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Lee DSW, Rojas OL, Gommerman JL. B cell depletion therapies in autoimmune disease: advances and mechanistic insights. Nat Rev Drug Discov 2021; 20:179-199. [PMID: 33324003 PMCID: PMC7737718 DOI: 10.1038/s41573-020-00092-2] [Citation(s) in RCA: 282] [Impact Index Per Article: 94.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/26/2020] [Indexed: 01/30/2023]
Abstract
In the past 15 years, B cells have been rediscovered to be not merely bystanders but rather active participants in autoimmune aetiology. This has been fuelled in part by the clinical success of B cell depletion therapies (BCDTs). Originally conceived as a method of eliminating cancerous B cells, BCDTs such as those targeting CD20, CD19 and BAFF are now used to treat autoimmune diseases, including systemic lupus erythematosus and multiple sclerosis. The use of BCDTs in autoimmune disease has led to some surprises. For example, although antibody-secreting plasma cells are thought to have a negative pathogenic role in autoimmune disease, BCDT, even when it controls the disease, has limited impact on these cells and on antibody levels. In this Review, we update our understanding of B cell biology, review the results of clinical trials using BCDT in autoimmune indications, discuss hypotheses for the mechanism of action of BCDT and speculate on evolving strategies for targeting B cells beyond depletion.
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Affiliation(s)
- Dennis S. W. Lee
- grid.17063.330000 0001 2157 2938Department of Immunology, University of Toronto, Toronto, ON Canada
| | - Olga L. Rojas
- grid.17063.330000 0001 2157 2938Department of Immunology, University of Toronto, Toronto, ON Canada
| | - Jennifer L. Gommerman
- grid.17063.330000 0001 2157 2938Department of Immunology, University of Toronto, Toronto, ON Canada
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Xue T, Yu J, Chen S, Wang Z, Yang Y, Chen Z, Wang Z. Different Targets of Monoclonal Antibodies in Neuromyelitis Optica Spectrum Disorders: A Meta-Analysis Evidenced From Randomized Controlled Trials. Front Neurol 2020; 11:604445. [PMID: 33391166 PMCID: PMC7773932 DOI: 10.3389/fneur.2020.604445] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 11/24/2020] [Indexed: 11/29/2022] Open
Abstract
Background: Neuromyelitis optica spectrum disorder (NMOSD), an autoimmune inflammatory disorder of the central nervous system, often leads to vision loss or paralysis. This meta-analysis focused on the assessment of the monoclonal antibody therapy in NMOSD and compared different targets of monoclonal antibodies with each other in terms of efficacy and safety outcomes. Method: We searched through the databases of MEDLINE, EMBASE, Central Register of Controlled Trials (CENTRAL), and clinicaltrials.gov for randomized controlled trials (RCTs) evaluating monoclonal antibody therapy in NMOSD up to April 2020. Results: We identified seven randomized controlled trials (RCTs), including 775 patients (monoclonal antibody group, n = 485 and placebo group, n = 290). Monoclonal antibody therapy decreased relapse risk (RR 0.33, 95% CI 0.21–0.52, P < 0.00001), annualized relapse rate (ARR) (mean −0.28, 95% CI −0.35−0.20, P < 0.00001), expanded disability status scale score (EDSS) (mean −0.19, 95% CI −0.32−0.07, P = 0.002) and serious adverse events (RR 0.78, 95% CI 0.61–1.00, P = 0.05). However, we did not observe any significant difference in terms of adverse events or mortality. Further, the subgroup analysis demonstrated that the anti-complement protein C5 monoclonal antibody (eculizumab) might have a lower relapse risk (RR 0.07, 95% CI 0.02–0.23, P < 0.0001) in the AQP4 seropositive patients, and anti-interleukin-6 receptor monoclonal antibodies (satralizumab and tocilizumab) showed decreased EDSS score (mean −0.17, 95% CI −0.31−0.02, P = 0.02) more effectively than other monoclonal antibodies. Conclusions: Monoclonal antibodies were effective and safe in NMOSD. Different targets of monoclonal antibodies might have their own advantages.
