Adhesion-and degranulation-promoting adaptor protein (ADAP) modulates T cell development and function and promotes TCR signaling. Regulation of ADAP protein expression during thymopoiesis and in development of other hematopoietic lineages has not been explored. Using intracellular staining, we detected ADAP protein in bone marrow lymphocyte precursors. Like its binding partner SH2-containing leukocyte phosphoprotein of 76 kDa, ADAP is dynamically regulated during thymocyte positive selection. ADAP is also found in unconventional thymocytes, including NKT, CD8aa, and TCRcd T cells. In peripheral T cells, ADAP is up-regulated after TCR stimulation and with acquisition of memory status. Although absent in splenic B cells, ADAP is present in pro-B cells, as well as in BM erythrocyte and myeloid progenitors. Studies with radiation chimeras show that ADAP is dispensable for NKT, CD8aa and TCRcd T cell development, while confirming that ADAP is required for optimal development of conventional TCRab T cells in the thymus. Interestingly, ADAP is necessary for CD8aa homeostasis in the small intestinal epithelium, yet is dispensable for optimal reconstitution of splenic B cell populations. Our observations highlight the dynamic regulation of ADAP during T cell maturation and document expression patterns that suggest a possible role for ADAP in development of non-T hematopoietic lineages.

Adhesion and degranulation promoting adapter protein (ADAP), a positive regulator of T cell receptor (TCR) signaling, is required for thymocyte development and T cell homeostasis. To investigate the role of ADAP in a T cell-driven autoimmune response, we generated ADAPdeficient, BDC2.5 TCR transgenic, diabetes-prone (C57BL/6) mice (BDC/B6). We observed a striking enhancement of diabetes incidence in ADAP-deficient mice, both in animals homozygous for I-A g7 , and in mice carrying one I-A b allele (BDC/B6 g7/b ). Increased disease correlates with significantly reduced numbers of pathological CD4 + T cells in the mice. Consistent with a state of functional lymphopenia in ADAP-deficient BDC/B6 g7/b mice, T cells display increased homeostatic proliferation. Transfer of syngeneic lymphocytes or T cells both blocks ADAP-dependent diabetes and relieves exaggerated homeostatic T cell proliferation observed in ADAP-deficient mice. Marked attenuation in cellularity of the CD4 + single-positive thymocyte compartment in ADAP-deficient BDC/B6 g7/b animals suggests a mechanism for induction of the lymphopenia. We conclude that inefficient positive selection in ADAP deficiency results in lymphopenia that leads to enhanced autoimmune diabetes in the BDC/B6 g7/b model. Our findings support the notion that ineffective thymic T cell output can be a powerful causative factor in lymphopenia-driven autoimmune diabetes.

Introduction: Rilonacept reduced pericarditis recurrence in the phase 3 trial RHAPSODY. The long-term extension (LTE) enabled further insights into efficacy, safety, and clinical decision making. Methods: The RHAPSODY run-in (RI) and randomized-withdrawal periods were followed by an LTE that enabled open-label rilonacept treatment up to 24 additional months. A decision at 18 months after the most recent recurrence was based on clinical status at investigator discretion: 1) continue rilonacept on-study, 2) suspend rilonacept for observation or 3) discontinue from the LTE without observation. Endpoints included recurrence and quality of life. Results: In May 2020, 74 of 75 eligible subjects continued to LTE; US subjects (n=45) switched to commercial therapy or discontinued in April 2021 (treatment duration from RI baseline [median; maximum] 18; 27 months). Non-US subjects (n=29) completed the LTE in June 2022 (treatment duration from RI baseline [median; maximum] 27; 33 months). Concomitant oral medications during LTE: 22% NSAIDS, 20% colchicine, 0% corticosteroids, 43% none. Inflammation signs (CRP), RP symptoms (PGIPS), and recurrences were low on-treatment. Before the 18-month decision (n=74), there were 3 investigator-assessed recurrences (0.04 per patient-year). At the 18-month decision (n=52), 64% (n=33) continued rilonacept on-study, 15% (n=8) suspended rilonacept for observation, and 21% (n=11) discontinued the study without observation, of whom 7 switched to commercial rilonacept. There was a 75% recurrence rate (n=6/8) in the off-treatment observation group (median time to event 11.8 [3.7, Not-Estimable (NE)] weeks) but only 1 recurrence in subjects on rilonacept (time to event NE [too few events]) associated with a 4-week interruption; HR 0.018, p<0.0001; Fig 1. Conclusions: Continued rilonacept treatment resulted in continued treatment response, whereas treatment suspension at 18 months may be associated with pericarditis recurrence.

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