Amelioration of Autoimmune Arthritis in Mice Treated With the DNA Methyltransferase Inhibitor 5′‐Azacytidine

Disease‐associated, differentially hypermethylated regions have been reported in rheumatoid arthritis (RA), but no DNA methyltransferase inhibitors have been evaluated in either RA or any animal models of RA. The present study was conducted to evaluate the therapeutic potential of 5′‐azacytidine (5′‐azaC), a DNA methyltransferase inhibitor, and explore the cellular and gene regulatory networks involved in the context of autoimmune arthritis.


INTRODUCTION
Rheumatoid arthritis (RA) is a systemic inflammatory autoimmune disorder that primarily leads to joint destruction. B cells play an indispensable role in its initiation via the production of highaffinity autoantibodies. It has recently been suggested that dysregulation of the B cell epigenome can contribute to this antibody production (1).
Currently, there is no cure for RA, but treatments can provide alleviation of symptoms and modify disease progression. In most cases, the optimal treatment can only be achieved through a combination of different drugs (2). When a combination of traditional disease-modifying antirheumatic drugs, nonsteroidal antiinflammatory drugs, and/or low-dose glucocorticoids does not provide a satisfactory response, highly specific biologic agents are introduced into the treatment regimen (2,3). Highly effective epigenetic enzyme inhibitors have already been developed, and their therapeutic potential has been demonstrated in cancer (4). However, no such drug is currently used to treat RA (5). Epigenetic enzyme targeting drugs represent a novel approach that might replace or be used in combination with conventional arthritis therapies to achieve more effective arthritis management.
DNA methylation, one of the most common epigenetic modifications, is catalyzed by DNA methyltransferases and associated with gene silencing when it takes place in promoter regions (6). Recent studies have shown that RA pathogenesis is associated with DNA methylome changes similarly to carcinogenesis. In both diseases characteristic global DNA hypomethylation (decreased methylation) events affecting intergenic and intragenic regions (7)(8)(9) and de novo hypermethylated (increased methylation) promoters have been described (8,10). Induced demethylation of disease-specific hypermethylated promoters using DNA methyltransferase inhibitors, such as 5′-azacytidine (5′-azaC), can rescue the epigenetically inactivated genes, resulting in impaired disease progression (11,12). However, the significance of DNA hypermethylation in RA pathogenesis has been shown only indirectly (13). We hypothesized that locus-specific hypermethylation in B cells may play a role in arthritis pathogenesis and that DNA methylation inhibitors may have therapeutic potential in RA.
Herein, we report that low-dose 5′-azaC treatment has a notable effect on disease progression in proteoglycan-induced arthritis (PGIA), a murine model of RA (14). The 5′-azaC-mediated suppressive effect is due to transcriptional silencing of activation-induced cytidine deaminase (AID), an enzyme responsible for multiple catalytic steps of high-affinity antibody maturation encompassing class-switch recombination (CSR) and somatic hypermutation (15,16). Furthermore, AID plays a pivotal role in germinal center (GC) formation (17), the site of autoantibody production in secondary lymphoid organs (18). We demonstrate that aryl hydrocarbon receptor (AHR) transcription factor, which is known to be involved in B cell differentiation (19) and directly regulates Aicda expression (20), is rescued from arthritisassociated promoter hypermethylation in B cells after 5′-azaC treatment and contributes to the suppression of antibody production. These data promote consideration of epigenetic drugs in arthritis therapy.

MATERIALS AND METHODS
Methylated CpG island recovery assay (MIRA). MIRAchromatin immunoprecipitation (ChIP) was performed as previously described. MIRA-enriched DNA fractions were analyzed by quantitative polymerase chain reaction (qPCR) wherein the Xist promoter and mouse Gapdh or human TBP promoters were used as positive and negative controls, respectively (Supplementary Table 1, available on the Arthritis & Rheumatology web site at http://onlin elibr ary.wiley. com/doi/10.1002/art.40877/ abstract). Measured C t values were compared to negative control promoter-related C t values as 1-fold baseline methylation level. DNA methylation raw data files are accessible at NCBI GEO (accession no. GSE98939).
Gene expression analysis using Agilent microarray platforms. RNA sample labeling, array hybridization, and primary data analysis were performed by Arraystar. Microarray data are available from the NCBI GEO database (accession no. GSE98932).
