WO2015132241A1 - Treatment of inflammatory diseases - Google Patents

Abstract

The present invention provides pharmaceutical compositions for treating an inflammatory disease as well as methods for treating inflammatory diseases.

Description

TREATMENT OF INFLAMMATORY DISEASES

FIELD

The present invention concerns methods within the field of treatment of

inflammatory diseases and disorders aiming to improve the treatment options and regimens for patients by providing methods for predicting responsiveness to a therapeutic agent.

BACKGROUND

Inflammatory diseases and disorders and in particular autoimmune diseases such as rheumatoid arthritis severely impact the well-being of many patients and treatment options are unsatisfactory for a large group of patients.

Rheumatoid arthritis (RA) is a clinically important, chronic systemic autoimmune disease and it is an autoimmune disorder of unknown etiology. Most RA patients suffer a chronic course of disease that, even with currently available therapies, often results in progressive joint destruction, deformity, disability and even premature death. Diagnosis of RA typically relies on clinical and laboratory evaluation of a patient's signs and symptoms.

The American College of Rheumatology (ACR) criteria are the standards used for diagnosis and determination of severity. In July 2010, the 2010 ACR/EULAR Rheumatoid Arthritis Classification Criteria were introduced. These new classification criteria include ACPA testing, and overruled the "old" ACR criteria of 1987 and are adapted for early RA diagnosis (Aletaha D. et al., Arthritis &Rheumatism, 62(9), 2569-2581 (2010)). Other standards are used for other types of autoimmune diseases.

As described in those criteria, laboratory evaluation of a patient suspected of having RA may include determination of the level of certain antibodies in serum known as rheumatoid factor (RF) and antibodies to cyclic citrullinated peptide (anti-CCP). While these antibodies are often found in the serum of RA patients (when both antibodies are found in the serum, the termed used is "seropositive"), not all RA patients have them.

Current treatments, such as treatment with anti-TNF agents or anti-CD20 agents are not always providing a safe and efficacious treatment for all patients and many patients do not respond well to specific treatments while others do. It is still unclear what is behind this and information on how to predict which patients will respond well is scarce. The underlying reason for the improved rates of ACR responses in anti-CD20 therapy (in particular with Rituximab) seems to be in rituximab's depletion of B lymphocytes. Rituximab has a markedly improved effect in sero positive patients (Edwards JCW et al., N Engl J Med 350, 2572-2581 (2004), Pyrpasopoulou A et al., Mol Diagn Ther. 14(1 ), 43-8 (2010)). Also the classic RA drug, methotrexate (MTX), has an improved profile in seropositive patients (van Dongen H et al., Arthritis Rheum. 56(5), 1424-32 (2007)).

Attempts have been made to improve diagnosis and prognosis based on

biomarkers, and recently methods for subgrouping RA patients and identification of patients groups which demonstrate a higher responsiveness to anti-CD20 therapy based on particular molecular profiles have been presented (WO201 1028945). However, no clinically validated diagnostic or prognostic markers have been identified that enable clinicians or others to accurately define pathophysiological aspects of rheumatoid arthritis and other inflammatory diseases, clinical activity, response to therapy, prognosis, or risk of developing the disease.

Accordingly, as RA patients seek treatment, there is considerable trial and error involved in the search for therapeutic agent(s) effective for a particular patient. Such trial and error often involves considerable risk and discomfort to the patient in order to find the most effective therapy. Thus, there is a need for more effective means for determining which patients will respond to which treatment and for incorporating such determinations into more effective treatment regimens for RA patients and patients suffering from other auto-immune diseases.

SUMMARY OF THE INVENTION

The present invention relates to use of pharmaceutical products or pharmaceutical compositions for treatment of an inflammatory disease, wherein said pharmaceutical composition comprises an anti-autoimmune agent (e.g. a biologic drug), such as e.g. an IL- 21 antagonist, wherein the expression level of one or more biomarkers selected from

FLVCR1-AS1 , CTNNA1 , HSBP1 L1 , and CHSY1 , in the patient suffering from the chronic inflammatory disease, is increased at least 20% compared to mean expression levels of patients suffering from said inflammatory disease. These markers can, either alone or in combinations with the serum/plasma biomarker CTX-I, be used to predict the response to therapy in individual patients with inflammatory diseases. What is herein provided is thus a method for identifying patients having a high likelihood for responding to the treatment in question. The present invention furthermore relates to methods for identifying better responder patients as well as kits used in these methods.

DESCRIPTION

The treatments presently available for inflammatory diseases or disorders, as well as for autoimmune diseases or disorders, have a relatively low success rate and treatment frequently involves some degree of trial and error. This invention provides a method for identification of a patient subgroup that have a high treatment success rate, whereby other patients can avoid most of the risk and discomfort associated with the difficulties in finding an effective therapy.

The inventors of the present inventions have found that patients with a high probability of a successful treatment can be identified based on examination of their level of expression of one or more biomarkers selected from the list consisting of: FLVCR1-AS1

RNA, CTNNA1 , HSBP1 L1 , CHSY1 , and CTX-1 . Any combination of said biomarkers can be used for obtaining even more accurate predictions. Optionally, said FLVCR1 -AS1 , CTNNA1 , HSBP1 L1 , or CHSY1 biomarkers is/are combined with the CTX-1 biomarker for obtaining even more accurate predictions.

The response rate in patients with chronic diseases such as inflammatory diseases is usually poor as it is not uncommon that only around 1/3 of the treated patients respond to the treatment. As seen in this application a high response rate can be obtained by combining multiple markers e.g. by targeting only the patient population that based on an expression profile or simple protein or RNA analysis have a higher likely hood of being responders.

The present invention furthermore provides a method for treatment of an inflammatory disease or disorder in a patient suffering from said disease, which method comprises administering a therapeutic amount of an anti-inflammatory agent (e.g. an antiinflammatory biologic drug) to said patient, wherein said patient expresses one or more biomarkers selected from the list consisting of: RNA FLVCR1-AS1 , CTNNA1 , HSBP1 L1 , and CHSY1 , optionally in combination with CTX-1. Treatment is of particular interest where the expression of the indicated markers deviates from the mean expression level of expression. Notable only the level prior to treatment initiation is relevant for this purpose, as this baseline expression level have been found to guide selection of a patient group with a high proportion of patients with a positive response.

Methods for identifying such better responder patients are furthermore provided herein.

In an embodiment the invention relates to a pharmaceutical composition comprising and IL-21 antagonist for use in a method for treatment of an inflammatory disease in a patient wherein the transcript level of FLVCR1-AS1 relative to the ACTB mRNA level as measured by qRT-PCR using Hs03678783_m1 (Applied Biosystems) and Hs99999903-m1 is not higher than 14. (e.g. a delta Ct of 14 or below).

In an embodiment the invention relates to a pharmaceutical composition comprising and IL- 21 antagonist for use in a method for treatment of an inflammatory disease in a patient wherein the mRNA level of CHSY1 relative to the ACTB mRNA level as measured by qRT- PCR using Hs00287043_m1 (Applied Biosystems) and Hs99999903_m1 is 1 or above (e.g. delta Ct is1 or above). In an embodiment the invention relates to a pharmaceutical composition comprising and IL- 21 antagonist for use in a method for treatment of an inflammatory disease in a patient wherein the mRNA level of CTNNA1 relative to ACTB mRNA level as measured by qRT-PCR using Hs000944794_m1 (Applied Biosystems) and Hs99999903_m1 is 0.5 or above (e.g. delta Ct is 0.5 or above).

As described herein above the level of expression may according to the invention be the baseline level of expression e.g. the level of expression prior to treatment initiation.

It may further be of relevance that the composition is only meant for patients where information on the expression level is available and/or obtained prior to initiation of treatment.

Brief description of drawings

Figure"! : Distribution of FLVCR1 -AS1 (RNA) expression levels and ROC curves. Figure 1 a) shows in the left graph the base-line expression levels of FLVCR1-AS1 RNA in American College of Rheumatology 50 % composite criteria (ACR50) non- responders ("No response") and ACR50-responders ("Response"). The ACR50 scores were evaluated at visit 7 which corresponds to week 12 in the study. The right graph shows that there is an equal distribution of FLVCR1-AS1 (RNA) expression levels at base-line between placebo and actively (anti-l L21 mAb) dosed patients.

Figure 1 b) shows a Receiver Operating Characteristic (ROC) curve of FLVCR1-AS1

RNA and American College of Rheumatology 50 % composite criteria (ACR50) responses in the phase-2a anti-l L21 trial. The threshold value of 6.695 (RMA normalized expression value) is indicated by the black dot on the ROC curve. Statistical details are provided in the box.

Figure 1 c) shows a Receiver Operating Characteristic (ROC) curve of FLVCR1 -AS1

RNA and American College of Rheumatology 70 % composite criteria (ACR50) responses in the phase-2a anti-l L21 trial. The threshold value of 6.695 (RMA normalized expression value) is indicated by the black dot on the ROC curve. Statistical details are provided in the box.

Figure 2 shows the implications with regard to the size of the patient pool and the ACR50 response rates when using the defined thresholds for either FLVCR1-AS1 (RNA) and CTX-I alone or when the two response predictors are combined. If a threshold of >6.695 is used for the FLVCR1 -AS1 predictor, a very pronounced enrichment in the ACR50 response rate is reached (from 25% (without stratification) to 67%). This threshold reduces the patient population to 15% of the original patient pool. The CTX-I predictor can likewise increase the ACR50 response rate from 25% to 38% when a threshold of >500 is applied. This will reduce the patient population to 35%. However, when combining the two predictors (e.g. by calculating a z-score) and using the threshold z>0, the patient pool is only reduced to 48% and the ACR50 response rate is still increased from 25% to 41 %.

Figure 3: Expression levels (RMA-normalized) of FLVCR1-AS1 RNA in individual patients over time. Different time-points from individual patients are connected by a line and colour coded (base-line (pre-dose sample) = white), week 1 = light-grey, week 3 = dark grey, and week 12 = black). This figure shows that expression levels of FLVCR1 -AS1 RNA are relatively stable over time in an individual patient - in particular for patients having high expression levels.

Figure 4: Expression levels of FLVCR1-AS1 RNA depending on the specific Single Nucleotide Polymorphism "SNP" (in this case the "rs1047881 " SNP in FLVCR1-AS1 (RNA)). For each A in the rs1047881 -genotype, the FLVCR1-AS1 RNA has 2.12 fold increased expression.

