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Albach FN, Geier C, Keicher C, Posch MG, Schreiber SJ, Grütz G, Akyüz L, Luo X, Le-Halpere A, Truffinet P, Wagner F. Phase 1 Trials of Gatralimab, a Next-Generation Humanized Anti-CD52 Monoclonal Antibody, in Participants with Progressive Multiple Sclerosis. Neurol Ther 2024:10.1007/s40120-024-00659-w. [PMID: 39251561 DOI: 10.1007/s40120-024-00659-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2024] [Accepted: 08/22/2024] [Indexed: 09/11/2024] Open
Abstract
INTRODUCTION Lymphocyte depletion via anti-CD52 monoclonal antibody (mAb) therapy is an effective treatment strategy for relapsing-remitting multiple sclerosis (MS) but is associated with infusion/injection-associated reactions (IARs) and autoimmune-related adverse events (AEs). Gatralimab is a next-generation humanized anti-CD52 mAb. METHODS Two first-in-human trials were conducted in participants with progressive MS to assess the pharmacodynamics, pharmacokinetics, and safety of gatralimab administered via subcutaneous (SC) and intravenous (IV) routes, and to determine the effect of different comedication regimes on IARs to SC gatralimab. A Phase 1 trial (NCT02282826) included double-blind, placebo-controlled sequential ascending single IV (1, 3.5, and 12 mg) and SC (12, 36, and 60 mg) dose groups. A Phase 1b trial (NCT02977533) involved five groups who received SC gatralimab (36, 48, or 60 mg) and different comedications. A long-term safety (LTS) study (NCT02313285) examined safety and pharmacodynamics over 4 years. RESULTS Gatralimab produced depletion of lymphocytes (dose-dependently) and CD4+ regulatory T cells, with partial repopulation to normal values by approximately 12 months. Peak serum gatralimab concentrations followed dose-proportionality and were delayed by 6.0-7.5 days following SC administration. Treatment-emergent AEs, including IARs, were reported for most participants but were generally of mild or moderate severity, and treatment-emergent serious AEs were mostly MS-related. Methylprednisolone and antihistamine comedications were associated with reduced incidence of fevers and skin and subcutaneous tissue AEs, respectively. During the LTS study, one participant (3.0%) experienced an autoimmune-related AE (Basedow's disease), and subsequently died from pulmonary sepsis deemed unrelated to gatralimab by the investigator. CONCLUSIONS These data show that gatralimab achieves the desired pharmacodynamic effect of lymphocyte depletion followed by repopulation, and has an acceptable safety profile, including low risk of non-MS autoimmunity. Although gatralimab is no longer in development for MS, insights from these trials may inform the development of comedication regimes of future anti-CD52 mAbs and subcutaneous formulations of other lymphocyte-depleting mAbs. TRIAL REGISTRATION NCT02282826, NCT02977533, NCT02313285.
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Affiliation(s)
| | | | | | | | | | - Gerald Grütz
- BIH Centre for Regenerative Therapies (BCRT), Immunocheck-Biomarker Unit, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Levent Akyüz
- BIH Centre for Regenerative Therapies (BCRT), Immunocheck-Biomarker Unit, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | | | | | | | - Frank Wagner
- Charité Research Organisation GmbH, Berlin, Germany
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Liang Y, Ozdogan E, Hansen MJ, Tang H, Saadiq I, Jordan KL, Krier JD, Gandhi DB, Grande JP, Lerman LO, Taner T. Human liver derived mesenchymal stromal cells ameliorate murine ischemia-induced inflammation through macrophage polarization. Front Immunol 2024; 15:1448092. [PMID: 39104523 PMCID: PMC11298378 DOI: 10.3389/fimmu.2024.1448092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2024] [Accepted: 07/04/2024] [Indexed: 08/07/2024] Open
Abstract
Introduction The immunomodulatory properties of mesenchymal stromal cells (MSC) have been well-characterized in in-vitro and in-vivo models. We have previously shown that liver MSC (L-MSC) are superior inhibitors of T-cell activation/proliferation, NK cell cytolytic function, and macrophage activation compared to adipose (A-MSC) and bone marrow MSC (BM-MSC) in-vitro. Method To test these observations in-vivo, we infused these types of MSC into mice with unilateral renal artery stenosis (RAS), an established model of kidney inflammation. Unilateral RAS was induced via laparotomy in 11-week-old, male 129-S1 mice under general anesthesia. Control mice had sham operations. Human L-MSC, AMSC, and BM-MSC (5x105 cells each) or PBS vehicle were injected intra-arterially 2 weeks after surgery. Kidney morphology was studied 2 weeks after infusion using micro-MRI imaging. Renal inflammation, apoptosis, fibrosis, and MSC retention were studied ex-vivo utilizing western blot, immunofluorescence, and immunohistological analyses. Results The stenotic kidney volume was smaller in all RAS mice, confirming significant injury, and was improved by infusion of all MSC types. All MSC-infused groups had lower levels of plasma renin and proteinuria compared to untreated RAS. Serum creatinine improved in micetreated with BM- and L-MSC. All types of MSC located to and were retained within the stenotic kidneys, but L-MSC retention was significantly higher than A- and BM-MSC. While all groups of MSC-treated mice displayed reduced overall inflammation and macrophage counts, L-MSC showed superior potency in-vivo at localizing to the site of inflammation and inducing M2 (reparative) macrophage polarization to reduce inflammatory changes. Discussion These in-vivo findings extend our in-vitro studies and suggest that L-MSC possess unique anti-inflammatory properties that may play a role in liver-induced tolerance and lend further support to their use as therapeutic agents for diseases with underlying inflammatory pathophysiology.
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Affiliation(s)
- Yun Liang
- Department of Surgery, Mayo Clinic, Rochester, MN, United States
| | - Elif Ozdogan
- Boston Children’s Hospital, Harvard Medical School, Boston, MA, United States
| | | | - Hui Tang
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, United States
| | - Ishran Saadiq
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, United States
| | - Kyra L. Jordan
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, United States
| | - James D. Krier
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, United States
| | - Deep B. Gandhi
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, United States
| | - Joseph P. Grande
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States
| | - Lilach O. Lerman
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, United States
| | - Timucin Taner
- Department of Surgery, Mayo Clinic, Rochester, MN, United States
- Department of Immunology, Mayo Clinic, Rochester, MN, United States
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Guan Y, Li F, Li N, Yang P. Decoding Behcet's Uveitis: an In-depth review of pathogenesis and therapeutic advances. J Neuroinflammation 2024; 21:133. [PMID: 38778397 PMCID: PMC11112928 DOI: 10.1186/s12974-024-03123-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Accepted: 05/04/2024] [Indexed: 05/25/2024] Open
Abstract
Behcet's disease (BD) is a rare but globally distributed vasculitis that primarily affects populations in the Mediterranean and Asian regions. Behcet's uveitis (BU) is a common manifestation of BD, occurring in over two-thirds of the patients. BU is characterized by bilateral, chronic, recurrent, non-granulomatous uveitis in association with complications such as retinal ischemia and atrophy, optic atrophy, macular ischemia, macular edema, and further neovascular complications (vitreous hemorrhage, neovascular glaucoma). Although the etiology and pathogenesis of BU remain unclear, numerous studies reveal that genetic factors (such as HLA-B51), dysregulated immune responses of both the innate and adaptive immune systems, infections (such as streptococcus), and environmental factors (such as GDP) are all involved in its development. Innate immunity, including hyperactivity of neutrophils and γδT cells and elevated NK1/NK2 ratios, has been shown to play an essential role in this disease. Adaptive immune system disturbance, including homeostatic perturbations, Th1, Th17 overaction, and Treg cell dysfunction, is thought to be involved in BU pathogenesis. Treatment of BU requires a tailored approach based on the location, severity of inflammation, and systemic manifestations. The therapy aims to achieve rapid inflammation suppression, preservation of vision, and prevention of recurrence. Systemic corticosteroids combined with other immunosuppressive agents have been widely used to treat BU, and beneficial effects are observed in most patients. Recently, biologics have been shown to be effective in treating refractory BU cases. Novel therapeutic targets for treating BU include the LCK gene, Th17/Treg balance, JAK pathway inhibition, and cytokines such as IL-17 and RORγt. This article summarizes the recent studies on BU, especially in terms of pathogenesis, diagnostic criteria and classification, auxiliary examination, and treatment options. A better understanding of the significance of microbiome composition, genetic basis, and persistent immune mechanisms, as well as advancements in identifying new biomarkers and implementing objective quantitative detection of BU, may greatly contribute to improving the adequate management of BU patients.
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Affiliation(s)
- Yuxuan Guan
- Department of Ophthalmology, Henan International Joint Research Laboratory for Ocular Immunology and Retinal Injury Repair, The First Affiliated Hospital of Zhengzhou University, Henan Province Eye Hospital, Zhengzhou, 450052, People's Republic of China
- The Academy of Medical Sciences, Zhengzhou University, Zhengzhou, 450052, People's Republic of China
| | - Fuzhen Li
- Department of Ophthalmology, Henan International Joint Research Laboratory for Ocular Immunology and Retinal Injury Repair, The First Affiliated Hospital of Zhengzhou University, Henan Province Eye Hospital, Zhengzhou, 450052, People's Republic of China
| | - Na Li
- Department of Ophthalmology, Henan International Joint Research Laboratory for Ocular Immunology and Retinal Injury Repair, The First Affiliated Hospital of Zhengzhou University, Henan Province Eye Hospital, Zhengzhou, 450052, People's Republic of China
| | - Peizeng Yang
- Department of Ophthalmology, Henan International Joint Research Laboratory for Ocular Immunology and Retinal Injury Repair, The First Affiliated Hospital of Zhengzhou University, Henan Province Eye Hospital, Zhengzhou, 450052, People's Republic of China.
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Engen RM, Bartosh SM. Long-term outcomes of two-dose alemtuzumab induction in pediatric kidney transplantation. Pediatr Transplant 2024; 28:e14753. [PMID: 38623881 DOI: 10.1111/petr.14753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Revised: 03/15/2024] [Accepted: 03/26/2024] [Indexed: 04/17/2024]
Abstract
BACKGROUND Alemtuzumab is a lymphocyte depleting agent used for induction in kidney transplant, but long-term information on its use in pediatric recipients remains sparse. METHODS We performed a single-center retrospective cohort study of 57 pediatric kidney transplant recipients receiving alemtuzumab 20 mg/m2/dose ×2 doses for induction immunosuppression. All patients underwent surveillance biopsies, and 91.3% underwent steroid withdrawal by day 4 post-transplant. Outcomes of interest included graft survival, development of donor specific antibodies (DSA), incidence of viremia and PTLD, and duration of lymphopenia. RESULTS Median follow-up time was 7.9 years (IQR 5-13.6 years). Median graft survival was 16.5 years (95% CI 11.6-unknown). DSA developed in 36.5% at a median of 944 days (IQR 252-2113 days). Incidences of BK polyomavirus DNAemia (BKPyV-DNAemia), CMV DNAemia, and EBV DNAemia were 38.6%, 22.8%, and 14%, respectively; one patient developed PTLD at 13.3 years post-transplant. Median duration of lymphopenia was 365 days (IQR 168-713 days); 19.3% of patients remained lymphopenic at 3 years post-transplant. There was no association between duration of lymphopenia and graft survival, rejection, DSA detection, or viremia. CONCLUSIONS A two-dose alemtuzumab induction protocol can have excellent outcomes with a steroid-free maintenance immunosuppression regimen. More comprehensive, multicenter, comparative studies of pediatric kidney transplant are needed to improve long-term outcomes.
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Affiliation(s)
- Rachel M Engen
- Department of Pediatrics, University of Wisconsin Madison, Madison, Wisconsin, USA
| | - Sharon M Bartosh
- Department of Pediatrics, University of Wisconsin Madison, Madison, Wisconsin, USA
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Pandrowala A, Khan S, Kataria D, Kakunje M, Mishra V, Mamtora D, Mudaliar S, Bodhanwala M, Agarwal B, Hiwarkar P. The role of graft T-cell size in patients receiving alemtuzumab serotherapy for non-malignant disorders: results of an institutional protocol. Sci Rep 2024; 14:988. [PMID: 38200046 PMCID: PMC10781954 DOI: 10.1038/s41598-023-50416-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 12/19/2023] [Indexed: 01/12/2024] Open
Abstract
Although graft T cells assist in engraftment, mediate antiviral immune-reconstitution, and cause graft-versus-host disease, graft size is not determined by T-cell content of the graft. The conventional method of graft size determination based on CD34+ cells with alemtuzumab serotherapy is associated with delayed immune reconstitution, contributing to an increased risk of viral infections and graft failure. Alemtuzumab, a long half-life anti-CD52 monoclonal antibody is a robust T-cell depleting serotherapy, and relatively spares memory-effector T cells compared to naïve T cells. We therefore hypothesized that graft size based on T-cell content in patients receiving peripheral blood stem cell graft with alemtuzumab serotherapy would facilitate immune-reconstitution without increasing the risk of graft-versus-host disease. We retrospectively analysed twenty-six consecutive patients with non-malignant disorders grafted using alemtuzumab serotherapy and capping of graft T cells to a maximum of 600 million/kg. The graft T-cell capping protocol resulted in early immune-reconstitution without increasing the risk of severe graft-versus-host disease. Graft T-cell content correlated with CD4+ T-cell reconstitution and acute graft-versus-host disease. The course of CMV viraemia was predictable without recurrence and associated with early T-cell recovery. No patient developed chronic graft-versus-host disease. Overall survival at one year was 100% and disease-free survival was 96% at a median of 899 days (range: 243-1562). Graft size determined by peripheral blood stem cell graft T-cell content in patients receiving alemtuzumab serotherapy for non-malignant disorders is safe and leads to early T-cell immune-reconstitution with excellent survival outcomes.
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Affiliation(s)
- Ambreen Pandrowala
- Department of Blood and Marrow Transplantation, Bai Jerbai Wadia Hospital for Children, Mumbai, 400012, India
| | - Sanna Khan
- Department of Blood and Marrow Transplantation, Bai Jerbai Wadia Hospital for Children, Mumbai, 400012, India
| | - Darshan Kataria
- Department of Blood and Marrow Transplantation, Bai Jerbai Wadia Hospital for Children, Mumbai, 400012, India
| | - Manasa Kakunje
- Department of Blood and Marrow Transplantation, Bai Jerbai Wadia Hospital for Children, Mumbai, 400012, India
| | - Varsha Mishra
- Department of Blood and Marrow Transplantation, Bai Jerbai Wadia Hospital for Children, Mumbai, 400012, India
| | - Dhruv Mamtora
- Department of Pathology, Bai Jerbai Wadia Hospital for Children, Mumbai, India
| | - Sangeeta Mudaliar
- Department of Paediatric Haematology, Bai Jerbai Wadia Hospital for Children, Mumbai, India
| | - Minnie Bodhanwala
- Department of Paediatrics, Bai Jerbai Wadia Hospital for Children, Mumbai, India
| | - Bharat Agarwal
- Department of Blood and Marrow Transplantation, Bai Jerbai Wadia Hospital for Children, Mumbai, 400012, India
- Department of Paediatric Haematology, Bai Jerbai Wadia Hospital for Children, Mumbai, India
| | - Prashant Hiwarkar
- Department of Blood and Marrow Transplantation, Bai Jerbai Wadia Hospital for Children, Mumbai, 400012, India.
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von Essen MR, Chow HH, Holm Hansen R, Buhelt S, Sellebjerg F. Immune reconstitution following alemtuzumab therapy is characterized by exhausted T cells, increased regulatory control of proinflammatory T cells and reduced B cell control. Front Immunol 2023; 14:1249201. [PMID: 37744364 PMCID: PMC10512074 DOI: 10.3389/fimmu.2023.1249201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 08/21/2023] [Indexed: 09/26/2023] Open
Abstract
Alemtuzumab is a monoclonal antibody targeting CD52 on the surface of immune cells, approved for the treatment of active relapsing-remitting multiple sclerosis (RRMS). The purpose of this study was to analyze the repopulation of peripheral lymphocytes following alemtuzumab-induced lymphocyte depletion and investigate associations with disease activity and development of secondary autoimmunity. For this, blood samples were collected two years after initiation of alemtuzumab treatment and lymphocytes were subjected to a comprehensive flow cytometry analysis. Included in the study were 40 patients treated with alemtuzumab and 40 treatment-naïve patients with RRMS. Disease activity and development of secondary autoimmune disease was evaluated after three years of treatment. Our study confirms that alemtuzumab treatment profoundly alters the circulating lymphocyte phenotype and describes a reconstituted immune system characterized by T cell activation/exhaustion, an increased regulatory control of IL-17 producing effector T cells and CD20+ T cells, and a reduced control of B cells. There were no obvious associations between immune cell subsets and disease activity or development of secondary autoimmune disease during treatment with alemtuzumab. Our results indicate that the reconstituted immune response is skewed towards a more effective regulatory control of MS-associated proinflammatory T cell responses. Also, the enlarged pool of naïve B cells together with the apparent decrease in control of B cell activity may explain why alemtuzumab-treated patients retain the ability to mount a humoral immune response towards new antigens.
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Affiliation(s)
- Marina Rode von Essen
- Danish Multiple Sclerosis Center, Department of Neurology, Copenhagen University Hospital - Rigshospitalet, Glostrup, Denmark
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Seyedsadr M, Wang Y, Elzoheiry M, Shree Gopal S, Jang S, Duran G, Chervoneva I, Kasimoglou E, Wrobel JA, Hwang D, Garifallou J, Zhang X, Khan TH, Lorenz U, Su M, Ting JP, Broux B, Rostami A, Miskin D, Markovic-Plese S. IL-11 induces NLRP3 inflammasome activation in monocytes and inflammatory cell migration to the central nervous system. Proc Natl Acad Sci U S A 2023; 120:e2221007120. [PMID: 37339207 PMCID: PMC10293805 DOI: 10.1073/pnas.2221007120] [Citation(s) in RCA: 23] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 04/26/2023] [Indexed: 06/22/2023] Open
Abstract
The objective of this study is to examine IL-11-induced mechanisms of inflammatory cell migration to the central nervous system (CNS). We report that IL-11 is produced at highest frequency by myeloid cells among the peripheral blood mononuclear cell (PBMC) subsets. Patients with relapsing-remitting multiple sclerosis (RRMS) have an increased frequency of IL-11+ monocytes, IL-11+ and IL-11R+ CD4+ lymphocytes, and IL-11R+ neutrophils in comparison to matched healthy controls. IL-11+ and granulocyte-macrophage colony-stimulating factor (GM-CSF)+ monocytes, CD4+ lymphocytes, and neutrophils accumulate in the cerebrospinal fluid (CSF). The effect of IL-11 in-vitro stimulation, examined using single-cell RNA sequencing, revealed the highest number of differentially expressed genes in classical monocytes, including up-regulated NFKB1, NLRP3, and IL1B. All CD4+ cell subsets had increased expression of S100A8/9 alarmin genes involved in NLRP3 inflammasome activation. In IL-11R+-sorted cells from the CSF, classical and intermediate monocytes significantly up-regulated the expression of multiple NLRP3 inflammasome-related genes, including complement, IL18, and migratory genes (VEGFA/B) in comparison to blood-derived cells. Therapeutic targeting of this pathway with αIL-11 mAb in mice with RR experimental autoimmune encephalomyelitis (EAE) decreased clinical scores, CNS inflammatory infiltrates, and demyelination. αIL-11 mAb treatment decreased the numbers of NFκBp65+, NLRP3+, and IL-1β+ monocytes in the CNS of mice with EAE. The results suggest that IL-11/IL-11R signaling in monocytes represents a therapeutic target in RRMS.
