Efficacy and Safety of Low-Dose Interleukin 2 for Behçet’s Syndrome: a phase 2 randomized double-blind placebo-controlled clinical trial

Efficacy and Safety of Low-Dose Interleukin 2 for Behçet’s Syndrome: a phase 2 randomized double-blind placebo-controlled clinical trial | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Efficacy and Safety of Low-Dose Interleukin 2 for Behçet’s Syndrome: a phase 2 randomized double-blind placebo-controlled clinical trial Liu Tian, Wenyan Zhou, Yan Zhu, Weiyi Xia, Jiali Chen, Xian Xiao, and 23 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5416266/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 07 Jan, 2026 Read the published version in Nature Communications → Version 1 posted You are reading this latest preprint version Abstract Behçet’s syndrome (BS), a chronic relapsing systemic vasculitis, leads to recurrent oral aphthous ulcers, severely impacting quality of life. We conducted a randomized double-blind placebo-controlled clinical trial to evaluate the efficacy and safety of Low-dose interleukin-2 (LD-IL-2) in BS patients. We randomly assigned BS patients (aged 18 to 70 years) with active oral ulcers to receive LD-IL-2 or placebo for 12 weeks (1:1 ratio). The primary endpoint was the oral ulcer count at week 12. Secondary endpoints included the changes in oral ulcer pain (100-mm VAS), overall disease activity and quality of life, genital ulcer count, and complete oral ulcer response rates, along with the change of CD4 + T cell subsets. A total of 60 randomly assigned participants received at least one dose of LD-IL-2 or placebo and 51 completed the trial. The mean number of oral ulcers at week 12 was significantly lower in the LD-IL-2 group than in the placebo group (0.69 ± 1.05 vs. 1.57 ± 0.90, P = 0.001). There were great reductions in oral ulcer pain, the Behçet’s Syndrome Activity Score, the Behcet's Disease Current Activity Index score as well as the Behçet’s Disease Quality of Life scale score in the LD-IL-2 group compared to the placebo group at week 12. No infections or severe adverse events were observed in either group. LD-IL-2 expanded regulatory T cells (Tregs) and decreased the ratio of effector T cell (Teff) to Tregs. LD-IL-2 therapy is an effective and safe treatment in BS patients and is associated with the modulation of Treg and Teffcells.ClinicalTrials.gov registration: NCT04065672. Health sciences/Medical research/Clinical trial design/Clinical trials/Phase II trials Health sciences/Diseases/Rheumatic diseases/Vasculitis syndromes Figures Figure 1 Figure 2 Introduction Behçet’s syndrome (BS) is a chronic and relapsing systemic vasculitis that causes recurrent oral aphthous ulcers, along with genital ulcers, skin lesions, and uveitis. 1 Patients may also present with arthralgia, arterial aneurysms, venous and arterial thrombosis, gastrointestinal tract and neurological symptoms may be involved as well. 2 Recurrent relapsing and remitting oral ulcers are the most common manifestations of BS, which have a substantial deleterious effect on quality of life. 3 – 4 Although colchicine is recommended as the first-line treatment for mucocutaneous lesions, the efficacy of colchicine has been debated. 5 – 7 Second-line immunosuppressive treatments for mucocutaneous involvement include azathioprine, thalidomide, interferon-α, and tumor necrosis factor (TNF-α) inhibitors. 5 Biologics including TNF-α inhibitors and Tocilizumab play an important role in the treatment of other organ involvement in BS, such as vascular, CNS, and eyes. 1 , 2 Several randomized, controlled trials have been conducted to assess the efficacy of Apremilast (a small molecule selective inhibitor of the phosphodiesterase 4 enzyme) for the treatment of BS oral ulcers, and this agent has been approved by the US FDA and EMA for the BS indication, 8 – 10 however, adverse events such as gastrointestinal side effects often limit its further use. 11 , 12 In addition, some BS patients were refractory to colchicine and/or Apremilast. Thus, there is an unmet need for therapies with better efficacy and lower adverse effects for BS patients. Interleukin-2 (IL-2) is a cytokine known to induceCD4 + Tcell activation and regulation. 13 Regulatory T cells (Tregs) are one of the subsets of CD4 + T cells, which inhibit the production and function of effector T cells (Teff) (including T helper 1 [Th1], Th2, Th17, and T follicular helper [Tfh] cells). 14 IL-2 regulates the development, proliferation, and survival of Tregs. 15 Different doses of IL-2 produce divergent effects on T cell subsets, and low-dose IL-2 (LD-IL-2) has been shown to selectively increase Tregs and suppress the differentiation of TfhandTh17subsets in various autoimmune diseases as well as inflammatory diseases. 16 In these diseases, LD-IL-2 helps to maintain immune tolerance, prevent autoimmunity, and inhibit inflammatory responses. Recently, LD-IL-2 has been extensively studied and used in the treatment of auto-inflammatory diseases such as systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), and inflammatory bowel disease (IBD). 17 – 19 Previous studies have demonstrated that the dysregulation of T cells is functionally involved in the development of BS, and LD-IL-2-promoted Treg restoration in BS patients. 20 , 21 These findings have motivated the exploration of LD-IL-2 for treating BS, and three small studies have reported efficacy for LD-IL-2 in treating BS patients. One of the studies showed efficacy for LD-IL-2 in a BS patient with oral ulcers, genital ulcers, and erythema nodosum, 22 while the other study monitored circulating Treg cells but did not formally assess clinical response, 19 and a recent open-label study showed the LD-IL-2 treatment response in 5/8 patients. 23 In the present Phase 2 trial, we evaluated the efficacy and safety of LD-IL-2 in BS. We assessed LD-IL-2 for the treatment of oral ulcers in patients with BS by monitoring changes in the number of oral ulcers. We also assessed the change in pain from oral ulcers from baseline to week 12, the effects on the number of genital ulcers, overall disease activity, and the effects of the therapy on the proportions of Treg, Tfh, and Th17 cells. Results Patient disposition and baseline characteristics From October 2021 through July 2023, a total of 60 patients from Peking University People’s Hospital were deemed eligible and were randomly assigned to receive either LD-IL-2 (30 patients) or placebo (30 patients). Of the 60 patients who underwent randomization, 56 completed the 12-week placebo-controlled period (26 in the LD-IL-2 group and 30 in the placebo group). Three patients in the LD-IL-2 group and two patients in the placebo group withdrew from the trial during the 12-week follow-up phase. Figure 1 shows the assignment of the patients to the trial groups and the reasons for discontinuation. The baseline demographic and disease characteristics of the patients, as well as their previous medications, were similar in the two trial groups (Table 1 ). Patients had a history of skin lesions (75%; including 27% erythema nodosum and 48% folliculitis at baseline), genital ulcers (40%), musculoskeletal involvement (20%), eye involvement (17%) (none of the patients had active uveitis at baseline, as judged by an ophthalmologist), and gastrointestinal involvement (12%). No patient had vascular or central nervous system (CNS) involvement. The concomitant medications in the two groups at baseline and week 12 are shown in Appendix Tables 1 and 2. Table 1 Baseline Demographic of the Patients, Including Previous Medications. Table 2 Clinical manifestation, Disease activity and Quality of life at Baseline, Week 4, Week 8, and Week 12 in LD-IL-2 group (n = 26) and Placebo group (n = 30) Primary outcome The mean number of oral ulcers per patient at baseline was 2.73 ± 2.20 (-95% CI, 1.84 to 3.62) in the LD-IL-2 group and 2.53 ± 2.08 (-95% CI, 1.75 to 3.31) in the placebo group. At week 12, the mean number of oral ulcers was significantly lower in the LD-IL-2 group than in the placebo group (0.69 ± 1.05, -95% CI, 0.27 to 1.12 vs. 1.57 ± 0.90, -95% CI, 1.23 to 1.90, P = 0.001). The decrease in the number of oral ulcers was evident by week 4 in the LD-IL-2 group and was sustained throughout the full 12-week treatment phase ( Fig. 2A ). Percentage of patients who had a complete response to oral ulcers by week 12 was 61.5% in the LD-IL-2 group (16 of 26 patients) and only 16.7% in the placebo group (5 of 30 patients) ( P < 0.001).The AUC of the total mean (± SE) number of oral ulcers during the 12-week placebo-controlled period was 87.6 ± 43.7 in the LD-IL-2 group, as compared with 134.8 ± 32.0 in the placebo group (least-squares mean difference, -47.2; 95% CI, -156.5 to 62.2). The results regarding the primary and secondary endpoints are presented in Table 2 and Table 3 . Table 3 Change of Clinical manifestation, Disease activity and Quality of life from Baseline to Week 12 Characteristic Placebo(n = 30) Low-dose IL-2(n = 26) Estimated Treatment Difference (95% Cl) P value Changes of the number of oral ulcers -0.97(-1.65, -0.28) -2.04(-2.90, -1.18) -1.07(-2.13, -0.13) 0.047 Changes of the number of genital ulcers -0.50(-0.86, -0.14) -0.69(-1.13, -0.25) -0.19(-0.74, 0.36) 0.488 Changes of the Behcet’s Disease Current Activity Form -1.00(-1.75, -0.25) -1.88(-2.50, -1.27) -0.88(-1.86, 0.09) 0.073 Changes of the Behcet’s Syndrome Activity Scale score -6.47(-10.17, -2.76) -20.12(-24.54, -15.69) -13.65(-19.24, -8.06) < 0.001 Changes of the pain associated with oral ulcers, as measured by VAS -1.67(-2.48, -0.85) -3.46(-4.39, -2.53) -1.79(-3.00, -0.59) 0.004 Changes of Behçet’s Disease Quality of Life scale score -1.23(-1.57, -0.89) -3.42(-4.14, -2.70) -2.19(-2.93, -1.45) < 0.001 Changes in outcome measures between the Low-dose interleukin2 group and the placebo group at week 12 from baseline(week 0) and were compared using a T-test with two-sided P values. Data are mean(95% Cl) and P value. Secondary clinical outcomes A total of 10 patients in the LD-IL-2 group and 13 patients in the placebo group had genital ulcers at baseline. The mean number of genital ulcers per patient at baseline was 0.69 ± 1.09 (-95% CI, 0.25 to 1.13) in the LD-IL-2 group and 0.67 ± 0.99 (-95% CI, 0.30 to 1.04) in the placebo group. The mean number of genital ulcers at week 12 was significantly lower in the LD-IL-2 group than in the placebo group (0 ± 0, -95% CI, 0 to 0 vs. 0.17 ± 0.38, -95% CI, 0.025 to 0.31, P = 0.031) ( Fig. 2B ). The percentage of patients who were free from genital ulcers at week 12 was 100% in the LD-IL-2 group (26 of 26 patients) and 83.3% in