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Affiliation(s)
- Tao Xue
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Jiahao Yu
- Department of Thoracic Surgery, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Shujun Chen
- Department of Neurology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Zilan Wang
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Yanbo Yang
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Zhouqing Chen
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Zhong Wang
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, China
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Graf J, Mares J, Barnett M, Aktas O, Albrecht P, Zamvil SS, Hartung HP. Targeting B cells to modify MS, NMOSD, and MOGAD: Part 2. NEUROLOGY-NEUROIMMUNOLOGY & NEUROINFLAMMATION 2020; 8:8/1/e919. [PMID: 33411674 PMCID: PMC8063618 DOI: 10.1212/nxi.0000000000000919] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 09/11/2020] [Indexed: 12/15/2022]
Abstract
Ocrelizumab, rituximab, ofatumumab, ublituximab, inebilizumab, and evobrutinib
are immunotherapies that target various B cell–related proteins. Most of
these treatments have proven efficacy in relapsing and progressive forms of MS
and neuromyelitis optica spectrum disease (NMOSD) or are in advanced stages of
clinical development. Currently, ocrelizumab and inebilizumab are licensed for
treatment of MS and NMOSD, respectively. This part of the review focuses on
monoclonal antibody B cell–depleting strategies in NMOSD and the emerging
related myelin oligodendrocyte glycoprotein (MOG) immunoglobulin
G–associated disease (MOGAD). Case series and phase 2/3 studies in these
inflammatory disorders are assessed. The safety profile of long-term B-cell
depletion in MS, NMOSD, and MOGAD will be highlighted. Finally implications of
the current coronavirus disease 2019 pandemic on the management of patients with
these disorders and the use of B cell–depleting agents will be
discussed.
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Affiliation(s)
- Jonas Graf
- From the Department of Neurology (J.G., O.A., P.A., H.-P.H.), University Hospital, Medical Faculty Heinrich Heine University, Düsseldorf, Germany; Department of Neurology (J.M.), Palacky University, Olomouc, Czech Republic; Department of Neurology, Brain and Mind Centre (M.B., H.-P.H.), Department of Neurology, University of Sydney, New South Wales, Australia; and Department of Neurology (S.S.Z.), UCSF Weill Institute of Neurosciences, University of California at San Francisco
| | - Jan Mares
- From the Department of Neurology (J.G., O.A., P.A., H.-P.H.), University Hospital, Medical Faculty Heinrich Heine University, Düsseldorf, Germany; Department of Neurology (J.M.), Palacky University, Olomouc, Czech Republic; Department of Neurology, Brain and Mind Centre (M.B., H.-P.H.), Department of Neurology, University of Sydney, New South Wales, Australia; and Department of Neurology (S.S.Z.), UCSF Weill Institute of Neurosciences, University of California at San Francisco
| | - Michael Barnett
- From the Department of Neurology (J.G., O.A., P.A., H.-P.H.), University Hospital, Medical Faculty Heinrich Heine University, Düsseldorf, Germany; Department of Neurology (J.M.), Palacky University, Olomouc, Czech Republic; Department of Neurology, Brain and Mind Centre (M.B., H.-P.H.), Department of Neurology, University of Sydney, New South Wales, Australia; and Department of Neurology (S.S.Z.), UCSF Weill Institute of Neurosciences, University of California at San Francisco
| | - Orhan Aktas
- From the Department of Neurology (J.G., O.A., P.A., H.-P.H.), University Hospital, Medical Faculty Heinrich Heine University, Düsseldorf, Germany; Department of Neurology (J.M.), Palacky University, Olomouc, Czech Republic; Department of Neurology, Brain and Mind Centre (M.B., H.-P.H.), Department of Neurology, University of Sydney, New South Wales, Australia; and Department of Neurology (S.S.Z.), UCSF Weill Institute of Neurosciences, University of California at San Francisco
| | - Philipp Albrecht
- From the Department of Neurology (J.G., O.A., P.A., H.-P.H.), University Hospital, Medical Faculty Heinrich Heine University, Düsseldorf, Germany; Department of Neurology (J.M.), Palacky University, Olomouc, Czech Republic; Department of Neurology, Brain and Mind Centre (M.B., H.-P.H.), Department of Neurology, University of Sydney, New South Wales, Australia; and Department of Neurology (S.S.Z.), UCSF Weill Institute of Neurosciences, University of California at San Francisco
| | - Scott S Zamvil
- From the Department of Neurology (J.G., O.A., P.A., H.-P.H.), University Hospital, Medical Faculty Heinrich Heine University, Düsseldorf, Germany; Department of Neurology (J.M.), Palacky University, Olomouc, Czech Republic; Department of Neurology, Brain and Mind Centre (M.B., H.-P.H.), Department of Neurology, University of Sydney, New South Wales, Australia; and Department of Neurology (S.S.Z.), UCSF Weill Institute of Neurosciences, University of California at San Francisco
| | - Hans-Peter Hartung
- From the Department of Neurology (J.G., O.A., P.A., H.-P.H.), University Hospital, Medical Faculty Heinrich Heine University, Düsseldorf, Germany; Department of Neurology (J.M.), Palacky University, Olomouc, Czech Republic; Department of Neurology, Brain and Mind Centre (M.B., H.-P.H.), Department of Neurology, University of Sydney, New South Wales, Australia; and Department of Neurology (S.S.Z.), UCSF Weill Institute of Neurosciences, University of California at San Francisco.
