Regional Registry-based Biobank Development and Pharmacogenetic Analysis: Synergistic Strategies Driving Towards Personalized Medicine in Rheumatoid Arthritis Management
Conditions: Rheumatoid Arthritis
Sponsor: Istituto Ortopedico Rizzoli

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Study Protocol 
Title: 
Regional registry-based biobank development and pharmacogenetic analysis: synergistic strategies 
driving towards personalized medicine in Rheumatoid Arthritis management-PRUA1GR-2013-00000203 
(RABiobank) 
 
 
Protocol version date 20 May 2014 
 
Principal Investigator: Dr Elisa Assirelli 
 
Deputy Director of the Laboratory of Immunorheumatology and Tissue Regeneration (head unit of the 
project) : Prof Erminia Mariani 
 
 
 

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Number of patients Involved in the study: 
Biobank creation - the total number of patients is not predictable, as it depends on the number of patients 
that will be eligible for inclusion in the Emilia Romagna Regional Registry of Rheumatoid Arthritis (Reuma 
Registry). 
 
Pharmacogenetic Analysis - 600 patients 
 
 
 
1.8 Sintesi delle premesse teoriche dello studio: 
Rheumatoid arthritis (RA) is highly heterogeneous disease with a clinical spectrum ranging from mild and 
self-limiting diseases to severe and progressive joint destruction leading to disability and great impairment 
of quality of life, associated to a wide variability in therapeutic response(1). 
Treat-to-target paradigm in RA arises by the evidence that early and effective treatment has been 
recognized a successfully strategy for slowing/halting RA progression. Even if this model is greatly 
acknowledged to optimize early arthritis management, it remains one of the main challenge in clinical 
practice(2). 
Indeed, despite the availability of highly effective treatment options a sizeable proportion of patients fail 
to adequately respond to treatment(3). 
Over the last years, a growing number of biological agents has become available on the market. 
A mounting body of evidence testifies to the effectiveness of these agents in controlling the clinical 
manifestations and in preventing disease progression both in disease-modifying antirheumatic drug 
(DMARD)-naive patients and in those that have failed previous DMARD therapy(4). 
Nevertheless, data derived by clinical trials and by register-based observational study indicate that only 
50-70% of RA patients responds successfully when treated with biologics(5-7). In addition, potential 
serious toxicity of these drugs has been observed(8). Therefore the identification of response predictors 
might strongly impact on clinical decision-making process so improving patient quality of life and the cost-
benefit performance. 

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To address this unmet need, pharmacogenetic approach might open promising perspectives, increasing 
our understanding on genetic-related drug efficacy/toxicity, and providing decision-making tools for therapy 
optimization(9). Nevertheless, to ensure feasibility and reliability of translational applications of this strategy 
in clinical practice, large population-based research represents a crucial key step in order to validate the 
hypothesis of a correlation between genetic variation, environment and drug-related effect(10). 
In these context, availability of register-based database and accessibility to a large-scale biobank are 
essential and primary tools to combine large collections of standardized disease-specific biological 
samples with comprehensive anthropometric, clinical and life-style information, providing a unique and 
exclusive opportunity to define disease-related molecular and genetic signature. 
 
In the region Emilia-Romagna, regional RA registry has been established in 2010 to monitor usage, efficacy 
and safety of biological treatments for RA. Taking advantage of this available resource an ongoing 
prospective population-based study (granted by Italian Ministry of Health-Ricerca Finalizzata 2009, RF-
2009-1549144), has been designed in order to improve the quality and effectiveness of the healthcare for 
patients with inflammatory arthropathies. 
Therefore, the development of a register-based biobank represents a key resource and a paramount added 
value fostering large-scale and high-quality basic and clinic research studies and enabling a wide variety 
of technical approaches including molecular genetics, proteomic, serologic and genomics investigations. 
 
Disease-based biobank and registry, as combined strategies, should be considered extraordinary 
opportunities to target the practice of personalized medicine, that remain one of the main challenge for 
Healthcare System 
 
Bibliography: 
1. Boonen A, Severens JL. The burden of illness of rheumatoid arthritis. Clin Rheumatol. 2011 Mar;30 
Suppl 1:S3-8. 
2. Hobbs KF, Cohen MD. Rheumatoid arthritis disease measurement: a new old idea. Rheumatology 
(Oxford). 2012 Dec;51 Suppl 6:vi21-7 
3. Upchurch KS, Kay J. Evolution of treatment for rheumatoid arthritis. Rheumatology (Oxford). 2012 
Dec;51 Suppl 6:vi28-36. 
4. Scott DL. Biologics-based therapy for the treatment of rheumatoid arthritis. Clin Pharmacol Ther. 2012 
Jan;91(1):30-43. 
5. Lipsky PE, van der Heijde DM, St Clair EW, et al. Anti-Tumor Necrosis Factor Trial in Rheumatoid 
Arthritis with Concomitant Therapy Study Group. Infliximab and methotrexate in the treatment of 