the placebo group (25 of 30 patients) ( P = 0.029). A total of 51 patients completed week 24 of the trial. The prespecified analyses of the number of oral ulcers and genital ulcers at week 24 are shown in Figs. 2A and 2B , respectively. At week 12, significant reductions from baseline in the pain from oral ulcers (as assessed on a 100-mm VAS) were observed for the LD-IL-2 group compared to the placebo group (LD-IL-2 group: -3.46, − 95% CI, -4.39to -2.53; placebo group: -1.67, − 95% CI, -2.48 to -0.85; P = 0.004). The mean change from baseline in the BSAS at week 12 was − 20.12 (− 95% CI, -24.54 to -15.69) in the LD-IL-2 group, which was significantly greater than for the placebo group (-6.47, -95%CI, -10.17 to -2.76) ( P < 0.001). At week 12, LD-IL-2 group patients had much more improvements in BDCAF compared to the placebo group (LD-IL-2 group: -1.88, -95%CI, -2.50 to -1.27; placebo group: -1.00, -95% CI, -1.75 to -0.25; P = 0.073). The mean change of BDQOL from baseline to week 12 was significantly greater in the LD-IL-2 group than in the placebo group (LD-IL-2 group: -3.42, -95%CI, -4.14 to -2.70; placebo group: -1.23, -95% CI, -1.57 to -0.89; P < 0.001). During the follow-up period, three patients in the LD-IL-2 group developed new skin lesions, presenting as folliculitis. In the placebo group, there were 2 cases of new folliculitis, 3 cases of new arthralgia, and 1 case of new uveitis during the follow-up. Safety No infections were observed in either group during the treatment or follow-up periods. There were injection site reactions in 4 of the LD-IL-2 group patients (13.3%), and 1 patient (3.3%) discontinued the trial due to a severe injection reaction. There was 1 injection site reaction (3.3%) in the placebo group. Whereas there were no fevers for the placebo group, 2 patients (6.7%) in the LD-IL-2 group had fevers after the IL-2 injection. However, the fever abated spontaneously within 24 hours without any medical treatment ( Appendix Table 4 ). Analysis of CD4 + T cell subsets in peripheral blood Immunological analysis from patient peripheral blood samples included flow-cytometry-based enumeration of Tregs and effector CD4 + T cell (Teff) subsets (Th1, Th2, Th17, and Tfh cells). Briefly, the LD-IL-2 group displayed a significant expansion of Treg cells as a proportion of total CD4 + T cells (from 9.23% at baseline to 15.66% at week 12, P < 0.001) ( Appendix Fig. 1A ), whereas no differences from baseline in the proportions of any examined cells were detected for the placebo group ( Appendix Fig. 1A-1E ). Moreover, the ratio of Teff (Tfh and Th17) cells to Tregs decreased rapidly following each LD-IL-2 administration ( Appendix Fig. 1D and 1E ). Discussion Management of Behçet’s syndrome is challenging due to the heterogeneous nature of the disease. 2 Different phenotypes of BS are thought to be governed by diversified mechanisms and may benefit from tailored therapeutic approaches. 24 – 26 In this double-blind, placebo-controlled study, we showed that LD-IL-2 administration is efficient for oral ulcers and genital ulcers in BS patients. The oral ulcers and their related pain can be alleviated rapidly, approximately within 2 weeks of LD-IL-2 therapy. Sixteen of 26 BS patients in the LD-IL-2 group (61.5%) reached complete remission after 12 weeks of active treatment. Reduced BSAS, BDCAF and BD-QOL scores and a high rate of resolution of clinical features were observed. In addition, these changes in disease activity permitted significant tapering of corticosteroid therapy during the study period in the LD-IL-2 group, 4 of the 11 patients (36.3%) in the LD-IL-2 group who were on corticosteroid therapy at baseline discontinued steroids at 12 weeks. In our study, we found evidence supporting the use of LD-IL-2 as an effective and safe second-line therapy for the treatment of active mucosal manifestations of BS. LD-IL-2 has demonstrated impressive clinical improvements in various skin conditions beyond BS, such as graft-versus-host disease (GVHD), HCV-associated vasculitis, and chronic urticaria. 27 – 29 These studies consistently show that LD-IL-2 therapy leads to significant symptom relief and enhanced skin condition. The mechanism behind these improvements is believed to be linked to the modulation of tissue-resident regulatory Tregs in the skin. 29 In the skin, Tregs help suppress local inflammation and autoimmunity, leading to improved skin health and symptom reduction. In our study, we observed a marked increase in Tregs and a decrease in Th17 cells in the LD-IL-2 group, which correlates with the clinical improvements seen in cutaneous manifestations. This shift in the immune cell balance is crucial for reducing inflammation and promoting healing in skin tissues. At baseline, in the LD-IL-2 group, 25/30 patients had a history of skin lesions, 7/30 patients had musculoskeletal involvement, 4/30 patients had eye involvement, and 1/30 had gastrointestinal involvement. At week 12, the proportions of these patients for which BDCAF decreased were 92% (23/25) in patients with skin lesions, 71% (5/7) with musculoskeletal involvement, 50% (2/4) with eye involvement and 100% (1/1) with gastrointestinal involvement. We speculate that BS with mucocutaneous and musculoskeletal involvement might be sensitive to LD-IL-2 therapy, but whether it is effective in patients with other manifestations of BS needs further research to clarify, especially since we did not include patients with vascular or CNS involvement. There were no serious adverse events observed in this study. Adverse events, including injection site reactions and fevers, occurred more frequently with LD-IL-2 administration than with a placebo. However, the injection site reactions and fever were transitory and would remission without any medical interruption. In particular, no infections were observed in the setting of LD-IL-2 treatment. This is consistent with previous studies. 30 , 31 We and others have shown that LD-IL-2 increases CD8 + T cells and NK cells 32 , 33 , which are required to build immune responses to infections. In this trial, we used a dosing schedule of LD-IL-2 based on our previous studies, 34 , 35 administering 1 million IU every other day for 3 months. This regimen was chosen for its demonstrated efficacy and safety in modulating the immune system. In contrast, Rosenzwajg et al. used a regimen of 1 million IU daily for the first 5 days, followed by 1 million IU every two weeks for 6 months, designed to investigate the long-term immunomodulatory effects of LD-IL-2. 19 Our chosen schedule, with more frequent administration over a shorter period, may be preferable for acute and intensive management, as well as for the rapid assessment of short-term efficacy, especially in patients with active disease. We observed improvement in BDCAF and BSAS scores through week 24, even though the LD-IL-2 treatment was discontinued at week 12 and the expanded Tregs declined afterward. There are a few explanations for the sustained clinical benefit after LD-IL-2 treatment. First, as shown in our previous report, 30 , 32 LD-IL-2 treatment significantly improved the suppressive function of Treg cells, and such functional improvement of Tregs might still be present when the LD-IL-2 treatment is discontinued. In addition, LD-IL-2 decreased inflammatory cytokines which can last in serafor a longer period after LD-IL-2 discontinuation. 36 , 37 Further studies are required to characterize the immunological changes with LD-IL-2, which can help to design the regimen of LD-IL-2 therapy. Different mechanisms have been investigated to clarify the effect of LD-IL2 on autoimmune disease. In our previous trial of pSS, the immunological analysis revealed that LD-IL-2 induced expansion of CD24 high CD27 + B cells which is the key regulator in B cells. 30 NK cells are important both in keeping the autoimmune balance and protecting against viral infections. The CD56 bright NK subset was preferentially expanded by LD-IL-2 in SLE patients. 32 In addition to Tregs, innate lymphoid cells (ILCs) are lymphoid cells that have important effector and regulatory functions in innate immunity and tissue remodeling. 38 Gunnur Deniz et al. reported increased total ILC and ILC3 cells in active BS patients, which shed light on the inflammatory microenvironment in BS patients. 39 We also detected the decline of ILC2 after IL-2 administration in refractory BS patients. 22 The ISBD working groups proposed 5 domains mandatory for BS trials (disease activity, new organ involvement, quality of life, adverse events, and death) and 2 optional domains for mucocutaneous involvement (number of lesions and pain of lesions). 40 These domains provide a guide for design trials in BS and help reduce the heterogeneity of trial designs in BS. In this trial, we assessed the disease activity, new organ involvement, quality of life, adverse events as well as the number of oral ulcers and the pain of oral ulcers. The current data does not definitively establish whether LD-IL-2 therapy is superior to conventional treatments. Comparative studies directly evaluating the efficacy and safety of LD-IL-2 against colchicine, apremilast, and anti-TNF agents would be necessary to unambiguously determine its relative benefits. Such studies would also help clarify whether LD-IL-2 can offer advantages in efficacy, safety profile, and long-term disease management. There are some limitations in this study. First, as our trial was designed primarily for patients with mucosal involvement, patients with vasculitis, CNS involvements were not included. Therefore, clinical stratification in a larger sample size would help our understanding of the particular clinical features likely to benefit from LD-IL-2 therapy. Second, our study showed a significant improvement in many clinical parameters within the placebo group. One potential explanation for this observed improvement is the effect of previous immunosuppressive therapy, rather than a true placebo effect. Immunosuppressive therapies, such as thalidomide or colchicine, often have prolonged effects, and their impact can persist even after discontinuation. This lingering effect can potentially confound the results in the placebo group. Most of our patients in the placebo group were using these medications at baseline, and their therapeutic effects might still be present during the study period. Therefore, the observed improvement in the placebo group may reflect a coincidental phase of background treatment-induced remission rather than a direct response to the placebo itself. Future studies should include longer wash out periods for