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Affiliation(s)
- Maryamsadat Seyedsadr
- Department of Neurology, Neuroimmunology Division, Thomas Jefferson University, Philadelphia, PA19107
- Department of Microbiology, Immunology and Molecular Genetics, University of California Los Angeles, Los Angeles, CA90095
| | - Yan Wang
- Department of Neurology, Neuroimmunology Division, Thomas Jefferson University, Philadelphia, PA19107
| | - Manal Elzoheiry
- Department of Neurology, Neuroimmunology Division, Thomas Jefferson University, Philadelphia, PA19107
| | - Sowmya Shree Gopal
- Department of Neurology, Neuroimmunology Division, Thomas Jefferson University, Philadelphia, PA19107
| | - Soohwa Jang
- Department of Neurology, Neuroimmunology Division, Thomas Jefferson University, Philadelphia, PA19107
| | - Gayel Duran
- Biomedical Research Institute, Department of Immunology, Hasselt University, Hasselt 3590, Belgium
| | - Inna Chervoneva
- Department of Pharmacology, Biostatistics, Physiology and Cancer Biology, Thomas Jefferson University, Philadelphia, PA19107
| | - Ezgi Kasimoglou
- Department of Neurology, Neuroimmunology Division, Thomas Jefferson University, Philadelphia, PA19107
| | - John A. Wrobel
- Linberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC27599
| | - Daniel Hwang
- Department of Neurology, Neuroimmunology Division, Thomas Jefferson University, Philadelphia, PA19107
| | - James Garifallou
- Center for Applied Genomics, Children's Hospital of Philadelphia, Philadelphia, PA19104
| | - Xin Zhang
- Department of Orthopedic Surgery, Duke University, Durham, NC27599
| | - Tabish H. Khan
- Divison of Laboratory and Genomic Medicine, Department of Pathology, Washington University School of Medicine, St. Louis, MO63110
| | - Ulrike Lorenz
- Divison of Laboratory and Genomic Medicine, Department of Pathology, Washington University School of Medicine, St. Louis, MO63110
| | - Maureen Su
- Department of Microbiology, Immunology and Molecular Genetics, University of California Los Angeles, Los Angeles, CA90095
| | - Jenny P. Ting
- Linberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC27599
| | - Bieke Broux
- Biomedical Research Institute, Department of Immunology, Hasselt University, Hasselt 3590, Belgium
| | - Abdolmohamad Rostami
- Department of Neurology, Neuroimmunology Division, Thomas Jefferson University, Philadelphia, PA19107
| | - Dhanashri Miskin
- Department of Neurology, Neuroimmunology Division, Thomas Jefferson University, Philadelphia, PA19107
| | - Silva Markovic-Plese
- Department of Neurology, Neuroimmunology Division, Thomas Jefferson University, Philadelphia, PA19107
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In-depth characterization of long-term humoral and cellular immune responses to COVID-19m-RNA vaccination in multiple sclerosis patients treated with teriflunomide or alemtuzumab. Mult Scler Relat Disord 2023; 72:104616. [PMID: 36933299 PMCID: PMC10008178 DOI: 10.1016/j.msard.2023.104616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Revised: 02/25/2023] [Accepted: 03/10/2023] [Indexed: 03/13/2023]
Abstract
BACKGROUND The impact of disease-modifying therapies on the efficacy to mount appropriate immune responses to COVID-19 vaccination in patients with multiple sclerosis (MS) is currently under investigation. OBJECTIVE To characterize long-term humoral and cellular immunity in mRNA-COVID-19 MS vaccinees treated with teriflunomide or alemtuzumab. METHODS We prospectively measured SARS-COV-2 IgG, memory B-cells specific for SARS-CoV-2 RBD, and memory T-cells secreting IFN-γ and/or IL-2, in MS patients vaccinated with BNT162b2-COVID-19 vaccine before, 1, 3 and 6 months after the second vaccine dose, and 3-6 months following vaccine booster. RESULTS Patients were either untreated (N = 31, 21 females), under treatment with teriflunomide (N = 30, 23 females, median treatment duration 3.7 years, range 1.5-7.0 years), or under treatment with alemtuzumab (N = 12, 9 females, median time from last dosing 15.9 months, range 1.8-28.7 months). None of the patients had clinical SARS-CoV-2 or immune evidence for prior infection. Spike IgG titers were similar between untreated, teriflunomide and alemtuzumab treated MS patients both at 1 month (median 1320.7, 25-75 IQR 850.9-3152.8 vs. median 901.7, 25-75 IQR 618.5-1495.8, vs. median 1291.9, 25-75 IQR 590.8-2950.9, BAU/ml, respectively), at 3 months (median 1388.8, 25-75 1064.6-2347.6 vs. median 1164.3 25-75 IQR 726.4-1399.6, vs. median 837.2, 25-75 IQR 739.4-1868.5 BAU/ml, respectively), and at 6 months (median 437.0, 25-75 206.1-1161.3 vs. median 494.3, 25-75 IQR 214.6-716.5, vs. median 176.3, 25-75 IQR 72.3-328.8 BAU/ml, respectively) after the second vaccine dose. Specific SARS-CoV-2 memory B cells were detected in 41.9%, 40.0% and 41.7% of subjects at 1 month, in 32.3%, 43.3% and 25% at 3 months, and in 32.3%, 40.0%, 33.3% at 6 months following vaccination in untreated, teriflunomide treated and alemtuzumab treated MS patients, respectively. Specific SARS-CoV-2 memory T cells were found in 48.4%, 46.7% and 41.7 at 1 month, in 41.9%, 56.7% and 41.7% at 3 months, and in 38.7%, 50.0%, and 41.7% at 6 months, of untreated, teriflunomide-treated and alemtuzumab -treated MS patients, respectively. Administration of a third vaccine booster significantly increased both humoral and cellular responses in all patients. CONCLUSIONS MS patients treated with teriflunomide or alemtuzumab achieved effective humoral and cellular immune responses up to 6 months following second COVID-19 vaccination. Immune responses were reinforced following the third vaccine booster.
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Le Floc'h A, Nagashima K, Birchard D, Scott G, Ben LH, Ajithdoss D, Gayvert K, Romero Hernandez A, Herbin O, Tay A, Farrales P, Korgaonkar CK, Pan H, Shah S, Kamat V, Chatterjee I, Popke J, Oyejide A, Lim WK, Kim JH, Huang T, Franklin M, Olson W, Norton T, Perlee L, Yancopoulos GD, Murphy AJ, Sleeman MA, Orengo JM. Blocking common γ chain cytokine signaling ameliorates T cell-mediated pathogenesis in disease models. Sci Transl Med 2023; 15:eabo0205. [PMID: 36630481 DOI: 10.1126/scitranslmed.abo0205] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
The common γ chain (γc; IL-2RG) is a subunit of the interleukin (IL) receptors for the γc cytokines IL-2, IL-4, IL-7, IL-9, IL-15, and IL-21. The lack of appropriate neutralizing antibodies recognizing IL-2RG has made it difficult to thoroughly interrogate the role of γc cytokines in inflammatory and autoimmune disease settings. Here, we generated a γc cytokine receptor antibody, REGN7257, to determine whether γc cytokines might be targeted for T cell-mediated disease prevention and treatment. Biochemical, structural, and in vitro analysis showed that REGN7257 binds with high affinity to IL-2RG and potently blocks signaling of all γc cytokines. In nonhuman primates, REGN7257 efficiently suppressed T cells without affecting granulocytes, platelets, or red blood cells. Using REGN7257, we showed that γc cytokines drive T cell-mediated disease in mouse models of graft-versus-host disease (GVHD) and multiple sclerosis by affecting multiple aspects of the pathogenic response. We found that our xenogeneic GVHD mouse model recapitulates hallmarks of acute and chronic GVHD, with T cell expansion/infiltration into tissues and liver fibrosis, as well as hallmarks of immune aplastic anemia, with bone marrow aplasia and peripheral cytopenia. Our findings indicate that γc cytokines contribute to GVHD and aplastic anemia pathology by promoting these characteristic features. By demonstrating that broad inhibition of γc cytokine signaling with REGN7257 protects from immune-mediated disorders, our data provide evidence of γc cytokines as key drivers of pathogenic T cell responses, offering a potential strategy for the management of T cell-mediated diseases.
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Affiliation(s)
- Audrey Le Floc'h
- Regeneron Pharmaceuticals, 777 Old Saw Mill River Road, Tarrytown, NY 10591, USA
| | - Kirsten Nagashima
- Regeneron Pharmaceuticals, 777 Old Saw Mill River Road, Tarrytown, NY 10591, USA
| | - Dylan Birchard
- Regeneron Pharmaceuticals, 777 Old Saw Mill River Road, Tarrytown, NY 10591, USA
| | - George Scott
- Regeneron Pharmaceuticals, 777 Old Saw Mill River Road, Tarrytown, NY 10591, USA
| | - Li-Hong Ben
- Regeneron Pharmaceuticals, 777 Old Saw Mill River Road, Tarrytown, NY 10591, USA
| | - Dharani Ajithdoss
- Regeneron Pharmaceuticals, 777 Old Saw Mill River Road, Tarrytown, NY 10591, USA
| | - Kaitlyn Gayvert
- Regeneron Pharmaceuticals, 777 Old Saw Mill River Road, Tarrytown, NY 10591, USA
| | | | - Olivier Herbin
- Regeneron Pharmaceuticals, 777 Old Saw Mill River Road, Tarrytown, NY 10591, USA
| | - Amanda Tay
- Regeneron Pharmaceuticals, 777 Old Saw Mill River Road, Tarrytown, NY 10591, USA
| | - Pamela Farrales
- Regeneron Pharmaceuticals, 777 Old Saw Mill River Road, Tarrytown, NY 10591, USA
| | | | - Hao Pan
- Regeneron Pharmaceuticals, 777 Old Saw Mill River Road, Tarrytown, NY 10591, USA
| | - Sweta Shah
- Regeneron Pharmaceuticals, 777 Old Saw Mill River Road, Tarrytown, NY 10591, USA
| | - Vishal Kamat
- Regeneron Pharmaceuticals, 777 Old Saw Mill River Road, Tarrytown, NY 10591, USA
| | - Ishita Chatterjee
- Regeneron Pharmaceuticals, 777 Old Saw Mill River Road, Tarrytown, NY 10591, USA
| | - Jon Popke
- Regeneron Pharmaceuticals, 777 Old Saw Mill River Road, Tarrytown, NY 10591, USA
| | - Adelekan Oyejide
- Regeneron Pharmaceuticals, 777 Old Saw Mill River Road, Tarrytown, NY 10591, USA
| | - Wei Keat Lim
- Regeneron Pharmaceuticals, 777 Old Saw Mill River Road, Tarrytown, NY 10591, USA
| | - Jee H Kim
- Regeneron Pharmaceuticals, 777 Old Saw Mill River Road, Tarrytown, NY 10591, USA
| | - Tammy Huang
- Regeneron Pharmaceuticals, 777 Old Saw Mill River Road, Tarrytown, NY 10591, USA
| | - Matthew Franklin
- Regeneron Pharmaceuticals, 777 Old Saw Mill River Road, Tarrytown, NY 10591, USA
| | - William Olson
- Regeneron Pharmaceuticals, 777 Old Saw Mill River Road, Tarrytown, NY 10591, USA
| | - Thomas Norton
- Regeneron Pharmaceuticals, 777 Old Saw Mill River Road, Tarrytown, NY 10591, USA
| | - Lorah Perlee
- Regeneron Pharmaceuticals, 777 Old Saw Mill River Road, Tarrytown, NY 10591, USA
| | - George D Yancopoulos
- Regeneron Pharmaceuticals, 777 Old Saw Mill River Road, Tarrytown, NY 10591, USA
| | - Andrew J Murphy
- Regeneron Pharmaceuticals, 777 Old Saw Mill River Road, Tarrytown, NY 10591, USA
| | - Matthew A Sleeman
- Regeneron Pharmaceuticals, 777 Old Saw Mill River Road, Tarrytown, NY 10591, USA
| | - Jamie M Orengo
- Regeneron Pharmaceuticals, 777 Old Saw Mill River Road, Tarrytown, NY 10591, USA
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10
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Liu R, Du S, Zhao L, Jain S, Sahay K, Rizvanov A, Lezhnyova V, Khaibullin T, Martynova E, Khaiboullina S, Baranwal M. Autoreactive lymphocytes in multiple sclerosis: Pathogenesis and treatment target. Front Immunol 2022; 13:996469. [PMID: 36211343 PMCID: PMC9539795 DOI: 10.3389/fimmu.2022.996469] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Accepted: 09/08/2022] [Indexed: 11/13/2022] Open
Abstract
Multiple sclerosis (MS) is a chronic inflammatory disease of the central nervous system (CNS) characterized by destruction of the myelin sheath structure. The loss of myelin leads to damage of a neuron’s axon and cell body, which is identified as brain lesions on magnetic resonance image (MRI). The pathogenesis of MS remains largely unknown. However, immune mechanisms, especially those linked to the aberrant lymphocyte activity, are mainly responsible for neuronal damage. Th1 and Th17 populations of lymphocytes were primarily associated with MS pathogenesis. These lymphocytes are essential for differentiation of encephalitogenic CD8+ T cell and Th17 lymphocyte crossing the blood brain barrier and targeting myelin sheath in the CNS. B-lymphocytes could also contribute to MS pathogenesis by producing anti-myelin basic protein antibodies. In later studies, aberrant function of Treg and Th9 cells was identified as contributing to MS. This review summarizes the aberrant function and count of lymphocyte, and the contributions of these cell to the mechanisms of MS. Additionally, we have outlined the novel MS therapeutics aimed to amend the aberrant function or counts of these lymphocytes.
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Affiliation(s)
- Rongzeng Liu
- Department of Immunology, School of Basic Medical Sciences, Henan University of Science and Technology, Luoyang, China
| | - Shushu Du
- Department of Immunology, School of Basic Medical Sciences, Henan University of Science and Technology, Luoyang, China
| | - Lili Zhao
- Department of Immunology, School of Basic Medical Sciences, Henan University of Science and Technology, Luoyang, China
| | - Sahil Jain
- Department of Biochemistry and Molecular Biology, Faculty of Life Sciences, Tel-Aviv University, Tel-Aviv, Israel
| | - Kritika Sahay
- Department of Biotechnology, Thapar Institute of Engineering and Technology, Patiala, India
| | - Albert Rizvanov
- Gene and cell Department, Kazan Federal University, Kazan, Russia
| | - Vera Lezhnyova
- Gene and cell Department, Kazan Federal University, Kazan, Russia
| | - Timur Khaibullin
- Neurological Department, Republican Clinical Neurological Center, Kazan, Russia
| | | | - Svetlana Khaiboullina
- Gene and cell Department, Kazan Federal University, Kazan, Russia
- *Correspondence: Svetlana Khaiboullina, ; Manoj Baranwal, ;
| | - Manoj Baranwal
- Department of Biotechnology, Thapar Institute of Engineering and Technology, Patiala, India
- *Correspondence: Svetlana Khaiboullina, ; Manoj Baranwal, ;
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11
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Mariottini A, Muraro PA, Lünemann JD. Antibody-mediated cell depletion therapies in multiple sclerosis. Front Immunol 2022; 13:953649. [PMID: 36172350 PMCID: PMC9511140 DOI: 10.3389/fimmu.2022.953649] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Accepted: 07/29/2022] [Indexed: 11/30/2022] Open
Abstract
Development of disease-modifying therapies including monoclonal antibody (mAb)-based therapeutics for the treatment of multiple sclerosis (MS) has been extremely successful over the past decades. Most of the mAb-based therapies approved for MS deplete immune cell subsets and act through activation of cellular Fc-gamma receptors expressed by cytotoxic lymphocytes and phagocytes, resulting in antibody-dependent cellular cytotoxicity or by initiation of complement-mediated cytotoxicity. The therapeutic goal is to eliminate pathogenic immune cell components and to potentially foster the reconstitution of a new and healthy immune system. Ab-mediated immune cell depletion therapies include the CD52-targeting mAb alemtuzumab, CD20-specific therapeutics, and new Ab-based treatments which are currently being developed and tested in clinical trials. Here, we review recent developments in effector mechanisms and clinical applications of Ab-based cell depletion therapies, compare their immunological and clinical effects with the prototypic immune reconstitution treatment strategy, autologous hematopoietic stem cell transplantation, and discuss their potential to restore immunological tolerance and to achieve durable remission in people with MS.
