Changes in ANA/ENA and Anti-dsDNA Autoantibodies During Adalimumab Therapy in Patients with Psoriasis: A Single-Centre Retrospective Study

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Comments for Manuscript “Autoantibody Development during Adalimumab Therapy in

Psoriasis: Implications for Treatment Immunogenicity and Biomarker-Based Monitoring”

 

1. The authors only provided that anti-dsDNA IgG and ANA/ENA levels increase after 12 months of Adalimumab treatment. I think this piece of data is not enough for the acceptance of this manuscript.
2. I would suggest the authors to include the data for how the disease severity change correlated with the increase of autoantibody levels. What is the level of cytokines (proinflammatory vs. anti-inflammatory cytokines).
3. Did the authors compare young female vs. old female to check if there is any difference between young males?

Author Response

1. The authors only provided that anti-dsDNA IgG and ANA/ENA levels increase after 12 months of Adalimumab treatment. I think this piece of data is not enough for the acceptance of this manuscript.

We sincerely thank the Reviewer for this valuable comment. The 12-month evaluation period was selected because it represents a clinically relevant follow-up interval commonly used in the monitoring of patients receiving biologic therapy. The primary objective of the present study was to evaluate changes in anti-dsDNA IgG and ANA/ENA autoantibodies during this predefined observation period rather than to investigate their long-term evolution.

We agree that a longer follow-up would provide valuable information regarding the persistence, progression, or possible normalization of treatment-induced autoantibody responses. However, assessment beyond 12 months was outside the scope of the current study. To address the Reviewer's concern, we have acknowledged this as a limitation of our study and have emphasized the need for future prospective studies with extended follow-up in the revised manuscript.

The corresponding changes have been incorporated into the Discussion (Lines 440-443).

2. I would suggest the authors to include the data for how the disease severity change correlated with the increase of autoantibody levels. What is the level of cytokines (proinflammatory vs. anti-inflammatory cytokines).

We sincerely thank the Reviewer for this valuable suggestion and agree that correlating disease activity and cytokine profiles with the development of autoantibodies would provide additional mechanistic insight.

However, the present study was designed as a retrospective, single-centre study based on routinely collected clinical data. In our clinical practice, serum cytokine profiling (including pro-inflammatory and anti-inflammatory cytokines) is not performed as part of standard monitoring in patients receiving adalimumab therapy. Consequently, these data were not available for retrospective analysis. Similarly, comprehensive longitudinal assessments correlating changes in disease severity with autoantibody development were not consistently available for all patients and therefore could not be reliably evaluated.

We agree that disease activity, inflammatory status, and cytokine milieu may influence the development of treatment-induced autoantibodies. Therefore, we have acknowledged the lack of these data as a limitation of our study and have highlighted the need for future prospective studies incorporating serial clinical assessments together with cytokine profiling and autoantibody monitoring to better elucidate these relationships.

The corresponding changes have been incorporated into the Discussion (Lines 443-447).

3. Did the authors compare young female vs. old female to check if there is any difference between young males?

We thank the Reviewer for this suggestion. We considered additional subgroup analyses stratified simultaneously by age and sex. However, after stratification into four subgroups, the number of patients in each subgroup became too small to provide adequately powered and reliable statistical estimates. We therefore decided not to include these exploratory analyses to avoid overinterpretation of the findings. This limitation is acknowledged in the Limitations section, where we state that the limited sample size may have reduced the statistical power of subgroup analyses (Lines 158-229; 234-235; 245-276).

 