prior treatments and stratified analyses based on treatment history to better differentiate between the effects of previous therapies and true placebo responses. Third, it is a single-center study and the cohort size is limited. The methodological limitations including measurement bias in ITT estimates and random confounding are another important limitation of the study. Fourth, it remains unknown whether the dose used, although modeled on studies in similar diseases, was optimal for the treatment of BS. Moreover, the ability of LD-IL-2 to maintain long-term reductions in disease activity remains to be determined. Future studies will be needed to gain insights into the therapeutic effects of LD-IL-2 in BS and to diversify the pharmacological approach to this complex disease. In summary, LD-IL-2 had a significant effect on BS patients by reducing oral ulcers and genital ulcers. The clinical benefits observed might result from the rise of Tregs and reduction of Teff cells, which may contribute to disease remission in BS. Methods Trial design and oversight This was a Phase 2, randomized, double-blind, placebo-controlled, parallel-group, superiority design trial to evaluate the efficacy and safety of LD-IL-2 in Behçet’s syndrome patients with active oral ulcers or genital ulcers that did not respond to previous topical glucocorticoid or systemic treatment. The trial was conducted from Oct 2021 to Jul 2023, at Peking University People’s Hospital. Trial reporting conformed to the Consolidated Standards of Reporting Trials (CONSORT) reporting guidelines. The trial design is shown in Figure 1 . Ethics approval was obtained from the Peking University People’s Hospital Ethics Committee and the trial was conducted by the Declaration of Helsinki and the International Conference on Harmonisation Good Clinical Practice guidelines. All participants provided written informed consent. Full details of the trial can be found in the protocol ( Supplement 1 ). Participants Eligible patients were aged 18 to 70 years and fulfilled the criteria of the 1990 International Study Group for Behçet’s Disease. 41 All patients had at least one oral ulcer within 28 days before screening, and had at least two oral ulcers at the time of randomization, despite the previous use of at least one non-biologic medication, such as (but not limited to) topical or systemic glucocorticoids, non-steroidal anti-inflammatory drugs, colchicine, thalidomide, or immunosuppressants. Patients were excluded if they had BS-related active major organ involvement, such as uveitis requiring systemic treatment or vascular or central nervous system involvement during the 12 months preceding trial entry or had a history of biologics usage, severe comorbidities, allergies to relevant reagents, active or chronic infection, or malignant neoplasm (see the protocol in the Supplement for details). Randomization and masking A simple randomization method was used to randomly group the participants, based on computer-generated random numbers prepared by a statistician who had no involvement in conducting the trial. Eligible participants were randomly assigned at a 1:1 ratio to receive either recombinant human IL-2 or placebo in a blinded manner. Randomization was assigned by the order in which patients qualified for treatment. The investigators and the study participants were masked to the allocation sequence and the intervention (study drug containing LD-IL-2 or placebo). The study drug was packaged, labeled, and randomly assigned by an independent third party (Beijing Stemexel Technology Co). The packaging and appearance of the placebo were identical to those of the active drug. At the study site, the study drug was matched to the independent randomization schedule and then distributed to each randomized study participant. Procedures After a screening period that lasted up to 4 weeks, patients were randomized to receive IL-2(recombinant human IL-2Ala 125 [Beijing SL Pharma]) at a dose of 1 million IU or placebo (sterile water for injection containing the same adjuvant as LD-IL-2) subcutaneously every other day. After the initiation of the therapy, patients could continue with concurrent medication but were prohibited from changing or adding immunosuppression therapy during the study. After a 12-week placebo-controlled treatment period and a 12-week observational treatment-free follow-up, patients were assessed for clinical symptoms, and both routine laboratory tests and the peripheral blood lymphocyte subsets were assessed at each visit (weeks 0, 4, 8, 12, and 24). End Points and Assessments The primary efficacy endpoint was the mean number of oral ulcers at week 12. Secondary efficacy endpoints for the placebo-controlled phase included the change in pain from oral ulcers from baseline to week 12, as measured on a 100-mm visual-analogue scale (VAS, with 0 representing no pain and 100 the worst pain ever experienced), 42 and the change in disease activity from baseline to week 12. Disease activity was evaluated using the Behçet's Syndrome Activity Score (BSAS, a scale ranging from 0 to 100, with higher scores indicating more active disease) 40 and the Behcet's Disease Current Activity Index score (BDCAF, ranging from 0 to 12, with higher scores indicating more active disease). 43 Qualityof life was evaluated at baseline and week 12with the use of the Behçet’s Disease Quality of Life scale (BDQOL, on which scores range from0 to 30, with higher scores indicating greater impairment of quality of life). 44 Secondary endpoints for the placebo-controlled period included the mean number of genital ulcer sat week 12, the proportion of patients with a complete response to oral ulcers (defined as the proportion of patients who had no oral ulcers at week 12), and the percentage of patients with genital ulcers at baseline who were ulcer-free at week 12. Secondary efficacy endpoints for the follow-up period were the mean number of oral ulcers and genital ulcers at week 24. The oral ulcers and genital ulcers were evaluated by a physician. At each trial visit, the safety endpoints were assessed, including discontinuations, incidence, and severity of adverse events, serious adverse events, the relationship of such events to LD-IL-2, and pre-established events of special interest. Adverse events were coded using the Medical Dictionary for Regulatory Activities version 18.0. Immunological Analysis Protocol-specific immunophenotypic analysis of peripheral blood lymphocyte subsets was performed at baseline and every 4 weeks until week 12 (weeks 0, 4,8, and 12).Relative proportions of Treg, Tfh, Th1, Th2, and Th17 cell subsets were analyzed by flow cytometry using a FACSAria III instrument (BD) and FlowJo software (Tree Star). Treg cells were defined as CD3 + CD4 + CD25 high CD127 low , Tfh cells as CD3 + CD4 + CXCR5 + PD1 high CCR7 low , Th1 cells as CD3 + CD4 + CXCR3 + CCR6 - CCR4 - CCR7 low , Th2 cells as CD3 + CD4 + CXCR3 + CCR6 - CCR4 + CCR7 low , and Th17 cells as CD3 + CD4 + CXCR3 - CCR6 + CCR4 + CCR7 low . Statistical Analysis The sample size of 26 patients per treatment group was chosen to provide 80% power to detect a treatment difference of 0.80 in the mean number of oral ulcers per patient between the placebo group and the LD-IL-2 group at week 12. This power calculation adopted a fixed superiority margin of 10%. Allowing for a 15% dropout rate, we aimed to recruit 30 participants for each group of the study. Efficacy and safety outcomes were analyzed using the intention-to-treat (ITT) principle. Data for multiple comparisons and non-normally distributed data are expressed as medians [interquartile range (IQR)]. For normally distributed data the results are presented as the mean ± standard deviation (SD). S-W test or K-S test was used to assess the Normality assumption. Differences between any two groups were analyzed using the Student's T test or the Mann-Whitney U test as appropriate. Levene's test was used to assess the homogeneity of variance. Quantitative outcomes were assessed with an analysis of the covariance (ANCOVA)model. Differences among the two groups were analyzed using the Kruskal-Wallis test followed by Dunn's post-hoc test with Bonferroni correction. Correlations were analyzed with Spearman's rank order test. A nominal significance level of 0.05 (two-sided) was applied to all of the statistical analyses, which were carried out using SPSS (version 20.0, IBM) or Graph Pad Prism (Version 5.0, Graph Pad Software). References 41 International Study Group for Behçet's Disease. Criteria for diagnosis of Behçet's disease. Lancet . 335 :1078-1080(1990). 42 Yilmaz, S., et al.Patient-driven assessment of disease activity in Behçet's syndrome: cross-cultural adaptation, reliability and validity of the Turkish version of the Behçet's Syndrome Activity Score. Clin. Exp. Rheumatol .31:77-83(2013). 43 Bhakta, B.B. et al. Behçet's disease: evaluation of a new instrument to measure clinical activity. Rheumatology (Oxford). 38:728-733(1999). 44 Gilworth, G., Chamberlain, M.A., Bhakta, B., Haskard, D., Silman, A.&Tennant, A.Development of the BD-QoL: a quality oflife measure specific to Behçet’s disease. J. Rheumatol . 31 :931-937(2014). Declarations Funding This study was supported by grants from the National Key R&D Program of China (2022YFE0131700 and 2022YFC3602000), National Natural Science Foundation of China (32141004,82271835,82071813, 81671602, 82171772, 81771743, 81871281, 82202003 and U1903210) and BeijingSci-Tech Program (Z191100006619110, Z191100006619114),Bethune-Puai Medical Research Fund (PAYJ-023)and Beijing Nova Program 20220484206. References Saadoun, D., Bodaghi, B. &Cacoub, P. Behçet's Syndrome. N. Engl. J.Med . 390 ,640-651(2024). Emmi,G. et al. Behçet's syndrome. Lancet . 403 , 1093-1108(2024). Yazici, H. et al. Behçet syndrome: a contemporary view. Nat. Rev. Rheumatol . 14 , 119(2018). Yazici, Y. et al. Behçet syndrome. Nat. Rev.Dis primers . 7 (1):67(2021). Hatemi, G. et al. 2018 update of the EULAR recommendations for the management of Behçet's syndrome. Ann.Rheum.Dis . 77 :808-818(2018). Leccese, P. et al. Management of skin, mucosa and joint involvement of Behçet's syndrome: A systematic review for update of the EULAR recommendations for the management of Behçet's syndrome. Semin.Arthritis.Rheu . 48 :752-762(2019). Alibaz-Oner, F.&Direskeneli, H. Advances in the Treatment of Behcet's Disease. Curr RheumatolRep . 23 :47 (2021). Hatemi, G. et al. Apremilast for Behçet's syndrome--a phase 2, placebo-controlled study. N. Engl. J. Med . 372 :1510-1528(2015). Hatemi, G. et al. Trial of Apremilast for Oral Ulcers in Behçet's Syndrome. N. Engl. J. Med . 