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rheumatoid arthritis. Anti-Tumor Necrosis Factor Trial in Rheumatoid Arthritis with Concomitant Therapy 
Study Group. N Engl J Med 2000;343:1594–602. 
6. Buch MH, Seto Y, Bingham SJ, et al. C-reactive protein as a predictor of infliximab treatment outcome 
in patients with rheumatoid arthritis: defining subtypes of nonresponse and subsequent response to 
etanercept. Arthritis Rheum 2005;52:42–8. 
7. Hyrich KL, Watson KD, Silman AJ, Symmons DP; British Society for Rheumatology Biologics Register. 
Predictors of response to anti-TNF-alpha therapy among patients with rheumatoid arthritis: results from the 
British Society for Rheumatology Biologics Register. Rheumatology (Oxford). 2006 Dec;45(12):1558- 65 
8. Ruderman EM. Overview of safety of non-biologic and biologic DMARDs. Rheumatology (Oxford). 2012 
Dec;51 Suppl 6:vi37-43. 
9. Prajapati R, Plant D, Barton A. Genetic and genomic predictors of anti-TNF response. 
Pharmacogenomics. 2011 Nov;12(11):1571-85. 
10. Marsal S, Julià A. Rheumatoid arthritis pharmacogenomics. Pharmacogenomics. 2010 
May;11(5):617-9. 
 
Aim of the study 
The main purpose of this project is the building-up of an integrated model of multidisciplinary research tools 
to support large-scale high quality disease studies. 
The main objectives of the project are: 
1) to develop a research biobank, integrated with the already existing Regional Registry of Rheumatoid 
Arthritis 
of 
Emilia-Romagna 
(REUMA 
Registry 
http://assr.regione.emilia- 
romagna.it/it/aree_attivita/governo-clinico/valutaz- qual-assistance / database / db-reuma / intro), starting 
a collection and storage of multiple biological samples (serum, plasma, whole blood, DNA) according to 
quality standards 
2) perform a preliminary pharmacogenetic study analyzing a panel of gene variants potentially involved in 
the pharmacological response. 
 
Inclusion Criteria: 
As regards the inclusion of biological material in biobanks, the project includes: 
a) the enrollment of each patient with rheumatoid arthritis that is inserted "ex-novo" in the REUMA Registry 
starting from the start date of the operational activities of the biobank; 
b) parallel to this, for the part of the project that concerns the study of pharmacogenetics, blood samples 
will be taken from all patients already present in the REUMA Registry at the time of project start. 
All patients will be enrolled according to the inclusion / exclusion criteria specified below. 

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Aim1-Biobank establishment 
 
 
Patients will be eligible for inclusion into the registry if they satisfy the criteria of the American College of 
Rheumatology (ACR) 1987 or the 2010 ACR/European League Against Rheumatism (EULAR) criteria. 
The following patients will be included: 
 
 
age over 18 
newly diagnosed patients 
already diagnosed patients with active fase disease (Disease Activity Score-DAS28 > o = 4,2), 
already treated patients when they start therapy with new biological agents 
 
Aim2: pharmacogenetic analysis 
patients already enrolled in the Regional Registry 
Exclusion criteria 
Patients non residing in regione Emilia-Romagna 
Patients unable to provide informed consent 
 
Study design 
 
 
Aim 1: Preparation of the collection of biological material related to the Regional Registry of Rheumatoid 
Arthritis 
 
Preliminary organization phase 
 
 
• Planning of the biobank governance plan. 
 
 
• Definition of standard operating procedures (SOP) for the collection, transport, treatment and storage of 
different biological samples (whole blood, serum, plasma, peripheral blood mononuclear cells-PBMC, 
DNA). 
 
• Development of the IT system already in use at Lab Immunorheumatology and Tissue Regeneration- 
IOR in order to obtain an IT management system fully developed for the workflow of the biobank. 
 
Operating activity 

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Section A - OBJECTIVE: Development of the research biobank associated with the 
Regional Registry of Rheumatoid Arthritis (REUMA Registry) 
 
1) Collection and delivery of biological material by the Recruitment Units 
 
 
1.1 - Patient selection and enrollment according to the criteria / inclusion / exclusion indicated 
 
1.2 - the total number of patients is not predictable, as it depends on the number of patients who 
 
they will be eligible for inclusion in the Reuma Register from the start of the Project. 
 