Reviewer 2 Report

Comments and Suggestions for Authors

This study examined changes in ANA and ENA positivity and anti-dsDNA IgG levels in patients with psoriasis after 12 months of adalimumab treatment. It includes analyses according to sex and age and an exploratory assessment of subsequent biologic switching. The manuscript is well structured and clearly written, and findings provide potentially useful information regarding autoantibody development during TNF-α blockade. The authors should explain an apparent paradox in the results though. TNF-α blockade has been associated with reduced IgG levels and impaired affinity maturation (DOI 10.1172/JCI192589), impaired induction and maintenance of antigen-specific B-cell responses (DOI 10.1136/rmdopen-2025-005724), reduced short- and long-term IgG responses with effects on memory B-cell and plasma-cell output (DOI 10.1111/all.16241), and reduced long-term antibody responses and fewer antigen-specific B cells (DOI 10.3390/vaccines10081186). Mechanistic evidence further indicates that reduced B-cell-derived TNF disrupts dendritic cell networks and germinal-centre responses (DOI 10.1172/JCI146776). In addition, TNF-α blockade has also been shown to reduce dendritic-cell and T-cell responses that would strengthen B cell humoral responses (DOI 10.1016/j.mucimm.2025.04.006). The authors should therefore clarify how adalimumab could be associated with increased autoantibody levels despite evidence that TNF-α blockade generally weakens antibody responses, and whether the present findings may instead reflect selective loss of B-cell tolerance, altered autoreactive clone selection or regulatory B-cell dysfunction instead of a general increase in antibody production.

Author Response

1. This study examined changes in ANA and ENA positivity and anti-dsDNA IgG levels in patients with psoriasis after 12 months of adalimumab treatment. It includes analyses according to sex and age and an exploratory assessment of subsequent biologic switching. The manuscript is well structured and clearly written, and findings provide potentially useful information regarding autoantibody development during TNF-α blockade. The authors should explain an apparent paradox in the results though. TNF-α blockade has been associated with reduced IgG levels and impaired affinity maturation (DOI 10.1172/JCI192589), impaired induction and maintenance of antigen-specific B-cell responses (DOI 10.1136/rmdopen-2025-005724), reduced short- and long-term IgG responses with effects on memory B-cell and plasma-cell output (DOI 10.1111/all.16241), and reduced long-term antibody responses and fewer antigen-specific B cells (DOI 10.3390/vaccines10081186). Mechanistic evidence further indicates that reduced B-cell-derived TNF disrupts dendritic cell networks and germinal-centre responses (DOI 10.1172/JCI146776). In addition, TNF-α blockade has also been shown to reduce dendritic-cell and T-cell responses that would strengthen B cell humoral responses (DOI 10.1016/j.mucimm.2025.04.006). The authors should therefore clarify how adalimumab could be associated with increased autoantibody levels despite evidence that TNF-α blockade generally weakens antibody responses, and whether the present findings may instead reflect selective loss of B-cell tolerance, altered autoreactive clone selection or regulatory B-cell dysfunction instead of a general increase in antibody production  

 

Response:

We sincerely thank the Reviewer for this insightful comment and agree that the apparent paradox between impaired protective humoral immunity and increased autoantibody production required further clarification. Accordingly, we have expanded the Discussion to better distinguish between antigen-specific protective immune responses and treatment-associated autoantibody development and to discuss the potential role of immune dysregulation rather than generalized antibody production.

We did not include the study by Bonilha et al. (DOI: 10.1016/j.mucimm.2025.04.006) because it investigates the immunological effects of PAD4 inhibition rather than TNF-α blockade. As the underlying therapeutic target and immunological mechanisms differ from those investigated in our study, we considered this reference to be outside the scope of the present discussion.

The corresponding changes have been incorporated into the Discussion (Lines 303-317).

Reviewer 3 Report

Comments and Suggestions for Authors

This manuscript evaluates the development of ANA/ENA and anti-dsDNA antibodies in patients with psoriasis treated with adalimumab for 12 months. The topic is clinically relevant because immunogenicity remains an important challenge during long-term biologic therapy, and biomarkers capable of identifying patients at risk of secondary loss of response would be valuable.

The manuscript is generally well written, and the results are clearly presented. However, the study has important methodological limitations that substantially restrict the conclusions that can be drawn.

Major comments

1. The novelty and clinical implications are overstated.

Although the study documents the development of ANA and anti-dsDNA antibodies during adalimumab treatment, this phenomenon has been repeatedly described in previous literature. The principal contribution of the present study is therefore confirmatory rather than novel. The title, abstract and Discussion should better reflect the descriptive nature of the findings and avoid suggesting that the study establishes clinically actionable biomarkers for immunogenicity or treatment monitoring.