Induction and assessment of PGIA in mice and 5′-azaC treatment. To induce PGIA, 3-month old female wild-type BALB/c mice (Charles River) were immunized intraperitoneally with human PG as previously described (14). At disease onset, the degree of arthritis in each paw was visually scored for redness and swelling on a scale of 0-4 every other day (21). The scoring was performed by one individual (TTG) in a blinded manner. Mice with a score of ≥1 on at least 1 limb were divided into 2 groups. The 5′-azaC-treated mice with PGIA received 2 mg/kg of 5′-azaC (Sigma-Aldrich) IP every other day for either 2 weeks or 4 weeks. The 5′-azaC was freshly dissolved at 0.5 mg/ml concentration in saline solution. The control mice with PGIA received saline solution alone. For in vitro tests, samples were obtained from the mice treated for 2 weeks. The animal studies were reviewed and approved by the Institutional Animal Care and Use Committee (IACUC) of Rush University Medical Center (IACUC # 15-065).
Histologic analysis. Tissue sections from mouse hind limbs were prepared, processed, examined, and photographed as previously described (21).

Enzyme-linked immunosorbent assay (ELISA).
Briefly, IgM isotype control (catalog no. 02-6800; ThermoFisher) or mouse purified IgG1 (0.025 μg/well) was coated onto an ELISA plate. IgM horseradish peroxidase (HRP) antibody (catalog no. 04-6820; ThermoFisher) was diluted to 1:2,000 in phosphate buffered saline (PBS) and added to serum samples diluted 1:100. IgG1 HRP antibody (catalog no. 559626; BD Biosciences) was diluted to 1:40,000 and added to serum samples diluted 1:160,000. For no-serum control (NSC), diluted antibodies were incubated in PBS. After a 1-hour incubation at room temperature, samples were added to coated wells and incubated for an additional hour at room temperature. After washes, the color reaction was developed and the optical density (OD) was read using a Synergy 2 ELISA reader. The OD of the NSC well was set to 100% binding, and the percentage of inhibition was calculated according to the formula % inhibition = 100−[(OD sample × 100)/OD NSC ]. To measure serum levels of the cytokine interleukin-4 (IL-4), a mouse IL-4 ELISA kit (catalog no. 555232; BD Biosciences) was used according to the recommendations of the manufacturer. Sections were fixed by cold 100% acetone (Sigma-Aldrich) and blocked with 1% normal goat serum (ThermoFisher) in PBS, then immunostained with fluorescence-labeled antibodies (Supplementary Table 3) for 1 hour. Stained sections were post-fixed in 10% formalin and images were captured on a Zeiss LSM 700 confocal microscope and analyzed with Zen 2.0 software (Zeiss).

Isolation of B cells and human peripheral blood mononuclear cells (PBMCs
Cell cultures and in vitro 5′-azaC treatment. A20 BALB/c mouse B lymphoma and HEK 293T cell lines were purchased from ATCC and were maintained in Dulbecco's modified Eagle's medium (Sigma-Aldrich) supplemented with 10% fetal bovine serum (FBS; HyClone) and antibiotics. The human B cell line GM12878 was purchased from the Coriell Institute of Aging Cell Repository and was cultured in RPMI 1640 medium (Lonza) supplemented with 15% FBS and antibiotics. All cells were maintained under standard culture conditions.
The 5′-azaC was dissolved in DMSO at a 10 mM concentration and stored at −20°C until used. A20 cells were plated into 6-well plates (2 × 10 5 cell/ml) in medium supplemented with 5′-azaC at a 10 μM final concentration. Control samples were treated with DMSO at a 0.1% final concentration. Cell cultures were incubated for 24, 48, or 72 hours. Media with the same reagents were replaced with fresh media every 24 hours.

RNA interference study.
An Ahr-specific short hairpin RNA (shRNA) sequence (Supplementary Table 1) was inserted into the pU6Abase vector (23) downstream of the human U6 promoter (pU6AshRNA). Exponentially growing A20 cells (10 7 ) were suspended in electroporation buffer (20 mM HEPES, 135 mM KCl, 2 mM MgCl 2 , and 0.5% Ficoll 400, pH 7.6) together with 20 μg plas-mid DNA. Electroporation was carried out using 940 volts/cm and 950 μF in a Gene Pulser II machine (Bio-Rad). Cells were plated onto 6-well plates and after a 12-hour incubation they were treated with 10 μM 5′-azaC. Twenty-four hours later the cells were resuspended in fresh tissue culture medium supplemented with 10 μM 5′-azaC and incubated for an additional 24 hours before isolation of total RNA. The pU6Abase without insert was used as control.