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Affiliation(s)
- Alice Mariottini
- Department of Brain Sciences, Imperial College London, London, United Kingdom
- Department of Neurosciences, Drug and Child Health, University of Florence, Florence, Italy
| | - Paolo A. Muraro
- Department of Brain Sciences, Imperial College London, London, United Kingdom
| | - Jan D. Lünemann
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Münster, Germany
- *Correspondence: Jan D. Lünemann,
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12
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Edo Á, Calvo-Barreiro L, Eixarch H, Bosch A, Chillón M, Espejo C. Therapeutic Effect of IL-21 Blockage by Gene Therapy in Experimental Autoimmune Encephalomyelitis. Neurotherapeutics 2022; 19:1617-1633. [PMID: 35902536 PMCID: PMC9606180 DOI: 10.1007/s13311-022-01279-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/11/2022] [Indexed: 11/24/2022] Open
Abstract
The pathogenic role of the interleukin 21 (IL-21) in different autoimmune diseases, such as multiple sclerosis (MS), has been extensively studied. However, its pleiotropic nature makes it a cytokine that may exhibit different activity depending on the immunological stage of the disease. In this study, we developed a gene therapy strategy to block the interaction between IL-21 and its receptor (IL-21R) by using adeno-associated vectors (AAV) encoding a new soluble cytokine receptor (sIL21R) protein. We tested this strategy in a murine model of experimental autoimmune encephalomyelitis (EAE), obtaining different clinical effects depending on the time at which the treatment was applied. Although the administration of the treatment during the development of the immune response was counterproductive, the preventive administration of the therapeutic vectors showed a protective effect by reducing the number of animals that developed the disease, as well as an improvement at the histopathological level and a modification of the immunological profile of the animals treated with the AAV8.sIL21R. The beneficial effect of the treatment was also observed when inducing the expression of the therapeutic molecule once the first neurological signs were established in a therapeutic approach with a doxycyline (Dox)-inducible expression system. All these clinical results highlight the pleiotropicity of this cytokine in the different clinical stages and its key role in the EAE immunopathogenesis.
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Affiliation(s)
- Ángel Edo
- Institut de Neurociències (INc), Department of Biochemistry and Molecular Biology, Universitat Autònoma de Barcelona, (Campus UAB), Bellaterra, Cerdanyola del Vallès (Ed. H 5th level), 08193, Barcelona, Spain
- Vall d'Hebron Institut de Recerca, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Laura Calvo-Barreiro
- Servei de Neurologia-Neuroimmunologia, Centre d'Esclerosi Múltiple de Catalunya, Vall d'Hebron Institut de Recerca, Hospital Universitari Vall d'Hebron, Vall d'Hebron Barcelona Hospital Campus, Pg. Vall d'Hebron 119-129 (Ed. Collserola, Lab. 149), 08035, Barcelona, Spain
- Universitat Autònoma de Barcelona, Bellaterra, Cerdanyola del Vallès, Spain
| | - Herena Eixarch
- Servei de Neurologia-Neuroimmunologia, Centre d'Esclerosi Múltiple de Catalunya, Vall d'Hebron Institut de Recerca, Hospital Universitari Vall d'Hebron, Vall d'Hebron Barcelona Hospital Campus, Pg. Vall d'Hebron 119-129 (Ed. Collserola, Lab. 149), 08035, Barcelona, Spain
- Universitat Autònoma de Barcelona, Bellaterra, Cerdanyola del Vallès, Spain
| | - Assumpció Bosch
- Institut de Neurociències (INc), Department of Biochemistry and Molecular Biology, Universitat Autònoma de Barcelona, (Campus UAB), Bellaterra, Cerdanyola del Vallès (Ed. H 5th level), 08193, Barcelona, Spain
- Vall d'Hebron Institut de Recerca, Hospital Universitari Vall d'Hebron, Barcelona, Spain
- Universitat Autònoma de Barcelona, Bellaterra, Cerdanyola del Vallès, Spain
| | - Miguel Chillón
- Institut de Neurociències (INc), Department of Biochemistry and Molecular Biology, Universitat Autònoma de Barcelona, (Campus UAB), Bellaterra, Cerdanyola del Vallès (Ed. H 5th level), 08193, Barcelona, Spain.
- Vall d'Hebron Institut de Recerca, Hospital Universitari Vall d'Hebron, Barcelona, Spain.
- Universitat Autònoma de Barcelona, Bellaterra, Cerdanyola del Vallès, Spain.
- Institució Catalana de Recerca I Estudis Avançats (ICREA), Barcelona, Spain.
- Vector Production Unit (UPV), Universitat Autònoma de Barcelona, Barcelona, Spain.
| | - Carmen Espejo
- Servei de Neurologia-Neuroimmunologia, Centre d'Esclerosi Múltiple de Catalunya, Vall d'Hebron Institut de Recerca, Hospital Universitari Vall d'Hebron, Vall d'Hebron Barcelona Hospital Campus, Pg. Vall d'Hebron 119-129 (Ed. Collserola, Lab. 149), 08035, Barcelona, Spain.
- Universitat Autònoma de Barcelona, Bellaterra, Cerdanyola del Vallès, Spain.
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13
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Brod SA. The genealogy, methodology, similarities and differences of immune reconstitution therapies for multiple sclerosis and neuromyelitis optica. Autoimmun Rev 2022; 21:103170. [PMID: 35963569 DOI: 10.1016/j.autrev.2022.103170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 08/07/2022] [Indexed: 11/09/2022]
Abstract
Immune reconstitution therapies (IRTs) are a type of short course procedure or pharmaceutical agent within the MS pharmacopeia. They emanate from oncology and induce transient incomplete lympho-ablation with or without myelo-ablation, resulting in potential prolonged immunomodulation. Thus, they provide significant prophylaxis from disease activity without retreatment. Modern IRT for autoimmunity encompasses a heterogeneous group of pulsed lympho- and non-myelo-ablative treatments designed to re-boot the adaptive immune system in a quasi-permanent manner - a re-induction of ontogeny. IRT is the extensive debulking of an auto-aggressive immune system to attempt to reach the Holy Grail of immune tolerance. This incomplete yet significant lympho-ablation induces lymphoproliferation, reduces pathogenic clonal cells, causes thymopoiesis and results in the induction of immune tolerance. Lympho-ablation with immune reconstitution can result in minimal residual autoimmunity. There is a resetting of the immune thermostat - i.e., the immunostat. IRTs have the potential to provide prolonged periods of disease inactivity without retreatment in part through the immunological results of their pulsatile lymphocyte depletion. It is vital to increase our understanding of how IRTs alter a patient's immune response to the antigenic target of the disease so that we can devise newer, more durable and safer forms of such agents. What common features do extant IRTs (i.e., stem cell transplant, alemtuzumab and oral cladribine) have to produce the durable therapeutic response without long term treatment in neuroimmunological diseases such as MS (multiple sclerosis) and NMOSD (neuromyelitis optica spectrum disorders)? Can we learn from these critical features to predict what other maneuvers or agents might effect similar clinical results with equal or greater efficacy and safety?
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Affiliation(s)
- Staley A Brod
- Division of MS/Neuro-immunology, Department of Neurology, Medical College of Wisconsin, 8701 W Watertown Plank Rd, Milwaukee, WI 53226, USA.
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14
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Kiapour N, Wu B, Wang Y, Seyedsadr M, Kapoor S, Zhang X, Elzoheiry M, Kasimoglu E, Wan Y, Markovic-Plese S. Therapeutic Effect of Anti-CD52 Monoclonal Antibody in Multiple Sclerosis and Its Animal Models Is Mediated via T Regulatory Cells. JOURNAL OF IMMUNOLOGY (BALTIMORE, MD. : 1950) 2022; 209:49-56. [PMID: 35750335 PMCID: PMC9458467 DOI: 10.4049/jimmunol.2100176] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 04/27/2022] [Indexed: 06/15/2023]
Abstract
The objective of this study is to determine the mechanism of action of anti-CD52 mAb treatment in patients with relapsing-remitting multiple sclerosis (RRMS). Experimental autoimmune encephalomyelitis (EAE), an animal model of the disease, was used to address the role of T regulatory cells (Tregs) in the anti-CD52 mAb-induced suppression of the disease. In vitro studies on PBMCs from RRMS patients and matched healthy controls determined the effect of IL-7 on the expansion of CD4+CD25+CD127- Tregs and induction of their suppressive phenotype. This study using EAE animal models of MS has shown that mouse anti-CD52 mAb suppression of clinical disease was augmented by coadministration of IL-7 and partially reversed by anti-IL-7 mAb. In vitro human studies showed that IL-7 induced expansion of CD4+CD25+CD127- Tregs and increased their FOXP3, GITIR, CD46, CTLA-4, granzyme B, and perforin expression. Anti-CD52 mAb treatment of mice with relapsing-remitting EAE induced expansion of Foxp3+CD4+ Tregs and the suppression of IL-17A+CD4+ and IFN-γ+CD4+ cells in peripheral immune organs and CNS infiltrates. The effect was detected immediately after the treatment and maintained over long-term follow-up. Foxp3+CD4+ Treg-mediated suppression of IL-17A+CD4+ and IFN-γ+CD4+ cells in the spinal cord infiltrates was reversed after inducible Foxp3 depletion. Our results demonstrated that the therapeutic effect of U.S. Food and Drug Administration-approved anti-CD52 mAb is dependent on the presence of Tregs.
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Affiliation(s)
- Nazanin Kiapour
- Department of Neurology, The University of North Carolina at Chapel Hill, Chapel Hill, NC
- Department of Cell Biology and Physiology, UNC Neuroscience Center, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Bing Wu
- Department of Microbiology and Immunology, The University of North Carolina at Chapel Hill, Chapel Hill, NC
- Frontier Science Center for Immunology and Metabolism of Medical Research Institute, Wuhan University, Wuhan, China
| | - Yan Wang
- Department of Neurology, Thomas Jefferson University, Philadelphia, PA; and
| | | | - Sahil Kapoor
- Department of Neurology, The University of North Carolina at Chapel Hill, Chapel Hill, NC
- Department of Cell Biology and Physiology, UNC Neuroscience Center, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Xin Zhang
- Department of Neurology, The University of North Carolina at Chapel Hill, Chapel Hill, NC
- Duke Molecular Physiology Institute, Department of Orthopedic Surgery, Duke University, Durham, NC
| | - Manal Elzoheiry
- Department of Neurology, Thomas Jefferson University, Philadelphia, PA; and
| | - Ezgi Kasimoglu
- Department of Neurology, Thomas Jefferson University, Philadelphia, PA; and
| | - Yisong Wan
- Department of Microbiology and Immunology, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Silva Markovic-Plese
- Department of Neurology, The University of North Carolina at Chapel Hill, Chapel Hill, NC;
- Department of Neurology, Thomas Jefferson University, Philadelphia, PA; and
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15
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Benazzo A, Bozzini S, Auner S, Berezhinskiy HO, Watzenboeck ML, Schwarz S, Schweiger T, Klepetko W, Wekerle T, Hoetzenecker K, Meloni F, Jaksch P. Differential expression of circulating miRNAs after alemtuzumab induction therapy in lung transplantation. Sci Rep 2022; 12:7072. [PMID: 35490174 PMCID: PMC9056512 DOI: 10.1038/s41598-022-10866-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2021] [Accepted: 04/13/2022] [Indexed: 11/17/2022] Open
Abstract
Alemtuzumab is a monoclonal antibody targeting CD52, used as induction therapy after lung transplantation (LTx). Its engagement produces a long-lasting immunodepletion; however, the mechanisms driving cell reconstitution are poorly defined. We hypothesized that miRNAs are involved in this process. The expression of a set of miRNAs, cytokines and co-signaling molecules was measured with RT-qPCR and flow cytometry in prospectively collected serum samples of LTx recipients, after alemtuzumab or no induction therapy. Twenty-six LTx recipients who received alemtuzumab and twenty-seven matched LTx recipients without induction therapy were included in the analysis. One year after transplantation four miRNAs were differentially regulated: miR-23b (p = 0.05) miR-146 (p = 0.04), miR-155 (p < 0.001) and miR-486 (p < 0.001). Expression of 3 miRNAs changed within the alemtuzumab group: miR-146 (p < 0.001), miR-155 (p < 0.001) and miR-31 (p < 0.001). Levels of IL-13, IL-4, IFN-γ, BAFF, IL-5, IL-9, IL-17F, IL-17A and IL-22 were different one year after transplantation compared to baseline. In no-induction group, concentration of sCD27, sB7.2 and sPD-L1 increased overtime. Expression of miR-23b, miR-146, miR-486, miR-155 and miR-31 was different in LTx recipients who received alemtuzumab compared to recipients without induction therapy. The observed cytokine pattern suggested proliferation of specific B cell subsets in alemtuzumab group and co-stimulation of T-cells in no-induction group.
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Affiliation(s)
- A Benazzo
- Department of Thoracic Surgery, Medical University of Vienna, Vienna, Austria.
- Department of Thoracic Surgery, Lung Transplantation Research Lab, Medical University of Vienna, Vienna, Austria.
- Division of Thoracic Surgery, Medical University of Vienna, Währinger Guertel 18-20, 1090, Vienna, Austria.
| | - S Bozzini
- Department of Internal Medicine, Unit of Respiratory Diseases, Laboratory of Cell Biology and Immunology, University of Pavia and IRCCS Policlinico San Matteo Foundation, Pavia, Italy
| | - S Auner
- Department of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
- Department of Thoracic Surgery, Lung Transplantation Research Lab, Medical University of Vienna, Vienna, Austria
| | - H Oya Berezhinskiy
- Department of Thoracic Surgery, Lung Transplantation Research Lab, Medical University of Vienna, Vienna, Austria
| | - M L Watzenboeck
- Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
| | - S Schwarz
- Department of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - T Schweiger
- Department of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - W Klepetko
- Department of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - T Wekerle
- Section of Transplantation Immunology, Division of Transplantation, Department of General Surgery, Medical University of Vienna, Vienna, Austria
| | - K Hoetzenecker
- Department of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - F Meloni
- Department of Internal Medicine, Unit of Respiratory Diseases, Laboratory of Cell Biology and Immunology, University of Pavia and IRCCS Policlinico San Matteo Foundation, Pavia, Italy
| | - P Jaksch
- Department of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
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16
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Krajnc N, Bsteh G, Berger T, Mares J, Hartung HP. Monoclonal Antibodies in the Treatment of Relapsing Multiple Sclerosis: an Overview with Emphasis on Pregnancy, Vaccination, and Risk Management. Neurotherapeutics 2022; 19:753-773. [PMID: 35378683 PMCID: PMC8978776 DOI: 10.1007/s13311-022-01224-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/14/2022] [Indexed: 01/10/2023] Open
Abstract
Monoclonal antibodies have become a mainstay in the treatment of patients with relapsing multiple sclerosis (RMS) and provide some benefit to patients with primary progressive MS. They are highly precise by specifically targeting molecules displayed on cells involved in distinct immune mechanisms of MS pathophysiology. They not only differ in the target antigen they recognize but also by the mode of action that generates their therapeutic effect. Natalizumab, an [Formula: see text]4[Formula: see text]1 integrin antagonist, works via binding to cell surface receptors, blocking the interaction with their ligands and, in that way, preventing the migration of leukocytes across the blood-brain barrier. On the other hand, the anti-CD52 monoclonal antibody alemtuzumab and the anti-CD20 monoclonal antibodies rituximab, ocrelizumab, ofatumumab, and ublituximab work via eliminating selected pathogenic cell populations. However, potential adverse effects may be serious and can necessitate treatment discontinuation. Most importantly, those are the risk for (opportunistic) infections, but also secondary autoimmune diseases or malignancies. Monoclonal antibodies also carry the risk of infusion/injection-related reactions, primarily in early phases of treatment. By careful patient selection and monitoring during therapy, the occurrence of these potentially serious adverse effects can be minimized. Monoclonal antibodies are characterized by a relatively long pharmacologic half-life and pharmacodynamic effects, which provides advantages such as permitting infrequent dosing, but also creates disadvantages regarding vaccination and family planning. This review presents an overview of currently available monoclonal antibodies for the treatment of RMS, including their mechanism of action, efficacy and safety profile. Furthermore, we provide practical recommendations for risk management, vaccination, and family planning.
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Affiliation(s)
- Nik Krajnc
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Gabriel Bsteh
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Thomas Berger
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Jan Mares
- Department of Neurology, Palacky University Olomouc, Olomouc, Czech Republic
| | - Hans-Peter Hartung
- Department of Neurology, Medical University of Vienna, Vienna, Austria.
- Department of Neurology, Palacky University Olomouc, Olomouc, Czech Republic.
- Department of Neurology, Medical Faculty, Heinrich-Heine University, Moorenstrasse 5, 40225, Düsseldorf, Germany.
- Brain and Mind Center, University of Sydney, Sydney, Australia.
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17
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Gopaluni S, Smith R, Goymer D, Cahill H, Broadhurst E, Wallin E, McClure M, Chaudhry A, Jayne D. Alemtuzumab for refractory primary systemic vasculitis-a randomised controlled dose ranging clinical trial of efficacy and safety (ALEVIATE). Arthritis Res Ther 2022; 24:81. [PMID: 35365179 PMCID: PMC8972754 DOI: 10.1186/s13075-022-02761-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 03/06/2022] [Indexed: 12/21/2022] Open
Abstract
Background Primary systemic vasculitis (PSV) is a heterogeneous group of autoimmune conditions. There is an unmet need for alternative therapies that lead to sustained remission in patients with refractory disease. Alemtuzumab, an anti-CD52 antibody, depletes lymphocytes for prolonged periods and, in retrospective studies, has induced sustained, treatment-free remissions in patients with refractory/relapsing vasculitis but has raised safety concerns of infection and secondary autoimmunity. This phase IIb clinical trial aimed to assess the efficacy and safety of alemtuzumab, at two different doses, in inducing remission in refractory vasculitis patients. Methods The ALEVIATE trial was a randomised, prospective, open-label, dose ranging clinical trial. Patients with refractory ANCA-associated vasculitis (AAV) or Behçet’s disease (BD) were randomised to receive either 60 mg or 30 mg alemtuzumab. Treatments were administered at baseline and 6 months or earlier where clinically appropriate. A maximum of three treatments were allowed within the 12-month study period. Results Twenty-three patients received at least one dose of alemtuzumab. Twelve had AAV, and 11 a diagnosis of BD. The median age was 40 years (range 28–44), with a prior disease duration of 61 months (42–103). Sixteen (70%) achieved either complete (6/23, 26%) or partial (10/23, 44%) response at 6 months. Eight (35%) maintained remission to the end of the trial without relapse. Ten severe adverse events were observed in 7 (30%) patients; 4 were related to alemtuzumab. There were no differences in clinical endpoints between the 60 and 30 mg alemtuzumab treatment groups. Conclusion In a selected group of refractory vasculitis patients, alemtuzumab led to remission in two thirds of patients at 6 months. Remission was maintained to 12 months in a third of the patients, and the safety profile was acceptable. Trial registration ClinicalTrials.gov identifier: NCT01405807, EudraCT Number: 2009-017087-17. Registered on April 07, 2011. Supplementary Information The online version contains supplementary material available at 10.1186/s13075-022-02761-6.