381 :1918-1928(2019). Hatemi, G. et al. Apremilast for oral ulcers associated with active Behçet's syndrome over 68 weeks: long-term results from a phase 3 randomised clinical trial. Clin ExpRheumatol . 132 :80-87(2021). Lopalco, G. et al. Real-world effectiveness of apremilast in multirefractory mucosal involvement of Behçet's disease. Ann.Rheum.Dis . 78 :1736-1737(2021). Takeno, M. et al. Apremilast in a Japanese subgroup with Behçet's syndrome: Results from a Phase 3, randomised, double-blind, placebo-controlled study. Mod.Rheumatol . 32 :413-421(2022). Klatzmann, D. & Abbas A.K. The promise of low-dose interleukin-2 therapy for autoimmune and inflammatory diseases. Nat. Rev. Rheumato l . 15 :283-294(2015). Dominguez-Villar, M. & Hafler, D.A. Regulatory T cells in autoimmune disease. Nat.Immunol . 19 :665-673(2018). Boyman, O. &Sprent, J. The role of interleukin-2 during homeostasis and activation of the immune system. Nat Rev Rheumatol. 12 :180-190(2012). Liao, W. Lin, J. X. &Leonard W.J. Interleukin-2 at the crossroads of effector responses, tolerance, and immunotherapy. Immunity . 38 :13-25(2013). He, J. et al. Low-dose interleukin-2 treatment selectively modulates CD4(+) T cell subsets in patients with systemic lupus erythematosus. Nat.Med . 22 :991-993(2016). Zhang, X. et al. Efficacy and safety of low-dose interleukin-2 in combination with methotrexate in patients with active rheumatoid arthritis: a randomized, double-blind, placebo-controlled phase 2 trial. Signal.Transduction. Tar. 7 :67(2022). Rosenzwajg, M. et al. Immunological and clinical effects of low-dose interleukin-2 across 11 autoimmune diseases in a single, open clinical trial. Ann.Rheum.Di s. 78 :209-217( 2019). Liu, X. et al. Low-dose IL-2 effectively restored decreased regulatory T cells in patients with Behçet's disease. Clin. Exp.Rheumatol. 39 :746-752(2021). Geri, G. et al. Critical role of IL-21 in modulating TH17 and regulatory T cells in Behçet disease. J. Allergy.Clin.Immunol. 128 :655-664(2011). Zhou, W. et al. Refractory Behçet's disease treated with low-dose interleukin-2: A case report. Medicine . 101 :e31173(2011). Lorenzon, R. et al. The universal effects of low-dose interleukin-2 across 13 autoimmune diseases in a basket clinical trial. J. Autoimmun . 144 :103172(2024). Bettiol, A. et al. Treating the Different Phenotypes of Behçet's Syndrome. Front. Immunol . 10 :2830(2019). Soejima, Y. et al. Changes in the proportion of clinical clusters contribute to the phenotypic evolution of Behçet's disease in Japan. Ann.Rheum.Dis. 23 :49(2021). Zhong, H. et al. Efficacy and safety of tocilizumab in Behçet's syndrome with refractory arterial lesions: a single-centre observational cohort study in China. Rheumatology(Oxford). 61 :2923-2930(2022). Koreth, J. et al. Interleukin-2 and regulatory T cells in graft-versus-host disease. N. Engl. J. Med . 365 :2055-2066(2011). Saadoun, D. et al. Regulatory T-cell responses to low-dose interleukin-2 in HCV-induced vasculitis. N. Engl. J. Med . 365 :2067-2077(2011). Wang, J.Q. et al.Consecutive injections of low-dose interleukin-2 improve symptoms and disease control in patients with chronic spontaneous urticaria. Clin.Immunol(Orlando, Fla) . 247 :109247(2023). He, J. et al. Efficacy and Safety of Low-Dose Interleukin 2 for Primary Sjögren Syndrome: A Randomized Clinical Trial. JAMA network open. 5 :e2241451(2022). Hartemann, A. et al. Low-dose interleukin 2 in patients with type 1 diabetes: a phase 1/2 randomised, double-blind, placebo-controlled trial. Lancet. Diabetes. Endo . 1 :295-305(2022). He, J. et al. Efficacy and safety of low-dose IL-2 in the treatment of systemic lupus erythematosus: a randomised, double-blind, placebo-controlled trial. Ann.Rheum.Dis . 79 :141-149(2022). Miao, M. et al. Short-term and low-dose IL-2 therapy restores the Th17/Treg balance in the peripheral blood of patients with primary Sjögren's syndrome. Ann.Rheum.Dis . 77 :1838-1840(2018). Miao, M.et al. Treatment of Active Idiopathic Inflammatory Myopathies by Low-Dose Interleukin-2: A Prospective Cohort Pilot Study. Rheumatol.Ther . 8 :835-847(2021). Zhufeng,Y. et al.Modificationofintestinalmicrobiotadysbiosisbylow-doseinterleukin-2in dermatomyositis: a post hoc analysis from a clinical trial study. Front Cell Infect.Mi . 12 :757099(2022). Kolios,A.G.A.,Tsokos, G.C. &Klatzmann, D.Interleukin-2 and regulatoryT cells in rheumatic diseases. Nat. Rev. Rheumatol . 17 :749-766(2021). Tchitchek, N. et al. Low-doseIL-2shapesatolerogenicgutmicrobiotathat improves autoimmunity and gut inflammation. JCI. Insight . 7 :e159406(2022). Clottu, AS. et al. Innate Lymphoid Cells in Autoimmune Diseases. Front. Immunol . 12 :789788(2021). Gelmez, MY. et al. Inflammatory status might direct ILC and NK cells to IL-17 expressing ILC3 and NK subsets in Behcet's disease. Immunol.Lett. 235 :1-8( 2021). Hatemi, G. et al. Core Set of Domains for Outcome Measures in Behçet's Syndrome. Arthritis.Care.Res . 74 :691-699(2022). Tables Tables 1 to 3 are available in the Supplementary Files section. Additional Declarations There is NO Competing Interest. Supplementary Files BDprotocolXSAP.pdf CONSORT2010ChecklistNM1108.pdf nreditorialpolicychecklist1107.pdf nrreportingsummary1107.pdf supplementary1023.pptx Tables.docx Cite Share Download PDF Status: Published Journal Publication published 07 Jan, 2026 Read the published version in Nature Communications → Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5416266","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":376691475,"identity":"5fb64f70-8734-4a3b-a082-8a813336e83c","order_by":0,"name":"Liu 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The placebo-controlled treatment lasted for 12 weeks, 26 out of the LD-IL-2 group and 30 out of the placebo group completed the study. During the 12-week follow-up phase, three patients from the LD-IL-2 group and two from the placebo group withdrew from the trial.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-5416266/v1/ec2d0dab5c955398c2f8f395.png"},{"id":69832206,"identity":"81826338-896f-4236-90ee-558838032896","added_by":"auto","created_at":"2024-11-25 15:41:48","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":49976,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eclinical manifestation change over time\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe clinical manifestation change from baseline in the the Low-dose interleukin2 and placebo groups is shown and was compared using a T-test with two-sided P values. Change in numbers oforal ulcers (A) , genital ulcers (B) and scores of Behcet’s Disease Current Activity Form (C) and visual-analogue scale (D) with time (weeks). The point is the mean and the error bars represent the SEM. *p \u0026lt; 0.05\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-5416266/v1/4d2b3263eec5eaab68e93cfb.png"},{"id":101933178,"identity":"f17ff000-e856-4c08-9697-230b4cf737b3","added_by":"auto","created_at":"2026-02-05 08:07:14","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1044441,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5416266/v1/0ca714b3-9f10-4a4e-ad90-713d2ad023e6.pdf"},{"id":69833290,"identity":"8e90eb51-bda7-4a87-8f2f-b6ccbba2afd6","added_by":"auto","created_at":"2024-11-25 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15:33:48","extension":"pdf","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":1748087,"visible":true,"origin":"","legend":"","description":"","filename":"nreditorialpolicychecklist1107.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5416266/v1/89927117bbfae07a9f6cb547.pdf"},{"id":69833284,"identity":"135b300c-e442-4f90-89c8-c4e0e7921c44","added_by":"auto","created_at":"2024-11-25 15:49:48","extension":"pdf","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":1749032,"visible":true,"origin":"","legend":"","description":"","filename":"nrreportingsummary1107.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5416266/v1/d612ac96228291920c85c89f.pdf"},{"id":69830519,"identity":"c56b5cac-6cff-4f65-b19e-0a668ac0ddf5","added_by":"auto","created_at":"2024-11-25 15:33:48","extension":"pptx","order_by":5,"title":"","display":"","copyAsset":false,"role":"supplement","size":338156,"visible":true,"origin":"","legend":"","description":"","filename":"supplementary1023.pptx","url":"https://assets-eu.researchsquare.com/files/rs-5416266/v1/3b8e4992334bf78c1433eecf.pptx"},{"id":69830518,"identity":"2b9bc6d2-2118-47c9-8649-2fd414bfe8b0","added_by":"auto","created_at":"2024-11-25 15:33:48","extension":"docx","order_by":6,"title":"","display":"","copyAsset":false,"role":"supplement","size":89247,"visible":true,"origin":"","legend":"","description":"","filename":"Tables.docx","url":"https://assets-eu.researchsquare.com/files/rs-5416266/v1/5b0d7fc23d87ab7c4e475814.docx"}],"financialInterests":"There is \u003cb\u003eNO\u003c/b\u003e Competing Interest.","formattedTitle":"Efficacy and Safety of Low-Dose Interleukin 2 for Behçet’s Syndrome: a phase 2 randomized double-blind placebo-controlled clinical trial","fulltext":[{"header":"Introduction","content":"\u003cp\u003eBeh\u0026ccedil;et\u0026rsquo;s syndrome (BS) is a chronic and relapsing systemic vasculitis that causes recurrent oral aphthous ulcers, along with genital ulcers, skin lesions, and uveitis.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e Patients may also present with arthralgia, arterial aneurysms, venous and arterial thrombosis, gastrointestinal tract and neurological symptoms may be involved as well.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e Recurrent relapsing and remitting oral ulcers are the most common manifestations of BS, which have a substantial deleterious effect on quality of life.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e Although colchicine is recommended as the first-line treatment for mucocutaneous lesions, the efficacy of colchicine has been debated.\u003csup\u003e\u003cspan additionalcitationids=\"CR6\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e Second-line immunosuppressive treatments for mucocutaneous involvement include azathioprine, thalidomide, interferon-α, and tumor necrosis factor (TNF-α) inhibitors.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e Biologics including TNF-α inhibitors and Tocilizumab play an important role in the treatment of other organ involvement in BS, such as vascular, CNS, and eyes.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e Several randomized, controlled trials have been conducted to assess the efficacy of Apremilast (a small molecule selective inhibitor of the phosphodiesterase 4 enzyme) for the treatment of BS oral ulcers, and this agent has been approved by the US FDA and EMA for the BS indication,\u003csup\u003e\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e however, adverse events such as gastrointestinal side effects often limit its further use.