ChIP assay. ChIP assay was performed on A20 cells after treatment with 10 μM 5′-azaC for 48 hours. For IP, 50 μg precleared chromatin was incubated with 20 μg rabbit polyclonal anti-Ahr antibody (catalog no. sc5579; Santa Cruz Biotechnology) or incubated without antibody (mock). DNA-Ahr antibody complexes were collected using magnetic beads. DNA-AHR antibody complexes were eluted and reverse crosslinked as input. One microliter of the eluted DNA fraction was used for qPCR in which region-specific primers were used (Supplementary Table  4, available on the Arthritis & Rheumatology web site at http:// onlin elibr ary.wiley.com/doi/10.1002/art.40877/ abstract). Quantitative data were calculated by the ΔΔC t method and presented as fold enrichment compared to the values for the mock-treated samples.  Luciferase assay. Briefly, the mouse Aicda minimal promoter and the longer variant (including region 13, named pGL4.1-Aicda-p+13r) or the shorter variant (without region 13, named pGL4.1-Aicda-p+Δ13r) of the intronic region of Aicda was cloned into pGL4.1 (Promega). A reporter plasmid with a human AHR-overexpressing plasmid (pCMV-hAHR; OriGene) or with a control vector (pCMV-EGFP; Addgene) were cotransfected into HEK 293T cells. Twenty-four hours after transfection, luciferase activity was measured. The relative luciferase activity was calculated by normalization of measured relative luminescence units to protein concentrations.
Statistical analysis. All statistical analyses were performed using GraphPad Prism software, version 7.04. Results are reported as the mean ± SEM. If the significance level for the pretest for normality (Shapiro-Wilk) was less than 0.05, the Mann-Whitney U test was used. If the significance level for the pretest was greater than 0.05, Student's unpaired 2-tailed t-test was used. Comparisons of more than 2 groups were performed by one-way analysis of variance (ANOVA), and groups affected by 2 factors were compared by two-way ANOVA followed by Sidak's post hoc comparison. P values less than 0.05 were considered significant.

RESULTS
Elimination of PGIA symptoms in mice treated with low doses of a DNA hypomethylating agent. To investigate the role of DNA methylation in RA pathology, we conducted an integrative analysis by exploring genome-wide DNA methylation and accompanying gene expression changes in B cells from mice with PGIA ( Figure 1A). We observed dominant arthritis-associated hypomethylation and rare hypermethylation events in the investi-gated intergenic and intragenic regions in arthritic B cells (Supplementary Table 5, available on the Arthritis & Rheumatology web site at http://onlin elibr ary.wiley.com/doi/10.1002/art.40877/ abstract). However, DNA methylation profile changes were infrequently followed by gene expression changes, implying that most of the methylation events have no direct effects on gene expression.
We recognized that carcinogenesis-and arthritis-associated DNA methylation profile changes are similar in a sense, as both are characterized by dominant genome-wide hypomethylation affecting intergenic and intragenic regions, and infrequent promoter-specific hypermethylation events (24). Accordingly, we hypothesized that a demethylating agent that proved to be effective in cancer treatment could also be effective in arthritis therapy. We treated arthritic mice with low-dose 5′-azaC every other day for 2 weeks, which resulted in gradual reduction of disease severity and halted arthritis progression ( Figure 1B). Next, we started 5′-azaC treatment at a more advanced stage of arthritis and continued treatment for 4 weeks, which similarly reduced paw swelling ( Figure 1C). Moreover, neither mortality nor toxic effect was observed among these mice. This was confirmed by the increased body weight of 5′-azaC-treated arthritic mice at the fourteenth administration of 5′-azaC ( Figure 1D). Furthermore, arthritis-specific massive joint inflammation, synovial pannus formation, cartilage damage, and bone destruction were undetectable by histopathologic analysis in 5′-azaC-treated animals by the end of the study ( Figure 1E). These results confirmed our working hypothesis that 5′-azaC-induced DNA demethylation can be an effective approach for the management of autoimmune arthritis.