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Affiliation(s)
- Seerapani Gopaluni
- University of Cambridge, Box 118, Addenbrooke's Hospital, Hills Road, Cambridge, CB20QQ, UK.
| | - Rona Smith
- University of Cambridge, Box 118, Addenbrooke's Hospital, Hills Road, Cambridge, CB20QQ, UK.,Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Donna Goymer
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Hugh Cahill
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | | | - Elizabeth Wallin
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Mark McClure
- University of Cambridge, Box 118, Addenbrooke's Hospital, Hills Road, Cambridge, CB20QQ, UK.,Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Afzal Chaudhry
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - David Jayne
- University of Cambridge, Box 118, Addenbrooke's Hospital, Hills Road, Cambridge, CB20QQ, UK.,Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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18
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Rolla S, De Mercanti SF, Bardina V, Maglione A, Taverna D, Novelli F, Cocco E, Vladic A, Habek M, Adamec I, Annovazzi POL, Horakova D, Clerico M. Long-Term Effects of Alemtuzumab on CD4+ Lymphocytes in Multiple Sclerosis Patients: A 72-Month Follow-Up. Front Immunol 2022; 13:818325. [PMID: 35296069 PMCID: PMC8919044 DOI: 10.3389/fimmu.2022.818325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 02/07/2022] [Indexed: 11/18/2022] Open
Abstract
Introduction Alemtuzumab is highly effective in the treatment of patients with relapsing multiple sclerosis (PwRMS) and selectively targets the CD52 antigen, with a consequent profound lymphopenia, particularly of CD4+ T lymphocytes. However, the immunological basis of its long-term efficacy has not been clearly elucidated. Methods We followed up 29 alemtuzumab-treated RMS patients over a period of 72 months and studied the immunological reconstitution of their CD4+ T cell subsets by means of phenotypic and functional analysis and through mRNA-related molecule expression, comparing them to healthy subject (HS) values (rate 2:1). Results In patients receiving only two-course alemtuzumab, the percentage of CD4+ lymphocytes decreased and returned to basal levels only at month 48. Immune reconstitution of the CD4+ subsets was characterized by a significant increase (p < 0.001) in Treg cell percentage at month 24, when compared to baseline, and was accompanied by restoration of the Treg suppressor function that increased within a range from 2- to 6.5-fold compared to baseline and that persisted through to the end of the follow-up. Furthermore, a significant decrease in self-reactive myelin basic protein-specific Th17 (p < 0.0001) and Th1 (p < 0.05) cells reaching HS values was observed starting from month 12. There was a change in mRNA of cytokines, chemokines, and transcriptional factors related to Th17, Th1, and Treg cell subset changes, consequently suggesting a shift toward immunoregulation and a reduction of T cell recruitment to the central nervous system. Conclusions These data provide further insight into the mechanism that could contribute to the long-term 6-year persistence of the clinical effect of alemtuzumab on RMS disease activity.
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Affiliation(s)
- Simona Rolla
- Department of Clinical and Biological Sciences, University of Torino, Torino, Italy
- *Correspondence: Simona Rolla,
| | | | - Valentina Bardina
- Department of Clinical and Biological Sciences, University of Torino, Torino, Italy
- Laboratory of Microbiology and Virology, Amedeo di Savoia Hospital, Torino, Italy
| | - Alessandro Maglione
- Department of Clinical and Biological Sciences, University of Torino, Torino, Italy
| | - Daniela Taverna
- Department of Molecular Biotechnology and Health Sciences, University of Torino, Torino, Italy
| | - Francesco Novelli
- Department of Molecular Biotechnology and Health Sciences, University of Torino, Torino, Italy
| | - Eleonora Cocco
- Department of Medical Science and Public Health, University of Cagliari and Multiple Sclerosis Center, Cagliari, Italy
| | - Anton Vladic
- Department of Neurology, Clinical Hospital Sveti Duh Zagreb and Medical Faculty, University J.J Strossmayer Osijek, Prague, Croatia
| | - Mario Habek
- Referral Center for Autonomic Nervous System, University Hospital Center Zagreb, Zagreb, Croatia
- School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Ivan Adamec
- Referral Center for Autonomic Nervous System, University Hospital Center Zagreb, Zagreb, Croatia
- School of Medicine, University of Zagreb, Zagreb, Croatia
| | | | - Dana Horakova
- Department of Neurology and Center of Clinical Neuroscience, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czechia
| | - Marinella Clerico
- Department of Clinical and Biological Sciences, University of Torino, Torino, Italy
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19
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Giovannoni G, Coyle PK, Vermersch P, Walker B, Aldridge J, Nolting A, Galazka A, Lemieux C, Leist TP. Integrated Lymphopenia Analysis in Younger and Older Patients With Multiple Sclerosis Treated With Cladribine Tablets. Front Immunol 2022; 12:763433. [PMID: 35003076 PMCID: PMC8740297 DOI: 10.3389/fimmu.2021.763433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 11/10/2021] [Indexed: 11/24/2022] Open
Abstract
Cladribine tablets (CladT) preferentially reduce B and T lymphocyte levels. As aging is associated with a decline in immune function, the effect of CladT on lymphocyte levels may differ by age. This post hoc analysis combined data from the Phase 3 CLARITY, CLARITY Extension, and ORACLE-MS studies to examine the effect of age (≤50 or >50 years) on lymphopenia following CladT 3.5 mg/kg (CladT3.5; cumulative dose over 2 years) treatment over 96 weeks. Both CladT3.5 and placebo were given over Weeks 1 and 5 (Year 1 treatment) and Weeks 48 and 52 (Year 2 treatment) from the start of the studies. Absolute lymphocyte count (ALC) and levels of lymphocyte subsets were examined in 1564 patients (Age ≤50 [placebo: N=566; CladT3.5: N=813]; Age >50 [placebo: N=75; CladT3.5: N=110]). In both age groups, following CladT3.5 treatment, nadir for ALC occurred at Week 9 (8 weeks following start of Year 1 treatment) and Week 55 (7 weeks following start of Year 2 treatment) of the 96-week period; for CD19+ B lymphocytes, nadir occurred at Week 9 (Year 1) and Week 52 (Year 2). For CD4+ T lymphocytes, nadir occurred at Week 16 (Year 1) in both age groups, and at Weeks 60 and 72 (Year 2) in the Age ≤50 and >50 groups, respectively. Nadir for CD8+ T lymphocytes occurred at Week 16 (Year 1) and Week 72 (Year 2) in the Age ≤50 group and levels remained in the normal range; nadir occurred at Week 9 (Year 1) and Week 96 (Year 2) in the Age >50 group. Lymphocyte recovery began soon after nadir following CladT3.5 treatment and median levels reached normal range by end of the treatment year in both age groups. By Week 96, ~25% of patients treated with CladT3.5 reported ≥1 episode of Grade ≥3 lymphopenia (Gr≥3L). The rate of certain infections was numerically higher in older versus younger patients who experienced Gr≥3L. In conclusion, CladT3.5 had a similar effect on ALC and lymphocyte subsets in both younger and older patient groups.
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Affiliation(s)
- Gavin Giovannoni
- Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Patricia K Coyle
- Department of Neurology, Stony Brook University, Stony Brook, NY, United States
| | - Patrick Vermersch
- Univ. Lille, INSERM U1172, Lille Neurosciences and Cognition, CHU Lille, FHU Precise, Lille, France
| | - Bryan Walker
- Department of Neurology, Duke University School of Medicine, Durham, NC, United States
| | - Julie Aldridge
- Research and Development Global Biostatistics, EMD Serono Research & Development Institute, Inc. (an affiliate of Merck KGaA), Billerica, MA, United States
| | - Axel Nolting
- Global Patient Safety, Merck Healthcare KGaA, Darmstadt, Germany
| | - Andrew Galazka
- Global Clinical Development, Ares Trading SA (an affiliate of Merck KGaA), Eysins, Switzerland
| | - Caroline Lemieux
- North American Medical Affairs, EMD Inc. (an affiliate of Merck KGaA), Mississauga, ON, Canada
| | - Thomas P Leist
- Comprehensive Multiple Sclerosis Center, Jefferson University, Philadelphia, PA, United States
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20
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Chukwu CA, Spiers HV, Middleton R, Kalra PA, Asderakis A, Rao A, Augustine T. Alemtuzumab in renal transplantation. Reviews of literature and usage in the United Kingdom. Transplant Rev (Orlando) 2022; 36:100686. [DOI: 10.1016/j.trre.2022.100686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 01/20/2022] [Accepted: 01/24/2022] [Indexed: 11/24/2022]
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21
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Ruck T, Barman S, Schulte-Mecklenbeck A, Pfeuffer S, Steffen F, Nelke C, Schroeter CB, Willison A, Heming M, Müntefering T, Melzer N, Krämer J, Lindner M, Riepenhausen M, Gross CC, Klotz L, Bittner S, Muraro PA, Schneider-Hohendorf T, Schwab N, Meyer zu Hörste G, Goebels N, Meuth SG, Wiendl H. OUP accepted manuscript. Brain 2022; 145:1711-1725. [PMID: 35661859 PMCID: PMC9166548 DOI: 10.1093/brain/awac064] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 01/04/2022] [Accepted: 01/27/2022] [Indexed: 11/12/2022] Open
Abstract
Alemtuzumab is a monoclonal antibody that causes rapid depletion of CD52-expressing immune cells. It has proven to be highly efficacious in active relapsing–remitting multiple sclerosis; however, the high risk of secondary autoimmune disorders has greatly complicated its use. Thus, deeper insight into the pathophysiology of secondary autoimmunity and potential biomarkers is urgently needed. The most critical time points in the decision-making process for alemtuzumab therapy are before or at Month 12, where the ability to identify secondary autoimmunity risk would be instrumental. Therefore, we investigated components of blood and CSF of up to 106 multiple sclerosis patients before and after alemtuzumab treatment focusing on those critical time points. Consistent with previous reports, deep flow cytometric immune-cell profiling (n = 30) demonstrated major effects on adaptive rather than innate immunity, which favoured regulatory immune cell subsets within the repopulation. The longitudinally studied CSF compartment (n = 18) mainly mirrored the immunological effects observed in the periphery. Alemtuzumab-induced changes including increased numbers of naïve CD4+ T cells and B cells as well as a clonal renewal of CD4+ T- and B-cell repertoires were partly reminiscent of haematopoietic stem cell transplantation; in contrast, thymopoiesis was reduced and clonal renewal of T-cell repertoires after alemtuzumab was incomplete. Stratification for secondary autoimmunity did not show clear immununological cellular or proteomic traits or signatures associated with secondary autoimmunity. However, a restricted T-cell repertoire with hyperexpanded T-cell clones at baseline, which persisted and demonstrated further expansion at Month 12 by homeostatic proliferation, identified patients developing secondary autoimmune disorders (n = 7 without secondary autoimmunity versus n = 5 with secondary autoimmunity). Those processes were followed by an expansion of memory B-cell clones irrespective of persistence, which we detected shortly after the diagnosis of secondary autoimmune disease. In conclusion, our data demonstrate that (i) peripheral immunological alterations following alemtuzumab are mirrored by longitudinal changes in the CSF; (ii) incomplete T-cell repertoire renewal and reduced thymopoiesis contribute to a proautoimmune state after alemtuzumab; (iii) proteomics and surface immunological phenotyping do not identify patients at risk for secondary autoimmune disorders; (iv) homeostatic proliferation with disparate dynamics of clonal T- and B-cell expansions are associated with secondary autoimmunity; and (v) hyperexpanded T-cell clones at baseline and Month 12 may be used as a biomarker for the risk of alemtuzumab-induced autoimmunity.
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Affiliation(s)
- Tobias Ruck
- Department of Neurology with Institute of Translational Neurology, University Hospital Muenster, 48149 Muenster, Germany
- Department of Neurology, Medical Faculty, Heinrich-Heine University Düsseldorf, 40225 Düsseldorf, Germany
- Correspondence to: PD Dr. med. Tobias Ruck Department of Neurology with Institute of Translational Neurology University Hospital Muenster Albert-Schweitzer-Campus 1 D-48149 Muenster, Germany E-mail:
| | - Sumanta Barman
- Department of Neurology, Medical Faculty, Heinrich-Heine University Düsseldorf, 40225 Düsseldorf, Germany
| | - Andreas Schulte-Mecklenbeck
- Department of Neurology with Institute of Translational Neurology, University Hospital Muenster, 48149 Muenster, Germany
| | - Steffen Pfeuffer
- Department of Neurology with Institute of Translational Neurology, University Hospital Muenster, 48149 Muenster, Germany
| | - Falk Steffen
- Department of Neurology, Focus Program Translational Neuroscience (FTN) and Immunotherapy (FZI), Rhine-Main Neuroscience Network (rmn2), University Medical Center of the Johannes Gutenberg University Mainz, 55131 Mainz, Germany
| | - Christopher Nelke
- Department of Neurology with Institute of Translational Neurology, University Hospital Muenster, 48149 Muenster, Germany
| | - Christina B. Schroeter
- Department of Neurology, Medical Faculty, Heinrich-Heine University Düsseldorf, 40225 Düsseldorf, Germany
| | - Alice Willison
- Department of Neurology, Medical Faculty, Heinrich-Heine University Düsseldorf, 40225 Düsseldorf, Germany
| | - Michael Heming
- Department of Neurology with Institute of Translational Neurology, University Hospital Muenster, 48149 Muenster, Germany
| | - Thomas Müntefering
- Department of Neurology, Medical Faculty, Heinrich-Heine University Düsseldorf, 40225 Düsseldorf, Germany
| | - Nico Melzer
- Department of Neurology with Institute of Translational Neurology, University Hospital Muenster, 48149 Muenster, Germany
| | - Julia Krämer
- Department of Neurology with Institute of Translational Neurology, University Hospital Muenster, 48149 Muenster, Germany
| | - Maren Lindner
- Department of Neurology with Institute of Translational Neurology, University Hospital Muenster, 48149 Muenster, Germany
| | - Marianne Riepenhausen
- Department of Neurology with Institute of Translational Neurology, University Hospital Muenster, 48149 Muenster, Germany
| | - Catharina C. Gross
- Department of Neurology with Institute of Translational Neurology, University Hospital Muenster, 48149 Muenster, Germany
| | - Luisa Klotz
- Department of Neurology with Institute of Translational Neurology, University Hospital Muenster, 48149 Muenster, Germany
| | - Stefan Bittner
- Department of Neurology, Focus Program Translational Neuroscience (FTN) and Immunotherapy (FZI), Rhine-Main Neuroscience Network (rmn2), University Medical Center of the Johannes Gutenberg University Mainz, 55131 Mainz, Germany
| | - Paolo A. Muraro
- Department of Brain Sciences, Imperial College London, London, UK
| | - Tilman Schneider-Hohendorf
- Department of Neurology with Institute of Translational Neurology, University Hospital Muenster, 48149 Muenster, Germany
| | - Nicholas Schwab
- Department of Neurology with Institute of Translational Neurology, University Hospital Muenster, 48149 Muenster, Germany
| | - Gerd Meyer zu Hörste
- Department of Neurology with Institute of Translational Neurology, University Hospital Muenster, 48149 Muenster, Germany
| | - Norbert Goebels
- Department of Neurology, Medical Faculty, Heinrich-Heine University Düsseldorf, 40225 Düsseldorf, Germany
| | - Sven G. Meuth
- Department of Neurology with Institute of Translational Neurology, University Hospital Muenster, 48149 Muenster, Germany
- Department of Neurology, Medical Faculty, Heinrich-Heine University Düsseldorf, 40225 Düsseldorf, Germany
| | - Heinz Wiendl
- Department of Neurology with Institute of Translational Neurology, University Hospital Muenster, 48149 Muenster, Germany
- Correspondence may also be addressed to: Univ.-Prof. Prof. h.c. Dr. med. Heinz Wiendl E-mail:
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22
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Kashani N, Kelland EE, Vajdi B, Anderson LM, Gilmore W, Lund BT. Immune Regulatory Cell Bias Following Alemtuzumab Treatment in Relapsing-Remitting Multiple Sclerosis. Front Immunol 2021; 12:706278. [PMID: 34777337 PMCID: PMC8581537 DOI: 10.3389/fimmu.2021.706278] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 09/17/2021] [Indexed: 12/12/2022] Open
Abstract
Alemtuzumab is a highly effective treatment for relapsing-remitting multiple sclerosis. It selectively targets the CD52 antigen to induce profound lymphocyte depletion, followed by recovery of T and B cells with regulatory phenotypes. We previously showed that regulatory T cell function is restored with cellular repletion, but little is known about the functional capacity of regulatory B-cells and peripheral blood monocytes during the repletion phase. In this study (ClinicalTrials.gov ID# NCT03647722) we simultaneously analyzed the change in composition and function of both regulatory lymphocyte populations and distinct monocyte subsets in cross-sectional cohorts of MS patients prior to or 6, 12, 18, 24 or 36 months after their first course of alemtuzumab treatment. We found that the absolute number and percentage of cells with a regulatory B cell phenotype were significantly higher after treatment and were positivity correlated with regulatory T cells. In addition, B cells from treated patients secreted higher levels of IL-10 and BDNF, and inhibited the proliferation of autologous CD4+CD25- T cell targets. Though there was little change in monocytes populations overall, following the second annual course of treatment, CD14+ monocytes had a significantly increased anti-inflammatory bias in cytokine secretion patterns. These results confirmed that the immune system in alemtuzumab-treated patients is altered in favor of a regulatory milieu that involves expansion and increased functionality of multiple regulatory populations including B cells, T cells and monocytes. Here, we showed for the first time that functionally competent regulatory B cells re-appear with similar kinetics to that of regulatory T-cells, whereas the change in anti-inflammatory bias of monocytes does not occur until after the second treatment course. These findings justify future studies of all regulatory cell types following alemtuzumab treatment to reveal further insights into mechanisms of drug action, and to identify key immunological predictors of durable clinical efficacy in alemtuzumab-treated patients.