2. The manuscript equates autoantibody development with immunogenicity

This is the major limitation of the study. Throughout the manuscript, ANA and anti-dsDNA are interpreted as biomarkers of treatment immunogenicity. However, immunogenicity is generally defined by the development of anti-drug antibodies (ADA), often together with reduced drug concentrations. Neither ADA nor adalimumab trough levels were measured in this study. Therefore, statements suggesting that ANA or anti-dsDNA reflect immunogenicity are speculative and should be rewritten accordingly. The Discussion should clearly distinguish between treatment-induced autoantibody production, true anti-drug immunogenicity, and clinical loss of response. The title, abstract and conclusions should also be modified to avoid implying that immunogenicity has been demonstrated.

3. Laboratory methodology requires substantially more detail

The Methods section lacks essential laboratory information. The authors should specify: ANA detection method (IIF or immunoassay); HEp-2 cells or other substrate, positivity threshold, ANA titers, ANA patterns, ENA panel composition, anti-dsDNA assay (ELISA, CLIA, Farr, Crithidia, etc.), assay manufacturer, and intra/inter-assay variability if available. Without these details, reproducibility is limited.

4. Clinical characterization of the cohort is insufficient

Very little information is provided regarding patient population. Important variables include:

• psoriasis duration;
• disease severity (PASI/BSA);
• psoriatic arthritis prevalence;
• previous biologic exposure;
• methotrexate use;
• concomitant immunosuppressants;
• corticosteroids;
• comorbid autoimmune diseases.

These factors may influence both immunogenicity and autoantibody production.

5. Statistical analysis could be strengthened

The analysis is almost exclusively descriptive. The authors should consider reporting confidence intervals, presenting effect sizes rather than only p-values, analyzing predictors of ANA seroconversion using logistic regression, analyzing predictors of anti-dsDNA increase, and/or adjusting for age and sex. Given the small sample size, at least exploratory multivariable analyses would strengthen the manuscript.

6. Clinical relevance remains uncertain

The study demonstrates laboratory changes but provides little evidence regarding their clinical significance. Treatment switching is analyzed, but reasons for discontinuation are not reported, disease activity is unavailable, loss of efficacy is not objectively defined, and autoimmune manifestations were not systematically assessed. Consequently, the conclusions regarding biomarker-based monitoring should be considerably moderated.

7. Interpretation of age subgroup analyses

The authors report significant increases only in patients ≥45 years while simultaneously stating that younger patients more frequently developed elevated anti-dsDNA levels. This section is confusing. The manuscript should clarify whether these observations reflect differences in baseline variability, different definitions (continuous vs dichotomous outcome), or insufficient statistical power.

Minor comments

1. The title overstates the findings by referring to "treatment immunogenicity". Since ADA were not measured, a more neutral title would be preferable.
2. The abstract should acknowledge the absence of direct immunogenicity measurements among the study limitations.
3. The exact statistical tests used for each comparison should be explicitly reported.
4. Normality testing should be described.
5. Means ± SD may not adequately describe anti-dsDNA levels given their apparent skewed distribution. Median (IQR) may be more appropriate.
6. Figure 1 would be more informative as boxplots or violin plots rather than overlapping distributions.
7. Table 1 should include confidence intervals and sample sizes for each comparison.
8. Table 2 would benefit from reporting p-values for within-group changes.
9. The Discussion contains some repetition regarding mechanisms of TNF inhibitor-induced autoimmunity and could be shortened.
10. Several speculative statements linking ANA development with ADA formation should be clearly identified as hypotheses rather than established facts.

Author Response

Major comments

1. The novelty and clinical implications are overstated.

Although the study documents the development of ANA and anti-dsDNA antibodies during adalimumab treatment, this phenomenon has been repeatedly described in previous literature. The principal contribution of the present study is therefore confirmatory rather than novel. The title, abstract and Discussion should better reflect the descriptive nature of the findings and avoid suggesting that the study establishes clinically actionable biomarkers for immunogenicity or treatment monitoring.

Response:

We thank the Reviewer for this thoughtful comment and agree that our findings should be presented as confirmatory rather than implying novelty or immediate clinical applicability. Accordingly, we have revised the Abstract, Discussion, and Conclusions to better reflect the descriptive nature of the study. Statements suggesting that ANA and anti-dsDNA antibodies represent clinically actionable biomarkers for treatment monitoring or biologic immunogenicity have been removed or revised. We now emphasize that our findings confirm previously reported treatment-associated autoantibody development during adalimumab therapy, while the clinical significance of these serological changes remains uncertain.

