; Yang, X.; Yu, X.; Ye, Y.; Sun, L. Antiinflammatory effect of Rho kinase
blockade via inhibition of NF-kappaB activation in rheumatoid arthritis. Arthritis Rheum. 2008, 58, 3366–3376.
[CrossRef] [PubMed]
189. Isgro, J.; Gupta, S.; Jacek, E.; Pavri, T.; Duculan, R.; Kim, M.; Kirou, K.A.; Salmon, J.E.; Pernis, A.B. Enhanced
Rho-Associated Protein Kinase Activation in Patients With Systemic Lupus Erythematosus. Arthritis Rheum.
2013, 65, 1592–1602. [CrossRef] [PubMed]
190. Zanin-Zhorov, A.; Weiss, J.M.; Nyuydzefe, M.S.; Chen, W.; Scher, J.U.; Mo, R. Selective oral ROCK2 inhibitor
down-regulates IL-21 and IL-17 secretion in human T cells via STAT3-dependent mechanism. Proc. Natl.
Acad. Sci. USA 2014, 111, 16814–16819. [CrossRef] [PubMed]
191. Flynn, R.; Paz, K.; Du, J.; Reichenbach, D.K.; Taylor, P.A.; Panoskaltsis-mortari, A.; Vulic, A.; Luznik, L.;
Macdonald, K.K.P.; Hill, G.R.; et al. Targeted Rho-associated kinase 2 inhibition suppresses murine and
human chronic GVHD through a Stat3-dependent mechanism. Blood 2016, 127, 2144–2155. [CrossRef]
[PubMed]
Molecules 2017, 22, 134 24 of 24

192. Zhao, Y.; Zhang, X.; Ding, Z.; Yang, X.; Zhang, H. The Therapeutic Potential of Rho Kinase Inhibitor Fasudil
Derivative FaD-1 in Experimental Autoimmune Encephalomyelitis. J. Mol. Neurosci. 2015, 55, 725–732.
[CrossRef] [PubMed]
193. Li, Y.; Yu, J.; Xin, Y.; Feng, L.; Chai, Z.; Liu, J.; Zhang, H. Protective effect of a novel Rho kinase inhibitor WAR-5
in experimental autoimmune encephalomyelitis by modulating inflammatory response and neurotrophic
factors. Exp. Mol. Pathol. 2015, 99, 220–228. [CrossRef] [PubMed]
194. Joetham, A.; Ohnishi, H.; Okamoto, M.; Takeda, K.; Schedel, M.; Domenico, J.; Dakhama, A.; Gelfand, E.W.
Loss of T Regulatory Cell Suppression following Signaling through Glucocorticoid-induced Tumor Necrosis
Receptor (GITR) Is Dependent on c-Jun N-terminal Kinase Activation. J. Biol. Chem. 2012, 287, 17100–17108.
[CrossRef] [PubMed]
195. Wang, S.; Shi, Y.; Yang, M.; Ma, J.; Tian, J.; Chen, J.; Mao, C.; Jiao, Z.; Ko, K.; Lu, L. Glucocorticoid-Induced
Tumor Necrosis Factor Receptor Family-Related Protein Exacerbates Collagen-Induced Arthritis by
Enhancing the Expansion of Th17 Cells. Am. J. Pathol. 2012, 180, 1059–1067. [CrossRef] [PubMed]
196. Tang, X.; Tian, J.; Ma, J.; Wang, J.; Qi, C.; Rui, K.; Wang, Y.; Xu, H.; Lu, L.; Wang, S. GITRL modulates the
activities of p38 MAPK and STAT3 to promote Th17 cell differentiation in autoimmune arthritis. Oncotarget
2015, 7. [CrossRef]
197. Li, L.; Wen, W.; Jia, R.; Li, Y.; Liu, X.; Sun, X. GITRL is associated with increased autoantibody production in
patients with rheumatoid arthritis. Clin. Rheumatol. 2016, 35, 2195–2202. [CrossRef] [PubMed]
198. Cohen, S.B.; Cheng, T.; Chindalore, V.; Damjanov, N.; Burgos-vargas, R.; Delora, P.; Zimany, K.; Travers, H.;
Caulfield, J.P. Evaluation of the efficacy and safety of pamapimod, a p38 MAP kinase inhibitor, in a
double-blind, methotrexate-controlled study of patients with active rheumatoid arthritis. Arthritis Rheum.
2009, 60, 335–344. [CrossRef] [PubMed]

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