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Affiliation(s)
- Nicole Kashani
- Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Eve E Kelland
- Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Borna Vajdi
- Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Lauren M Anderson
- Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Wendy Gilmore
- Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Brett T Lund
- Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
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23
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Lymphocyte Counts and Multiple Sclerosis Therapeutics: Between Mechanisms of Action and Treatment-Limiting Side Effects. Cells 2021; 10:cells10113177. [PMID: 34831400 PMCID: PMC8625745 DOI: 10.3390/cells10113177] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 11/04/2021] [Accepted: 11/09/2021] [Indexed: 01/18/2023] Open
Abstract
Although the detailed pathogenesis of multiple sclerosis (MS) is not completely understood, a broad range of disease-modifying therapies (DMTs) are available. A common side effect of nearly every MS therapeutic agent is lymphopenia, which can be both beneficial and, in some cases, treatment-limiting. A sound knowledge of the underlying mechanism of action of the selected agent is required in order to understand treatment-associated changes in white blood cell counts, as well as monitoring consequences. This review is a comprehensive summary of the currently available DMTs with regard to their effects on lymphocyte count. In the first part, we describe important general information about the role of lymphocytes in the course of MS and the essentials of lymphopenic states. In the second part, we introduce the different DMTs according to their underlying mechanism of action, summarizing recommendations for lymphocyte monitoring and definitions of lymphocyte thresholds for different therapeutic regimens.
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24
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Walo-Delgado PE, Monreal E, Medina S, Quintana E, Sainz de la Maza S, Fernández-Velasco JI, Lapuente P, Comabella M, Ramió-Torrentà L, Montalban X, Midaglia L, Villarrubia N, Carrasco-Sayalero A, Rodríguez-Martín E, Roldán E, Meca-Lallana J, Alvarez-Lafuente R, Masjuan J, Costa-Frossard L, Villar LM. Role of B Cell Profile for Predicting Secondary Autoimmunity in Patients Treated With Alemtuzumab. Front Immunol 2021; 12:760546. [PMID: 34691084 PMCID: PMC8531491 DOI: 10.3389/fimmu.2021.760546] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 09/21/2021] [Indexed: 11/27/2022] Open
Abstract
Objective To explore if baseline blood lymphocyte profile could identify relapsing remitting multiple sclerosis (RRMS) patients at higher risk of developing secondary autoimmune adverse events (AIAEs) after alemtuzumab treatment. Methods Multicenter prospective study including 57 RRMS patients treated with alemtuzumab followed for 3.25 [3.5-4.21] years, (median [interquartile range]). Blood samples were collected at baseline, and leukocyte subsets determined by flow cytometry. We had additional samples one year after the first cycle of alemtuzumab treatment in 39 cases. Results Twenty-two patients (38.6%) developed AIAEs during follow-up. They had higher B-cell percentages at baseline (p=0.0014), being differences mainly due to plasmablasts/plasma cells (PB/PC, p=0.0011). Those with no AIAEs had higher percentages of CD4+ T cells (p=0.013), mainly due to terminally differentiated (TD) (p=0.034) and effector memory (EM) (p=0.031) phenotypes. AIAEs- patients also showed higher values of TNF-alpha-producing CD8+ T cells (p=0.029). The percentage of PB/PC was the best variable to differentiate both groups of patients. Baseline values >0.10% closely associated with higher AIAE risk (Odds ratio [OR]: 5.91, 95% CI: 1.83-19.10, p=0.004). When excluding the 12 patients with natalizumab, which decreases blood PB/PC percentages, being the last treatment before alemtuzumab, baseline PB/PC >0.1% even predicted more accurately the risk of AIAEs (OR: 11.67, 95% CI: 2.62-51.89, p=0.0007). The AIAEs+ group continued having high percentages of PB/PC after a year of alemtuzumab treatment (p=0.0058). Conclusions A PB/PC percentage <0.1% at baseline identifies MS patients at low risk of secondary autoimmunity during alemtuzumab treatment.
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Affiliation(s)
- Paulette Esperanza Walo-Delgado
- Department of Immunology, Ramón y Cajal University Hospital, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Red Española de Esclerosis Múltiple (REEM), Madrid, Spain
| | - Enric Monreal
- Department of Neurology, Ramón y Cajal University Hospital, IRYCIS, Red Española de Esclerosis Múltiple (REEM), Madrid, Spain
| | - Silvia Medina
- Department of Immunology, Ramón y Cajal University Hospital, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Red Española de Esclerosis Múltiple (REEM), Madrid, Spain
| | - Ester Quintana
- Neuroimmunology and Multiple Sclerosis Unit, Neurology Department, Neurodegeneration and Neuroinflammation Research Group, Biomedical Research Institute (IDIBGI), Red Española de Esclerosis Múltiple (REEM), Girona, Spain
| | - Susana Sainz de la Maza
- Department of Neurology, Ramón y Cajal University Hospital, IRYCIS, Red Española de Esclerosis Múltiple (REEM), Madrid, Spain
| | - José Ignacio Fernández-Velasco
- Department of Immunology, Ramón y Cajal University Hospital, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Red Española de Esclerosis Múltiple (REEM), Madrid, Spain
| | - Paloma Lapuente
- Department of Immunology, Ramón y Cajal University Hospital, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Red Española de Esclerosis Múltiple (REEM), Madrid, Spain
| | - Manuel Comabella
- Servei de Neurologia-Neuroimmunologia, Centre d'Esclerosi Múltiple de Catalunya (Cemcat), Institut de Recerca Vall d'Hebron (VHIR), Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Red Española de Esclerosis Múltiple (REEM), Barcelona, Spain
| | - Lluis Ramió-Torrentà
- Neuroimmunology and Multiple Sclerosis Unit, Neurology Department, Neurodegeneration and Neuroinflammation Research Group, Biomedical Research Institute (IDIBGI), Red Española de Esclerosis Múltiple (REEM), Girona, Spain
| | - Xavier Montalban
- Servei de Neurologia-Neuroimmunologia, Centre d'Esclerosi Múltiple de Catalunya (Cemcat), Institut de Recerca Vall d'Hebron (VHIR), Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Red Española de Esclerosis Múltiple (REEM), Barcelona, Spain
| | - Luciana Midaglia
- Servei de Neurologia-Neuroimmunologia, Centre d'Esclerosi Múltiple de Catalunya (Cemcat), Institut de Recerca Vall d'Hebron (VHIR), Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Red Española de Esclerosis Múltiple (REEM), Barcelona, Spain
| | - Noelia Villarrubia
- Department of Immunology, Ramón y Cajal University Hospital, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Red Española de Esclerosis Múltiple (REEM), Madrid, Spain
| | - Angela Carrasco-Sayalero
- Department of Immunology, Ramón y Cajal University Hospital, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Red Española de Esclerosis Múltiple (REEM), Madrid, Spain
| | - Eulalia Rodríguez-Martín
- Department of Immunology, Ramón y Cajal University Hospital, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Red Española de Esclerosis Múltiple (REEM), Madrid, Spain
| | - Ernesto Roldán
- Department of Immunology, Ramón y Cajal University Hospital, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Red Española de Esclerosis Múltiple (REEM), Madrid, Spain
| | - José Meca-Lallana
- Department of Neurology, Virgen de la Arrixaca University Hospital, Murcia, Spain
| | - Roberto Alvarez-Lafuente
- Grupo de Investigación de Factores Ambientales en Enfermedades Degenerativas, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos, Hospital Clínico San Carlos, Red Española de Esclerosis Múltiple (REEM), Madrid, Spain
| | - Jaime Masjuan
- Department of Neurology, Ramón y Cajal University Hospital, IRYCIS, Red Española de Esclerosis Múltiple (REEM), Madrid, Spain
| | - Lucienne Costa-Frossard
- Department of Neurology, Ramón y Cajal University Hospital, IRYCIS, Red Española de Esclerosis Múltiple (REEM), Madrid, Spain
| | - Luisa Maria Villar
- Department of Immunology, Ramón y Cajal University Hospital, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Red Española de Esclerosis Múltiple (REEM), Madrid, Spain
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25
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Gabelić T, Barun B, Adamec I, Krbot Skorić M, Habek M. Product review on MAbs (alemtuzumab and ocrelizumab) for the treatment of multiple sclerosis. Hum Vaccin Immunother 2021; 17:4345-4362. [PMID: 34668842 DOI: 10.1080/21645515.2021.1969850] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Traditionally, the management of active relapsing remitting MS was based on the, so-called, maintenance therapy, which is characterized by continuous treatment with particular disease modifying therapy (DMT), and a return of disease activity when the drug is discontinued. Another approach is characterized by a short treatment course of a DMT, which is hypothesized to act as an immune reconstitution therapy (IRT), with the potential to protect against relapses for years after a short course of treatment. Introduction of monoclonal antibodies in the treatment of MS has revolutionized MS treatment in the last decade. However, given the increasingly complex landscape of DMTs approved for MS, people with MS and neurologists are constantly faced with the question which DMT is the most appropriate for the given patient, a question we still do not have an answer to. In this product review, we will discuss the first DMT that acts as IRT, an anti-CD52 monoclonal antibody alemtuzumab and an anti CD20 monoclonal antibody, ocrelizumab that has the potential to act as an IRT, but is administered continuously. Special emphasis will be given on safety in the context of COVID-19 pandemics and vaccination strategies.
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Affiliation(s)
- Tereza Gabelić
- Department of Neurology, University Hospital Center Zagreb, Zagreb, Croatia.,School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Barbara Barun
- Department of Neurology, University Hospital Center Zagreb, Zagreb, Croatia.,School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Ivan Adamec
- Department of Neurology, University Hospital Center Zagreb, Zagreb, Croatia
| | - Magdalena Krbot Skorić
- Department of Neurology, University Hospital Center Zagreb, Zagreb, Croatia.,Faculty of Electrical Engineering and Computing, University of Zagreb, Zagreb, Croatia
| | - Mario Habek
- Department of Neurology, University Hospital Center Zagreb, Zagreb, Croatia.,School of Medicine, University of Zagreb, Zagreb, Croatia
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26
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Qiu X, Li J, Bonenfant J, Jaroszewski L, Mittal A, Klein W, Godzik A, Nair MG. Dynamic changes in human single-cell transcriptional signatures during fatal sepsis. J Leukoc Biol 2021; 110:1253-1268. [PMID: 34558746 DOI: 10.1002/jlb.5ma0721-825r] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 07/30/2021] [Accepted: 09/03/2021] [Indexed: 12/11/2022] Open
Abstract
Systemic infections, especially in patients with chronic diseases, may result in sepsis: an explosive, uncoordinated immune response that can lead to multisystem organ failure with a high mortality rate. Patients with similar clinical phenotypes or sepsis biomarker expression upon diagnosis may have different outcomes, suggesting that the dynamics of sepsis is critical in disease progression. A within-subject study of patients with Gram-negative bacterial sepsis with surviving and fatal outcomes was designed and single-cell transcriptomic analyses of peripheral blood mononuclear cells (PBMC) collected during the critical period between sepsis diagnosis and 6 h were performed. The single-cell observations in the study are consistent with trends from public datasets but also identify dynamic effects in individual cell subsets that change within hours. It is shown that platelet and erythroid precursor responses are drivers of fatal sepsis, with transcriptional signatures that are shared with severe COVID-19 disease. It is also shown that hypoxic stress is a driving factor in immune and metabolic dysfunction of monocytes and erythroid precursors. Last, the data support CD52 as a prognostic biomarker and therapeutic target for sepsis as its expression dynamically increases in lymphocytes and correlates with improved sepsis outcomes. In conclusion, this study describes the first single-cell study that analyzed short-term temporal changes in the immune cell populations and their characteristics in surviving or fatal sepsis. Tracking temporal expression changes in specific cell types could lead to more accurate predictions of sepsis outcomes and identify molecular biomarkers and pathways that could be therapeutically controlled to improve the sepsis trajectory toward better outcomes.
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Affiliation(s)
- Xinru Qiu
- Graduate Program in Genetics, Genomics and Bioinformatics, University of California Riverside, Riverside, California, USA
| | - Jiang Li
- Division of Biomedical Sciences, School of Medicine, University of California Riverside, Riverside, California, USA
| | - Jeff Bonenfant
- Division of Pulmonary and Critical Care, Riverside University Health System Medical Center, Riverside, California, USA.,Department of Internal Medicine, Division of Pulmonary and Critical Care, Loma Linda University, Loma Linda, California, USA
| | - Lukasz Jaroszewski
- Division of Biomedical Sciences, School of Medicine, University of California Riverside, Riverside, California, USA
| | - Aarti Mittal
- Division of Pulmonary and Critical Care, Riverside University Health System Medical Center, Riverside, California, USA
| | - Walter Klein
- Division of Pulmonary and Critical Care, Riverside University Health System Medical Center, Riverside, California, USA
| | - Adam Godzik
- Division of Biomedical Sciences, School of Medicine, University of California Riverside, Riverside, California, USA
| | - Meera G Nair
- Division of Biomedical Sciences, School of Medicine, University of California Riverside, Riverside, California, USA
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27
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Kasarello K, Mirowska-Guzel D. Anti-CD52 Therapy for Multiple Sclerosis: An Update in the COVID Era. Immunotargets Ther 2021; 10:237-246. [PMID: 34268256 PMCID: PMC8273745 DOI: 10.2147/itt.s240890] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 05/22/2021] [Indexed: 01/01/2023] Open
Abstract
CD52 is a small surface glycoprotein composed of 12 amino acids. CD52 is found mostly on the surface of mature immune cells, such as lymphocytes, monocytes, eosinophils, and dendritic cells, as well as the male genital tract: within the epididymis and on the surface of mature sperm. Low CD52 expression is also found in neutrophils. CD52 function is not fully understood, although experiments with anti-CD52 antibodies have shown that CD52 is essential for lymphocyte transendothelial migration and may contribute to costimulation of CD4+ T cells and T-cell activation and proliferation. Although knowledge about exact CD52 function is still poor, CD52 presence on the surface of a broad spectrum of immune cells makes it a therapeutic target, especially in immunomediated diseases, such as multiple sclerosis. In multiple sclerosis, alemtuzumab is registered for adult patients with the relapsing-remitting form of the disease defined by clinical and imaging features. Despite the high efficacy of the drug, the main issue is its safety. The main adverse effects of alemtuzumab are associated with drug infusion due to cytokine release and cytotoxic effects of antibodies associated with lymphocyte depletion, which leads to immunosuppression, and secondary autoimmunity that may be the effect of excessive B-cell repopulation and cancer. This review presents current knowledge on the drug's mechanism of action, efficacy and safety data from clinical trials, and real-world observations, including available though scarce data on using alemtuzumab in the COVID era.
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Affiliation(s)
- Kaja Kasarello
- Department of Experimental and Clinical Physiology, Centre for Preclinical Research, Medical University of Warsaw, Warsaw, Poland
| | - Dagmara Mirowska-Guzel
- Department of Experimental and Clinical Pharmacology, Centre for Preclinical Research, Medical University of Warsaw, Warsaw, Poland
- Second Department of Neurology, Institute of Psychiatry and Neurology, Warsaw, Poland
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28
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Veroni C, Aloisi F. The CD8 T Cell-Epstein-Barr Virus-B Cell Trialogue: A Central Issue in Multiple Sclerosis Pathogenesis. Front Immunol 2021; 12:665718. [PMID: 34305896 PMCID: PMC8292956 DOI: 10.3389/fimmu.2021.665718] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 06/07/2021] [Indexed: 12/11/2022] Open
Abstract
The cause and the pathogenic mechanisms leading to multiple sclerosis (MS), a chronic inflammatory disease of the central nervous system (CNS), are still under scrutiny. During the last decade, awareness has increased that multiple genetic and environmental factors act in concert to modulate MS risk. Likewise, the landscape of cells of the adaptive immune system that are believed to play a role in MS immunopathogenesis has expanded by including not only CD4 T helper cells but also cytotoxic CD8 T cells and B cells. Once the key cellular players are identified, the main challenge is to define precisely how they act and interact to induce neuroinflammation and the neurodegenerative cascade in MS. CD8 T cells have been implicated in MS pathogenesis since the 80's when it was shown that CD8 T cells predominate in MS brain lesions. Interest in the role of CD8 T cells in MS was revived in 2000 and the years thereafter by studies showing that CNS-recruited CD8 T cells are clonally expanded and have a memory effector phenotype indicating in situ antigen-driven reactivation. The association of certain MHC class I alleles with MS genetic risk implicates CD8 T cells in disease pathogenesis. Moreover, experimental studies have highlighted the detrimental effects of CD8 T cell activation on neural cells. While the antigens responsible for T cell recruitment and activation in the CNS remain elusive, the high efficacy of B-cell depleting drugs in MS and a growing number of studies implicate B cells and Epstein-Barr virus (EBV), a B-lymphotropic herpesvirus that is strongly associated with MS, in the activation of pathogenic T cells. This article reviews the results of human studies that have contributed to elucidate the role of CD8 T cells in MS immunopathogenesis, and discusses them in light of current understanding of autoreactivity, B-cell and EBV involvement in MS, and mechanism of action of different MS treatments. Based on the available evidences, an immunopathological model of MS is proposed that entails a persistent EBV infection of CNS-infiltrating B cells as the target of a dysregulated cytotoxic CD8 T cell response causing CNS tissue damage.
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Affiliation(s)
| | - Francesca Aloisi
- Department of Neuroscience, Istituto Superiore di Sanità, Rome, Italy
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29
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Cencioni MT, Mattoscio M, Magliozzi R, Bar-Or A, Muraro PA. B cells in multiple sclerosis - from targeted depletion to immune reconstitution therapies. Nat Rev Neurol 2021; 17:399-414. [PMID: 34075251 DOI: 10.1038/s41582-021-00498-5] [Citation(s) in RCA: 123] [Impact Index Per Article: 41.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/20/2021] [Indexed: 02/04/2023]
Abstract
Increasing evidence indicates the involvement of B cells in the pathogenesis of multiple sclerosis (MS), but their precise roles are unclear. In this Review, we provide an overview of the development and physiological functions of B cells and the main mechanisms through which B cells are thought to contribute to CNS autoimmunity. In MS, abnormalities of B cell function include pro-inflammatory cytokine production, defective B cell regulatory function and the formation of tertiary lymphoid-like structures in the CNS, which are the likely source of abnormal immunoglobulin production detectable in the cerebrospinal fluid. We also consider the hypothesis that Epstein-Barr virus (EBV) is involved in the B cell overactivation that leads to inflammatory injury to the CNS in MS. We also review the immunological effects - with a focus on the effects on B cell subsets - of several successful therapeutic approaches in MS, including agents that selectively deplete B cells (rituximab, ocrelizumab and ofatumumab), agents that less specifically deplete lymphocytes (alemtuzumab and cladribine) and autologous haematopoietic stem cell transplantation, in which the immune system is unselectively ablated and reconstituted. We consider the insights that these effects on B cell populations provide and their potential to further our understanding and targeting of B cells in MS.