The corresponding changes have been incorporated into the Title (if applicable), Abstract, Discussion, and Conclusions (Lines  1-4 (title); 13-14; 26-34).

2. The manuscript equates autoantibody development with immunogenicity

This is the major limitation of the study. Throughout the manuscript, ANA and anti-dsDNA are interpreted as biomarkers of treatment immunogenicity. However, immunogenicity is generally defined by the development of anti-drug antibodies (ADA), often together with reduced drug concentrations. Neither ADA nor adalimumab trough levels were measured in this study. Therefore, statements suggesting that ANA or anti-dsDNA reflect immunogenicity are speculative and should be rewritten accordingly. The Discussion should clearly distinguish between treatment-induced autoantibody production, true anti-drug immunogenicity, and clinical loss of response. The title, abstract and conclusions should also be modified to avoid implying that immunogenicity has been demonstrated.

Response:

We thank the Reviewer for this important comment and agree that treatment-induced autoantibody development and biologic immunogenicity should be clearly distinguished. Accordingly, we have revised the Title, Abstract, Discussion, Conclusions, and Limitations to avoid implying that immunogenicity was demonstrated in the present study. Throughout the manuscript, statements suggesting that ANA or anti-dsDNA represent biomarkers or surrogate markers of biologic immunogenicity have been removed or revised. We now emphasize that our findings describe treatment-associated autoantibody development, whereas biologic immunogenicity is defined by anti-drug antibody formation and/or reduced drug concentrations, neither of which was assessed in our study. Consequently, no conclusions regarding biologic immunogenicity or its relationship with clinical loss of response are drawn from our data.

The corresponding changes have been incorporated into the Title, Abstract, Discussion, Conclusions, and Limitations (Lines 1-4 (title); 12-34;  325-327; 347-349; 372-376; 401-405; 421-423; 426-430; 453-468.

3. Laboratory methodology requires substantially more detail

The Methods section lacks essential laboratory information. The authors should specify: ANA detection method (IIF or immunoassay); HEp-2 cells or other substrate, positivity threshold, ANA titers, ANA patterns, ENA panel composition, anti-dsDNA assay (ELISA, CLIA, Farr, Crithidia, etc.), assay manufacturer, and intra/inter-assay variability if available. Without these details, reproducibility is limited.

Response:

ANA/ENA results were reported by the accredited clinical laboratory as qualitative (positive/negative) findings rather than ANA titres. Therefore, ANA titres and fluorescence patterns were not available for retrospective analysis and could not be included. We have clarified this limitation in the Methods section. In addition, information on intra-assay and inter-assay variability was not available because all analyses were performed as part of routine clinical diagnostics rather than within a prospective research protocol.

The corresponding changes have been incorporated into the Methods (Lines 112-127).

4. Clinical characterization of the cohort is insufficient

Very little information is provided regarding patient population. Important variables include:

• psoriasis duration;
• disease severity (PASI/BSA);
• psoriatic arthritis prevalence;
• previous biologic exposure;
• methotrexate use;
• concomitant immunosuppressants;
• corticosteroids;
• comorbid autoimmune diseases.

These factors may influence both immunogenicity and autoantibody production.

Response:

We thank the Reviewer for this valuable comment and agree that a more comprehensive description of the study population improves the interpretation of our findings. Accordingly, we have expanded the Results section by including additional baseline clinical characteristics, including age, sex, PASI, BSA, the prevalence of psoriatic arthritis, and concomitant autoimmune diseases. We have also clarified that none of the patients received concomitant systemic corticosteroid therapy during adalimumab treatment.

Data regarding psoriasis duration, previous biologic exposure, methotrexate use, and concomitant immunosuppressive therapy were not consistently available because of the retrospective study design and therefore could not be reliably analysed.

The corresponding changes have been incorporated into the Results (Lines 149-157).

5. Statistical analysis could be strengthened

The analysis is almost exclusively descriptive. The authors should consider reporting confidence intervals, presenting effect sizes rather than only p-values, analyzing predictors of ANA seroconversion using logistic regression, analyzing predictors of anti-dsDNA increase, and/or adjusting for age and sex. Given the small sample size, at least exploratory multivariable analyses would strengthen the manuscript.