Figure 5 The table includes expression data for FLVCR1-AS1 and CTX-1 at base line and the calculated Z-scores obtained in the study described herein together with an indication on the treatment (active or placebo) and ACR50 response. Based on these numbers the composite FLVCR1-AS1 and CTX-I z-score is calculated.

Definitions CTX-I: In bone physiology, the C-terminal telopeptide (carboxy-terminal collagen type I crosslinks, and known by the acronym CTX-I) is a (serum) biomarker used to measure the rate of bone turnover.

The term "polynucleotide" or "nucleic acid," as used interchangeably herein, refers to polymers of nucleotides of any length, and include DNA and RNA. The nucleotides can be deoxyribonucleotides, ribonucleotides, modified nucleotides or bases, and/or their analogs, or any substrate that can be incorporated into a polymer by DNA or RNA polymerase. A polynucleotide may comprise modified nucleotides, such as methylated nucleotides and their analogs. If present, modification to the nucleotide structure may be imparted before or after assembly of the polymer. The sequence of nucleotides may be interrupted by non-nucleotide components. A polynucleotide may be further modified after polymerization, such as by conjugation with a labeling component and other types of modifications known in the art. The term "primer" refers to a single stranded polynucleotide that is capable of hybridizing to a nucleic acid and allowing the polymerization of a complementary nucleic acid, generally by providing a free 3' -OH group.

The term "array" or "microarrav" refers to an ordered arrangement of hybridizable array elements, preferably polynucleotide probes (e.g., oligonucleotides), on a substrate. The substrate can be a solid substrate, such as a glass slide, or a semi-solid substrate, such as nitrocellulose membrane.

The term "increased expression" or "increased levels" refers to an elevated or increased expression level of a gene, usually measured at the mRNA or protein level. The expression level is considered increased relative to a reference level, e.g. the level of expression is "higher" than a predetermined level of relevance. Increased expression level of a gene, may represent a gene which is expressed at "a high" level in an individual, relative to other genes and/or relative to the level of expression in other individuals.

The term "decreased expression" or "decrease levels" refers to a reduced or decreased expression level of a gene, usually measured at the mRNA or protein level. The expression level is considered decreased relative to a reference level, e.g. the level of expression is "lower" that a predetermined level of relevance. Decreased expression level of gene, may represent a gene which is expressed at a "a low" level in an individual, relative to other genes and/or relative to the level of expression in other individuals.

The term "plasma sample" refers to any plasma sample obtained from an individual.

Methods for obtaining plasma from mammals are well known in the art. Blood plasma is a derived from blood by removal of blood cells.

The term "serum sample" refers to any serum sample obtained from an individual. Methods for obtaining sera from mammals are well known in the art. Blood serum is derived from blood by removal of blood cells and coagulation factors.

The term "prediction" is used herein to refer to the likelihood that a patient will respond either favourably or unfavourably to a drug such as e.g. an IL-21 antagonist. In one embodiment, the prediction relates to the extent of those responses. In one embodiment, the prediction relates to the probability that a patient will improve following treatment, for example treatment with a particular therapeutic agent, and for a certain period of time without disease recurrence. The predictive methods of the invention can be used clinically to make treatment decisions by choosing the most appropriate treatment modalities for any particular patient. The predictive methods of the present invention are valuable tools in predicting if a patient is likely to respond favourably to a treatment regimen, such as a given therapeutic regimen, including for example, administration of a given medicament or therapeutic agent or combinations hereof. As used herein, "treatment" refers to clinical intervention in an attempt to alter the natural course of the individual being treated, and can be performed before or during the course of clinical pathology. Desirable effects of treatment include preventing the occurrence or recurrence of a disease or a condition or symptom thereof, alleviating a condition or symptom of the disease, diminishing any direct or indirect pathological consequences of the disease, decreasing the rate of disease progression, ameliorating or palliating the disease state, and achieving remission or improved prognosis. In some embodiments, methods and compositions of the invention are useful in attempts to delay development of a disease or disorder.

An "effective amount" refers to an amount effective, at dosages and for periods of time necessary, to achieve the desired therapeutic or prophylactic result. A "therapeutically effective amount" of a therapeutic agent may vary according to factors such as the disease state, age, sex, and weight of the individual, and the ability of the antibody to elicit a desired response in the individual. A therapeutically effective amount is also one in which any toxic or detrimental effects of the therapeutic agent are outweighed by the therapeutically beneficial effects. A "prophylactically effective amount" refers to an amount effective, at dosages and for periods of time necessary, to achieve the desired prophylactic result. Typically but not necessarily, since a prophylactic dose is used in subjects prior to or at an earlier stage of disease, the prophylactically effective amount will be less than the therapeutically effective amount.

An "individual," "subject" or "patient" is a mammal, preferably a human being. The term "patient" further indicates that the subject is not a healthy subject. In one embodiment a "patient" is an individual diagnosed or suffering from sign(s) or symptom(s) associated with inflammatory diseases or disorders, such as e.g. RA.

By "correlate" or "correlating" is meant comparing, in any way, the performance and/or results of a first analysis or protocol with the performance and/or results of a second analysis or protocol. For example, one may use the results of a first analysis or protocol in carrying out a second protocols and/or one may use the results of a first analysis or protocol to determine whether a second analysis or protocol should be performed. With respect to the embodiment of gene expression analysis or protocol, one may use the results of the gene expression analysis or protocol to determine whether a specific therapeutic regimen should be performed.

The term "patient response" or "response" can be assessed using any endpoint indicating a benefit to the patient, including, without limitation, (1 ) inhibition, to some extent, of disease progression, including slowing down and complete arrest; (2) reduction in the number of disease episodes and/or symptoms; (3) reduction in lesional size; (4) inhibition (i.e., reduction, slowing down or complete stopping) of disease cell infiltration into adjacent peripheral organs and/or tissues; (5) inhibition (i.e. reduction, slowing down or complete stopping) of disease spread; (6) decrease of auto-immune response, which may, but does not have to, result in the regression or ablation of the disease lesion; (7) relief, to some extent, of one or more symptoms associated with the disorder; (8) increase in the length of disease-free presentation following treatment; and/or (9) decreased mortality at a given point of time following treatment.

The term "inadequate response" or "an inadequate responder" is used to describe patients that experience an unsatisfactory effect of a given treatment. This may be characterized by a low therapeutic effect and/or by substantial side effects. The criteria is considered equivalent to none-responsiveness. The "term inadequate response" is used in connection with therapeutics for where a given response is expected or aimed at based on previous trials. If after a certain period no "adequate response" is obtained, the treatment is usually discontinued and the patient is considered "an inadequate responder". It may also be that the patient continues the treatment, but in combination with further treatment in order to improve treatment response.

The term "adequate response" is used to describe the effect of a treatment in a patient when expectations to treatment efficacy are fulfilled.

An "anti-inflammatory agent" is a compound, medicament or agent, that can, or is expected to decrease an inflammatory response or symptom(s) of inflammatory diseases or disorders. Anti-inflammatory agents include biologic drugs such, e.g. IL-21 antagonists.

A "therapeutic agent," or an "anti-inflammatory agent", refer to an agent that when provided in an effective amount is known, clinically shown, or expected by clinicians to provide a therapeutic benefit in a subject who has been diagnosed with an auto-inflammatory disease.

An "antagonist" refers to a molecule capable of neutralizing, blocking, inhibiting, abrogating, reducing or interfering with the activities of a particular or specified protein, including its binding to one or more receptors in the case of a ligand or binding to one or more ligands in case of a receptor. Antagonists include antibodies and antigen-binding fragments thereof, proteins, peptides, glycoproteins, glycopeptides, glycolipids,

polysaccharides, oligosaccharides, nucleic acids, bioorganic molecules, peptidomimetics, pharmacological agents and their metabolites, transcriptional and translation control sequences, and the like. Antagonists also include small molecule inhibitors of the protein, and fusion proteins, receptor molecules and derivatives which bind specifically to the protein thereby sequestering its binding to its target, antagonist variants of the protein, antisense molecules directed to the protein, RNA aptamers, and ribozymes against the protein. "Antibody": The term "antibody", "monoclonal antibody", monomeric antibody, and "mAb" as used herein, is intended to refer to immunoglobulin molecules and fragments thereof that have the ability to specifically bind to an antigen. Antibodies herein are either serum derived or recombinant antibodies. Full-length antibodies comprise four polypeptide chains, two heavy (H) chains and two light (L) chains interconnected by disulfide bonds. Each heavy chain is comprised of a heavy chain variable region (abbreviated herein as HCVR or VH) and a heavy chain constant region. The heavy chain constant region is comprised of three domains, CH1 , CH2 and CH3. Each light chain is comprised of a light chain variable region (abbreviated herein as LCVR or VL) and a light chain constant region. The light chain constant region is comprised of one domain, CL. The VH and VL regions can be further subdivided into regions of hypervariability, termed complementarity determining regions (CDR), interspersed with regions that are more conserved, termed framework regions (FR). Each VH and VL is composed of three CDRs and four FRs, arranged from amino-terminus to carboxy-terminus in the following order: FR1 , CDR1 , FR2, CDR2, FR3, CDR3, FR4. Antibodies can be in the form of different isotypes; e.g. IgG (e.g. lgG1 , lgG2, lgG3, lgG4), IgGAI , lgA2, IgD, and IgE. A full-length antibody is normally bi-valent/di-valent, i.e. it has the capacity to bind to the antigen with both "arms". In contrast, a monovalent antibody (e.g. a Fab fragment) comprises only one binding site specific for the antigen. The terms "human antibody", as used herein, means antibodies having variable and constant regions derived from human germline immunoglobulin sequences. "Humanized antibodies" comprise CDR sequences from a non-human source (e.g. a mouse) grafted onto a human scaffold.