\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e In addition, some BS patients were refractory to colchicine and/or Apremilast. Thus, there is an unmet need for therapies with better efficacy and lower adverse effects for BS patients.\u003c/p\u003e \u003cp\u003eInterleukin-2 (IL-2) is a cytokine known to induceCD4\u0026thinsp;+\u0026thinsp;Tcell activation and regulation.\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e Regulatory T cells (Tregs) are one of the subsets of CD4\u0026thinsp;+\u0026thinsp;T cells, which inhibit the production and function of effector T cells (Teff) (including T helper 1 [Th1], Th2, Th17, and T follicular helper [Tfh] cells).\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e IL-2 regulates the development, proliferation, and survival of Tregs.\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e Different doses of IL-2 produce divergent effects on T cell subsets, and low-dose IL-2 (LD-IL-2) has been shown to selectively increase Tregs and suppress the differentiation of TfhandTh17subsets in various autoimmune diseases as well as inflammatory diseases.\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e In these diseases, LD-IL-2 helps to maintain immune tolerance, prevent autoimmunity, and inhibit inflammatory responses. Recently, LD-IL-2 has been extensively studied and used in the treatment of auto-inflammatory diseases such as systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), and inflammatory bowel disease (IBD).\u003csup\u003e\u003cspan additionalcitationids=\"CR18\" citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e Previous studies have demonstrated that the dysregulation of T cells is functionally involved in the development of BS, and LD-IL-2-promoted Treg restoration in BS patients.\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e,\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e These findings have motivated the exploration of LD-IL-2 for treating BS, and three small studies have reported efficacy for LD-IL-2 in treating BS patients. One of the studies showed efficacy for LD-IL-2 in a BS patient with oral ulcers, genital ulcers, and erythema nodosum,\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e while the other study monitored circulating Treg cells but did not formally assess clinical response,\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e and a recent open-label study showed the LD-IL-2 treatment response in 5/8 patients.\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eIn the present Phase 2 trial, we evaluated the efficacy and safety of LD-IL-2 in BS. We assessed LD-IL-2 for the treatment of oral ulcers in patients with BS by monitoring changes in the number of oral ulcers. We also assessed the change in pain from oral ulcers from baseline to week 12, the effects on the number of genital ulcers, overall disease activity, and the effects of the therapy on the proportions of Treg, Tfh, and Th17 cells.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003ePatient disposition and baseline characteristics\u003c/h2\u003e \u003cp\u003eFrom October 2021 through July 2023, a total of 60 patients from Peking University People\u0026rsquo;s Hospital were deemed eligible and were randomly assigned to receive either LD-IL-2 (30 patients) or placebo (30 patients). Of the 60 patients who underwent randomization, 56 completed the 12-week placebo-controlled period (26 in the LD-IL-2 group and 30 in the placebo group). Three patients in the LD-IL-2 group and two patients in the placebo group withdrew from the trial during the 12-week follow-up phase. Figure\u0026nbsp;1 shows the assignment of the patients to the trial groups and the reasons for discontinuation.\u003c/p\u003e \u003cp\u003eThe baseline demographic and disease characteristics of the patients, as well as their previous medications, were similar in the two trial groups (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Patients had a history of skin lesions (75%; including 27% erythema nodosum and 48% folliculitis at baseline), genital ulcers (40%), musculoskeletal involvement (20%), eye involvement (17%) (none of the patients had active uveitis at baseline, as judged by an ophthalmologist), and gastrointestinal involvement (12%). No patient had vascular or central nervous system (CNS) involvement. The concomitant medications in the two groups at baseline and week 12 are shown in Appendix Tables\u0026nbsp;1 and 2.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBaseline Demographic of the Patients, Including Previous Medications.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eClinical manifestation, Disease activity and Quality of life at Baseline, Week 4, Week 8, and Week 12 in LD-IL-2 group (n\u0026thinsp;=\u0026thinsp;26) and Placebo group (n\u0026thinsp;=\u0026thinsp;30)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003ePrimary outcome\u003c/h3\u003e\n\u003cp\u003e The mean number of oral ulcers per patient at baseline was 2.73\u0026thinsp;\u0026plusmn;\u0026thinsp;2.20 (-95% CI, 1.84 to 3.62) in the LD-IL-2 group and 2.53\u0026thinsp;\u0026plusmn;\u0026thinsp;2.08 (-95% CI, 1.75 to 3.31) in the placebo group. At week 12, the mean number of oral ulcers was significantly lower in the LD-IL-2 group than in the placebo group (0.69\u0026thinsp;\u0026plusmn;\u0026thinsp;1.05, -95% CI, 0.27 to 1.12 \u003cem\u003evs.\u003c/em\u003e1.57\u0026thinsp;\u0026plusmn;\u0026thinsp;0.90, -95% CI, 1.23 to 1.90, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.001). The decrease in the number of oral ulcers was evident by week 4 in the LD-IL-2 group and was sustained throughout the full 12-week treatment phase (\u003cb\u003eFig.\u0026nbsp;2A\u003c/b\u003e). Percentage of patients who had a complete response to oral ulcers by week 12 was 61.5% in the LD-IL-2 group (16 of 26 patients) and only 16.7% in the placebo group (5 of 30 patients) (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001).The AUC of the total mean (\u0026plusmn;\u0026thinsp;SE) number of oral ulcers during the 12-week placebo-controlled period was 87.6\u0026thinsp;\u0026plusmn;\u0026thinsp;43.7 in the LD-IL-2 group, as compared with 134.8\u0026thinsp;\u0026plusmn;\u0026thinsp;32.0 in the placebo group (least-squares mean difference, -47.2; 95% CI, -156.5 to 62.2). The results regarding the primary and secondary endpoints are presented in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e\u003cb\u003eand\u003c/b\u003e Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eChange of Clinical manifestation, Disease activity and Quality of life from Baseline to Week 12\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026minus;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026minus;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026minus;\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePlacebo(n\u0026thinsp;=\u0026thinsp;30)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLow-dose IL-2(n\u0026thinsp;=\u0026thinsp;26)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eEstimated Treatment Difference (95% Cl)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eChanges of the number of oral ulcers\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c2\"\u003e \u003cp\u003e-0.97(-1.65, -0.28)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c3\"\u003e \u003cp\u003e-2.04(-2.90, -1.18)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c4\"\u003e \u003cp\u003e-1.07(-2.13, -0.13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.047\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eChanges of the number of genital ulcers\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c2\"\u003e \u003cp\u003e-0.50(-0.86, -0.14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c3\"\u003e \u003cp\u003e-0.69(-1.13, -0.25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c4\"\u003e \u003cp\u003e-0.19(-0.74, 0.36)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.488\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eChanges of the Behcet\u0026rsquo;s Disease Current Activity Form\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c2\"\u003e \u003cp\u003e-1.00(-1.75, -0.25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c3\"\u003e \u003cp\u003e-1.88(-2.50, -1.27)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c4\"\u003e \u003cp\u003e-0.88(-1.86, 0.09)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.073\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eChanges of the Behcet\u0026rsquo;s Syndrome Activity Scale score\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c2\"\u003e \u003cp\u003e-6.47(-10.17, -2.76)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c3\"\u003e \u003cp\u003e-20.12(-24.54, -15.69)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c4\"\u003e \u003cp\u003e-13.65(-19.24, -8.06)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eChanges of the pain associated with oral ulcers, as measured by VAS\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c2\"\u003e \u003cp\u003e-1.67(-2.48, -0.85)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c3\"\u003e \u003cp\u003e-3.46(-4.39, -2.53)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c4\"\u003e \u003cp\u003e-1.79(-3.00, -0.59)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.004\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eChanges of Beh\u0026ccedil;et\u0026rsquo;s Disease Quality of Life scale score\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c2\"\u003e \u003cp\u003e-1.23(-1.57, -0.89)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c3\"\u003e \u003cp\u003e-3.42(-4.14, -2.70)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c4\"\u003e \u003cp\u003e-2.19(-2.93, -1.45)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eChanges in outcome measures between the Low-dose interleukin2 group and the placebo group at week 12 from baseline(week 0) and were compared using a T-test with two-sided P values. Data are mean(95% Cl) and P value.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\n\u003ch3\u003eSecondary clinical outcomes\u003c/h3\u003e\n\u003cp\u003eA total of 10 patients in the LD-IL-2 group and 13 patients in the placebo group had genital ulcers at baseline. The mean number of genital ulcers per patient at baseline was 0.69\u0026thinsp;\u0026plusmn;\u0026thinsp;1.09 (-95% CI, 0.25 to 1.13) in the LD-IL-2 group and 0.67\u0026thinsp;\u0026plusmn;\u0026thinsp;0.99 (-95% CI, 0.30 to 1.04) in the placebo group. The mean number of genital ulcers at week 12 was significantly lower in the LD-IL-2 group than in the placebo group (0\u0026thinsp;\u0026plusmn;\u0026thinsp;0, -95% CI, 0 to 0 \u003cem\u003evs.