Response:

We thank the Reviewer for this valuable comment. In response, we have revised and expanded the Statistical Analysis section to provide a more comprehensive description of the analytical approach. Following these methodological refinements, the statistical analyses were updated accordingly, and the Results section was revised to reflect the additional analyses and statistical reporting. These revisions strengthen the statistical evaluation of the data while remaining appropriate for the retrospective design and sample size of the study.

The corresponding changes have been incorporated into the Methods and Results sections (Lines 129-145).

6. Clinical relevance remains uncertain

Response:

The study demonstrates laboratory changes but provides little evidence regarding their clinical significance. Treatment switching is analyzed, but reasons for discontinuation are not reported, disease activity is unavailable, loss of efficacy is not objectively defined, and autoimmune manifestations were not systematically assessed. Consequently, the conclusions regarding biomarker-based monitoring should be considerably moderated.

We thank the Reviewer for this important comment. In response, we have expanded the clinical information presented in the manuscript. Additional baseline clinical characteristics have been included in Section 3.1, and Section 3.10 has been substantially revised to provide a more detailed description of biologic treatment switching, including the documented reasons for treatment modification. (Lines 155-165; 281-294)

As this was a retrospective study based on data extracted from routine medical records, standardized longitudinal clinical data were not available for all patients. Consequently, PASI and BSA scores at 12 months could not be evaluated consistently and were therefore not included in the analyses. Similarly, assessment of autoimmune manifestations was limited to information documented during routine clinical care.

The Discussion and Conclusions have also been revised to present a more cautious interpretation of the clinical relevance of the observed laboratory findings (Lines 278-292)

 

7. Interpretation of age subgroup analyses

The authors report significant increases only in patients ≥45 years while simultaneously stating that younger patients more frequently developed elevated anti-dsDNA levels. This section is confusing. The manuscript should clarify whether these observations reflect differences in baseline variability, different definitions (continuous vs dichotomous outcome), or insufficient statistical power.

Response:

We thank the Reviewer for this helpful comment. To improve clarity, the manuscript has been revised to better explain the age-related findings and to distinguish between the different outcome measures used in the analyses. Corresponding clarifications have been incorporated into both the Results and Discussion sections. In addition, a statement has been added to the Limitations section acknowledging that subgroup analyses should be interpreted with caution because the relatively small sample size may have limited the statistical power to detect age-related differences.

The corresponding changes have been incorporated into the Results, Discussion, and Limitations sections (Lines 182-186; 189-193; 196-204; 433-436).

Minor comments

• The title overstates the findings by referring to "treatment immunogenicity". Since ADA were not measured, a more neutral title would be preferable.
• The abstract should acknowledge the absence of direct immunogenicity measurements among the study limitations.
• The exact statistical tests used for each comparison should be explicitly reported.
• Normality testing should be described.
• Means ± SD may not adequately describe anti-dsDNA levels given their apparent skewed distribution. Median (IQR) may be more appropriate.
• Figure 1 would be more informative as boxplots or violin plots rather than overlapping distributions.
• Table 1 should include confidence intervals and sample sizes for each comparison.
• Table 2 would benefit from reporting p-values for within-group changes.
• The Discussion contains some repetition regarding mechanisms of TNF inhibitor-induced autoimmunity and could be shortened.
• Several speculative statements linking ANA development with ADA formation should be clearly identified as hypotheses rather than established facts.

We thank the Reviewer for these constructive comments. The manuscript has been comprehensively revised in response to these suggestions. The title and Abstract have been modified to more accurately reflect the scope of the study and to acknowledge the absence of direct measurements of biologic immunogenicity. The Methods section has been expanded to provide a detailed description of the statistical analyses, including assessment of data distribution and the statistical tests applied.

The Results section has been substantially revised to present descriptive statistics appropriate for the data distribution, additional statistical analyses, effect estimates, confidence intervals where applicable, and revised tables and figures. Figure 1 has been replaced with boxplots to better illustrate the distribution of anti-dsDNA levels. The Discussion has been shortened, repetitive sections have been removed, and speculative statements have been revised to clearly distinguish hypotheses from evidence supported by the present study.

