rs231775 — CTLA4 Thr17Ala

Missense variant in the CTLA-4 leader peptide that reduces surface expression of this immune checkpoint receptor, increasing T cell activity and autoimmune disease risk

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CTLA4 Thr17Ala — The Immune Brake Variant

CTLA-4 (Cytotoxic T-Lymphocyte Associated Protein 4) is one of the immune system's most powerful brakes. Expressed on activated T cells, it competes with CD28 to bind CD80 and CD86 on antigen- presenting cells — and when CTLA-4 wins, T cell activation is dampened. The rs231775 variant (also called +49A>G or Thr17Ala) sits in the leader peptide11 leader peptide
The signal peptide is a short N-terminal sequence that guides newly synthesised protein into the secretory pathway; it is cleaved from the mature protein of the CTLA-4 protein. This single amino acid change — threonine to alanine at position 17 — affects how efficiently CTLA-4 traffics to the T cell surface, subtly weakening the immune checkpoint and increasing susceptibility to a broad range of autoimmune conditions. With 539 published studies in the literature22 539 published studies in the literature
Ensembl VEP annotates 539 publications for rs231775, this is among the most intensively studied common autoimmune susceptibility variants.

The Mechanism

CTLA-4 is synthesized with an N-terminal signal peptide that guides it into the endoplasmic reticulum and ultimately to the cell surface. The Thr17Ala substitution changes the glycosylation profile of the leader peptide, altering the efficiency with which the protein is processed and trafficked33 processed and trafficked
ClinVar expert panel notes flow cytometry data showing Thr17Ala produces cell surface staining comparable to wild-type, while population-level studies document functional immune differences to the plasma membrane. The G allele (Ala17) is associated with reduced CTLA-4 surface density on T cells, meaning fewer inhibitory signals reach the T cell receptor complex. With less CTLA-4 at the surface, the molecular brake on T cell activation is partially released, allowing T cells to respond more vigorously — and potentially to self-antigens they should ignore.

This variant is in partial linkage disequilibrium with the CT60 variant (rs3087243) in the CTLA4 3'UTR, which has an independent effect on mRNA stability. Together, the two variants can compound to lower CTLA-4 expression through complementary mechanisms: reduced surface trafficking (rs231775) and reduced mRNA stability (rs3087243).

The Evidence

The G allele of rs231775 is one of the most replicated common autoimmune susceptibility variants in the human genome. A meta-analysis of 63 published studies44 meta-analysis of 63 published studies
Tang et al. 2012, Gene, reviewing data through December 2011 confirmed that the G allele increases type 1 diabetes susceptibility with an odds ratio of 1.47 (95% CI 1.36–1.60, P<0.001), a remarkably consistent signal that held across both Caucasian and Asian populations and all age groups.

For Graves' disease and autoimmune thyroid disease, the association is similarly robust. A meta-analysis of 42 case-control studies55 meta-analysis of 42 case-control studies
Si et al. 2013, 8,288 cases and 9,372 controls, predominantly Asian and Caucasian populations found G allele risk across multiple genetic models: additive OR = 1.44 (95% CI 1.32–1.58), dominant OR = 1.62 (95% CI 1.43–1.84), and recessive OR = 1.59 (95% CI 1.40–1.81). The association was significant and consistent across all models tested.

In systemic lupus erythematosus, an updated meta-analysis of 18 studies66 updated meta-analysis of 18 studies
Chang et al. 2012, 1,806 SLE cases and 2,490 controls found GG versus AA OR = 1.53 overall, rising to OR = 1.89 in Asian populations. A broader autoimmune meta-analysis77 broader autoimmune meta-analysis
Yu et al. 2021, 47 studies involving 11,893 cases and 12,032 controls across AS, RA, and SLE confirmed the G allele significantly elevates risk for rheumatoid arthritis in Caucasian and Mongolian populations.

Practical Implications

Carrying one or two copies of the G allele does not mean you will develop an autoimmune disease — most carriers never do. However, the G allele is a consistent signal of reduced immune checkpoint function, which means your immune system has a somewhat lower threshold for mounting inflammatory responses against self-tissues. The conditions most strongly linked to this variant are Graves' disease, Hashimoto's thyroiditis, type 1 diabetes, and systemic lupus erythematosus.