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Affiliation(s)
- Maria T Cencioni
- Department of Brain Sciences, Faculty of Medicine, Imperial College London, London, UK
| | - Miriam Mattoscio
- Department of Brain Sciences, Faculty of Medicine, Imperial College London, London, UK
| | - Roberta Magliozzi
- Department of Brain Sciences, Faculty of Medicine, Imperial College London, London, UK.,Department of Neurology, University of Verona, Verona, Italy
| | - Amit Bar-Or
- Center for Neuroinflammation and Experimental Therapeutics and Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Paolo A Muraro
- Department of Brain Sciences, Faculty of Medicine, Imperial College London, London, UK.
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30
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Alborghetti M, Bellucci G, Gentile A, Calderoni C, Nicoletti F, Capra R, Salvetti M, Centonze D. Drugs used in the treatment of multiple sclerosis during COVID-19 pandemic: a critical viewpoint. Curr Neuropharmacol 2021; 20:107-125. [PMID: 33784961 PMCID: PMC9199540 DOI: 10.2174/1570159x19666210330094017] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 03/15/2021] [Accepted: 03/24/2021] [Indexed: 11/22/2022] Open
Abstract
Since COVID-19 has emerged as a word public health problem, attention has been focused on how immune-suppressive drugs used for the treatment of autoimmune disorders influence the risk for SARS-CoV-2 infection and the development of acute respiratory distress syndrome (ARDS). Here, we discuss the disease-modifying agents approved for the treatment of multiple sclerosis (MS) within this context. Interferon (IFN)-β1a and -1b, which display antiviral activity, could be protective in the early stage of COVID-19 infection, although SARS-CoV-2 may have developed resistance to IFNs. However, in the hyperinflammation stage, IFNs may become detrimental by facilitating macrophage invasion in the lung and other organs. Glatiramer acetate and its analogues should not interfere with the development of COVID-19 and may be considered safe. Teriflunomide, a first-line oral drug used in the treatment of relapsing-remitting MS (RRMS), may display antiviral activity by depleting cellular nucleotides necessary for viral replication. The other first-line drug, dimethyl fumarate, may afford protection against SARS-CoV-2 by activating the Nrf-2 pathway and reinforcing the cellular defenses against oxidative stress. Concern has been raised regarding the use of second-line treatments for MS during the COVID-19 pandemic. However, this concern is not always justified. For example, fingolimod might be highly beneficial during the hyperinflammatory stage of COVID-19 for a number of mechanisms, including the reinforcement of the endothelial barrier. Caution is suggested for the use of natalizumab, cladribine, alemtuzumab, and ocrelizumab, although MS disease recurrence after discontinuation of these drugs may overcome a potential risk for COVID-19 infection.
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Affiliation(s)
- Marika Alborghetti
- Departments of Neuroscience Mental Health and Sensory Organs (NESMOS), University Sapienza of Rome. Italy
| | - Gianmarco Bellucci
- Departments of Neuroscience Mental Health and Sensory Organs (NESMOS), University Sapienza of Rome. Italy
| | - Antonietta Gentile
- Synaptic Immunopathology Lab, IRCCS San Raffaele Pisana, 00166 Rome. Italy
| | - Chiara Calderoni
- Departments of Physiology and Pharmacology, University Sapienza of Rome. Italy
| | | | - Ruggero Capra
- Multiple Sclerosis Center, ASST Ospedali Civili, Brescia. Italy
| | - Marco Salvetti
- Departments of Neuroscience Mental Health and Sensory Organs (NESMOS),University Sapienza of Rome. Italy
| | - Diego Centonze
- Department of Systems Medicine, Tor Vergata University, 00133 Rome. Italy
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31
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Sabbah S, Liew A, Brooks AM, Kundu R, Reading JL, Flatt A, Counter C, Choudhary P, Forbes S, Rosenthal MJ, Rutter MK, Cairns S, Johnson P, Casey J, Peakman M, Shaw JA, Tree TIM. Autoreactive T cell profiles are altered following allogeneic islet transplantation with alemtuzumab induction and re-emerging phenotype is associated with graft function. Am J Transplant 2021; 21:1027-1038. [PMID: 32865886 DOI: 10.1111/ajt.16285] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 07/15/2020] [Accepted: 08/10/2020] [Indexed: 01/25/2023]
Abstract
Islet transplantation is an effective therapy for life-threatening hypoglycemia, but graft function gradually declines over time in many recipients. We characterized islet-specific T cells in recipients within an islet transplant program favoring alemtuzumab (ATZ) lymphodepleting induction and examined associations with graft function. Fifty-eight recipients were studied: 23 pretransplant and 40 posttransplant (including 5 with pretransplant phenotyping). The proportion with islet-specific T cell responses was not significantly different over time (pre-Tx: 59%; 1-6 m posttransplant: 38%; 7-12 m: 44%; 13-24 m: 47%; and >24 m: 45%). However, phenotype shifted significantly, with IFN-γ-dominated response in the pretransplant group replaced by IL-10-dominated response in the 1-6 m posttransplant group, reverting to predominantly IFN-γ-oriented response in the >24 m group. Clustering analysis of posttransplant responses revealed two main agglomerations, characterized by IFN-γ and IL-10 phenotypes, respectively. IL-10-oriented posttransplant response was associated with relatively low graft function. Recipients within the IL-10+ cluster had a significant decline in C-peptide levels in the period preceding the IL-10 response, but stable graft function following the response. In contrast, an IFN-γ response was associated with subsequently decreased C-peptide. Islet transplantation favoring ATZ induction is associated with an initial altered islet-specific T cell phenotype but reversion toward pretransplant profiles over time. Posttransplant autoreactive T cell phenotype may be a predictor of subsequent graft function.
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Affiliation(s)
- Shereen Sabbah
- Department of Immunobiology, Faculty of Life Sciences & Medicine, King's College London, London, UK.,NIHR Biomedical Research Centre, Guy's and St Thomas' NHS Foundation Trust and King's College London, London, UK
| | - Aaron Liew
- Newcastle University Translational and Clinical Research Institute, Newcastle, UK
| | - Augustin M Brooks
- Newcastle University Translational and Clinical Research Institute, Newcastle, UK
| | - Rhiannon Kundu
- Department of Immunobiology, Faculty of Life Sciences & Medicine, King's College London, London, UK.,NIHR Biomedical Research Centre, Guy's and St Thomas' NHS Foundation Trust and King's College London, London, UK
| | - James L Reading
- Department of Immunobiology, Faculty of Life Sciences & Medicine, King's College London, London, UK.,NIHR Biomedical Research Centre, Guy's and St Thomas' NHS Foundation Trust and King's College London, London, UK
| | - Anneliese Flatt
- Newcastle University Translational and Clinical Research Institute, Newcastle, UK
| | - Claire Counter
- Organ Donation and Transplantation, NHS Blood and Transplant, Bristol, UK
| | - Pratik Choudhary
- Diabetes Research Group, Guy's, King's and St. Thomas' School of Medicine, King's College London, London, UK
| | - Shareen Forbes
- Edinburgh Transplant Centre and Endocrinology Unit, University of Edinburgh, Edinburgh, UK
| | | | - Martin K Rutter
- Division of Diabetes, Endocrinology and Gastroenterology, Faculty of Biology, Medicine and Health, School of Medical Sciences, University of Manchester, Manchester, UK.,Diabetes, Endocrinology and Metabolism Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Stephanie Cairns
- Clinical Immunology Department, Scottish National Blood Transfusion Service, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Paul Johnson
- Oxford Centre for Diabetes Endocrinology and Metabolism, University of Oxford, Oxford, UK
| | - John Casey
- Edinburgh Transplant Centre and Endocrinology Unit, University of Edinburgh, Edinburgh, UK
| | - Mark Peakman
- Department of Immunobiology, Faculty of Life Sciences & Medicine, King's College London, London, UK.,NIHR Biomedical Research Centre, Guy's and St Thomas' NHS Foundation Trust and King's College London, London, UK
| | - James A Shaw
- Newcastle University Translational and Clinical Research Institute, Newcastle, UK.,Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Timothy I M Tree
- Department of Immunobiology, Faculty of Life Sciences & Medicine, King's College London, London, UK.,NIHR Biomedical Research Centre, Guy's and St Thomas' NHS Foundation Trust and King's College London, London, UK
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Benazzo A, Cho A, Nechay A, Schwarz S, Frommlet F, Wekerle T, Hoetzenecker K, Jaksch P. Combined low-dose everolimus and low-dose tacrolimus after Alemtuzumab induction therapy: a randomized prospective trial in lung transplantation. Trials 2021; 22:6. [PMID: 33397442 PMCID: PMC7783986 DOI: 10.1186/s13063-020-04843-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 10/23/2020] [Indexed: 11/28/2022] Open
Abstract
Background Long-term outcomes of lung transplantation are severely affected by comorbidities and development of chronic rejection. Among the comorbidities, kidney insufficiency is one of the most frequent and it is mainly caused by the cumulative effect of calcineurin inhibitors (CNIs). Currently, the most used immunosuppression protocols worldwide include induction therapy and a triple-drug maintenance immunosuppression, with one calcineurin inhibitor, one anti-proliferative drug, and steroids. Our center has pioneered the use of alemtuzumab as induction therapy, showing promising results in terms of short- and long-term outcomes. The use of alemtuzumab followed by a low-dose double drug maintenance immunosuppression, in fact, led to better kidney function along with excellent results in terms of acute rejection, chronic lung allograft dysfunction, and survival (Benazzo et al., PLoS One 14(1):e0210443, 2019). The hypothesis driving the proposed clinical trial is that de novo introduction of low-dose everolimus early after transplantation could further improve kidney function via a further reduction of tacrolimus. Based on evidences from kidney transplantation, moreover, alemtuzumab induction therapy followed by a low-dose everolimus and low-dose tacrolimus may have a permissive action on regulatory immune cells thus stimulating allograft acceptance. Methods A randomized prospective clinical trial has been set up to answer the research hypothesis. One hundred ten patients will be randomized in two groups. Treatment group will receive the new maintenance immunosuppression protocol based on low-dose tacrolimus and low-dose everolimus and the control group will receive our standard immunosuppression protocol. Both groups will receive alemtuzumab induction therapy. The primary endpoint of the study is to analyze the effect of the new low-dose immunosuppression protocol on kidney function in terms of eGFR change. The study will have a duration of 24 months from the time of randomization. Immunomodulatory status of the patients will be assessed with flow cytometry and gene expression analysis. Discussion For the first time in the field of lung transplantation, this trial proposes the combined use of significantly reduced tacrolimus and everolimus after alemtuzumab induction. The new protocol may have a twofold advantage: (1) further reduction of nephrotoxic tacrolimus and (2) permissive influence on regulatory cells development with further reduction of rejection episodes. Trial registration EUDRACT Nr 2018-001680-24. Registered on 15 May 2018
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Affiliation(s)
| | - Ara Cho
- Medizinische Universitat Wien, Vienna, Austria
| | - Anna Nechay
- Medizinische Universitat Wien, Vienna, Austria
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Jalkh G, Abi Nahed R, Macaron G, Rensel M. Safety of Newer Disease Modifying Therapies in Multiple Sclerosis. Vaccines (Basel) 2020; 9:12. [PMID: 33375365 PMCID: PMC7823546 DOI: 10.3390/vaccines9010012] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Revised: 08/06/2020] [Accepted: 08/11/2020] [Indexed: 12/14/2022] Open
Abstract
In the past decade, the therapeutic arsenal for multiple sclerosis has expanded greatly. Newer more potent disease modifying therapies (DMTs) with varying mechanisms of actions are increasingly used early in the disease course. These newer DMTs include oral therapies (teriflunomide, dimethyl fumarate, fingolimod, siponimod, ozanimod, and cladribine) and infusion therapies (natalizumab, alemtuzumab, and ocrelizumab), and are associated with better control of disease activity and long-term outcomes in patients with MS compared to older injectable therapies (interferon beta and glatiramer acetate). However, they are associated with safety concerns and subsequent monitoring requirements. Adverse events are initially observed in phase 2 and 3 clinical trials, and further long-term data are collected in phase 3 extension studies, case series, and post-marketing reports, which highlight the need to periodically re-evaluate and adjust monitoring strategies to optimize treatment safety in an individualized approach.
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Affiliation(s)
- Georges Jalkh
- Department of Neurology, Faculty of Medicine, Université Saint Joseph, Beirut B.P. 11-5076, Lebanon; (G.J.); (R.A.N.); (G.M.)
- Department of Neurology, Hotel-Dieu de France Hospital, Beirut 16-6830, Lebanon
| | - Rachelle Abi Nahed
- Department of Neurology, Faculty of Medicine, Université Saint Joseph, Beirut B.P. 11-5076, Lebanon; (G.J.); (R.A.N.); (G.M.)
- Department of Neurology, Hotel-Dieu de France Hospital, Beirut 16-6830, Lebanon
| | - Gabrielle Macaron
- Department of Neurology, Faculty of Medicine, Université Saint Joseph, Beirut B.P. 11-5076, Lebanon; (G.J.); (R.A.N.); (G.M.)
- Department of Neurology, Hotel-Dieu de France Hospital, Beirut 16-6830, Lebanon
- Mellen Center for Multiple Sclerosis, Neurological Institute, Cleveland Clinic Foundation, Cleveland, OH 44195, USA
| | - Mary Rensel
- Mellen Center for Multiple Sclerosis, Neurological Institute, Cleveland Clinic Foundation, Cleveland, OH 44195, USA
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Abstract
Alemtuzumab (Lemtrada®) is an anti-CD52 monoclonal antibody approved in the EU for the treatment of highly active relapsing-remitting multiple sclerosis (RRMS). In phase 3 trials in patients with active RRMS, intravenous alemtuzumab was more effective than subcutaneous interferon β-1a in terms of decreasing relapse rates (in treatment-naïve or -experienced patients) and disability progression (treatment-experienced patients). Treatment benefits were maintained over up to 9 years of follow-up, with ≈ 50% of patients not requiring retreatment. The efficacy of alemtuzumab in patients with highly active disease was generally similar to that in the overall population. Alemtuzumab has an acceptable tolerability profile, with infusion-associated reactions, infections and autoimmunity being the main safety and tolerability issues. Current evidence indicates that alemtuzumab is an effective treatment option for adults with highly active RRMS, with an acceptable safety and tolerability profile and convenient treatment regimen.
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Affiliation(s)
- Yahiya Y Syed
- Springer Nature, Mairangi Bay, Private Bag 65901, Auckland, 0754, New Zealand.
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35
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Alemtuzumab outcomes by age: Post hoc analysis from the randomized CARE-MS studies over 8 years. Mult Scler Relat Disord 2020; 49:102717. [PMID: 33476880 DOI: 10.1016/j.msard.2020.102717] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 11/25/2020] [Accepted: 12/21/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND Alemtuzumab significantly improved clinical and MRI outcomes vs. subcutaneous interferon beta-1a (SC IFNB-1a) in the CARE-MS trials (NCT00530348, NCT00548405), with sustained efficacy in 2 consecutive extensions (NCT00930553, NCT02255656 [TOPAZ]). METHODS Post hoc analysis of 8-year alemtuzumab efficacy and safety in pooled CARE-MS patients (N=811) stratified by baseline age (≥18 to ≤25, >25 to ≤35, >35 to ≤45, >45 to ≤55 years). RESULTS Compared with SC IFNB-1a over 2 years across age cohorts, alemtuzumab lowered annualized relapse rates (ARR; 0.22-0.24 vs. 0.38-0.51), improved or stabilized disability (freedom from 6-month confirmed disability worsening [CDW]: 85%-92% vs. 62%-88%; achievement of 6-month confirmed disability improvement [CDI]: 20%-31% vs. 13%-25%), increased proportions free of MRI disease activity (70%-86% vs. 42%-63% per year), and slowed brain volume loss (BVL; -0.45% to -0.87% vs. -0.50% to -1.39%). Through Year 2, the treatment effect with alemtuzumab did not significantly differ among age groups for ARR (p-interaction=0.6325), 6-month CDW-free (p-interaction=0.4959), 6-month CDI (p-interaction=0.9268), MRI disease activity-free (p-interaction=0.6512), and BVL (p-interaction=0.4970). Alemtuzumab remained effective on outcomes through Year 8 across age groups. Age-related increases in malignancies (≤45 years: 0.9%-2.2% vs. >45 years: 8.1%) and deaths (0%-1.7% vs. 7.0%) were observed. Serious infections also increased from the youngest (5.1%) to oldest (12.8%) age cohorts. CONCLUSIONS Alemtuzumab had greater efficacy than SC IFNB-1a over 2 years across comparable age groups, with no significant differences between alemtuzumab-treated age groups. Efficacy on relapse, disability, and MRI outcomes continued through Year 8 across age groups. Age-related increases in serious infections, malignancies, and deaths were observed.
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36
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Hsueh MF, Zhang X, Wellman SS, Bolognesi MP, Kraus VB. Synergistic Roles of Macrophages and Neutrophils in Osteoarthritis Progression. Arthritis Rheumatol 2020; 73:89-99. [PMID: 32783329 DOI: 10.1002/art.41486] [Citation(s) in RCA: 71] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Revised: 07/21/2020] [Accepted: 07/28/2020] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To evaluate the role of immune cells and their effector cytokines in the pathogenesis and progression of knee osteoarthritis (OA) in matched OA synovial fluid (SF) and synovial tissue samples. METHODS Cells from matched samples of synovial tissue and SF acquired from individuals undergoing total knee replacement for OA (n = 39) were characterized for immune cell-associated surface markers and intracellular cytokine expression using polychromatic flow cytometry. Additional individuals with radiographic knee OA (Kellgren/Lawrence severity grades ≥1) who had available etarfolatide (inflammatory cell) imaging (n = 26) or baseline and 3-year data on progression of radiographic knee OA (n = 85) were also assessed. SF cytokine concentrations in all cohorts were evaluated for associations with synovial tissue and SF cell phenotypes and severity of radiographic knee OA. RESULTS Macrophages (predominant in the synovial tissue, 53% of total cells) and neutrophils (predominant in the SF, 26% of total cells) were the major immune cell populations identified in the OA knee joints, exhibiting expression of or association with transforming growth factor β1 (TGFβ1) and elastase, respectively, in the SF. Expression levels of TGFβ1 and elastase were significantly associated with severity of radiographic knee OA. Baseline SF concentrations of TGFβ1 and elastase along with radiographic knee OA severity scores were predictive of knee OA progression, with areas under the receiver operating characteristic curves of 0.810 (for TGFβ1), 0.806 (for elastase), and 0.846 (for both TGFβ1 and elastase combined), with greater stability of prediction when both markers were utilized. CONCLUSION Our findings demonstrate the hitherto underappreciated role of neutrophils in the sterile inflammatory process and progression of OA. Two soluble mediators, SF elastase and TGFβ1, are strong predictors of knee OA progression, reflecting a synergistic role of neutrophil and macrophage populations in the pathogenesis and worsening of OA that could potentially be utilized to identify patients who may have a greater risk of more rapid disease progression.