The corresponding changes have been incorporated throughout the Results section (Lines 158-229), the Methods section (Lines 98-145), the Discussion (Lines 293-451), as well as in the Title (1-4) and Abstract (12-34).

Round 2

Reviewer 2 Report

Comments and Suggestions for Authors

The authors have succesfully addressed my concerns.

Author Response

The authors have succesfully addressed my concerns.

Response:
We want to thank you for your positive evaluation and for your constructive comments, which have helped improve the manuscript.

Reviewer 3 Report

Comments and Suggestions for Authors

I would like to thank the authors for the comprehensive revision of the manuscript and for carefully addressing the concerns raised during the first review round. Overall, I consider that the major conceptual issues have been adequately addressed. However, some minor points should be clarified before the manuscript can be considered for publication.

Major comments

1. Clarification of the relationship between autoantibodies and immunogenicity

The authors have appropriately revised the manuscript to avoid presenting ANA and anti-dsDNA antibodies as direct markers of biologic immunogenicity. The revised title and abstract now better reflect the descriptive nature of the study and acknowledge that anti-drug antibodies were not assessed. However, a final careful revision of the Discussion is recommended to ensure that no statements could still be interpreted as suggesting that ANA/anti-dsDNA positivity represents a surrogate marker of anti-drug antibody formation or biologic immunogenicity. The manuscript should consistently distinguish between treatment-associated autoantibody development, anti-drug antibody formation, and pharmacokinetic changes and loss of response. The present study provides information regarding serological changes during adalimumab therapy but cannot establish immunogenicity-related mechanisms.

2. Missing treatment-related clinical variables

The authors have improved the clinical characterization of the cohort by adding relevant information, including psoriatic arthritis prevalence, PASI, BSA, concomitant autoimmune diseases, and corticosteroid exposure. However, information regarding previous biologic exposure, methotrexate use, and concomitant immunosuppressive therapies was not available. Given that these factors may influence both autoantibody development and treatment persistence, their absence should be explicitly acknowledged in the Limitations section rather than only mentioned because of retrospective data collection.

3. Interpretation of exploratory regression analyses

The additional statistical analyses improve the manuscript. The authors have appropriately described the analyses as exploratory. Nevertheless, given the relatively small sample size, these regression models should be interpreted cautiously. The results should be considered hypothesis-generating rather than demonstrating independent predictors of autoantibody development. Please ensure that the wording throughout the Results and Discussion reflects this limitation.

Minor comments

1. Reporting of anti-dsDNA values

The authors have appropriately changed the main analyses to median and interquartile range due to the non-normal distribution of anti-dsDNA levels. For consistency, consider reporting median (IQR) values rather than mean ± SD in the Abstract as well, since the distribution of these measurements is clearly skewed.

2. Tables and denominators

Please ensure that all variables with incomplete availability clearly indicate the corresponding denominator (for example, PASI and BSA data available only for a subset of patients).

3. Figure presentation

The replacement of the original distribution plot with boxplots is appropriate given the skewed distribution of anti-dsDNA values. Please ensure that the figure clearly indicates sample size and units.

4. Final wording of conclusions

The conclusions are substantially improved and now appropriately emphasize uncertainty regarding the clinical significance of autoantibody changes. The authors should maintain this cautious interpretation throughout the final manuscript.

 

Author Response

Major comments:

Comment:

1. Clarification of the relationship between autoantibodies and immunogenicity

The authors have appropriately revised the manuscript to avoid presenting ANA and anti-dsDNA antibodies as direct markers of biologic immunogenicity. The revised title and abstract now better reflect the descriptive nature of the study and acknowledge that anti-drug antibodies were not assessed. However, a final careful revision of the Discussion is recommended to ensure that no statements could still be interpreted as suggesting that ANA/anti-dsDNA positivity represents a surrogate marker of anti-drug antibody formation or biologic immunogenicity. The manuscript should consistently distinguish between treatment-associated autoantibody development, anti-drug antibody formation, and pharmacokinetic changes and loss of response. The present study provides information regarding serological changes during adalimumab therapy but cannot establish immunogenicity-related mechanisms.