For those already diagnosed with autoimmune disease, rs231775 G allele status has a practical clinical implication: abatacept (Orencia), a biologic medication that is literally a recombinant CTLA-4 fusion protein88 recombinant CTLA-4 fusion protein
Abatacept mimics CTLA-4 by binding CD80/CD86 and blocking T cell costimulation, compensating for the reduced endogenous CTLA-4 activity used in rheumatoid arthritis and other autoimmune conditions, may work especially well for G allele carriers. A retrospective cohort of 109 RA patients found the G allele was associated with an OR of 3.48 for achieving EULAR response at 12 months and OR = 4.68 for low disease activity, suggesting that restoring what the variant reduces — CTLA-4 activity — is particularly effective treatment for those with this genotype.

Women with G allele genotypes should be aware that thyroid autoimmunity (Graves' disease, Hashimoto's) is considerably more common in women and is further elevated by this variant. Annual thyroid function testing (TSH, free T4) is a low-cost, high-yield monitoring strategy for G allele carriers with personal or family history of thyroid disease.

Interactions

The strongest documented epistatic interaction for rs231775 is with MSH5 rs3131379 in systemic lupus erythematosus. A gene-gene epistasis study of 4,248 SLE cases and 3,818 controls99 gene-gene epistasis study of 4,248 SLE cases and 3,818 controls
Hughes et al. 2012, identified gene-gene interactions across SLE susceptibility loci and documented epistasis between rs3131379 and rs231775 found the combination of rs3131379 risk allele and rs231775 G allele shows an interaction OR of 1.19 (P=7.8×10⁻⁵), the strongest pairwise epistasis signal in that dataset. This means carriers of both risk alleles face disproportionately higher SLE risk than expected from either variant alone.

Within the CTLA4 locus, the CT60 variant rs3087243 (a 3'UTR regulatory variant) interacts with rs231775 to compound autoimmune susceptibility through independent mechanisms: rs231775 reduces surface trafficking efficiency while rs3087243 reduces mRNA stability. Combined risk alleles at both positions are most common in populations with high autoimmune thyroid disease prevalence.

CTLA4 rs231775 also interacts with PTPN22 rs2476601 (the R620W variant) in determining risk for seropositive autoimmune conditions including RA and type 1 diabetes. Both variants impair the braking mechanisms that prevent T cell activation against self-antigens, and their co-occurrence increases absolute disease risk beyond what either confers individually.

Drug Interactions

abatacept dose_adjustment literature

Genotype Interpretations

What each possible genotype means for this variant.

AA Full Immune Checkpoint Function Normal

Both copies produce standard CTLA-4 surface trafficking and normal checkpoint activity

You carry two copies of the ancestral A allele (threonine at position 17), which produces normal CTLA-4 signal peptide processing and standard surface expression of this immune checkpoint receptor. Your T cells receive full inhibitory CTLA-4 signaling, meaning the molecular brake on immune activation functions as expected. This is the lower-risk genotype for autoimmune thyroid disease, type 1 diabetes, and lupus. Approximately 39% of people of European descent and 12% of East Asian populations share this genotype.

AG Reduced Checkpoint Activity Intermediate

One copy of the Ala17 variant partially reduces CTLA-4 surface density and modestly increases autoimmune risk

The G allele's effect in heterozygotes is real but modest relative to homozygotes, consistent with the additive inheritance pattern. Studies in type 1 diabetes (Tang et al. 2012, PMID 22964358) and Graves' disease (Si et al. 2013, PMID 23181132) both show significant but intermediate risk. Your immune system maintains substantial CTLA-4 function from the A allele copy, providing meaningful protection against the unchecked T cell activation that the GG genotype experiences more severely.

GG Substantially Reduced Checkpoint Activity High Risk

Two copies of the Ala17 variant significantly reduce CTLA-4 surface expression and substantially elevate autoimmune risk

GG homozygotes face the clearest clinical picture from the published literature. The Si et al. 2013 meta-analysis (PMID 23181132, 8,288 Graves' cases) found recessive model OR = 1.59 for Graves' disease in GG versus AA/AG carriers. Chang et al. 2012 (PMID 22718509, SLE meta- analysis) found GG versus AA OR = 1.53 globally and 1.89 in Asian populations. The additive nature of the variant means GG confers nearly double the per-allele risk of heterozygotes.

Of particular clinical relevance: if you develop rheumatoid arthritis, this genotype is associated with significantly better response to abatacept — a CTLA-4 fusion protein that compensates for the reduced endogenous CTLA-4 activity at the immune synapse. Retrospective data (PMID 33187286) found GG/AG G allele carriers had OR = 3.48 for achieving EULAR response and OR = 4.68 for low disease activity at 12 months on abatacept. If biologic therapy for an autoimmune condition is being considered, this genotype information is worth discussing with your rheumatologist.