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Affiliation(s)
| | - Xin Zhang
- Duke University, Durham, North Carolina
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Fereidan-Esfahani M, Tobin WO. Cyclophosphamide in treatment of tumefactive multiple sclerosis. Mult Scler Relat Disord 2020; 47:102627. [PMID: 33246262 DOI: 10.1016/j.msard.2020.102627] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 10/29/2020] [Accepted: 11/10/2020] [Indexed: 11/19/2022]
Abstract
OBJECTIVE . To review the Mayo clinic experience of cyclophosphamide in the treatment of tumefactive Multiple Sclerosis (TMS). METHODS . Retrospective chart review was performed to identify patients with TMS who did not respond to corticosteroid and plasma exchange and were treated with cyclophosphamide. Demographic, clinical, treatment, and outcome parameters were collected. RESULTS . We identified 12 patients with TMS who were treated with cyclophosphamide. Median follow-up was 17 (range 1-72) months after cyclophosphamide administration. The tumefactive attack was the first clinical symptom in 5/12 patients. The median age at index attack onset was 36 (range 22-57). The median age at the first demyelinating attack was 29.3 (range 20-55). The most common clinical presentation at the index attack was the visual disturbance, followed by motor symptoms. The index attack was accompanied by headache in 5/12 patients. Median attack related Expanded Disability Status Scale (EDSS) score was 6 (range 3-9.5), which improved to 5.25 (range 1-10) after treatment with cyclophosphamide. All patients were treated with corticosteroids and plasma exchange prior to treatment with cyclophosphamide. EDSS score improved in 8/12 patients and targeted neurological deficits improved to a moderate or marked degree in 9/12 patients after cyclophosphamide administration. The number of gadolinium enhancing lesions decreased in 10/12 and 8/12 patients had lack of disease activity (no new T2 or GAD lesions) in a median (range) time of 11 months (1-16) after the last dose of cyclophosphamide. CONCLUSION . Cyclophosphamide could be an effective option for the treatment of TMS, refractory to corticosteroids and plasmapheresis, and is associated with improvement of clinical and radiological disease activity.
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Affiliation(s)
- Mahboobeh Fereidan-Esfahani
- Department of Neurology, Mayo Clinic Rochester, MN, USA; Center for Multiple Sclerosis and Autoimmune Neurology, Mayo Clinic Rochester, MN, USA
| | - W Oliver Tobin
- Department of Neurology, Mayo Clinic Rochester, MN, USA; Center for Multiple Sclerosis and Autoimmune Neurology, Mayo Clinic Rochester, MN, USA.
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Hilger C, Riedhammer C, Orsó E, Weissert R. Effects of Alemtuzumab on (Auto)antigen-Specific Immune Responses. Front Immunol 2020; 11:563645. [PMID: 33133074 PMCID: PMC7578345 DOI: 10.3389/fimmu.2020.563645] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 09/21/2020] [Indexed: 11/13/2022] Open
Abstract
Alemtuzumab (anti-CD52 mAb) leads to a long-lasting disease activity suppression in patients with relapsing forms of multiple sclerosis (MS). In this study, we examined the change of the immune cell repertoire and the cellular reactivity after treatment with alemtuzumab. We analyzed the number of IFN-γ–secreting cells in presence of several peptides which had been eluted from the central nervous system (CNS) of MS patients and are possible targets of autoreactive T cells in MS. The patients showed a stabilized disease activity measured in clinical parameters and lesion formation after the treatment. We detected a reduction of the number of IFN-γ–secreting cells in the presence of every tested self-antigen. The number of IFN-γ–secreting cells was also reduced in the presence of non-self-antigens. We also found a clear change in the immune cell repertoire. After an almost complete depletion of all lymphocytes, the cell specificities showed different reconstitution patterns, resulting in different cell fractions. The percentage of CD4+ T cells was clearly reduced after therapy, whereas the fractions of B and NK cells were elevated. When we evaluated the number of IFN-γ–secreting cells in relation to the number of present CD4+ T cells, we still found a significant reduction. We conclude that the reduction of IFN-γ–secreting cells by alemtuzumab is not only due to a reduction of the CD4+ T cell fraction within the peripheral blood mononuclear cell (PBMC) compartment but might also be caused by functional changes or a shift in the distribution of different subtypes in the CD4+ T cell pool.
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Affiliation(s)
- Clara Hilger
- Department of Neurology, University Hospital of Regensburg, Regensburg, Germany
| | | | - Evelyn Orsó
- Institute for Clinical Chemistry and Laboratory Medicine, University Hospital of Regensburg, Regensburg, Germany
| | - Robert Weissert
- Department of Neurology, University Hospital of Regensburg, Regensburg, Germany
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Sovetkina A, Nadir R, Scalfari A, Tona F, Murphy K, Rigoni E, Dorsey R, Malik O, Nandoskar A, Singh-Curry V, Nicholas R, Martin N. Development of Autoimmune Thyroid Disease in Multiple Sclerosis Patients Post-Alemtuzumab Improves Treatment Response. J Clin Endocrinol Metab 2020; 105:5872006. [PMID: 32667988 DOI: 10.1210/clinem/dgaa453] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Accepted: 07/12/2020] [Indexed: 01/16/2023]
Abstract
CONTEXT Alemtuzumab is an anti-CD52 monoclonal antibody used in the treatment of relapsing-remitting multiple sclerosis (MS). Between 20% and 40% of alemtuzumab-treated MS patients develop autoimmune thyroid disease (AITD) as a side effect. OBJECTIVE The objective of this work is to determine whether MS disease progression following alemtuzumab treatment differs in patients who develop AITD compared to those who do not. DESIGN, SETTING, AND PATIENTS A retrospective analysis of 126 patients with relapsing-remitting MS receiving alemtuzumab from 2012 to 2017 was conducted at a tertiary referral center. MAIN OUTCOME MEASURES Thyroid status, new relapses, Expanded Disability Status Scale (EDSS) score change, and disability progression following alemtuzumab were evaluated. RESULTS Twenty-six percent (33 out of 126, 25 female, 8 male) of alemtuzumab-treated patients developed AITD, 55% of which was Graves disease. EDSS score following alemtuzumab was reduced in patients who developed AITD compared to those who did not (median [interquartile range]; AITD: -0.25 [-1 to 0.5] vs non-AITD: 0 [1-0]. P = .007]. Multivariable regression analysis confirmed that the development of AITD was independently associated with EDSS score improvement (P = .011). Moreover, AITD patients had higher relapse-free survival following alemtuzumab (P = .023). There was no difference in the number of new focal T2 lesions and contrast-enhancing magnetic resonance imaging lesions developed following alemtuzumab between the 2 groups. CONCLUSION Graves disease was the most common form of AITD developed by MS patients following alemtuzumab. This study suggests that MS patients who develop AITD may have an improved response to alemtuzumab, as measured by reduced disability and lower relapse rate.
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Affiliation(s)
- Alina Sovetkina
- Section of Endocrinology and Investigative Medicine, Imperial College London, London, UK
| | - Rans Nadir
- Section of Endocrinology and Investigative Medicine, Imperial College London, London, UK
| | - Antonio Scalfari
- Department of Neurology, Imperial Healthcare NHS Trust, London, UK
| | - Francesca Tona
- Department of Radiology, Imperial College Healthcare NHS Trust, London, UK
| | - Kevin Murphy
- Section of Endocrinology and Investigative Medicine, Imperial College London, London, UK
| | - Eleonora Rigoni
- Department of Neurology, Imperial Healthcare NHS Trust, London, UK
| | - Rachel Dorsey
- Department of Pharmacy, Imperial Healthcare NHS Trust, London, UK
| | - Omar Malik
- Department of Neurology, Imperial Healthcare NHS Trust, London, UK
| | | | | | - Richard Nicholas
- Department of Neurology, Imperial Healthcare NHS Trust, London, UK
| | - Niamh Martin
- Section of Endocrinology and Investigative Medicine, Imperial College London, London, UK
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Matías-Guiu J, Montero-Escribano P, Pytel V, Porta-Etessam J, Matias-Guiu JA. Potential COVID-19 infection in patients with severe multiple sclerosis treated with alemtuzumab. Mult Scler Relat Disord 2020; 44:102297. [PMID: 32554284 PMCID: PMC7286822 DOI: 10.1016/j.msard.2020.102297] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 05/20/2020] [Accepted: 06/09/2020] [Indexed: 01/08/2023]
Abstract
BACKGROUND Management of disease-modifying therapies in Multiple Sclerosis (MS) during the COVID-19 pandemic is a controversial issue. Alemtuzumab is an immunosuppressive drug that induces lymphocytes depletion. In this study, we aimed to evaluate the frequency and severity of COVID-19 in a case series of patients treated with alemtuzumab in our center. METHODS Ten patients with a diagnosis of relapsing-remitting MS were phoned and asked about symptoms suggestive and COVID-19 using a semi-structured questionnaire. RESULTS The mean age was 43.7 ± 9.65 years old, and 8 (80%) were females. The mean time since disease diagnosis was 17.30 ± 8.59 years, and all were patients with relapsing-remitting MS. Mean time from the last dose of Alemtuzumab was 9.80 ± 6.64 months, and last lymphocyte count was 760 ± 231 / μL. Two patients (20%) developed symptoms highly suggestive of COVID-19. Disease duration was 2 and 7 days. None patient required hospital admission. Patients with COVID-19 symptoms had longer clinical course of MS. Conversely, we did not find statistically significant differences regarding age, EDSS, last lymphocyte count, and months since the last dose of alemtuzumab administered between patients having or not symptoms of COVID-19. CONCLUSIONS Our data suggest that patients receiving alemtuzumab showed very mild symptoms of COVID-19. We speculate that immune reconstitution induced by treatment may induce positive changes in the immune system in the defense against SARS-CoV2. Further research about alemtuzumab and their role in COVID-infection is necessary to confirm these preliminary findings.
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Affiliation(s)
- Jorge Matías-Guiu
- Department of Neurology, Institute of Neurosciences. Hospital Clínico San Carlos. San Carlos Health Research Institute (IdISSC). Universidad Complutense de Madrid, Profesor Martín Lagos s/n., 28040 Madrid, Spain
| | - Paloma Montero-Escribano
- Department of Neurology, Institute of Neurosciences. Hospital Clínico San Carlos. San Carlos Health Research Institute (IdISSC). Universidad Complutense de Madrid, Profesor Martín Lagos s/n., 28040 Madrid, Spain
| | - Vanesa Pytel
- Department of Neurology, Institute of Neurosciences. Hospital Clínico San Carlos. San Carlos Health Research Institute (IdISSC). Universidad Complutense de Madrid, Profesor Martín Lagos s/n., 28040 Madrid, Spain
| | - Jesús Porta-Etessam
- Department of Neurology, Institute of Neurosciences. Hospital Clínico San Carlos. San Carlos Health Research Institute (IdISSC). Universidad Complutense de Madrid, Profesor Martín Lagos s/n., 28040 Madrid, Spain
| | - Jordi A Matias-Guiu
- Department of Neurology, Institute of Neurosciences. Hospital Clínico San Carlos. San Carlos Health Research Institute (IdISSC). Universidad Complutense de Madrid, Profesor Martín Lagos s/n., 28040 Madrid, Spain.
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Moser T, Akgün K, Proschmann U, Sellner J, Ziemssen T. The role of TH17 cells in multiple sclerosis: Therapeutic implications. Autoimmun Rev 2020; 19:102647. [PMID: 32801039 DOI: 10.1016/j.autrev.2020.102647] [Citation(s) in RCA: 147] [Impact Index Per Article: 36.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 03/08/2020] [Indexed: 12/13/2022]
Abstract
Multiple sclerosis (MS) is an inflammatory demyelinating disease of the central nervous system (CNS) where immunopathology is thought to be mediated by myelin-reactive CD4+ T helper (TH) cells. The TH cells most commonly implicated in the pathogenesis of the disease are of TH1 and TH17 lineage, which are defined by the production of interferon-γ and interleukin-17, respectively. Moreover, there is emerging evidence for the involvement of TH17.1 cells, which share the hallmarks of TH1 and TH17 subsets. In this review, we summarise current knowledge about the potential role of TH17 subsets in the initiation and progression of the disease and put a focus on their response to approved immunomodulatory MS drugs. In this regard, TH17 cells are abundant in peripheral blood, cerebrospinal fluid and brain lesions of MS patients, and their counts and inflammatory mediators are further increased during relapses. Fingolimod and alemtuzumab induce a paramount decrease in central memory T cells, which harbour the majority of peripheral TH17 cells, while the efficacy of natalizumab, dimethyl fumarate and importantly hematopoietic stem cell therapy correlates with TH17.1 cell inhibition. Interestingly, also CD20 antibodies target highly inflammatory TH cells and hamper TH17 differentiation by IL-6 reductions. Moreover, recovery rates of TH cells best correlate with long-term efficacy after therapeutical immunodepletion. We conclude that central memory TH17.1 cells play a pivotal role in MS pathogenesis and they represent a major target of MS therapeutics.
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Affiliation(s)
- Tobias Moser
- Center of Clinical Neuroscience, University Hospital Carl Gustav Carus, Dresden University of Technical, Fetscherstrasse 74, 01307 Dresden, Germany; Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University, Ignaz-Harrer-Straße 79, 5020 Salzburg, Austria
| | - Katja Akgün
- Center of Clinical Neuroscience, University Hospital Carl Gustav Carus, Dresden University of Technical, Fetscherstrasse 74, 01307 Dresden, Germany
| | - Undine Proschmann
- Center of Clinical Neuroscience, University Hospital Carl Gustav Carus, Dresden University of Technical, Fetscherstrasse 74, 01307 Dresden, Germany
| | - Johann Sellner
- Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University, Ignaz-Harrer-Straße 79, 5020 Salzburg, Austria; Department of Neurology, Landesklinikum Mistelbach-Gänserndorf, Liechtensteinstrasse 67, 3120 Mistelbach, Austria; Department of Neurology, Klinikum rechts der Isar, Technische Universität München, Ismaninger Strasse 22, 81675 München, Germany
| | - Tjalf Ziemssen
- Center of Clinical Neuroscience, University Hospital Carl Gustav Carus, Dresden University of Technical, Fetscherstrasse 74, 01307 Dresden, Germany.
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Hamdy SM, Abdel-Naseer M, Shehata HS, Hassan A, Elmazny A, Shalaby NM, Abokrysha NT, Kishk NA, Nada MAF, Ahmed SM, Hegazy MI, Mekkawy D, Mourad HS, Abdelalim A, Berger T. Managing Disease-Modifying Therapies and Breakthrough Activity in Multiple Sclerosis Patients During the COVID-19 Pandemic: Toward an Optimized Approach. Ther Clin Risk Manag 2020; 16:651-662. [PMID: 32801722 PMCID: PMC7398889 DOI: 10.2147/tcrm.s257714] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 06/21/2020] [Indexed: 12/12/2022] Open
Abstract
The emergence of the novel coronavirus disease 2019 (COVID-19) pandemic has become a major public health challenge of global concern since December 2019, when the virus was recognized in Wuhan, the capital city of Hubei province in China and epicenter of the COVID-19 epidemic. Given the novelty of COVID-19 and the lack of specific anti-virus therapies, the current management is essentially supportive. There is an absence of consensus on guidelines or treatment strategies for complex disorders such as multiple sclerosis (MS), in which the risk of infections is higher than in the general population. This is due to the overall impairment of the immune system typical of autoimmune diseases, in addition to accumulation of disabilities, and the iatrogenic effect generated by corticosteroids and the recommended disease-modifying therapies (DMTs). DMTs have different modes of action, but all modulate and interfere with the patient's immune response, thereby raising concerns about adverse effects, such as an increased susceptibility to infections. In this review, we analyze the evidence for use of DMTs during the current critical period and ratify an algorithmic approach for management to optimize care between keeping DMTs, with their infection hazards, or coming off them, with the risk of disease activation. We also provide an algorithmic approach to the management of breakthrough activity during the COVID-19 pandemic.
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Affiliation(s)
- Sherif M Hamdy
- Neurology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Maged Abdel-Naseer
- Neurology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Hatem S Shehata
- Neurology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Amr Hassan
- Neurology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Alaa Elmazny
- Neurology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Nevin M Shalaby
- Neurology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Noha T Abokrysha
- Neurology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Nirmeen A Kishk
- Neurology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Mona A F Nada
- Neurology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Sandra M Ahmed
- Neurology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Mohamed I Hegazy
- Neurology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Doaa Mekkawy
- Neurology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Husam S Mourad
- Neurology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Ahmed Abdelalim
- Neurology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Thomas Berger
- Neurology Department, Medical University of Vienna, Vienna, Austria
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Lycke J, Lenhoff S. Intensive immunosuppression followed by autologous hematopoietic stem cell transplantation for the treatment of multiple sclerosis. Ther Adv Neurol Disord 2020; 13:1756286420929467. [PMID: 32636931 PMCID: PMC7315665 DOI: 10.1177/1756286420929467] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Accepted: 03/22/2020] [Indexed: 12/20/2022] Open
Abstract
Autologous hematopoietic stem cell transplantation (AHSCT) to treat multiple sclerosis (MS) has mostly been used in devastating cases as the last option to stop further neurological deterioration. However, evidence from several retrospective clinical trials indicates that young, less disabled patients with highly inflammatory active MS are the most likely to benefit from AHSCT, and after moving from high-intensity to nonmyeloablative procedures the tolerability of AHSCT has increased and its associated risk and mortality have declined considerably. Recent meta-analyses and randomized clinical trials show that AHSCT is more effective than currently approved disease-modifying therapies (DMTs), with suppression of disease activity in 70-90% of patients and long-term cessation of disease activity in two-thirds of treated patients. The rationale for AHSCT is to eliminate autoimmunity and achieve immune resetting by intense immunosuppression followed by infusion of autologous hematopoietic stem cells. Similar effects on the immune system have been suggested for cladribine and alemtuzumab treatment and, together with AHSCT, they constitute the induction or immune-reconstitution therapies for MS. Although, further randomized controlled trials of AHSCT for MS are needed, it has become clear that improved patient selection and lower intensity conditioning regimens have reduced AHSCT associated risks and mortality and strengthened the position of AHSCT among other DMTs. Do we have enough experience and scientific support for AHSCT in MS to move from an exclusive treatment for aggressive, treatment-resistant MS and acquire broader indications, similar to other effective DMTs?