"IL-21 " is a type I cytokine, which exerts pleiotropic effects on both innate and adaptive immune responses. It is mainly produced by activated CD4+ T cells, follicular T cells and Natural killer cells. In addition, recent evidence suggests that Th17 cells can produce large amounts of IL-21 . IL-21 increases the cytotoxicity of CD8+ T cells and can promote proliferation of CD8+ cells in the presence of antigens. IL-21 is induced by IL-6, a cytokine known to promote development of Th17 cells. IL-21 acts on T helper cells in an autocrine manner promoting its own production and supporting differentiation of T-helper cells into Th17 cells. IL-21 also acts on B-cells and increases antibody production. The ability of IL-21 to augment immunity has spurred substantial interest in the therapeutic use of IL-21 . Animal studies have demonstrated a synergistic effect between IL-21 and tumour specific antibodies, which could suggest a future therapeutic use of IL-21 as a potentiator of anti- tumour antibodies. Furthermore, IL-21 plays a complex role in autoimmune diseases. The ability of IL-21 to promote Th17 development makes it a pro-inflammatory cytokine and IL-21 inhibitors/antagonists, such as e.g. antagonistic IL-21 antibodies, are currently investigated for potential use in treatment of a range of different autoimmune diseases.

An "IL-21 antagonist" is based on the above definitions a molecule capable of neutralizing, blocking, inhibiting, abrogating, reducing or interfering with the activities of IL-21 , enabling such compounds to acting antagonistic or neutralizing of the endogenous IL-21. Examples of IL-21 antagonists are anti-IL-21 antibodies as described herein below.

Additional types of compounds, with equivalent functionality, are also considered IL-21 antagonists. SEQ ID No 1 : hlL-21 (incl. signal peptide spanning amino acids 1-29 - mAb 5 epitope shown in bold; IL-21 Ra binding site shown in underline; amino acid residues forming the mAb 14 epitope shown with lower case letters in italics)

MRSSPGNMERIVICLMVIFLGTLVHKSSSQGQDRHMIRMRQLIDIVDQLKNYVNDL VPEFLPAPedi efnCewSAFSCFQKAQLKSANTGNNERIINVSIKKLKRKPPSTNAGRRQ/ /?rLT CPSCDSYEKKPPKEFLERFKS/LQ/iml/?q/?LSSRTHGSEDS "IL-21 antibody": Preferred IL-21 antagonists herein are biologic drugs such as

(antagonistic/neutralizing) IL-21 antibodies. Monoclonal (recombinant) antibodies specific for IL-21 are known in the art, for example from WO20071 1 1714 and WO2010055366 (Zymo- Genetics, Inc.). In particular, WO2010055366 describes an anti-IL-21 antibody, designated by clone number 362.78.1 .44 ("mAb 5"), which has a high affinity for its cognate antigen, and other desirable properties, showing specificity for human and cynomolgus monkey IL-21. Another antibody described therein is identified as clone number 366.328.10.63 ("mAb 14"). Preferred IL-21 antibodies herein are those that can compete/interfere with binding of the IL- 21 receptor (IL-21 R) to IL-21 - examples of such antibodies are disclosed in W0120981 13, including "mAb 5". Other preferred IL-21 antibodies herein are those that can

compete/interfere with binding of the common gamma chain to IL-21 - examples of such antibodies are disclosed in WO201216402, incl. "mAb 14". Antibodies disclosed in

WO120981 13 and WO2012164021 having the ability to compete/interfere with a receptor binding to IL-21 are thus incorporated herein.

Preferably, the IL-21 antibody herein binds to helix 1 and 3 of human IL-21 .

Preferably, the IL-21 antibody binds to a discontinuous epitope on IL-21 , wherein said epitope comprises amino acids I37 to Y52 and N92 to P108 as set forth in SEQ ID NO 1 . Preferably, the IL-21 antibody comprises the three CDR sequences as set forth in SEQ ID NO 2 and the three CDR sequences as set forth in SEQ ID NO 3. Preferably, the IL-21 antibody competes with yC (gamma chain) for binding to IL-21 . Preferably, the IL-21 antibody binds to helix 2 and 4 of human IL-21 . Preferably, the IL-21 antibody binds to an epitope comprising amino acids Glu 65, Asp 66, Val 67, Glu 68, Thr 69, Asn 70, Glu 72, Trp 73, Lys 1 17, His 1 18, Arg 1 19, Leu 143, Lys 146, Met 147, His 149, Gin 150, and His 151 as set forth in SEQ ID N0.1. Prefeably, the IL-21 antibody comprises the three CDR sequences as set forth in SEQ ID NO 4 and the three CDR sequences as set forth in SEQ ID No 5. SEQ ID No 2: "mAb 5": light chain (signal peptide omitted - CDR sequences shown in bold/underline - constant region shown in lowercase letters - variable region in uppercase letters)

EIVLTQSPGTLSLSPGERATLSCRASQSVSSSYLAWYQQKPGQAPRLLIYGASSR ATGIPDRFSGSGSGTDFTLTISRLEPEDFAVYYCQQYGSWTFGQGTKVEIKRtvaapsvfifDDsd eqlksgtasvvcllnnfypreakvqwkvdnalqsgnsqesvteqdskdstyslsstltlskadyekhkvyacevthqglsspvtksf nrgec

SEQ ID No 3: "mAb 5": heavy chain of the lgG1 isotype (signal peptide omitted - CDR sequences shown in bold/underline - constant region shown in lowercase letters - variable region in uppercase letters)

QVQLVESGGGWQPGRSLRLSCAASGFTFSSYGMHWVRQAPGKGLEWVAFIWY DGSDKYYADSVKGRFTISRDNSKNTLYLQMNSLRAEDTAVYYCARDGDSSDWYGDYYFG MDVWGQGTTVTVSSastkgpsvfplapsskstsggtaalgclvkdyfpepvtvswnsgaltsgvhtfpavlqssglyslss vvtvpssslgtqtyicnvnhkpsntkvdkkvepkscdkthtcppcpapeaegapsvflfppkpkdtlmisrtpevtcvvvdvshe dpevkfnwyvdgvevhnaktkpreeqynstyrvvsvltvlhqdwlngkeykckvsnkalpssiektiskakgqprepqvytlpps rdeltknqvsltclvkgfypsdiavewesngqpennykttppvldsdgsfflyskltvdksrwqqgnvfscsvmhealhnhytqksl slspgk

SEQ ID No 4: "mAb14" light chain (signal peptide omitted - CDR sequences shown in bold/underline, constant region shown in lowercase letters)

AIQLTQSPSSLSASVGDRVTITCRASQDIDSALAWYQQKPGKAPKILIHDASSLESG VPSRFSGSGSGTDFTLTISSLQPEDFATYYCQQFNSYPYTFGQGTKLEIKRtvaaDSvfifDDsdeg Iksgtasvvcllnnfypreakvqwkvdnalqsgnsqesvteqdskdstyslsstltlskadyekhkvyacevthqglsspvtksfnr gee

SEQ ID No 5: "mAb14" heavy chain of the lgG4 isotype (signal peptide omitted - CDR sequences shown in bold/underline, constant region shown in lowercase letters)

EVQLVESGGGLVKPGGSLRLSCAASGFIFSSYSMNWVRQAPGKGLEWVSSITSGS YYIHYADSVKGRFTISRDNAKNSLYLQMNSLRAEDTAVYYCVRERGWGYYGMDVWGQGT TVTVSSastkgpsvfplapcsrstsestaalgclvkdyfpepvtvswnsgaltsgvhtfpavlqssglyslssvvtvpssslgtkty tcnvdhkpsntkvdkrveskygppcpscpapeflggpsvflfppkpkdtlmisrtpevtcvvvdvsqedpevqfnwyvdgvevh naktkpreeqfnsty^vsvltvlhqdwlngkeykckvsnkglpssiektiskakgqpre^

ypsdiavewesngqpennykttppvldsdgsfflysrltvdksnwqegnvfscsvmhealhnhytqkslslslgk

"Single-nucleotide polymorphism" ("SNP") is a DNA sequence variation occurring when a Single Nucleotide— A, T, C or G— in the genome (or other shared sequence) differs between members of a biological species or paired chromosomes. SNPs according to the present invention include SNPs indicative of altered expression levels of one or more of the biomarkers herein. Since SNP detection takes place on DNA level, such measurements may be performed on almost any type of biological samples, including samples obtained using non-invasive methods (e.g. urine and saliva samples).

The "expression level" of a biomaker associated with an increased probability of successful treatment is the detectable level in a biological sample from said patient. The expression level can be measured by methods known to one skilled in the art and also disclosed herein. The level of expression is compared to a reference level and deviations here from (up or down) may indicate that the patient will have an increased likelihood of a positive treatment response.

The "mean expression levels of patients suffering from said inflammatory disease" is herein used as the reference level for the individual biomarkers. The level of expression may be determined by various methods. Examples are described in the general methods. The skilled person will further understand that the "reference level" or "mean expression levels of patients" need not be determined every time. The reference level may be set based on experience in the field and the key is the focus on altered expression of the identified biomarkes.

"Inflammatory diseases" or disorders (or conditions) or auto-immune diseases (or conditions) may be selected from the list consisting of rheumatoid arthritis, juvenile rheumatoid arthritis, psoriasis, psoriatic arthritis, ankylosing spondylitis, Sjogren's syndrome, multiple sclerosis, inflammatory bowel diseases such as ulcerative colitis and Crohn's disease, systemic lupus erythematosus, or lupus nephritis, and any combination thereof, as well as co-morbidities associated with these diseases, with cardiovascular disease being a non-limiting example of said comorbidities. Other exemplary diseases or disorders include, but are not limited to, juvenile chronic arthritis, osteoarthritis, other spondyloarthropathies than ankylosing spondylitis, systemic sclerosis (scleroderma), idiopathic inflammatory myopathies (dermatomyositis, polymyositis), vasculitis, systemic vasculitis, temporal arteritis, atherosclerosis, sarcoidosis, myasthenia gravis, autoimmune hemolytic anemia (immune pancytopenia, paroxysmal nocturnal hemoglobinuria), pernicious anemia, autoimmune thrombocytopenia (idiopathic thrombocytopenic purpura, immune-mediated thrombocytopenia), thyroiditis (Grave's disease, Hashimoto's thyroiditis, juvenile lymphocytic thyroiditis, atrophic thyroiditis), diabetes mellitus, Type 2 diabetes, immune-mediated renal disease (glomerulonephritis, tubulointerstitial nephritis, autoimmune oophiritis), pancreatitis, autoimmune orchitis, autoimmune uveitis, anti- phospholipid syndrome, demyelinating diseases of the central and peripheral nervous systems in addition to multiple sclerosis, idiopathic demyelinating polyneuropathy or Guillain- Barre syndrome, and chronic inflammatory demyelinating polyneuropathy, hepatobiliary diseases such as infectious hepatitis (hepatitis A, B. C, D, E and other non-hepatotropic viruses), autoimmune chronic active hepatitis, viral hepatitis, primary biliary cirrhosis, granulomatous hepatitis, Wegener's granulomatosis, Behcet's disease, and sclerosing cholangitis, inflammatory bowel diseases such as celiac disease, gluten-sensitive enteropathy, and Whipple's disease, autoimmune or immune-mediated skin diseases including bullous skin diseases, erythema multiforme and contact dermatitis, atopic dermatitis, dermitis herpetiformis, pemphigus vulgaris, vitiligo (leukoderma), allergic diseases such as asthma, allergic rhinitis, atopic dermatitis, food hypersensitivity and urticaria, sepsis, endotoxemia, immunologic diseases of the lung such as eosinophilic pneumonias, idiopathic pulmonary fibrosis and hypersensitivity pneumonitis, chronic obstructive pulmonary disease, and organ or bone marrow transplantation associated diseases including graft rejection and graft-versus-host disease.