Attenuated IgG1 antibody production in 5′-azaCtreated mice with PGIA. The lack of joint inflammation prompted us to measure serum levels of IgM and IgG1 antibod- ies. Samples were collected before the first 5′-azaC treatment and when the experiment was terminated. IgM levels were enhanced in both animal groups, but IgG1 levels were increased only in vehicletreated mice (Figures 2A and B). This suggested a compromised CSR (25,26) in 5′-azaC-treated mice. Hence, we measured IgG1specific genome rearrangement in B cells using a modified version of digestion-circulation PCR (22). The level of class-switched DNA ( Figure 2C) and the level of post-recombination IgG1 messenger RNA (mRNA) ( Figure 2D) were significantly lower in 5′-azaC-treated mice. Since Aicda regulates CSR (26), we determined its expression level, which was significantly lower in 5′-azaC-treated animals (Figure 2E). These data suggest that 5′-azaC inhibits Aicda expression, leading to diminished CSR and attenuated antibody production in B cells, ultimately resulting in the suppression of arthritis symptoms.  Treatment with 5′-azaC inhibits GC formation and shifts the proportion of former B cell subpopulations in mice with PGIA. Self-reactive antibodies are mainly generated in GCs of secondary lymphoid organs (18). Thus, we investigated GC formation and determined the proportion of GC B cells in the mouse lymph nodes and spleen. Reduced GC formation and significantly decreased GC B cell frequency were observed in both organs in 5′-azaC-treated mice ( Figures 3A-D and Supplementary Figures 1A  and B, available on the Arthritis & Rheumatology web site at http:// onlin elibr ary.wiley.com/doi/10.1002/art.40877/ abstract). Moreover, as a consequence of diminished GC formation, the proportion of plasma cells was also decreased in the BM of 5′-azaC-treated animals ( Figure 3E and Supplementary Figure 1C).
To explore the origin of the altered frequency of GC B cells, we examined B cell subpopulations in mouse BM and spleen. In both organs, the proportions of B cells were significantly lower in the lymphocyte compartments in 5′-azaC-treated animals (Supplementary Figure 2, available on the Arthritis & Rheumatology web site at http://onlin elibr ary.wiley.com/doi/10.1002/ art.40877/ abstract). The proportions of early precursor B cells were increased (Figure 3F), while the frequencies of late precursor ( Figure 3F) and immature B cells ( Figure 3G) were reduced upon 5′-azaC treatment. In the periphery, we detected a decreased proportion of transitional type 1 (T1) B cells, while the frequencies of follicle-colonizing T2 and marginal zone (MZ) B cells were elevated within the B cell populations of 5′-azaC-treated mice ( Figure 3H). Finally, 5′-azaC treatment also elevated the percentage of the mature recirculating B cells in the BM ( Figure 3G). The proportion of follicular B cells, which are essential in GC responses (18), was similar in the vehicle-treated and 5′-azaC-treated mice Since follicular B cells can evolve GCs in a T cell-dependent manner (27), we investigated the frequency of CD4+ T cells and measured serum levels of IL-4 cytokine, which is predominantly produced by GC-forming follicular T helper cells (28). Interestingly, neither the frequency of CD4+ T cells nor the serum level of IL-4 was changed in 5′-azaC-treated mice compared to vehicletreated arthritic animals (data not shown).
Hypermethylated Ahr regulatory regions in arthritic mouse B cells and human samples. DNA hypomethylation induced by 5′-azaC is nonspecific (29), in contrast to the locusspecific Aicda-mediated hypomethylation events in the B cell epigenome, which are essential for effective GC formation (17). Accordingly, it is conceivable that 5′-azaC-induced demethylation may provoke genes that inhibit GC formation. Taking this into account, our aim was to identify genes that could be induced by 5′-azaC and suppress Aicda expression. To this end, we compared arthritisassociated up-regulated and down-regulated genes ( Figure 1A) with characteristic sets of MZ and GC B cell genes (30) ( Figure 4A) that express Aicda (15,25). We focused on down-regulated genes that were also hypermethylated in arthritis, which can be possible targets of 5′-azaC-triggered activation (Supplementary Table 6, available on the Arthritis & Rheumatology web site at http://onlin elibr ary. wiley.com/doi/10.1002/art.40877/ abstract). These down-regulated genes included the Ahr gene, which encodes a transcription factor that is known to suppress Aicda expression after agonist stimulation (20). Indeed, Ahr expression was down-regulated ( Figure 4B) and its promoter was hypermethylated in B cells isolated from mice with PGIA ( Figure 4C  Importantly, the disease specificity of down-regulated AHR expression was confirmed in PBMCs and B cells (Figures 4D and  E) isolated from treatment-naive RA patients. RA-associated DNA hypermethylation was not observed in the AHR promoter region; however, a distant intergenic region (differentially methylated region C) 155 kb upstream of the AHR transcription start site (TSS) was differentially hypermethylated ( Figure 4F and Supplementary Figure  5, available on the Arthritis & Rheumatology web site at http://onlin elibr ary.wiley.com/doi/10.1002/art.40877/ abstract). These results suggest that the AHR gene can be silenced in a DNA methylation-dependent manner and that AHR silencing may be involved in RA pathology.