\u003c/em\u003e 0.17\u0026thinsp;\u0026plusmn;\u0026thinsp;0.38, -95% CI, 0.025 to 0.31, P\u0026thinsp;=\u0026thinsp;0.031) (\u003cb\u003eFig.\u0026nbsp;2B\u003c/b\u003e). The percentage of patients who were free from genital ulcers at week 12 was 100% in the LD-IL-2 group (26 of 26 patients) and 83.3% in the placebo group (25 of 30 patients) (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.029). A total of 51 patients completed week 24 of the trial. The prespecified analyses of the number of oral ulcers and genital ulcers at week 24 are shown in \u003cb\u003eFigs.\u0026nbsp;2A and 2B\u003c/b\u003e, respectively.\u003c/p\u003e \u003cp\u003eAt week 12, significant reductions from baseline in the pain from oral ulcers (as assessed on a 100-mm VAS) were observed for the LD-IL-2 group compared to the placebo group (LD-IL-2 group: -3.46, \u0026minus;\u0026thinsp;95% CI, -4.39to -2.53; placebo group: -1.67, \u0026minus;\u0026thinsp;95% CI, -2.48 to -0.85; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.004). The mean change from baseline in the BSAS at week 12 was \u0026minus;\u0026thinsp;20.12 (\u0026minus;\u0026thinsp;95% CI, -24.54 to -15.69) in the LD-IL-2 group, which was significantly greater than for the placebo group (-6.47, -95%CI, -10.17 to -2.76) (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). At week 12, LD-IL-2 group patients had much more improvements in BDCAF compared to the placebo group (LD-IL-2 group: -1.88, -95%CI, -2.50 to -1.27; placebo group: -1.00, -95% CI, -1.75 to -0.25; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.073). The mean change of BDQOL from baseline to week 12 was significantly greater in the LD-IL-2 group than in the placebo group (LD-IL-2 group: -3.42, -95%CI, -4.14 to -2.70; placebo group: -1.23, -95% CI, -1.57 to -0.89; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e \u003cp\u003eDuring the follow-up period, three patients in the LD-IL-2 group developed new skin lesions, presenting as folliculitis. In the placebo group, there were 2 cases of new folliculitis, 3 cases of new arthralgia, and 1 case of new uveitis during the follow-up.\u003c/p\u003e\n\u003ch3\u003eSafety\u003c/h3\u003e\n\u003cp\u003eNo infections were observed in either group during the treatment or follow-up periods. There were injection site reactions in 4 of the LD-IL-2 group patients (13.3%), and 1 patient (3.3%) discontinued the trial due to a severe injection reaction. There was 1 injection site reaction (3.3%) in the placebo group. Whereas there were no fevers for the placebo group, 2 patients (6.7%) in the LD-IL-2 group had fevers after the IL-2 injection. However, the fever abated spontaneously within 24 hours without any medical treatment (\u003cb\u003eAppendix Table\u0026nbsp;4\u003c/b\u003e).\u003c/p\u003e\n\u003ch3\u003eAnalysis of CD4 + T cell subsets in peripheral blood\u003c/h3\u003e\n\u003cp\u003eImmunological analysis from patient peripheral blood samples included flow-cytometry-based enumeration of Tregs and effector CD4\u0026thinsp;+\u0026thinsp;T cell (Teff) subsets (Th1, Th2, Th17, and Tfh cells). Briefly, the LD-IL-2 group displayed a significant expansion of Treg cells as a proportion of total CD4\u0026thinsp;+\u0026thinsp;T cells (from 9.23% at baseline to 15.66% at week 12, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001) (\u003cb\u003eAppendix Fig.\u0026nbsp;1A\u003c/b\u003e), whereas no differences from baseline in the proportions of any examined cells were detected for the placebo group (\u003cb\u003eAppendix Fig.\u0026nbsp;1A-1E\u003c/b\u003e). Moreover, the ratio of Teff (Tfh and Th17) cells to Tregs decreased rapidly following each LD-IL-2 administration (\u003cb\u003eAppendix Fig.\u0026nbsp;1D and 1E\u003c/b\u003e).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eManagement of Beh\u0026ccedil;et\u0026rsquo;s syndrome is challenging due to the heterogeneous nature of the disease.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003eDifferent phenotypes of BS are thought to be governed by diversified mechanisms and may benefit from tailored therapeutic approaches.\u003csup\u003e\u003cspan additionalcitationids=\"CR25\" citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e In this double-blind, placebo-controlled study, we showed that LD-IL-2 administration is efficient for oral ulcers and genital ulcers in BS patients. The oral ulcers and their related pain can be alleviated rapidly, approximately within 2 weeks of LD-IL-2 therapy. Sixteen of 26 BS patients in the LD-IL-2 group (61.5%) reached complete remission after 12 weeks of active treatment. Reduced BSAS, BDCAF and BD-QOL scores and a high rate of resolution of clinical features were observed. In addition, these changes in disease activity permitted significant tapering of corticosteroid therapy during the study period in the LD-IL-2 group, 4 of the 11 patients (36.3%) in the LD-IL-2 group who were on corticosteroid therapy at baseline discontinued steroids at 12 weeks. In our study, we found evidence supporting the use of LD-IL-2 as an effective and safe second-line therapy for the treatment of active mucosal manifestations of BS.\u003c/p\u003e \u003cp\u003eLD-IL-2 has demonstrated impressive clinical improvements in various skin conditions beyond BS, such as graft-versus-host disease (GVHD), HCV-associated vasculitis, and chronic urticaria.\u003csup\u003e\u003cspan additionalcitationids=\"CR28\" citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e These studies consistently show that LD-IL-2 therapy leads to significant symptom relief and enhanced skin condition. The mechanism behind these improvements is believed to be linked to the modulation of tissue-resident regulatory Tregs in the skin.\u003csup\u003e\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e In the skin, Tregs help suppress local inflammation and autoimmunity, leading to improved skin health and symptom reduction. In our study, we observed a marked increase in Tregs and a decrease in Th17 cells in the LD-IL-2 group, which correlates with the clinical improvements seen in cutaneous manifestations. This shift in the immune cell balance is crucial for reducing inflammation and promoting healing in skin tissues.\u003c/p\u003e \u003cp\u003eAt baseline, in the LD-IL-2 group, 25/30 patients had a history of skin lesions, 7/30 patients had musculoskeletal involvement, 4/30 patients had eye involvement, and 1/30 had gastrointestinal involvement. At week 12, the proportions of these patients for which BDCAF decreased were 92% (23/25) in patients with skin lesions, 71% (5/7) with musculoskeletal involvement, 50% (2/4) with eye involvement and 100% (1/1) with gastrointestinal involvement. We speculate that BS with mucocutaneous and musculoskeletal involvement might be sensitive to LD-IL-2 therapy, but whether it is effective in patients with other manifestations of BS needs further research to clarify, especially since we did not include patients with vascular or CNS involvement.\u003c/p\u003e \u003cp\u003eThere were no serious adverse events observed in this study. Adverse events, including injection site reactions and fevers, occurred more frequently with LD-IL-2 administration than with a placebo. However, the injection site reactions and fever were transitory and would remission without any medical interruption. In particular, no infections were observed in the setting of LD-IL-2 treatment. This is consistent with previous studies.\u003csup\u003e\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e,\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/sup\u003e We and others have shown that LD-IL-2 increases CD8\u0026thinsp;+\u0026thinsp;T cells and NK cells\u003csup\u003e\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e,\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u003c/sup\u003e, which are required to build immune responses to infections.\u003c/p\u003e \u003cp\u003eIn this trial, we used a dosing schedule of LD-IL-2 based on our previous studies,\u003csup\u003e\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e,\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e\u003c/sup\u003e administering 1\u0026nbsp;million IU every other day for 3 months. This regimen was chosen for its demonstrated efficacy and safety in modulating the immune system. In contrast, Rosenzwajg et al. used a regimen of 1\u0026nbsp;million IU daily for the first 5 days, followed by 1\u0026nbsp;million IU every two weeks for 6 months, designed to investigate the long-term immunomodulatory effects of LD-IL-2.\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e Our chosen schedule, with more frequent administration over a shorter period, may be preferable for acute and intensive management, as well as for the rapid assessment of short-term efficacy, especially in patients with active disease.\u003c/p\u003e \u003cp\u003eWe observed improvement in BDCAF and BSAS scores through week 24, even though the LD-IL-2 treatment was discontinued at week 12 and the expanded Tregs declined afterward. There are a few explanations for the sustained clinical benefit after LD-IL-2 treatment. First, as shown in our previous report,\u003csup\u003e\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e,\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u003c/sup\u003e LD-IL-2 treatment significantly improved the suppressive function of Treg cells, and such functional improvement of Tregs might still be present when the LD-IL-2 treatment is discontinued. In addition, LD-IL-2 decreased inflammatory cytokines which can last in serafor a longer period after LD-IL-2 discontinuation.\u003csup\u003e\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e,\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e\u003c/sup\u003e Further studies are required to characterize the immunological changes with LD-IL-2, which can help to design the regimen of LD-IL-2 therapy.\u003c/p\u003e \u003cp\u003eDifferent mechanisms have been investigated to clarify the effect of LD-IL2 on autoimmune disease. In our previous trial of pSS, the immunological analysis revealed that LD-IL-2 induced expansion of CD24\u003csup\u003ehigh\u003c/sup\u003eCD27\u003csup\u003e+\u003c/sup\u003eB cells which is the key regulator in B cells.