"Rheumatoid arthritis" (RA) may be diagnosed based on the criteria defined by the American college of Rheumatology (ACR) or the like. The responsiveness to a treatment may be based on degrees score when applying such criteria. Prevention or retardation of radiographic damage is also a goal for RA treatment. The American College of

Rheumatology (ACR) 20% composite criteria for improvement describes patients as

"improved" if there is 20% improvement in the tender and swollen joint counts and 20% improvement in at least three of five additional measures (pain, physical function, patient global health assessment, physician global health assessment and acute phase reactant levels). Similarly, the ACR50 and ACR70 represent even higher degrees of improvement for the patient.

The effectiveness of an anti-inflammatory agent as a therapeutic for RA may thus be quantified based on the number of patients or the fraction of patients that obtains ACR20, ACR50 and/or ACR70.

Alternative to the ACR scores, progression of rheumatoid arthritis can also be followed using a Disease Activity Score of 28 joints (DAS28). It is a combined index that has been developed in Nijmegen in the 1980's and has been widely used as an indicator of RA disease activity and response to treatment also in combination with the DAS based

European League Against Rheumatism (EULAR) response criteria. The joints included in DAS28 are (bilaterally): proximal interphalangeal joints (10 joints), metacarpophalangeal joints (10), wrists (2), elbows (2), shoulders (2) and knees (2). When looking at these joints, both the number of joints with tenderness upon touching (TJC28) and swelling (SJC28) are counted. Measurements of the level of C-reactive protein (CRP) (in mg/l) may be included and the patient also makes a subjective assessment (SA) of disease activity during the preceding 7 days on a scale between 0 and 100, where 0 is "no activity" and 100 is "highest activity possible". Based herein DAS28 is calculated.

Using the DAS, several thresholds have been developed for high disease activity, low disease activity or even remission. The score can also be used as response criteria, when the DAS of a patient is measured at two time points (e.g. before the start of a treatment and after treatment), the clinical response in the patients can be assessed.

As for RA, effect of treatment of systemic lupus erythematous may be based on the basis of the American College of Rheumatology (ACR) classification criteria. These criteria were established mainly for use in scientific research and in clinical trial and not for diagnostic purposes, so not all SLE patients pass the full criteria.

For multiple sclerosis, several subtypes of the disease exist and different prognosis and progression is observed. The United States National Multiple Sclerosis Society in 1996 standardized four subtype definitions: as 1 ) relapsing remitting, 2) secondary progressive, 3) primary progressive, and 4) progressive relapsing. Various criteria for diagnosing and evaluation are used which severely complicates testing of drugs potentially effective in treatment of MS. Based on MS being an autoimmune disease immune-modulators including anti-inflammatory agents may be useful for treatment or management of MS.

Psoriatic arthritis may be diagnosed based on the criteria defined by the American college of Rheumatology (ACR) or the like. The responsiveness to a treatment may be based on degrees score when applying such criteria. Prevention or retardation of radiographic damage is also a goal for PSA treatment. The America college of Rheumatology (ACR) 20% composite criteria for improvement describes patents as "improved" if there is 20% improvement in the tender and swollen joint counts and 20% improvement in at least three of five additional measures (pain, physical function, patient global health assessment, physician global health assessment and acute phase reactant levels). Similarly, the ACR50 and ACR70 represent even higher degrees of improvement for the patient. The effectiveness of an anti-inflammatory agent as a therapeutic for PSA may thus be quantified based on the number of patients or the fraction of patients that obtains ACR20, ACR50 and/or ACR70.

Alternative to the ACR scores, progression of psoriatic arthritis can also be followed using a Disease Activity Score of 28 joints (DAS28). It is a combined index that has been developed in Nijmegen in the eighties and is has been widely used as an indicator of PSA disease activity and response to treatment also in combination with the EULAR response criteria. The joints included in DAS28 are (bilaterally): proximal interphalangeal joints (10 joints), metacarpophalangeal joints (10), wrists (2), elbows (2), shoulders (2) and knees (2). When looking at these joints, both the number of joints with tenderness upon touching (TJC28) and swelling (SJC28) are counted.

Measurements of the level of C-reactive protein (CRP) (in mg/l) may be included and the patient also makes a subjective assessment (SA) of disease activity during the preceding 7 days on a scale between 0 and 100, where 0 is "no activity" and 100 is "highest activity possible". Based herein DAS28 is calculated.

Using the DAS, several thresholds have been developed for high disease activity, low disease activity or even remission. The score can also be used as response criteria, when the DAS of a patient is measured at two time points (e.g. before the start of a treatment and after treatment), the clinical response in the patients can be assessed.

Skin psoriasis is a major aspect of PsA, although the extent of activity in the skin does not necessarily correlate with joint activity. A number of instruments to assess skin psoriasis have been developed. A widely used instrument is the psoriasis area and severity index (PASI). The PASI assesses individual psoriatic lesions for erythema,

thickness/induration, and scale, and then uses a formula to account for the overall extent of the body surface area of skin involved, with scores ranging from 0-72.

The Psoriatic Arthritis Response Criteria (PsARC) was specifically developed for

PSA clinical trials. The PsARC is composed of four measures: 1 ) patient global assessment of disease activity (improvement of 1 on a 5 point Likert scale is required for a response), 2) physician global assessment of disease activity (improvement of 1 on a 5 point Likert scale is required for a response), 3) joint pain (reduction of 30% or more in total score, assessing either 68 or 78 joints, using a 4 point scale is required for a response), and 4) joint swelling (reduction of 30% or more in total score, assessing either 66 or 76 joints using a 4 point scoring scale, is required for a response). In order to be a 'PsARC responded, patients must achieve improvement in 2 of 4 measures, one of which must be joint pain or swelling, without worsening in any measure.

In one embodiment the subject is a patient e.g. an individual diagnosed or suffering from sign(s) or symptom(s) associated with inflammatory diseases or disorders as described herein. In one embodiment the patient is suffering from an autoimmune disease or disorders. In a specific embodiment the patient is an RA patient or suffering from symptoms of RA.

Drugs that a patient is being treated with or has previously been treated with may include one or more of the following: non-steroidal anti-inflammatory drugs (NSAIDs) like Asprin™, Ibuprofen™ etc, Corticosteroids, disease-modifying anti-rheumatic drugs (DMARDs) like Plaquenil™, Azulfidine™, Methotrexate™, etc, Copaxone™ (glatirimer acetate), Gilneya™ (fingolimod), antibiotics like Flagyl™, Cipro™, Topical (skin applied) medications including topical corticosteroids, vitamin D analogue creams (Dovonex™), topical retinoids (Tazorac™), moisturizers, topical immunomodulators (tacrolimus and pimecrolimus), coal tar, anthralin, and others, Raptiva™, Ustekimumab™, light therapy like PUVA, UVB and CellCept™ (mycophenolate mofetil). Also including biological antiinflammatory agents including, but are not limited to, IFN-beta, Orencia™, Humira™, Enbrel™, Remicade™, Simponi™, Cimzia™, Tysabri™, Rituxan/MabThera™,

Actemra/RoActemra™ and Kineret™ and the like. In one embodiment, this treatment is continued alongside the treatment according to the invention.

In one embodiment of the present invention, the patient is also being treated with one or more DMARDs such as e.g. methotrexate.

As described herein above multiple pathways are involved in inflammation and each pathway may be targeted at multiple levels. Inhibition of receptor signalling may be obtained by blocking a receptor, by providing a soluble receptor fragment or by preventing the ligand from binding or signalling through the receptor as exemplified by targeted biological therapeutics for treatment of certain autoimmune diseases and/or cancer.

In one embodiment, the anti-inflammatory agent is an anti-hlL-21 antibody and is administered in an amount of about 1 , 2, 3, 4, or 5 mg/kg subcutaneously or intravenously once-weekly or twice weekly or once monthly or twice monthly.

An anti-inflammatory agent for use herein may be in a pharmaceutical composition e.g. a pharmaceutical composition comprising an anti-inflammatory agent and a

pharmaceutically acceptable carrier and a label. The anti-inflammatory agent or

pharmaceutical composition may be suitable for oral, intravenous (i.v.) and/or subcutaneous (s.c.) administration. In one embodiment, the pharmaceutical composition comprising an antiinflammatory agent for use according to the present invention is suitable for subcutaneous use. The anti-inflammatory agent, or pharmaceutical composition, may be in an appropriate delivery form, such as an administration device, for repeated administration such as e.g. once monthly or once weekly.

The present invention also provides an article of manufacture (e.g. a kit) comprising, packaged together, (i) a pharmaceutical composition comprising an anti-inflammatory agent and a pharmaceutically acceptable carrier and (ii) a label stating that the pharmaceutical composition can be used for treating a patient suffering from an autoimmune disease or disorder, wherein said patient expresses one or more biomarkers herein. The invention as described herein is summarized, but not limited, in the following list of embodiments. All embodiments can be combined.