Demethylation of the Ahr promoter plays a significant role in the inhibition of Aicda.
To verify that 5′-azaC induced Ahr expression, we defined the promoter methylation and expression of Ahr in B cells. Indeed, Ahr promoter demethylation and accompanying elevated Ahr gene expression (Figures 5A and  B) were identified in 5′-azaC-treated mice with PGIA. To determine the mechanistic connection between 5′-azaC-induced Ahr and Aicda, we conducted experiments with A20 cells, a BALB/c mouse B lymphoma cell line (31). In these cells, Ahr expression was down-regulated as in arthritic mouse B cells ( Figure 4B). Furthermore, 5′-azaC treatment evoked a significant increase in Ahr expression ( Figure 5C) due to its promoter demethylation ( Figure 5D). Moreover, Ahr was translocated into the nucleus (Figure 5E), indicating its engagement in transcriptional regulation.
Next, to confirm the involvement of 5′-azaC-induced Ahr in down-regulated Aicda expression ( Figures 5E and F), we used an shRNA-mediated inhibition approach. Treatment with 5′-azaC  did not increase Ahr expression when Ahr-specific shRNA was expressed in A20 cells, resulting in only a moderate decrease in Aicda expression ( Figure 6A). Furthermore, we performed Ahrspecific ChIP focused on such regions (Supplementary Table 4, available on the Arthritis & Rheumatology web site at http://onlin elibr ary.wiley.com/doi/10.1002/art.40877/ abstract) in the genomic context of the Aicda gene that harbor in silico predicted Ahr binding sites (32). We detected 5′-azaC-induced Ahr binding in the first intron, termed region 13 ( Figure 6B). Although region 13 does not contain a canonical Ahr binding site (33), it carries reasonably similar sequences to a ChIP-Seq-defined Ahr binding consensus motif (34), which was capable of binding Ahr effectively (Supplementary Figure 6, available on the Arthritis & Rheumatology web site at http://onlin elibr ary.wiley.com/doi/10.1002/art.40877/ abstract).
Finally, in transient expression studies, AHR only reduced the activity of an Aicda promoter-driven reporter gene if the inserted Aicda first intronic segment included region 13 ( Figure 6C). These data demonstrate that Ahr bound directly to the regulatory region of Aicda after 5′-azaC treatment, but this region did not overlap with a previously described intronic silencer region (20). Our in vitro and in vivo experiments showed that 5′-azaC-induced demethylation rescues Ahr from hypermethylation-mediated down-regulation. B cell culture-based data demonstrated that reactivated Ahr directly contributed to the suppression of Aicda expression through a novel regulatory region in B cells. Therefore, it is plausible that the Ahr-Aicda regulatory cascade is responsible for attenuated GC formation and antibody production, which ultimately ameliorates arthritis symptoms.

DISCUSSION
Targeted inhibition of DNA methylation has already been proven to be an effective approach to restoring the expression of tumor suppressor genes and their cellular function (12). Herein we demonstrated that in vivo treatment with a DNA methyltransferase inhibitor has therapeutic potential in autoimmune arthritis as well.
We identified a number of differentially hypermethylated regions in arthritic mouse B cells ( Figure 1A) and detected genome-wide hypomethylation, consistent with the findings of previous studies (35). However, the hypomethylation cannot be considered disease-specific because DNA demethylation also occurs during "normal" B cell maturation and activation (17,(36)(37)(38). In contrast, disease-associated, less frequent hypermethylation events probably play more significant roles in arthritis etiology. This concept was supported by the findings of a study investigating fibroblast-like synoviocytes in RA patients (10) and an in vitro study of PBMCs from RA patients (13).