Response:

Thank you for your careful review and constructive comments. The Discussion has been revised to ensure consistent terminology throughout the manuscript. We have carefully avoided any wording that could imply that ANA or anti-dsDNA antibodies are surrogate markers of anti-drug antibody formation or biologic immunogenicity. The revised text consistently distinguishes treatment-associated autoantibody development from anti-drug antibody formation, pharmacokinetic changes, and loss of therapeutic response. We also emphasize that, because anti-drug antibodies were not assessed, the present study is limited to describing serological changes observed during adalimumab therapy and cannot establish immunogenicity-related mechanisms. (Line 441-445, 499-501, 521-525)

Comment:

2. Missing treatment-related clinical variables

The authors have improved the clinical characterization of the cohort by adding relevant information, including psoriatic arthritis prevalence, PASI, BSA, concomitant autoimmune diseases, and corticosteroid exposure. However, information regarding previous biologic exposure, methotrexate use, and concomitant immunosuppressive therapies was not available. Given that these factors may influence both autoantibody development and treatment persistence, their absence should be explicitly acknowledged in the Limitations section rather than only mentioned because of retrospective data collection.

Response:

Thank you for this valuable comment. We have revised the Limitations section to explicitly acknowledge the absence of complete treatment-related clinical variables. We now clarify that detailed information regarding previous biologic therapies administered as part of earlier clinical trials was not consistently available and, therefore, their potential influence on treatment-associated autoantibody development could not be evaluated. We also specify that other concomitant immunosuppressive therapies, including systemic corticosteroids, were not used during the therapy. Although methotrexate use before and during adalimumab therapy was assessed, the number of patients receiving concomitant methotrexate was too small to allow meaningful conclusions. These limitations and their potential impact on the interpretation of treatment persistence and autoantibody development are now explicitly discussed. (Line 488-494, 164-170)

Comment:

3. Interpretation of exploratory regression analyses

The additional statistical analyses improve the manuscript. The authors have appropriately described the analyses as exploratory. Nevertheless, given the relatively small sample size, these regression models should be interpreted cautiously. The results should be considered hypothesis-generating rather than demonstrating independent predictors of autoantibody development. Please ensure that the wording throughout the Results and Discussion reflects this limitation.

Response:

Thank you for this important comment. We have carefully revised the wording throughout the Results and Discussion to emphasize the exploratory nature of the regression analyses. We now explicitly state that, given the relatively small sample size, these findings should be interpreted with caution and considered hypothesis-generating rather than evidence of independent predictors of autoantibody development. (Line 237-239, 271-272, 485-488)

 

Minor comments

Comment:

1. Reporting of anti-dsDNA values

The authors have appropriately changed the main analyses to median and interquartile range due to the non-normal distribution of anti-dsDNA levels. For consistency, consider reporting median (IQR) values rather than mean ± SD in the Abstract as well, since the distribution of these measurements is clearly skewed.

Response:

Thank you for this helpful suggestion. For consistency with the statistical analyses presented in the manuscript, the anti-dsDNA values in the Abstract have been revised to report the median and interquartile range (IQR) instead of the mean ± standard deviation. (Line 24-25)

Comment:

2. Tables and denominators

Please ensure that all variables with incomplete availability clearly indicate the corresponding denominator (for example, PASI and BSA data available only for a subset of patients).

Response:

Thank you for this helpful comment. A footnote has been added to the table to indicate that PASI and BSA data were available for 56 patients, thereby clarifying the denominator for variables with incomplete data availability. (Line 180-181)

Comment:

3. Figure presentation

The replacement of the original distribution plot with boxplots is appropriate given the skewed distribution of anti-dsDNA values. Please ensure that the figure clearly indicates sample size and units.

Response:

Thank you for this helpful comment. The figure has been revised to indicate the sample size (n = 71), thereby improving the clarity of the figure presentation.

Comment:

4. Final wording of conclusions

The conclusions are substantially improved and now appropriately emphasize uncertainty regarding the clinical significance of autoantibody changes. The authors should maintain this cautious interpretation throughout the final manuscript.

Response:

Thank you for this positive assessment. We have carefully reviewed the manuscript to ensure that the conclusions and the discussion consistently maintain a cautious interpretation of the findings and appropriately acknowledge the uncertainty regarding the clinical significance of treatment-associated autoantibody changes. (Line 499-501, 521-525, 532-536)