1. A pharmaceutical composition for use in treatment of an inflammatory disease, such as e.g. an auto-immune disease, wherein said pharmaceutical composition comprises an IL-21 antagonist, wherein the expression level in the patient to be treated (who suffers from the inflammatory disease) of one or more biomarkers selected from the list consisting of:

FLVCR1-AS1 (increased expression), CTNNA1 (decreased expression), HSBP1 L1 , and CHSY1 (decreased expression) deviates at least 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or 100% compared to mean expression levels of patients suffering from said inflammatory disease. Expression levels (of FLVCR1-AS1 ) may, alternatively, be at least 6.5 (RMA normalized expression value).

2. A pharmaceutical composition for use in treatment of an inflammatory disease, such as e.g. an auto-immune disease, wherein said pharmaceutical composition comprises an antiinflammatory agent, such as e.g. an IL-21 antagonist, wherein the expression level in the patient to be treated (suffering from the inflammatory disease) of CTX-I is increased at least 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or 100% compared to mean expression levels of patients suffering from said inflammatory disease. Expression levels may, alternatively, be at least 6.5 (RMA normalized expression value).

3. A pharmaceutical composition for use in treatment of an inflammatory disease, such as e.g. an auto-immune disease, wherein said pharmaceutical composition comprises an anti- inflammatory agent, such as e.g. an IL-21 antagonist, wherein the expression level in the patient to be treated (suffering from the inflammatory disease) of CTX-1 and one or more biomarkers selected from the list consisting of: FLVCR1 -AS1 (increased expression), CTNNA1 (decreased expression), HSBP1 L1 , and CHSY1 (decreased expression) deviates at least 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or 100% compared to mean expression levels of patients suffering from said inflammatory disease. Expression levels (of FLVCR1-AS1 and/or CTX-1 ) may, alternatively, be at least 6.5 (RMA normalized expression value). In one embodiment, said expression levels of RNA FLVCR1-AS1 and CTX-1 are increased. 4. A pharmaceutical composition for use in treatment of an inflammatory disease, such as e.g. an auto-immune disease, wherein said pharmaceutical composition comprises an anti- inflammatory agent, such as e.g. an IL-21 antagonist, wherein the patient to be treated (suffering from the inflammatory disease) is homozygous for one or more SNPs associated with increased or decreased expression levels of one or more biomarkers selected from the list consisting of: FLVCR1-AS1 (RNA) (increased expression), CTNNA1 (decreased expression), HSBP1 L1 , and CHSY1 (decreased expression). In one embodiment, said SNP is the rs1047881 SNP in FLVCR1-AS1 (RNA). Increased expression levels means that expression levels of one or more of said biomarkers is increased at least 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or 100% compared to mean expression levels of patients suffering from said inflammatory disease. Expression levels (of FLVCR1 -AS1 (RNA)) may, alternatively, be at least 6.5 (RMA normalized expression value).

5. A pharmaceutical composition for use in treatment of an inflammatory disease, such as e.g. an auto-immune disease, wherein said pharmaceutical composition comprises an anti- inflammatory agent, such as e.g. an IL-21 antagonist, wherein the patient to be treated

(suffering from the inflammatory disease) is homozygous for one or more SNPs associated with increased expression levels of CTX-1 .

6. A pharmaceutical composition for use in treatment of an inflammatory disease, such as e.g. an auto-immune disease, wherein said pharmaceutical composition comprises an antiinflammatory agent, such as e.g. an IL-21 antagonist, wherein the patient to be treated (suffering from the inflammatory disease) is homozygous for one or more SNPs associated with increased expression levels of CTX-1 and homozygous for one or more SNPs associated with increased or decreased expression levels of one or more biomarkers selected from the list consisting of: FLVCR1 -AS1 (RNA) (increased expression), CTNNA1 (decreased expression), HSBP1 L1 , and CHSY1 (decreased expression). In one

embodiment, said SNP is the rs1047881 "AA" SNP in FLVCR1-AS1 (RNA). SNP analysis and biomarker expression profiles may be combined. In one embodiment, said patient to be treated is homozygous for one or more SNPs associated with increased expression of RNA FLVCR1-AS1 (RNA) and one or more SNPs associated with increased expression of CTX-1.

7. A pharmaceutical composition according to the invention, wherein the anti-inflammatory antagonist is an IL-21 antibody that competes with binding of IL-21 with either the IL-21 R or the common gamma chain. Preferred anti IL-21 antibodies according to the invention are described herein and include IL-21 antibodies binding to helix 1 +3 or helix 2+4 of IL-21 , such as e.g. "mAb5" or "mAb14", or antibodies comprising at least the CDR3 sequences (or all CDR sequences) and/or the VL/VH sequences of mAb5 or mAb14.

8. A pharmaceutical composition according to the invention, wherein the patient is also being treated with methotrexate.

9. A pharmaceutical composition according to the invention, wherein the inflammatory disease is an auto-immune disease selected from the list consisting of: rheumatoid arthritis, psoriasis, psoriatic arthritis, multiple sclerosis, Crohn's disease, ulcerative colitis, systemic lupus erythematosus, lupus nepthritis, type 1 diabetes (T1 D), and diabetic nephropathy, such as e.g. Crohn's disease or T1 D.

10. A method for identification of a patient with an increased probability of responding to an anti-inflammatory agent, such as e.g. an IL-21 antagonist, wherein said method comprises obtaining information on the level of expression of one or more biomarkers selected from the list consisting of: RNA FLVCR1 -AS1 (RNA), CTNNA1 , HSBP1 L1 , CHSY1 , and CTX-1 in a biological sample from said subject. In one embodiment, said method comprises obtaining information on the level of expression from RNA FLVCR1 -AS1 (RNA) and CTX-1. In one embodiment, PCR based techniques (such as e.g. multi-plex PCR or qRT-PCR, or micro array chips) are used for obtaining information regarding expression levels - probes disclosed herein may be used. Expression levels deviating 20% or more of said one or more biomarker compared to mean expression levels are indicative of a better responder patient. In another embodiment, detection of SNPs associated with increased or decreased expression of the biomarker in question is used for identifying better responder patients. SNP analysis and biomarker expression profiles may of course be combined.

1 1 . A method for treating an inflammatory disease, such as e.g. an auto-immune disease, in a patient, wherein said method comprises administering a therapeutic amount of an antiinflammatory agent, such as e.g. an IL-21 antagonist, to said patient, wherein, prior to administration of said anti-inflammatory agent, or said IL-21 antagonist, at least one test, according to the method in embodiment 10, has shown that the expression levels of one or more biomarkers selected from the list consisting of: RNA FLVCR1-AS1 (RNA), CTNNA1 , HSBP1 L1 , CHSY1 , and CTX-1 , in a biological sample from said patient deviates at least 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or 100% compared to mean expression levels of patients suffering from said inflammatory disease and thus predictive of a response of the patient to the antiinflammatory agent or IL-21 antagonist.

14. The method according to the invention, wherein the patient suffers from an inflammatory disease selected from the list consisting of: rheumatoid arthritis, psoriasis, psoriatic arthritis, multiple sclerosis, Crohn's disease, ulcerative colitis, systemic lupus erythematosus, lupus nepthritis, type 1 diabetes (T1 D), and diabetic nephropathy.

15. A kit comprising a pharmaceutical composition according to the invention as well as one or more detecting agents for determining the expression level of one or more biomarkers herein in a patient sample, and instructions for use of the kit, including how to correlate expression level(s) with response probability of a subject. The detecting agents could e.g. be probes for detecting presence of one or more expression-related SNPs, alternatively various probes for detecting expression levels of the one or more biomarkers in questions (e.g. antibodies, primers, etc.).

16. A pharmaceutical composition comprising and IL-21 antagonist for use in a method for treatment of an inflammatory disease in a patient wherein

a. the transcript level of FLVCR1-AS1 relative to the ACTB mRNA level as measured by qRT-PCR using Hs03678783_m1 (Applied Biosystems) and Hs99999903-m1 is not higher than 14. (e.g. a delta Ct of 14 or below) or

b. the mRNA level of CHSY1 relative to the ACTB mRNA level as measured by qRT- PCR using Hs00287043_m1 (Applied Biosystems) and Hs99999903_m1 is 1 or above (e.g. delta Ct is1 or above) or

c. the mRNA level of CTNNA1 relative to ACTB mRNA level as measured by qRT- PCR using Hs000944794_m1 (Applied Biosystems) and Hs99999903_m1 is 0.5 or above (e.g. delta Ct is 0.5 or above).

17. A pharmaceutical composition for use in a method for treatment of an inflammatory disease, wherein said pharmaceutical composition comprises an IL-21 antagonist and wherein the expression level in the patient to be treated of one or more biomarkers selected from the list consisting of: FLVCR1 -AS1 (increased expression), CTNNA1 (decreased expression), HSBP1 L1 , and CHSY1 (decreased expression) deviates from a predetermined reference level, as follows:

a. the level of expression of the FLVCR1-AS1 transcript deviates from the reference level when the expression of the FLVCR1 -AS1 transcript relative to the ACTB expression as measured by qRT-PCR using Hs03678783_m1 (Applied Biosystems) and Hs99999903- m1 is not higher than 14 (e.g. a delta Ct of 14 or below), or

b. the level of expression of the CHSY1 mRNA deviates from the reference level when the expression of the CHSY1 transcript relative to the ACTB expressions as measured by qRT-PCR using Hs00287043_m1 (Applied Biosystems) and Hs99999903_m1 is 1 or above (e.g. delta Ct is1 or above) or

c. the level of expression of the CTNNA1 mRNA deviates from the reference level when the expression of the CTNNA1 transcript relative to ACTB expression as measured by qRT- PCR using Hs000944794_m1 (Applied Biosystems) and Hs99999903_m1 is 0.5 or above (e.g. delta Ct is 0.5 or above).

18. A pharmaceutical composition for use in a method for treatment of an inflammatory disease, wherein said pharmaceutical composition comprises an IL-21 antagonist and wherein the expression level of the FLVCR1 -AS1 transcript in the patient, when measured using micro array chip is above 6.50, such as above 6.60, such as above 6.65 or even such as above 6,69 on a log2 scale of RMA normalized AffyMetrix micro array levels.

19 A pharmaceutical composition for use in treatment of an inflammatory disease, wherein said pharmaceutical composition comprises an IL-21 antagonist and wherein an FLVCR1- AS1 expression correlated SNPs can be detected in the patient.