\u003csup\u003e\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e NK cells are important both in keeping the autoimmune balance and protecting against viral infections. The CD56\u003csup\u003ebright\u003c/sup\u003e NK subset was preferentially expanded by LD-IL-2 in SLE patients.\u003csup\u003e\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u003c/sup\u003e In addition to Tregs, innate lymphoid cells (ILCs) are lymphoid cells that have important effector and regulatory functions in innate immunity and tissue remodeling.\u003csup\u003e\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e\u003c/sup\u003eGunnur Deniz et al. reported increased total ILC and ILC3 cells in active BS patients, which shed light on the inflammatory microenvironment in BS patients.\u003csup\u003e\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e\u003c/sup\u003eWe also detected the decline of ILC2 after IL-2 administration in refractory BS patients.\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe ISBD working groups proposed 5 domains mandatory for BS trials (disease activity, new organ involvement, quality of life, adverse events, and death) and 2 optional domains for mucocutaneous involvement (number of lesions and pain of lesions).\u003csup\u003e\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e\u003c/sup\u003e These domains provide a guide for design trials in BS and help reduce the heterogeneity of trial designs in BS. In this trial, we assessed the disease activity, new organ involvement, quality of life, adverse events as well as the number of oral ulcers and the pain of oral ulcers.\u003c/p\u003e \u003cp\u003eThe current data does not definitively establish whether LD-IL-2 therapy is superior to conventional treatments. Comparative studies directly evaluating the efficacy and safety of LD-IL-2 against colchicine, apremilast, and anti-TNF agents would be necessary to unambiguously determine its relative benefits. Such studies would also help clarify whether LD-IL-2 can offer advantages in efficacy, safety profile, and long-term disease management.\u003c/p\u003e \u003cp\u003eThere are some limitations in this study. First, as our trial was designed primarily for patients with mucosal involvement, patients with vasculitis, CNS involvements were not included. Therefore, clinical stratification in a larger sample size would help our understanding of the particular clinical features likely to benefit from LD-IL-2 therapy. Second, our study showed a significant improvement in many clinical parameters within the placebo group. One potential explanation for this observed improvement is the effect of previous immunosuppressive therapy, rather than a true placebo effect. Immunosuppressive therapies, such as thalidomide or colchicine, often have prolonged effects, and their impact can persist even after discontinuation. This lingering effect can potentially confound the results in the placebo group. Most of our patients in the placebo group were using these medications at baseline, and their therapeutic effects might still be present during the study period. Therefore, the observed improvement in the placebo group may reflect a coincidental phase of background treatment-induced remission rather than a direct response to the placebo itself. Future studies should include longer wash out periods for prior treatments and stratified analyses based on treatment history to better differentiate between the effects of previous therapies and true placebo responses. Third, it is a single-center study and the cohort size is limited. The methodological limitations including measurement bias in ITT estimates and random confounding are another important limitation of the study. Fourth, it remains unknown whether the dose used, although modeled on studies in similar diseases, was optimal for the treatment of BS. Moreover, the ability of LD-IL-2 to maintain long-term reductions in disease activity remains to be determined. Future studies will be needed to gain insights into the therapeutic effects of LD-IL-2 in BS and to diversify the pharmacological approach to this complex disease.\u003c/p\u003e \u003cp\u003eIn summary, LD-IL-2 had a significant effect on BS patients by reducing oral ulcers and genital ulcers. The clinical benefits observed might result from the rise of Tregs and reduction of Teff cells, which may contribute to disease remission in BS.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eTrial design and oversight\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis was a Phase 2, randomized, double-blind, placebo-controlled, parallel-group, superiority design trial to evaluate the efficacy and safety of LD-IL-2 in Beh\u0026ccedil;et\u0026rsquo;s syndrome patients\u0026nbsp;with active oral ulcers or genital ulcers that did not respond to previous topical glucocorticoid or systemic treatment.\u0026nbsp;The trial was conducted from\u0026nbsp;Oct 2021 to Jul 2023, at Peking University People\u0026rsquo;s Hospital.\u0026nbsp;Trial reporting conformed to the Consolidated Standards of Reporting Trials (CONSORT) reporting guidelines.\u0026nbsp;The trial design is shown in\u0026nbsp;\u003cstrong\u003eFigure 1\u003c/strong\u003e.\u0026nbsp;Ethics approval was obtained from the Peking University People\u0026rsquo;s Hospital Ethics Committee and the trial was conducted by the Declaration of Helsinki and the International Conference on Harmonisation Good Clinical Practice guidelines.\u0026nbsp;All participants provided written informed consent.\u0026nbsp;Full details of the trial can be found in the protocol (\u003cstrong\u003eSupplement 1\u003c/strong\u003e).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eParticipants\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEligible patients were aged 18 to 70 years and fulfilled the\u0026nbsp;criteria of the 1990 International Study Group for Beh\u0026ccedil;et\u0026rsquo;s Disease.\u003csup\u003e41\u003c/sup\u003eAll patients\u0026nbsp;had at least one oral ulcer within 28 days before screening, and had at least two oral ulcers at the time of randomization,\u0026nbsp;despite the previous use of at least one non-biologic medication, such as (but not limited to) topical or systemic glucocorticoids, non-steroidal anti-inflammatory drugs, colchicine, thalidomide, or immunosuppressants.\u003c/p\u003e\n\u003cp\u003ePatients were excluded if they had BS-related active major organ involvement, such as uveitis requiring systemic treatment or vascular or central nervous system involvement during the 12 months preceding trial entry or had a history of biologics usage, severe comorbidities, allergies to relevant reagents, active or chronic infection, or malignant neoplasm (see the protocol in the Supplement for details).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRandomization and masking\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA simple randomization method was used to randomly group the participants, based on computer-generated random numbers prepared by a statistician who had no involvement in conducting the trial.\u0026nbsp;Eligible participants were randomly assigned at a 1:1 ratio to receive either recombinant human IL-2 or placebo in a blinded manner.\u0026nbsp;Randomization was assigned by the order in which patients qualified for treatment.\u0026nbsp;The investigators and the study participants were masked to the allocation sequence and the intervention (study drug containing LD-IL-2 or placebo).\u0026nbsp;The study drug was packaged, labeled, and randomly assigned by an independent third party (Beijing Stemexel Technology Co).\u0026nbsp;The packaging and appearance of the placebo were identical to those of the active drug.\u0026nbsp;At the study site, the study drug was matched to the independent randomization schedule and then distributed to each randomized study participant.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eProcedures\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAfter a screening period that lasted up to 4 weeks, patients were randomized to receive IL-2(recombinant human IL-2Ala\u003csup\u003e125\u003c/sup\u003e [Beijing SL Pharma]) at a dose of 1 million IU or placebo (sterile water for injection containing the same adjuvant as LD-IL-2) subcutaneously every other day.\u0026nbsp;After the initiation of the therapy, patients could continue with concurrent medication but were prohibited from changing or adding immunosuppression therapy during the study.\u0026nbsp;After a 12-week placebo-controlled treatment period and a 12-week observational\u0026nbsp;treatment-free\u0026nbsp;follow-up, patients were assessed for clinical symptoms, and both routine laboratory tests and the peripheral blood lymphocyte subsets were assessed at each visit (weeks 0, 4, 8, 12, and 24).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEnd Points and Assessments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe primary efficacy endpoint was the mean number of oral ulcers at week 12. Secondary efficacy endpoints for the placebo-controlled phase included the change in pain from oral ulcers from baseline to week 12, as measured on a 100-mm visual-analogue scale (VAS, with 0 representing no pain and 100 the worst pain ever experienced),\u003csup\u003e42\u0026nbsp;\u003c/sup\u003eand the change in disease activity from baseline to week 12. Disease activity was evaluated using the Beh\u0026ccedil;et\u0026apos;s Syndrome Activity Score (BSAS, a scale ranging from 0 to 100, with higher scores indicating more active disease)\u003csup\u003e40\u003c/sup\u003e and the Behcet\u0026apos;s Disease Current Activity Index score (BDCAF, ranging from 0 to 12, with higher scores indicating more active disease). \u003csup\u003e43\u003c/sup\u003eQualityof life was evaluated at baseline and week 12with the use of the Beh\u0026ccedil;et\u0026rsquo;s Disease Quality of Life scale (BDQOL, on which scores range from0 to 30, with higher scores indicating greater impairment of quality of life).\u003csup\u003e44\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eSecondary endpoints for the placebo-controlled period included the\u0026nbsp;mean number of genital ulcer sat week 12, the proportion of patients with a complete response to oral ulcers (defined as the proportion of patients who had no oral ulcers at week 12), and the percentage of patients with genital ulcers at baseline who were ulcer-free at week 12.\u0026nbsp;Secondary efficacy endpoints for the\u0026nbsp;follow-up\u0026nbsp;period were the\u0026nbsp;mean number of oral ulcers and genital ulcers at week 24.\u0026nbsp;The\u0026nbsp;oral ulcers and genital ulcers\u0026nbsp;were evaluated by a physician.