1.3 - Follow-up and clinical, radiological and laboratory evaluations. All patients will be 
characterized based on clinical, imaging and laboratory evaluations (following routine clinical 
course). 
 
Follow-up time: 3, 6, 12 months after first sight and every 6 months thereafter 
(Perspective route defined based on the timing of data entry in the REUMA Registry) 
 
1.4 Collection / shipment of blood samples to be kept in the biobank and data collection of the 
patient. 
 
Blood samples will be taken from all patients (upon obtaining informed consent) during the first visit 
and prospectively at the established follow-up time and will be sent to the SC Lab. 
Immunorheumatology and Tissue Regeneration IOR. 
 
For each patient, all the data, demographic, anthropometric, radiological, laboratory, clinical and 
pharmacological, related to the first visit and subsequent follow-up times, will be inserted by the 
personnel of the individual Units of Rheumatology in the REUMA database. 
 
2) Reception and treatment of samples 
 
 
Units involved: SC Lab. Immunorheumatology and Tissue Regeneration IOR 
 
 
- All blood samples received will be immediately treated following Standard Operating Procedures in 
order to obtain: 
• plasma 
• serum 
• whole blood 
• mononuclear cells of peripheral blood 
- The different biological samples will be divided and maintained under controlled temperature conditions 
that guarantee long-term preservation 
- Part of the aliquots of the whole blood samples will be subsequently sent to the Department of Medical 
Genetics of Ferrara where DNA extraction - conservation and all the pharmacogenetic investigations 
will be carried out. 

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Section B - OBJECTIVE: pharmacogenetic study 
 
 
1) Collection and sending of biological material by the Recruitment Units 
 
 
1.1 - Patient selection and enrollment according to the inclusion criteria indicated 
 
 
1.2 Number of patients: about 600 patients (estimated number based on the Report on the processing of 
the Reuma Register indicators provided by the Emilia Romagna Region and updated at 30/11/2013) 
 
 
1.3 - Blood samples collection 
 
 
Blood samples (2 tubes with EDTA and 2 tubes without anticoagulant) will be taken from all patients (after 
obtaining informed consent) already entered in the REUMA Registry and belonging to the 
Rheumatology Units for the follow-up controls foreseen. 
 
The next steps of the study protocol of the study will be the same as described in Section A: points 1.3, 
1.4 and paragraph 2. 
 
 
3) Experimental phase 
 
 
Units involved: UR2 - Department of Medical Genetics of Ferrara 
 
 
3.1 - Extraction and conservation of genomic DNA 
3.2 - Analysis of the genotype polymorphisms in the candidate gene variants to influence the response to 
anti-TNFalpha drugs will be evaluated by real-time polymerase chain reaction (PCR):). Other genetic 
variants potentially involved in influencing the response to anti-TNF-alpha, anti-CD20 or anti-IL-6 drugs 
will also be tested. 
 
3.3 - Statistical analysis 
The association between the response to drug therapy and the genotype will be performed with multivariate 
and data-mining approaches (eg multifactorial reduction of dimensionality), which will also take into 
account clinical and demographic data. 

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All the costs related to the carrying out of the experimental analyzes are totally covered by the funding 
obtained by the Emilia-Romagna Region in the framework of the Young Researchers Announcement 
"Alessandro Liberati" 2013 - Project Code PRUA1GR-2013-00000203 (Total funding obtained € 194.320) 
 
 
 
Summary of primary and secondary efficacy evaluation parameters: 
 
 
1) Rate of overlap between the samples inserted in the biobank and the patients entered the register 
[Indicator: (total number of biobank entries / number of registry entries) x100] 
2) Percentage of blood samples not correctly collected or sent by the Operating Units of collection 
[Indicator: number of blood samples not correctly collected or shipped / total number of biobank records] 
x100] 
3) High quality guarantee of the samples stored in the biobank [Indicators and timing will be defined in 
the specific operating procedures] 
Points 1) and 2) can be strongly influenced by two specific factors: patient compliance and /or physician 
compliance. In order to deal with these problems, planned strategies will be implemented 
 
 
All scientific and informational publications (articles in newspapers and websites) presentations at 
conventions and congresses, etc. related to the research activities carried out within the scope of this 
Project will report the source of the funding received in the manner and the mandatory wording required 
from the Emilia-Romagna Region