20. The pharmaceutical composition or method according to any of the above embodiments, wherein the plasma level of the biomarker CTX-I in the patient is above 500 pg/ml. 21 . The pharmaceutical composition or method according to any of the above embodiments wherein a composite score (z-score) combining information on FLVCR1-AS1 and CTX-I expression levels are used and the composite z-Score is above 0.

22. The pharmaceutical composition or method according to any of the above embodiments wherein the expression level is measured prior to treatment initiation (baseline).

EXAMPLES

General Methods Total RNA may be obtained from any type of biological sample by various standard methods. The Examples herein are based on data obtained using the PaxGene blood RNA KIT IVD (QIAGEN), which is suitable for samples that are collected over time and to be analysed subsequently. The PaxGene blood samples were handled following the instructions of the manufacturer (Qiagen) and total RNA was isolated following the protocol for the PaxGene PAXgene Blood RNA Kit (QIAGEN).

Globin mRNA reduction: A reduction of Globin mRNA in a total RNA sample can be obtained using e.g. the GLOBINCIear kit (Applied Biosystems, Foster City, CA, USA) following the instructions of the manufacturer.

RNA integrity confirmation: The Agilent 2100 Bioanalyzer and total RNA Nano chips (Agilent Technologies, Santa Clara, CA, USA) can e.g. be used for analysing RNA integrity following the manufacturer's instructions. Generally a sample giving an RNA integrity number (RIN-score) above 7 is considered acceptable for further analysis.

AffyMetrix GeneChip hybridization, scanning and analysis: Using a total RNA sample, labelled cRNA (targets) can be prepared from a minimum of fifty nanograms of total RNA by 3' IVT Express Kit (Affymetrix, Santa Clara, Ca, USA) following the instructions of the manufacturer. Hybridization cocktails are prepared as described by the manufacturer and hybridised onto Human Genome U133 Plus 2.0 GeneChips® (Affymetrix) at 45° C for 17h (60 RPM) in a Hybridization Oven 640 (Affymetrix). After hybridization, the GeneChips are washed and stained in a GeneChip® fluidics station 450 using the fluidics protocol "EukGE- WS2v5_450" (Affymetrix). The GeneChips® are scanned in a GeneChip® scanner 3000 (Affymetrix). The out-put, the "^*.cel files" are used for RMA (Robust Multiarray Average) normalization of GeneChip data by using the R environment and the Bioconductor package "Affy" which can be found at the URL: cran.r-project.org & bioconductor.org.

Statistical analysis of the microarrav data can be performed with open-source tools available in the statistical programming environment, R (available at the URL: cran.r- project.org) as well as with QluCore Omics explorer 2.2 (QluCore AB, Sweden). Microarrays can be normalized by RMA (Robust Multiarray Average) using the Affy package (available at the URL: cran.r-project.org) and the custom Chip Definition File (HGU133Plus2_Hs_ENSG) available at the URL: brainarray.mbni.med.umich.edu).

Quantative RT-PCR analysis can be performed by preparing 25 microliters of cDNA from 200 ng total RNA using random primers and TaqMan Reverse Transcription reagents (Applied Biosystems, Foster City, CA, USA) according to the manufacturer's instructions. The qPCR analysis is performed in a total volume of 25 microliters, at least in duplicates on each sample (6, 95 microliters of a 10-fold dilution of cDNA), using TaqMan PCR core reagents (Applied Biosystems) and the ABI PRISM® 7900HT Sequence Detection System (Applied Biosystems).

Expression levels of FLVCR1 -AS1 (RNA), CHSY1 , CTNNA1 , and ACTB mRNAs can be determined using primers and FAM-labelled-probes. The primers and probes can be ordered as Assays-on-Demand (Applied Biosystems). Probe sequences for these assays were as follows: FLVCR1-AS1 (RNA) assay (GATGTGCCCACTAAAGAGGAATAAC (SEQ ID NO 6) (ID: Hs03678783_m1 )), CHSY1 (TGGCCGCCTACAGAACATGGTCCAA (SEQ ID NO 7) (ID: Hs00208704_m1 )), CTNNA1 (CTTGTTACACAGGTTACAACCCTTG (SEQ ID NO 8) (ID: HS00944794_m1 )) and ACTB (CCTTTGCCGATCCGCCGCCCGTCCA (SEQ ID NO 9) (ID: Hs99999903_m1 ). Data were analysed using ABI Prism SDS 2.2 software (Applied Biosystems), and expression levels were normalized to ACTB. In one embodiment, the present invention relates to one or more probes selected from SEQ ID NO 6, SEQ ID NO 7, SEQ ID NO 8, and SEQ ID NO 9, or the use of such probes in a method for identification of a patient with an increased probability of responding to an IL-21 antagonist

The PCR product should be detectable within cycle (Ct-value) 32 in the FLVCR1-

AS1 (RNA) assay (ID: Hs03678783_m1 ), within cycle 30 in the CHSY1 assay (ID:

Hs00208704_m1 ), within cycle 31 in the CTNNA1 assay (ID: HS00944794_m1 ), whereas detection of ACTB mRNA (assay ID Hs99999903_m1 ) should be obtained within cycle 22,5 to ensure the quality of the PCR reaction.. Normalization could also be done by calculating a delta-Ct value. The official Gene Symbol identifiers are used for the analysed transcripts.

ROC curves: A number of transcripts were identified to be differentially expressed when comparing ACR-50 responders and non-responders. In order to examine the usefulness of these transcripts as a high response predictor in anti-IL21 antibody dosed patients, Receiver Operating Characteristics (ROC)-curves were prepared, as shown in Figure 1 . The receiver operating characteristics (ROC) curves were prepared in GraphPad Prism 5 (GraphPad Software, CA, USA). The GraphPad software supplies the following explanations for the ROC curve. "When evaluating a diagnostic test, it is often difficult to determine the threshold laboratory value that separates a clinical diagnosis

If a high threshold value is set (with the assumption that the test value increases with disease severity), some individuals with low test values or mild forms of the disease may be missed. The sensitivity (the fraction of people who have the disease that will be correctly identified with a positive test), will thus be low. Few of the positive tests will be false positives, but many of the negative tests will be false negatives.

On the other hand, if a low threshold value is set, most better responder individuals with the disease may be identified, but relatively many of them may be "false positives". Few of the negative tests will be false negatives, but many of the positive tests will thus be false positives.

It is currently possible to achieve a higher sensitivity or a higher specificity, but not both. A receiver-operator characteristic (ROC) curve helps to visualize and understand the tradeoff between high sensitivity and high specificity".

The area under curve (AUC) for the ROC curve, which is indicative of the accuracy of the predictors was found to be best for the FLVCR1 -AS1 RNA. For ACR-50 response, the AUC was found to be 0,816, indicative of a good prediction of ACR50 responses based on FLVCR1-AS1 (RNA) levels.

For defining a threshold level of FLVCR1 -AS1 RNA at which it could be a good predictor of high responses in the anti-l L21 RA-trial, the thresholds for an optimal classification of the patients in either ACR50 responders and ACR50 non-responders were defined, as well as for ACR70 responders and non-responders. This was done with base-line FLVCR1-AS1 RNA levels. For optimal ACR50 classification a FLVCR1-AS1 RNA threshold of 6.695 (log2 scale of RMA normalized AffyMetrix microarray levels) was found. The used threshold of 6.695 is indicated by the black dots on the ROC curves

The CTX-1 plasma concentration can be measured using commercially available tools, such as using the Roche ECLIA method as described below, providing the

concentration of the protein.

Example 1

Based on data from an anti-IL21 clinical trial in rheumatoid arthritis (RA), biomarkers useful for predicting clinical responses (ACR50 and ACR70) to anti-inflammatory drugs (e.g. anti-l L-21 ) in individual rheumatoid arthritis patients were identified. These markers are also useful for identifying "better responder" patients suffering from other types of autoimmune diseases. The markers may be considered relevant for all inflammatory diseases as long as the therapeutic compound is an I L-21 antagonist.

Whole blood samples from a phase-2a study (anti-IL-21 in RA patients) trial, was used for identifying gene expression profiles (micro-array) predictive of drug response. The antibody disclosed in WO2010055366 as clone number 362.78.1 .44 ("mAb5") was administered to the patients in this trial. Patients in this study were: (i) diagnosed with Rheumatoid Arthritis (RA), (ii) aged between 18 and 75 years (males + females), (iii) Biologically naive or having previously failed to respond to biologic therapies for RA, and (iv) having a DAS28 (CRP)≥4.5 and Minimum TJC (tender joint counts)≥5 and SJC (swollen joint counts)≥5. The duration of the study was at least 6 months and patients were on MTX (metothrexate) treatment for at least 16 weeks at a stable dose (15-25 mg/week) for at least 6 weeks.

Full transcriptome profiles of whole blood samples from pre-dose, week 1 , week 3, and week 12 were analysed by the Affymetrix GeneChip HGU133plus2.0 and used for identifying transcripts having the potential to discriminate ACR50 responders from non- responders.

A t-test comparing all dosed responding patients to all dosed non-responding patients was performed. In order to identify transcripts exhibiting relative stability over time, all 4 sampling points (pre-dose, week 1 , week 3, and week 12) for the individual patients were included in the t-test. A total of 39 transcripts showed a statistical difference between responders and non-responders (False discovery rate (FDR) = 1 %). The best operating characteristics (Based on ROC curve analyses) for these 39 transcripts were found for the non-protein coding RNA FLVCR1-AS1 (feline leukemia virus subgroup C cellular receptor 1 - anti-sense RNA 1 ). The area under curve (AUC) in a ROC curve is indicative of the accuracy of the predictor evaluated in the plot. Generally, an AUC around 0.7 would be expected for a fair predictor, an AUC of at least 0.8 for a good predictor, and an AUC of at least 0.9 for an excellent predictor. The area under curve (AUC) for the FLVCR1-AS1 predictor was 0.82 (for ACR50) and 0,87 (for ACR70) indicating a high degree of accuracy for this predictor in anti- IL-21 dosed RA patients. In addition to the FLVCR1 -AS1 predictor, the following transcripts were found to have AUCs around 0.75 (for ACR50 prediction): CTNNA1 (catenin (cadherin- associated protein), alpha 1 ), HSBP1 L1 (heat shock factor binding protein 1 -like 1 ), and CHSY1 (chondroitin sulfate synthase 1 ). Those transcripts are thus suitable for use as biomarkers predicting better responder patients.