\u003c/p\u003e\n\u003cp\u003eAt each trial visit, the safety endpoints were\u0026nbsp;assessed,\u0026nbsp;including\u0026nbsp;discontinuations, incidence, and severity of adverse events, serious adverse events,\u0026nbsp;the relationship of such events to\u0026nbsp;LD-IL-2, and pre-established events of special interest.\u0026nbsp;Adverse events were coded using the Medical Dictionary for Regulatory Activities version 18.0.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eImmunological Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eProtocol-specific immunophenotypic analysis of peripheral blood lymphocyte subsets was performed at baseline and every 4 weeks until week 12 (weeks 0, 4,8, and 12).Relative proportions of Treg, Tfh, Th1, Th2, and Th17 cell subsets were analyzed by flow cytometry using a FACSAria III instrument (BD) and FlowJo software (Tree Star).\u0026nbsp;Treg cells were defined as\u0026nbsp;CD3\u003csup\u003e+\u003c/sup\u003eCD4\u003csup\u003e+\u003c/sup\u003eCD25\u003csup\u003ehigh\u003c/sup\u003eCD127\u003csup\u003elow\u003c/sup\u003e, Tfh cells as CD3\u003csup\u003e+\u003c/sup\u003eCD4\u003csup\u003e+\u003c/sup\u003eCXCR5\u003csup\u003e+\u003c/sup\u003ePD1\u003csup\u003ehigh\u003c/sup\u003eCCR7\u003csup\u003elow\u003c/sup\u003e, Th1 cells as CD3\u003csup\u003e+\u003c/sup\u003eCD4\u003csup\u003e+\u003c/sup\u003eCXCR3\u003csup\u003e+\u003c/sup\u003eCCR6\u003csup\u003e-\u003c/sup\u003eCCR4\u003csup\u003e-\u003c/sup\u003eCCR7\u003csup\u003elow\u003c/sup\u003e, Th2 cells as CD3\u003csup\u003e+\u003c/sup\u003eCD4\u003csup\u003e+\u003c/sup\u003eCXCR3\u003csup\u003e+\u003c/sup\u003eCCR6\u003csup\u003e-\u003c/sup\u003eCCR4\u003csup\u003e+\u003c/sup\u003eCCR7\u003csup\u003elow\u003c/sup\u003e, and Th17 cells as CD3\u003csup\u003e+\u003c/sup\u003eCD4\u003csup\u003e+\u003c/sup\u003eCXCR3\u003csup\u003e-\u003c/sup\u003eCCR6\u003csup\u003e+\u003c/sup\u003eCCR4\u003csup\u003e+\u003c/sup\u003eCCR7\u003csup\u003elow\u003c/sup\u003e.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe sample size of 26 patients per treatment group was chosen to provide 80% power to detect a treatment difference of 0.80 in the mean number of oral ulcers per patient between the placebo group and the\u0026nbsp;LD-IL-2\u0026nbsp;group at week 12.\u0026nbsp;This power calculation adopted a fixed superiority margin of 10%.\u0026nbsp;Allowing for a 15% dropout rate, we aimed to recruit 30 participants for each group of the study.\u003c/p\u003e\n\u003cp\u003eEfficacy and safety outcomes were analyzed using the intention-to-treat (ITT) principle. Data for multiple comparisons and non-normally distributed data are expressed as medians [interquartile range (IQR)]. For normally distributed data the results are presented as the mean \u0026plusmn; standard deviation (SD). S-W test or K-S test was used to assess the Normality assumption. Differences between any two groups were analyzed using the Student\u0026apos;s T test or the Mann-Whitney U test as appropriate. Levene\u0026apos;s test was used to assess the homogeneity of variance. Quantitative outcomes were assessed with an analysis of the covariance (ANCOVA)model. Differences among the two groups were analyzed using the Kruskal-Wallis test followed by Dunn\u0026apos;s post-hoc test with Bonferroni correction. Correlations were analyzed with Spearman\u0026apos;s rank order test. A nominal significance level of 0.05 (two-sided) was applied to all of the statistical analyses, which were carried out using SPSS (version 20.0, IBM) or Graph Pad Prism (Version 5.0, Graph Pad Software).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eReferences\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e41\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;International Study Group for Beh\u0026ccedil;et\u0026apos;s Disease. Criteria for diagnosis of Beh\u0026ccedil;et\u0026apos;s disease. \u003cem\u003eLancet\u003c/em\u003e. \u003cstrong\u003e335\u003c/strong\u003e:1078-1080(1990).\u003c/p\u003e\n\u003cp\u003e42 \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Yilmaz, S., et al.Patient-driven assessment of disease activity in Beh\u0026ccedil;et\u0026apos;s syndrome: cross-cultural adaptation, reliability and validity of the Turkish version of the Beh\u0026ccedil;et\u0026apos;s Syndrome Activity Score. \u003cem\u003eClin. Exp. Rheumatol\u003c/em\u003e.31:77-83(2013).\u003c/p\u003e\n\u003cp\u003e43 \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Bhakta, B.B. et al. Beh\u0026ccedil;et\u0026apos;s disease: evaluation of a new instrument to measure clinical activity. \u003cem\u003eRheumatology (Oxford).\u0026nbsp;\u003c/em\u003e38:728-733(1999).\u003c/p\u003e\n\u003cp\u003e44 \u0026nbsp; \u0026nbsp; Gilworth, G., Chamberlain, M.A., Bhakta, B., Haskard, D., Silman, A.\u0026amp;Tennant, A.Development of the BD-QoL: a quality oflife measure specific to Beh\u0026ccedil;et\u0026rsquo;s disease.\u003cem\u003eJ. Rheumatol\u003c/em\u003e.\u003cstrong\u003e31\u003c/strong\u003e:931-937(2014).\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThis study was supported by grants from the National Key R\u0026amp;D Program of China (2022YFE0131700 and 2022YFC3602000), National Natural Science Foundation of China (32141004,82271835,82071813, 81671602, 82171772, 81771743, 81871281, 82202003 and U1903210) and BeijingSci-Tech Program (Z191100006619110, Z191100006619114),Bethune-Puai Medical Research Fund (PAYJ-023)and Beijing Nova Program 20220484206.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eSaadoun, D., Bodaghi, B. \u0026amp;Cacoub, P. Beh\u0026ccedil;et\u0026apos;s Syndrome. \u003cem\u003eN. Engl. J.Med\u003c/em\u003e.\u003cstrong\u003e390\u003c/strong\u003e,640-651(2024).\u003c/li\u003e\n\u003cli\u003eEmmi,G. et al. 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Insight\u003c/em\u003e.\u003cstrong\u003e7\u003c/strong\u003e:e159406(2022).\u003c/li\u003e\n\u003cli\u003eClottu, AS. et al. Innate Lymphoid Cells in Autoimmune Diseases. \u003cem\u003eFront. Immunol\u003c/em\u003e. \u003cstrong\u003e12\u003c/strong\u003e:789788(2021). \u003c/li\u003e\n\u003cli\u003eGelmez, MY. et al. Inflammatory status might direct ILC and NK cells to IL-17 expressing ILC3 and NK subsets in Behcet\u0026apos;s disease. \u003cem\u003eImmunol.Lett.\u003c/em\u003e\u003cstrong\u003e235\u003c/strong\u003e:1-8( 2021).\u003c/li\u003e\n\u003cli\u003eHatemi, G. et al. Core Set of Domains for Outcome Measures in Beh\u0026ccedil;et\u0026apos;s Syndrome. \u003cem\u003eArthritis.Care.Res\u003c/em\u003e. \u003cstrong\u003e74\u003c/strong\u003e:691-699(2022).\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 to 3 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"nature-portfolio","isNatureJournal":true,"hasQc":false,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"","title":"Nature Portfolio","twitterHandle":"","acdcEnabled":false,"dfaEnabled":false,"editorialSystem":"ejp","reportingPortfolio":"","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-5416266/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5416266/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eBeh\u0026ccedil;et\u0026rsquo;s syndrome (BS), a chronic relapsing systemic vasculitis, leads to recurrent oral aphthous ulcers, severely impacting quality of life. We conducted a randomized double-blind placebo-controlled clinical trial to evaluate the efficacy and safety of Low-dose interleukin-2 (LD-IL-2) in BS patients. We randomly assigned BS patients (aged 18 to 70 years) with active oral ulcers to receive LD-IL-2 or placebo for 12 weeks (1:1 ratio). The primary endpoint was the oral ulcer count at week 12. Secondary endpoints included the changes in oral ulcer pain (100-mm VAS), overall disease activity and quality of life, genital ulcer count, and complete oral ulcer response rates, along with the change of CD4\u0026thinsp;+\u0026thinsp;T cell subsets. A total of 60 randomly assigned participants received at least one dose of LD-IL-2 or placebo and 51 completed the trial. The mean number of oral ulcers at week 12 was significantly lower in the LD-IL-2 group than in the placebo group (0.69\u0026thinsp;\u0026plusmn;\u0026thinsp;1.05 vs. 1.57\u0026thinsp;\u0026plusmn;\u0026thinsp;0.90, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.001). There were great reductions in oral ulcer pain, the Beh\u0026ccedil;et\u0026rsquo;s Syndrome Activity Score, the Behcet's Disease Current Activity Index score as well as the Beh\u0026ccedil;et\u0026rsquo;s Disease Quality of Life scale score in the LD-IL-2 group compared to the placebo group at week 12. No infections or severe adverse events were observed in either group. LD-IL-2 expanded regulatory T cells (Tregs) and decreased the ratio of effector T cell (Teff) to Tregs. LD-IL-2 therapy is an effective and safe treatment in BS patients and is associated with the modulation of Treg and Teffcells.ClinicalTrials.gov registration: NCT04065672.\u003c/p\u003e","manuscriptTitle":"Efficacy and Safety of Low-Dose Interleukin 2 for Behçet’s Syndrome: a phase 2 randomized double-blind placebo-controlled clinical trial","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-11-25 15:33:43","doi":"10.21203/rs.3.rs-5416266/v1","editorialEvents":[],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"nature-communications","isNatureJournal":true,"hasQc":false,"allowDirectSubmit":false,"externalIdentity":"NCOMMS","sideBox":"Learn more about [Nature Communications](http://www.nature.com/ncomms/)","snPcode":"","submissionUrl":"https://mts-ncomms.nature.com/","title":"Nature Communications","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"ejp","reportingPortfolio":"Nature Communications","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"47da5729-49cc-43ea-ad83-33f85f3265b3","owner":[],"postedDate":"November 25th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":40097438,"name":"Health sciences/Medical research/Clinical trial design/Clinical trials/Phase II trials"},{"id":40097439,"name":"Health sciences/Diseases/Rheumatic diseases/Vasculitis syndromes"}],"tags":[],"updatedAt":"2026-02-05T08:07:09+00:00","versionOfRecord":{"articleIdentity":"rs-5416266","link":"https://doi.org/10.1038/s41467-025-68100-w","journal":{"identity":"nature-communications","isVorOnly":false,"title":"Nature Communications"},"publishedOn":"2026-01-07 05:00:00","publishedOnDateReadable":"January 7th, 2026"},"versionCreatedAt":"2024-11-25 15:33:43","video":"","vorDoi":"10.1038/s41467-025-68100-w","vorDoiUrl":"https://doi.org/10.1038/s41467-025-68100-w","workflowStages":[]},"version":"v1","identity":"rs-5416266","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5416266","identity":"rs-5416266","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}