DNA demethylation induced by 5′-azaC halted arthritis progression in mice ( Figures 1B and C), which can be attributed to the inhibited production of IgG1 antibodies ( Figure 2B), since they can participate in joint destruction by forming immune complexes on the articular cartilage surface (39). Furthermore, high-affinity anti-  Table 4, available on the Arthritis & Rheumatology web site at http://onlin elibr ary.wiley. com/doi/10.1002/art.40877/ abstract) in the first intron of Aicda in A20 cells treated with 5′-azaC or control for 48 hours (n = 3 per group). The intergenic region was used as a negative control and the CYP1a1 promoter region was used as a positive control. Data are presented as fold enrichment compared to the values for control treatment. C, Relative luciferase activity of the mouse Aicda promoter-driven reporter gene alone (pGL4.1-Aicda-p), the Aicda promoter-driven reporter gene with a segment of the first intron of Aicda including region 13 (pGL4.1-Aicda-p+13r), or the Aicda promoter-driven reporter gene with the same segment without region 13 (pGL4.1-Aicda-p+Δ13r). Reporter plasmids were cotransfected with a human AHR-expressing plasmid (pCMV-hAHR) or enhanced green fluorescent protein (EGFP)-expressing plasmid (pCMV-EGFP). Luciferase activity was normalized to cellular protein concentrations (n = 3 samples per group). Bars show the mean ± SEM. * = P ≤ 0.05; ** = P ≤ 0.01; *** = P ≤ 0.001; **** = P ≤ 0.0001, by two-way ANOVA with Sidak's test. See Figure 1 for other definitions.
bodies, including self-reactive antibodies, are generated in GCs of secondary lymphoid organs (18) wherein CSR occurs due to high Aicda expression (25,26). Thus, the reduced Aicda expression and CSR, which ultimately lead to inhibited IgG1 production, can be attributed to the diminished GC formation in 5′-azaC-treated mice (Figures 3A and B).
To clarify the cause of the decrease in the proportion of GC B cells, we determined the frequencies of former B cell subpopulations. The frequencies of these subpopulations were similar to those previously found in anti-CD20-depleted mice (40). In light of the consistency of the findings, our results and those of the previous study can be explained in a similar way. The lower proportions of total B cells in the lymphocyte compartments after 5′-azaC treatment (Supplementary Figure 2, available on the Arthritis & Rheumatology web site at http://onlin elibr ary.wiley.com/doi/10.1002/ art.40877/ abstract) induced a compensatory mechanism which is intended to sustain the constant frequency of follicular B cells and resulted in increased proportions of early precursor B cells ( Figure 3F) (40) or follicular B cell-derived (41) mature recirculating B cells ( Figure 3G). At the same time, a selective incident with a higher negative selection pressure could be induced, resulting in a decreased frequency of late precursor, immature ( Figures 3F and  G), and T1 B cells ( Figure 3H) (42). Moreover, mature recirculating B cells constitute a reservoir for MZ B cells (41); thus, there might be a positive relationship between the increased frequencies of these cells (Figures 3G and H). Ultimately, these changes did not disturb the proportion of GC-forming (18) follicular B cells (Figure 3H). Taken together with an unchanged frequency of CD4+ T cells and serum IL-4 level, these data suggest that B cell intrinsic factors are the cause of diminished GC formation.
The contribution of Ahr to autoimmune arthritis has been investigated in two previous studies using the collagen-induced arthritis model. In the first study, Ahr altered T cell differentiation and promoted pathogenesis (43), while the other study showed that it exerted a preventive effect by inhibiting mesenchymal stem cell differentiation (44). Our findings are consistent with those of the latter study and demonstrate that DNA hypermethylation-mediated silencing of Ahr contributes to arthritis pathogenesis. This hypermethylated region is located in the Ahr promoter in arthritic mouse B cells ( Figure 4C (45)(46)(47), suggesting that this region is a B cell-specific enhancer.
We demonstrated that 5′-azaC-induced demethylation could rescue Ahr from hypermethylation-related down-regulation ( Figure 5B). This rescued Ahr contributed to the attenuated IgG1 production through the suppression of Aicda (Figure 5F), which is an essential regulator of GC formation (17). Ahr bound directly to the intronic regulatory region of Aicda after 5′-azaC treatment (Figure 6B), but this region did not overlap with a previously described silencer region in the first intron ~1.3 kb downstream from the TSS (20). This finding provides evidence of the existence of a different Ahr regulatory mechanism in 5′-azaC-treated arthritic B cells, which may come from distinct activation methods.
In summary, in this study, we demonstrated that 5′-azaC, a Food and Drug Administration-approved anticancer agent used for the treatment of various blood cell malignancies, effectively treats autoimmune arthritis when administered at low doses beginning at the early phase of the disease. Furthermore, we explored the notion that the beneficial effect of 5′-azaC is owed to compromised GC formation and subsequent reduced antibody production in which Ahr promoter demethylation can play a pivotal role. Our data provide a foundation for further studies exploring the therapeutic potential of low-dose DNA methyltransferase inhibitors in RA and other antibody-dependent diseases.