The abovementioned transcripts/biomarkers show relative stability over time as shown for FLVCR1 -AS1 in figure 3, which provides a stabilizing effect on the prediction model. Genes exhibiting pronounced day to day variation would likely provide noise in a prediction model.

With baseline information on the whole blood expression levels of one or more of the above mentioned biomarker transcripts it will be possible to predict the clinical effect of anti-l L21 dosing in RA-patients.

Based on data with expression values of the biomarker transcripts identified herein and DNA variation measurements, a number of expression-increasing genotypes were identified. In connection with improving treatment options of inflammatory diseases such as e.g. RA.it is useful to measure these as an easier accessible proxy for the identified transcripts. Mean expression values are based on mean RNA expression values in "PaxGene" RNA samples from 61 RA patients.

Example 2

The biomarker transcripts identified in Example 1 , and claimed herein, are useful in connection with improving treatment options of inflammatory diseases such as e.g. RA.

A method for analysing biomarker transcripts may thus include the following steps - said method may be used for identifying patients that are more likely to respond to treatment with an anti-inflammatory agent such as e.g. an IL-21 antagonist:

(i) Obtaining a base-line whole blood (preferably collected in a PAXGene tube (commercial product from Qiagen/Becton Dickinson/PreAnalytiX) sample from a patient before dosing the anti-inflammatory agent (e.g. anti-IL21 ) in that individual patient.

(ϋ) Extracting total RNA from the blood sample.

(iii) Making a gene expression profiling (by methods like e.g. qRT-PCR, DNA micro-array, or RNA sequencing) to obtain the levels of one or more of the biomarkers disclosed herein. Alternatively a single nucleotide polymorphism (SNP) associated with increased expression of one or more of said biomarkers.

(iv) Based on ROC curve sensitivity analyses a certain threshold for

FLVCR1 -AS1 (RNA) or a combination of the Biomarker transcripts identified herein, is applied to, with a defined sensitity and specificity, predict whether the patient will respond (as evaluated by ACR50 scoring). Based on the predicted outcome it will be possible to evaluate whether a patient should start on anti-IL-21 treatment or not.

Table 1 : expression levels of biomarkers.

CHSY expression

60% higher than 40% higher than 20% higher than higher than lower than 20% lower than 40% lower than 60% lower than mean mean mean mean mean mean mean mean

ACR50 response- rate (%) 0 0 2 10 38 50 100 N.A.

Number of patients 2 4 12 25 16 4 2 N.A.

CTNNAl expression

60% higher than 40% higher than 20% higher than higher than lower than 20% lower than 40% lower than 60% lower than mean mean mean mean mean mean mean mean

ACR50 response- rate (%) 0 20 22 9 42 57 N.A. N.A.

Number of patients 1 5 9 22 19 7 N.A. N.A.

FLVCRl-ASl expression

60% higher than 40% higher than 20% higher than higher than lower than 20% lower than 40% lower than 60% lower than mean mean mean mean mean mean mean mean

ACR50 response- rate (%) 100 50 38 37 0 0 0 0

Number of patients 3 8 16 27 14 9 6 2

Example 3

Based on these whole blood expression level findings, it was additionally investigated if any DNA variation biomarkers ("SNPs") could be identified.

The difference between whole blood expression biomarkers and DNA variation biomarkers is fundamental: the first reflects the state of the blood sample at a specific time, whereas the second is constant throughout the life of an individual in blood and all other cell types. This difference makes whole blood expression levels a more direct marker of patient state and therefore ostensibly a better stratification biomarker. However, a DNA variation is much easier to measure because it only requires a saliva sample and it never changes with time.

The expression level of the FLVCR1-AS1 (RNA), CTNNA1 , HSBP1 L1 , and CHSY1 biomarkers were measured in a cohort of individuals in whom DNA variation had also been measured using a genotyping microarray platform (lllumina HumanOmniExpress). The cohort consisted of 360 samples from 216 individuals, both healthy volunteers and RA patients. For three of the transcripts, DNA variation was within a genetic distance (from the coding regions) of 200 kilobases could be used to determine the expression level of the transcript (False Discovery Rate (FDR), or a corrected p value, of 5%). The strongest effect was found for the FLVCR1 -AS1 transcript. A specific DNA variation named rs1047881 (refers to the specific polymorphism and its position on the chromosome) could explain 58.9% of the variation in the FLVCR1-AS1 transcript level (figure 4).

Detection of DNA variation of e.g. FLVCR1-AS1 , incl. up- and down-stream regions (or any of 42 other similar DNA variations), can thus be used as an indication of whole blood expression level measurement. Since high expression levels of FLVCR1-AS1 correlate with a high probability of a patient being a better responder to e.g. anti IL-21 treatment, detection of e.g. the rs1047881 ("AA") SNP in FLVCR1 -AS1 may thus be used as an alternative to, or in addition to, FLVCR1 -AS1 expression measurement.

Such SNP detection techniques have the advantages of being detectable from any type of patient sample comprising intact chromosomal DNA. A further advantage is that the result from the SNP detection may be easier to interpret in the clinic, in particular for patients being homozygous with respect to the SNP in question. In figure 4, the major (or most frequent) allele is "A" and the minor (least frequent) allele is "G". In figure 4, patients being homozygous for the major allele ("A") have the highest level of expression of FLVCR1 -AS1 (RNA) and are thus most likely to be better responders to e.g. anti IL-21 treatment. In this form, (almost) any biological sample from a patient, including blood samples but also non-invasive samples, such as e.g. a saliva sample or a urine sample, can be used for identifying better responder patients. The sequence of interest, e.g. FLVCR1 -AS1 , can be analysed with a PCR, hybridization or sequencing-based method. The sequence for detecting an individual with high FLVCR1-AS1 (RNA) level (which will be a high-responding patient) is as follows:

SEQ ID NO 10 (rs1047881 "A" SNP in FLVCR1-AS1 ):

CTACTCCGTT AGAGAGTGCA AGTCCTCAGA CTGCAGGAGG AGGAACTCCC GTCCTTCGGTAGTGTCACTA CTTAGAGGCA A CTGTGAGGAG CTGTGATTAA TCGTGGAATG TGCTGATGTG CCCACTAAAG GTAGGGGCTG TTGGTGCACT AATGACCATT AATCCTTCAA CCTAAGCCTG CGCATTGACG TTATCTCTGA GTAGAGGGCT GGGCCGGGCT CGGTGGCCAC GTCTGTAATC The sequence for detecting an individual with low FLVCR1-AS1 level (which will be a poor responding patient) is as follows:

SEQ ID NO 11 (rs1047881 "G" SNP in FLVCR1-AS1 ):

CTACTCCGTT AGAGAGTGCA AGTCCTCAGA CTGCAGGAGG AGGAACTCCC GTCCTTCGGTAGTGTCACTA CTTAGAGGCA G CTGTGAGGAG CTGTGATTAA TCGTGGAATG TGCTGATGTG CCCACTAAAG GTAGGGGCTG TTGGTGCACT AATGACCATT AATCCTTCAA CCTAAGCCTG CGCATTGACG TTATCTCTGA GTAGAGGGCT GGGCCGGGCT CGGTGGCCAC GTCTGTAATC 42 other DNA variations have furthermore been identified in the same genomic region that are linked to the rs1047881 DNA variation and are potentially indicative of expression levels.

Example 4 Based on data from an anti-IL21 clinical trial in rheumatoid arthritis (RA), an additional biomarker for predicting a clear clinical response (e.g. ACR50 response) to antiinflammatory drugs (e.g. anti-IL-21 ) in individual rheumatoid arthritis patients was identified. Plasma samples were collected from the clinical trial population described in example 1 . Plasma samples were collected at baseline (pre-dose) from fasting patients. CTX-I was measured in plasma samples by use the Roche electrochemiluminescent immunoassay (ECLIA) method for the measurement of C-Terminal Telopeptide of Type I Collagen (CTX-I) on a Roche Cobas E41 1 analyzer.

Initially the base line measurements of CTX-I were compared between ACR50 responders and non-responders, and a significant difference was observed. Based on this observation, the CTX-I measurements at baseline were divided into tertiles (three groups); Q1 : <300 pg/ml; Q2: 300-566 pg/ml; Q3:>566 pg/ml) and compared to DAS8-CRP. The disease activity (DAS28-CRP) change from baseline at week 12 (i.e. the decrease in disease activity at week 12 compared to pre-dose) progressively decrease as the baseline CTX-I value increase. Thus, patients with a high baseline CTX-I value respond better to treatment with Anti-IL-21 treatment (Table 2).

Table 2: Based on CTX-I values measured at baseline, the clinical trial population was divided in to tertiles and compared to the disease activity, measured as change in DAS28-CRP.

Previous work by Syversen et al. (J Rheumatol. 2009 Feb;36(2):266-72), has shown a weak association between serum CTX-I levels and subsequent joint destruction. Another prospective study of patients with early RA showed that high baseline levels of urinary CTX-I predict increased risk of radiological progression and correlation with more rapid progression of joint destruction (Garnero et al., Arthritis Rheum 2002; 46:2847-56).

The data presented in this example indicate that high CTX-I values predict a better response to Anti-IL-21 treatment and that this, based on the observations described above, could lead to less severe disease progression and less joint destruction if such patient are treated. Example 5

Combined use of FLVCR1 -AS1 and CTX-I.

For improving the sensitivity of the FLVCR1-AS1 biomarker predictor, it was tested whether a composite score combining the FLVCR1 -AS1 RNA levels and the CTX-I levels could capture more of the ACR50 responding patients in the study. As an example, the two test values (FLVCR1-AS1 RNA levels and CTX-I levels) were combined by first calculating the z-scores of the individual measurements of FLVCR1-AS1 (RNA) and CTX-I, and then combing the two z-scores for the individual sample by calculating the mean z-score. The z- scores can be calculated with the "STANDARDIZE" formula in Microsoft Excel or by following the equation: (z= (sample value - mean (of all samples))/standard deviation (of all samples)). As shown in Figure 2 ("to exemplify combination of CTX-I and FLVCR1 -AS1 predictors"), the specificity of predicting ACR50-responders is roughly the same (ACR50 response rate of 38% with CTX-I predictor alone and ACR50 response rate of 41 % with composite score) when applying a threshold of the combined z-scores (z>0). Importantly, with this threshold (z>0) the patient pool is enlarged to 48% from 35%. This means that the combined FLVCR1 - AS1/CTX-I score can predict ACR50 responders with an increased sensitivity without losing the specificity which can be obtained with the CTX-I predictor alone. More responding patients will thus be identified by this combined approach. The specificity of the FLVCR1- AS1 test alone (ACR50 response rate of 67%) is still considerably higher than both the composite score and the CTX-I test alone. However, the FLVCR1 -AS1 predictor is also reducing the patient pool significantly (with the threshold >6.695 to 15% of the total patient pool in the current study).

