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Nurtured by metabolically highly active macrophages and synovial cells (55) lactate-depending CD4 + T cells will be functionally biased toward IL-17 production, mediated by nuclear PKM2/STAT3 and enhanced fatty acid synthesis (56)

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They advocate for a treatment approach that is: • Symptom-led : Recognising that many patients become symptomatic well before their next scheduled dose, meaning they are being under-treated