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Affiliation(s)
- Jan Lycke
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Gröna stråket 11, 3 tr, Sahlgrenska University Hospital, Gothenburg, 415 45, Sweden
| | - Stig Lenhoff
- Department of Hematology, Oncology and Radiophysics, Skane University Hospital, Lund, Sweden
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Steingo B, Al Malik Y, Bass AD, Berkovich R, Carraro M, Fernández Ó, Ionete C, Massacesi L, Meuth SG, Mitsikostas DD, Pardo G, Simm RF, Traboulsee A, Choudhry Z, Daizadeh N, Compston DAS. Long-term efficacy and safety of alemtuzumab in patients with RRMS: 12-year follow-up of CAMMS223. J Neurol 2020; 267:3343-3353. [PMID: 32583052 PMCID: PMC7578137 DOI: 10.1007/s00415-020-09983-1] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Revised: 06/04/2020] [Accepted: 06/06/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND In the phase 2 CAMMS223 trial (NCT00050778), alemtuzumab significantly improved clinical and MRI outcomes versus subcutaneous interferon beta-1a over 3 years in treatment-naive patients with relapsing-remitting MS. Here, we assess efficacy and safety of alemtuzumab over 12 years in CAMMS223 patients who enrolled in the CAMMS03409 extension (NCT00930553), with available follow-up through the subsequent TOPAZ extension (NCT02255656). METHODS In CAMMS223, patients received 2 alemtuzumab courses (12 mg/day; baseline: 5 days; 12 months later: 3 days); 22% received a third course. In the open-label, nonrandomized extensions, patients could receive as-needed additional alemtuzumab or other disease-modifying therapies. RESULTS Of 108 alemtuzumab-treated patients in CAMMS223, 60 entered the CAMMS03409 extension; 33% received a total of 2 alemtuzumab courses, and 73% received no more than 3 courses through Year 12. Over 12 years, annualized relapse rate was 0.09, 71% of patients had stable or improved Expanded Disability Status Scale scores, and 69% were free of 6-month confirmed disability worsening. In Year 12, 73% of patients were free of MRI disease activity. Cumulatively throughout the extensions (Years 7-12), 34% of patients had no evidence of disease activity. Adverse event (AE) incidence declined through Year 12. Infusion-associated reactions peaked at first course and declined thereafter. Cumulative thyroid AE incidence was 50%; one immune thrombocytopenia event occurred, and there were no autoimmune nephropathy cases. CONCLUSIONS Alemtuzumab efficacy was maintained over 12 years in CAMMS223 patients, with 73% receiving no more than three courses. The safety profile in this cohort was consistent with other alemtuzumab clinical trials.
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Affiliation(s)
| | - Yaser Al Malik
- King Saud Bin Abdulaziz University for Health Sciences, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Ann D Bass
- Neurology Center of San Antonio, San Antonio, TX, USA
| | - Regina Berkovich
- Keck School of Medicine of University of Southern California, Los Angeles, CA, USA
- Synergy Healthcare Medical Associates, Los Angeles, CA, USA
| | | | - Óscar Fernández
- Fundación IMABIS, Hospital Universitario Carlos Haya, Málaga, Spain
| | - Carolina Ionete
- University of Massachusetts Memorial Medical Center, Worcester, MA, USA
| | - Luca Massacesi
- Department of Neurosciences, Drugs and Child Health, University of Florence, Florence, Italy
| | - Sven G Meuth
- Clinic of Neurology with Institute of Translational Neurology, University Clinic Münster, Münster, Germany
| | - Dimos D Mitsikostas
- First Neurology Department, Aeginition Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Gabriel Pardo
- Oklahoma Medical Research Foundation, Oklahoma City, OK, USA
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Repopulation of T, B, and NK cells following alemtuzumab treatment in relapsing-remitting multiple sclerosis. J Neuroinflammation 2020; 17:189. [PMID: 32539719 PMCID: PMC7296935 DOI: 10.1186/s12974-020-01847-9] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Accepted: 05/19/2020] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVE To characterize long-term repopulation of peripheral immune cells following alemtuzumab-induced lymphopenia in relapsing-remitting MS (RRMS), with a focus on regulatory cell types, and to explore associations with clinical outcome measures. METHODS The project was designed as a multicenter add-on longitudinal mechanistic study for RRMS patients enrolled in CARE-MS II, CARE-MS II extension at the University of Southern California and Stanford University, and an investigator-initiated study conducted at the Universities of British Columbia and Chicago. Methods involved collection of blood at baseline, prior to alemtuzumab administration, and at months 5, 11, 17, 23, 36, and 48 post-treatment. T cell, B cell, and natural killer (NK) cell subsets, chemokine receptor expression in T cells, in vitro cytokine secretion patterns, and regulatory T cell (Treg) function were assessed. Clinical outcomes, including expanded disability status score (EDSS), relapses, conventional magnetic resonance imaging (MRI) measures, and incidents of secondary autoimmunity were tracked. RESULTS Variable shifts in lymphocyte populations occurred over time in favor of CD4+ T cells, B cells, and NK cells with surface phenotypes characteristic of regulatory subsets, accompanied by reduced ratios of effector to regulatory cell types. Evidence of increased Treg competence was observed after each treatment course. CD4+ and CD8+ T cells that express CXCR3 and CCR5 and CD8+ T cells that express CDR3 and CCR4 were also enriched after treatment, indicating heightened trafficking potential in activated T cells. Patterns of repopulation were not associated with measures of clinical efficacy or secondary autoimmunity, but exploratory analyses using a random generalized estimating equation (GEE) Poisson model provide preliminary evidence of associations between pro-inflammatory cell types and increased risk for gadolinium (Gd+) enhancing lesions, while regulatory subsets were associated with reduced risk. In addition, the risk for T2 lesions correlated with increases in CD3+CD8+CXCR3+ cells. CONCLUSIONS Lymphocyte repopulation after alemtuzumab treatment favors regulatory subsets in the T cell, B cell, and NK cell compartments. Clinical efficacy may reflect the sum of interactions among them, leading to control of potentially pathogenic effector cell types. Several immune measures were identified as possible biomarkers of lesion activity. Future studies are necessary to more precisely define regulatory and effector subsets and their contributions to clinical efficacy and risk for secondary autoimmunity in alemtuzumab-treated patients, and to reveal new insights into mechanisms of immunopathogenesis in MS. TRIAL REGISTRATION Parent trials for this study are registered with ClinicalTrials.gov: CARE-MS II: NCT00548405, CARE-MS II extension: NCT00930553 and ISS: NCT01307332.
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Rolla S, Maglione A, De Mercanti SF, Clerico M. The Meaning of Immune Reconstitution after Alemtuzumab Therapy in Multiple Sclerosis. Cells 2020; 9:E1396. [PMID: 32503344 PMCID: PMC7348777 DOI: 10.3390/cells9061396] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 06/02/2020] [Accepted: 06/02/2020] [Indexed: 12/11/2022] Open
Abstract
Alemtuzumab is a monoclonal antibody that binds to CD52, a protein present on the surface of mature lymphocytes, but not on the stem cells from which these lymphocytes are derived. It is currently used as an immune reconstitution therapy in patients with relapsing-remitting multiple sclerosis. Alemtuzumab treatment is an intermittent infusion that induces long-term remission of Multiple Sclerosis also in the treatment-free period. After the robust T and B cell depletion induced by alemtuzumab, the immune system undergoes radical changes during its reconstitution. In this review, we will discuss the current knowledge on the reconstitution of the lymphocyte repertoire after alemtuzumab treatment and how it could affect the development of side effects, which led to its temporary suspension by the European Medical Agency.
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Affiliation(s)
- Simona Rolla
- Department of Clinical and Biological Sciences, University of Turin, 10043 Orbassano (TO), Italy; (A.M.); (S.F.D.M.); (M.C.)
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Thakolwiboon S, Zhao-Fleming H, Pan J, Scott JK, Shoji E, Sohn G, Avila M. Disease-Modifying Therapies During the COVID-19 Outbreak: A Narrative Review of International and National Recommendations. Int J MS Care 2020; 22:151-157. [PMID: 32863782 DOI: 10.7224/1537-2073.2020-037] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Background Managing multiple sclerosis (MS) during the novel coronavirus disease 2019 (COVID-19) pandemic is a challenge due to the lack of evidence from clinical studies. Disease-modifying therapies (DMTs) may affect the immune response and subsequently alter the risk of COVID-19 infections. Methods A literature search was conducted on the MEDLINE, Embase, and Cochrane databases. A focused Google search was also performed. Recommendations regarding the use of DMTs during the COVID-19 outbreak from national and international MS/neurology societies were identified and reviewed. Results The review included 16 recommendations from international and national MS organizations. All recommendations are based on expert opinions. The recommendations regarding DMT initiation and management during this outbreak are summarized. Moreover, the experts' views about the risk of COVID-19 infection with each DMT are discussed. Conclusions There is significant agreement among most experts' recommendations from a variety of sources based on collective clinical experience. However, the recommendations will likely evolve because sufficient clinical data are limited. Several ongoing registries will help provide information for future recommendations.
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Woelfinger P, Epp K, Schaefer L, Kriege D, Theobald M, Bopp T, Wagner-Drouet EM. CD52-negative T cells predict acute graft-versus-host disease after an alemtuzumab-based conditioning regimen. Br J Haematol 2020; 191:253-262. [PMID: 32410220 DOI: 10.1111/bjh.16706] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Accepted: 04/09/2020] [Indexed: 11/28/2022]
Abstract
Allogeneic haematopoietic stem cell transplantation (HSCT) after a reduced-intensity conditioning (RIC) regimen with fludarabine, melphalan and alemtuzmab is an effective therapy for haematological malignancies. Alemtuzumab, a monoclonal antibody against CD52, a glycosylphosphatidylinositol-anchor-bound surface protein on lymphocytes, depletes T cells to prevent graft-versus-host disease (GVHD). Despite this, acute and chronic GVHD (a/cGVHD) remain life-threatening complications after HSCT. The aim of the present study was to identify parameters to predict GVHD. In 69 patients after HSCT, T-cell subsets were functionally analysed. Reconstitution of CD52neg T cells and CD52neg regulatory T cells (Tregs) correlated with onset, severity and clinical course of aGVHD. Patients with aGVHD showed significantly lower levels of CD52pos T cells compared to patients with cGVHD or without GVHD (P < 0·001). Analysis of T-cell reconstitution revealed a percentage of <40% of CD52pos CD4pos T cells or CD52pos Tregs at day +50 as a risk factor for the development of aGVHD. In contrast, CD52neg Tregs showed significant decreased levels of glycoprotein A repetitions predominant (GARP; P < 0·001), glucocorticoid-induced TNFR-related protein (GITR; P < 0·001), chemokine receptor (CXCR3; P = 0·023), C-C chemokine receptor type 5 (CCR5; P = 0·004), but increased levels of immunoglobulin-like transcript 3 (ILT3; P = 0·001), as well as a reduced suppressive capacity. We conclude that reconstitution of CD52neg T cells and CD52neg Tregs is a risk factor for development of aGVHD.
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Affiliation(s)
- Pascal Woelfinger
- Department of Hematology, Oncology and Pneumology, University Cancer Center Mainz (UCT), University Medical Center Mainz, Mainz, Germany
| | - Katharina Epp
- Department of Hematology, Oncology and Pneumology, University Cancer Center Mainz (UCT), University Medical Center Mainz, Mainz, Germany
| | - Lukas Schaefer
- Department of Hematology, Oncology and Pneumology, University Cancer Center Mainz (UCT), University Medical Center Mainz, Mainz, Germany
| | - Diana Kriege
- Department of Hematology, Oncology and Pneumology, University Cancer Center Mainz (UCT), University Medical Center Mainz, Mainz, Germany
| | - Matthias Theobald
- Department of Hematology, Oncology and Pneumology, University Cancer Center Mainz (UCT), University Medical Center Mainz, Mainz, Germany
| | - Tobias Bopp
- Institute for Immunology, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Eva-Maria Wagner-Drouet
- Department of Hematology, Oncology and Pneumology, University Cancer Center Mainz (UCT), University Medical Center Mainz, Mainz, Germany
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Oh J, Achiron A, Celius EG, Chambers C, Derwenskus J, Devonshire V, Hellwig K, Hutton GJ, McCombe P, Moore M, Rog D, Schneider JR, Simm RF, Sousa L, Vincent SG, Chung L, Daizadeh N, Mitchell C, Compston DAS. Pregnancy outcomes and postpartum relapse rates in women with RRMS treated with alemtuzumab in the phase 2 and 3 clinical development program over 16 years. Mult Scler Relat Disord 2020; 43:102146. [PMID: 32498033 DOI: 10.1016/j.msard.2020.102146] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 02/28/2020] [Accepted: 04/21/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Relapsing-remitting multiple sclerosis (RRMS) is frequently diagnosed in women of reproductive age. Because the use of disease-modifying therapies (DMTs) early in the disease course is increasing, it is important to evaluate the safety of DMTs in pregnant women and their developing fetuses. Alemtuzumab, approved for the treatment of relapsing forms of MS, is administered as 2 courses of 12 mg/day on 5 consecutive days at baseline and on 3 consecutive days 12 months later. Alemtuzumab is eliminated from the body within approximately 30 days after administration; it is recommended that women of childbearing potential use effective contraception during and for 4 months after treatment. Here, we report pregnancy outcomes in alemtuzumab-treated women from the phase 2 and 3 clinical development program over 16 years. METHODS We followed 972 women who had alemtuzumab in phase 2 (CAMMS223 [NCT00050778]) and phase 3 (CARE-MS I [NCT00530348], CARE-MS II [NCT00548405]) studies, and/or in 2 consecutive extension studies (NCT00930553; NCT02255656 [TOPAZ]). In the extension studies, patients could receive additional alemtuzumab (12 mg/day on 3 days; ≥12 months apart) as needed for disease activity. All women who received alemtuzumab in the clinical development program were included. Pregnant or lactating patients were followed up for safety. RESULTS As of November 26, 2018, 264 pregnancies occurred in 160 alemtuzumab-treated women, with a mean age at conception of 32.6 years, and mean time from last alemtuzumab dose to conception of 35.9 months. Of the 264 pregnancies, 233 (88%) were completed, 11 (4%) were ongoing, and 20 (8%) had unknown outcomes; 16 (6%) conceptions occurred within 4 months, and 5 conceptions within 1 month of the last alemtuzumab dose. Of the 233 completed pregnancies with known outcomes, there were 155 (67%) live births with no congenital abnormalities or birth defects, 52 (22%) spontaneous abortions, 25 (11%) elective abortions, and 1 (0.4%) stillbirth. Maternal age was associated with an increased risk of spontaneous abortion in alemtuzumab-treated patients (<35 years: 15%; ≥35 years: 37%; relative risk [RR], 2.46 [95% CI: 1.53-3.95], p=0.0002). Risk of spontaneous abortion was not increased in patients becoming pregnant ≤4 months versus >4 months since alemtuzumab exposure (19% vs 23%; RR, 1.08 [95% CI: 0.41-2.85], p=0.88). Autoimmune thyroid adverse events did not increase risk for spontaneous abortion (patients with vs without thyroid adverse events, 23.7% vs 21.3%; RR, 1.11 [95% CI: 0.69-1.80], p=0.75). Annualized relapse rate was 0.10 and 0.12 in the 2 years prior to pregnancy (post alemtuzumab), and was 0.22, 0.12, and 0.12 in each of the first 3 years postpartum, respectively. CONCLUSION Normal live births were the most common outcome in women exposed to alemtuzumab 12 mg or 24 mg in clinical studies. Spontaneous abortion rate in alemtuzumab-treated patients was comparable with rates in the general population and treatment-naive MS patients, and was not increased in women with pregnancy onset within 4 months of alemtuzumab exposure. There was a minimal increase in postpartum relapses.
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Affiliation(s)
- Jiwon Oh
- St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.
| | - Anat Achiron
- The Chaim Sheba Medical Center, Tel Hashomer, Israel; Tel Aviv University, Tel Aviv, Israel.
| | - Elisabeth G Celius
- Oslo University Hospital Ullevål and Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
| | | | - Joy Derwenskus
- Murfreesboro Medical Clinic and SurgiCenter, Murfreesboro, TN, United States
| | | | - Kerstin Hellwig
- St. Josef Hospital, Ruhr University Bochum, Bochum, Germany.
| | | | | | - Marie Moore
- Carolinas Health MS Center, Charlotte, NC, United States.
| | - David Rog
- Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Salford, United Kingdom.
| | | | | | - Livia Sousa
- Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal.
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Mixed chimerism established by hematopoietic stem cell transplantation is maintained by host and donor T regulatory cells. Blood Adv 2020; 3:734-743. [PMID: 30824417 DOI: 10.1182/bloodadvances.2018025502] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Accepted: 01/21/2019] [Indexed: 12/30/2022] Open
Abstract
Transplantation is an effective treatment of many clinical disorders, but the mechanisms that regulate immunological tolerance are uncertain and remain central to improving patient outcome. Hemopoietic stem cell transplantation (SCT) often establishes "mixed chimerism" in which immune cells from both the donor and patient coexist in vivo in a setting of immunological tolerance. We studied immune function in 69 patients within 2 months following SCT; 37 were fully donor and 32 displayed mixed chimerism. The proportion of T regulatory (Treg) cells was increased during mixed chimerism and comprised equal numbers of donor and host-derived regulatory cells. This was associated with a tolerogenic PD-L1+ profile on dendritic cells. Importantly, effector T cells from patients with mixed chimerism exhibited reduced cytotoxicity against host target cells in vitro, but this was restored following depletion of CD4+ Treg cells. These data show that Treg cells play a major role in sustaining immunological tolerance during mixed chimerism. These insights should help to guide novel interventions to improve clinical transplantation.
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