The combined CTX-I and FLVCR1-AS1 predictor thus represents an attractive trade-off between the sensitivity and specificity of an ACR50 (and ACR70) response test, whereby a larger fraction of the better responder patients can be identified.

The expression values and z-scores for CTX-I and FLVCR1 -AS1 as obtained in the study described above are included in Fig. 5 together with the indication of treatment (antibody or placebo) and response detected. The calculated combined z-score is also included.

By including similar expression values for CTX-I and FLVCR1 -AS1 for a given new patients the calculations can be redone to obtain the mean z-score using the standardize formula in Microsoft Excel. Based on the z scores and the combined z-score for a new patient it can be determined if that patient is in the group of patients of higher likelihood of response. If alternative expression data are available these could equally well be used.

Example 6

Transformation of array data to qRT-PCR

To examine if FLVCR1 -AS1 , CHSY1 and CTNNA1 mRNA baseline (pre-dose) measurement using RT-PCR can be used to identify high responders quantitative RT-PCR analyses were performed as described herein above and data obtained from duplicate analysis of each of the cDNA samples.

The mRNA levels detected by qRT-PCR were normalised to ACTB mRNA levels which were also determined by qRT-PCR.

To obtain a stratification based on qRT-PCR data resembling the stratification obtained with a threshold of 6.695 (or above) expression value for FLVCR1-AS1 using the micro array data, the PCR product should be detected within cycle (Ct-value) 32 in the FLVCR1-AS1 assay (ID: Hs03678783_m1 )) and using the same cDNA, detection of ACTB mRNA (assay Hs99999903_m1 ) should be obtained with a Ct=18-20. Delta Ct is a measurement of the expression of the FLVCR1 -AS1 transcript relative to the level of ACTB mRNA. Delta Ct for the FLVCR1 -AS1 mRNA measurement can be calculated as 32 minus 18 providing a Delta Ct of 14. This indirectly provides a marker for patients where the expression of FLVCR1-AS1 deviates from the average expression of FLVCR1-AS1 and this may be used to identify patients with a higher likelihood of responding to anti-IL-21 treatment by measuring by qRT- PCR using Hs03678783_m1 (Applied Biosystems) and Hs99999903 the relative expression level of FLVCR1-AS1 and if delta Ct is14 or below such patients are therefore of higher likely hood of being high responders.

To obtain a stratification based on qRT-PCR data for CHSY1 using the micro array data, the PCR product should be detected at cycle (Ct-value) of 21 or below in the CHSY1 assay (ID: Hs 00287043_m1 )) and using the same cDNA, detection of ACTB mRNA (assay Hs99999903_m1 ) should be obtained with a Ct=18-20. Delta Ct for the CHSY1 mRNA measurement can be calculated as 21 minus 20 providing a Delta Ct of 1. Subjects with a baseline delta Ct of 1 or above are therefore of higher likely hood of being high responders.

To obtain a stratification based on qRT-PCR data for CTNNA1 using the micro array data, the PCR product should be detected at cycle (Ct-value) of 20 or below in the CTNNA1 assay (ID: Hs000944794_m1 ) and using the same cDNA, detection of ACTB mRNA (assay Hs99999903_m1 ) should be obtained with a Ct=18-20. Delta Ct for the CTNNAI mRNA measurement can be calculated as 21 minus 20 providing a Delta Ct of 1. Subjects with a baseline delta Ct of 0.5 or above are therefore of higher likely hood of being high responders

Claims

1. A pharmaceutical composition comprising and IL-21 antagonist for use in a method for treatment of an inflammatory disease in a patient wherein

a. the transcript level of FLVCR1 -AS1 relative to the ACTB mRNA level as measured by qRT-PCR using Hs03678783_m1 (Applied Biosystems) and Hs99999903-m1 is not higher than 14. (e.g. a delta Ct of 14 or below) or

b. the mRNA level of CHSY1 relative to the ACTB mRNA level as measured by qRT-PCR using Hs00287043_m1 (Applied Biosystems) and Hs99999903_m1 is 1 or above (e.g. delta Ct is1 or above) or

c. the mRNA level of CTNNA1 relative to ACTB mRNA level as measured by qRT-PCR using Hs000944794_m1 (Applied Biosystems) and Hs99999903_m1 is 0.5 or above (e.g. delta Ct is 0.5 or above).

2. A pharmaceutical composition for use in a method of treatment of an inflammatory disease, wherein said pharmaceutical composition comprises an IL-21 antagonist and wherein the expression level in the patient to be treated of one or more biomarkers selected from the list consisting of: FLVCR1 -AS1 (increased expression), CTNNA1 (decreased expression), HSBP1 L1 , and CHSY1 (decreased expression) deviates from a predetermined reference level, as follows:

a. the level of expression of the FLVCR1-AS1 transcript deviates from the reference level when the expression of the FLVCR1 -AS1 transcript relative to the ACTB expression as measured by qRT-PCR using Hs03678783_m1 (Applied Biosystems) and Hs99999903- m1 is not higher than 14 (e.g. a delta Ct of 14 or below), or

b. the level of expression of the CHSY1 mRNA deviates from the reference level when the expression of the CHSY1 transcript relative to the ACTB expressions as measured by qRT-PCR using Hs00287043_m1 (Applied Biosystems) and Hs99999903_m1 is 1 or above (e.g. delta Ct is1 or above) or

c. the level of expression of the CTNNA1 mRNA deviates from the reference level when the expression of the CTNNA1 transcript relative to ACTB expression as measured by qRT-

PCR using Hs000944794_m1 (Applied Biosystems) and Hs99999903_m1 is 0.5 or above (e.g. delta Ct is 0.5 or above).

3. A pharmaceutical composition for use in a method for treatment of an inflammatory disease, wherein said pharmaceutical composition comprises an IL-21 antagonist and wherein an increase in expression level of the FLVCR1-AS1 transcript can be detected in the patient, when measured using micro array chip the transcript level is above 6.50, such as above 6.60 or such as above 6.69) on a log2 scale of RMA normalized AffyMetrix micro array levels.

4. A pharmaceutical composition for use in treatment of an inflammatory disease, wherein said pharmaceutical composition comprises an IL-21 antagonist and wherein an FLVCR1- AS1 expression correlated SNPs can be detected in the patient.

5. The pharmaceutical composition or method according to any of the above embodiments, wherein the plasma level of the biomarker CTX-I in the patient is above 500 pg/ml.

6. The pharmaceutical composition or method according to any of the above embodiments wherein a composite score (z-score) combining information on FLVCR1-AS1 and CTX-I expression levels are used and the composite z-Score is above 0.

7. A pharmaceutical composition for use in a method of treatment of an inflammatory disease, wherein said pharmaceutical composition comprises an IL-21 antagonist, wherein a) the expression level in the patient suffering from the inflammatory disease of one or more biomarkers selected from the list consisting of: FLVCR1 -AS1 (RNA), CTNNA1 , HSBP1 L1 , and CHSY1 deviates at least 20% compared to mean expression levels of patients suffering from said inflammatory disease or

b) the expression level in the patient suffering from the inflammatory disease of CTX-I is increased at least 20% compared to mean expression levels of patients suffering from said inflammatory disease or

c) the expression level in the patient suffering from the inflammatory disease of CTX-1 and one or more biomarkers selected from the list consisting of: FLVCR1-AS1 (RNA), CTNNA1 , HSBP1 L1 , and CHSY1 deviates at least 20% compared to mean expression levels of patients suffering from said inflammatory disease.

8. A pharmaceutical composition for use in a method of treatment of an inflammatory disease, wherein said pharmaceutical composition comprises an IL-21 antagonist, wherein the patient suffering from the inflammatory disease is homozygous for one or more SNPs associated with increased or decreased expression levels of one or more biomarkers selected from the list consisting of: FLVCR1 -AS1 (RNA), CTNNA1 , HSBP1 L1 , and CHSY1.

9. A pharmaceutical composition according to any one of the preceding claims, wherein the IL-21 antagonist is an IL-21 antibody that competes with binding of IL-21 with either the IL- 21 R or the common gamma chain.

10. A pharmaceutical composition according to any of the preceding claims, wherein the patient is also being treated with methotrexate.

1 1 . A pharmaceutical composition according to any one of the preceding claims, wherein the inflammatory disease is an auto-immune disease selected from the list consisting of:

rheumatoid arthritis, psoriasis, psoriatic arthritis, multiple sclerosis, Crohn's disease, ulcerative colitis, systemic lupus erythematosus, lupus nepthritis, type 1 diabetes, and diabetic nephropathy.

12. A method for identification of a patient with an increased probability of responding to an IL-21 antagonist, wherein said method comprises obtaining information on the level of expression of one or more biomarkers selected from the list consisting of: RNA FLVCR1 - AS1 , CTNNA1 , HSBP1 L1 , CHSY1 , and CTX-1 in a biological sample from said subject.

13. A method for treating an auto-inflammatory disease in a patient comprising administering a therapeutic amount of an IL-21 antagonist to said patient, wherein, prior to administration of said IL-21 antagonist, at least one test, according to the method in claim 14, has shown that the expression levels of one or more biomarkers selected from the list consisting of: RNA FLVCR1-AS1 , CTNNA1 , HSBP1 L1 , CHSY1 , and CTX-1 , in a biological sample from said patient deviates at least 20% and thus predictive of a response of the patient to the anti- inflammatory agent.

14. The method according to claim 1 1 , wherein the patient suffers from an inflammatory disease selected from the list consisting of: rheumatoid arthritis, psoriasis, psoriatic arthritis, multiple sclerosis, Crohn's disease, ulcerative colitis, systemic lupus erythematosus, lupus nepthritis, type 1 diabetes, and diabetic nephropathy.