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Xie Q, Sun M, Sun J, Zheng T, Wang M. New progress in the treatment of neuromyelitis optica spectrum disorder with monoclonal antibodies (Review). Exp Ther Med 2020; 21:148. [PMID: 33456515 DOI: 10.3892/etm.2020.9579] [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: 07/29/2020] [Accepted: 11/27/2020] [Indexed: 12/14/2022] Open
Abstract
Neuromyelitis optica spectrum disorder (NMOSD) is a group of immune-mediated inflammatory demyelinating diseases mainly affecting the central nervous system. It is characterized by high risk of relapse and progression to disability. The frequent recurrences of neuromyelitis optica spectrum disorder often exacerbate the neurological dysfunction and severely affect the patient's quality of life. Conventional treatments for neuromyelitis optica spectrum disorder, including acute treatment and sequential therapy, aim to decrease the degree of disability and recurrences. In recent years, new monoclonal antibodies have yielded encouraging results. The present review discusses the research status and recent progress in the treatment of NMOSD with monoclonal antibodies.
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Affiliation(s)
- Qinfang Xie
- Department of Neurology, Lanzhou University Second Hospital, Lanzhou, Gansu 730030, P.R. China
| | - Mengjiao Sun
- Department of Neurology, Lanzhou University Second Hospital, Lanzhou, Gansu 730030, P.R. China
| | - Jing Sun
- Department of Neurology, Lanzhou University Second Hospital, Lanzhou, Gansu 730030, P.R. China
| | - Ting Zheng
- Department of Neurology, Lanzhou University Second Hospital, Lanzhou, Gansu 730030, P.R. China
| | - Manxia Wang
- Department of Neurology, Lanzhou University Second Hospital, Lanzhou, Gansu 730030, P.R. China
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Findling O, Sellner J. Second-generation immunotherapeutics in multiple sclerosis: can we discard their precursors? Drug Discov Today 2020; 26:416-428. [PMID: 33248250 DOI: 10.1016/j.drudis.2020.11.022] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 07/18/2020] [Accepted: 11/17/2020] [Indexed: 12/27/2022]
Abstract
Options for disease-modifying therapies in multiple sclerosis have increased over the past two decades. Among these innovations are interferon-β, glatiramer acetate, fumaric acid and dihydroorotate dehydrogenase inhibitors, an antibody targeting the migration of immune cells, a compound that traps immune cells in lymphoid organs by sphingosine 1-phosphate receptor (S1PR) modulation and immune-reconstitution therapies. Second-generation drugs such as pegylated interferon-β, advanced CD20 depleting antibodies, more-specific S1PR modulators and new formulations have been developed to achieve higher efficacy while exhibiting fewer side effects. In this review, we address the shortcomings of the parent drugs, present the pros and cons of the second-generation therapies and summarize upcoming developments in the field of immunotherapy for multiple sclerosis.
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Affiliation(s)
- Oliver Findling
- Department of Neurology, Kantonsspital Aarau, Aarau, Switzerland; Department of Neurology, University Hospital Tulln, Karl-Landsteiner-University, Tulln, Austria
| | - Johann Sellner
- Department of Neurology, Landesklinikum Mistelbach-Gänserndorf, Mistelbach, Austria; Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University, Salzburg, Austria; Department of Neurology, Klinikum rechts der Isar, Technische Universität München, München, Germany.
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Levy M, Fujihara K, Palace J. New therapies for neuromyelitis optica spectrum disorder. Lancet Neurol 2020; 20:60-67. [PMID: 33186537 DOI: 10.1016/s1474-4422(20)30392-6] [Citation(s) in RCA: 78] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 09/18/2020] [Accepted: 10/01/2020] [Indexed: 01/05/2023]
Abstract
BACKGROUND Neuromyelitis optica spectrum disorder is an autoimmune disease of the CNS that primarily affects the optic nerves and spinal cord. Most patients have serum antibodies targeting the aquaporin-4 water channel expressed on the end-feet of astrocytes. Although the prevalence of neuromyelitis optica spectrum disorder is limited to around 1-2 people per 100 000, severe immune-mediated attacks can quickly lead to blindness and paralysis if undiagnosed and untreated. However, diagnosis is straightforward when the highly specific serum aquaporin-4 antibodies are detected with cell-based assays. RECENT DEVELOPMENTS Four randomised controlled trials have tested the efficacy of three new therapies (eculizumab, satralizumab, and inebilizumab) for patients with neuromyelitis optica spectrum disorder that all showed a benefit in preventing future attacks. These therapies have different targets within the immune pathogenic process, and the four trials have similarities and differences that mean they might change the therapeutic landscape for people with neuromyelitis optica spectrum disorder in different ways. Efficacy, safety, tolerability, and practical considerations, including potential cost, differ for each drug and might affect the rate of use in real-world populations of patients with neuromyelitis optica spectrum disorder. WHERE NEXT?: Despite the rarity of neuromyelitis optica spectrum disorder, a relative abundance of preventive treatment options now exists. In the future, trials should focus on areas of unmet need, including aquaporin-4 seronegative disease, and on development of treatments for acute relapses and for recovery from autoimmune attacks in the CNS.
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Affiliation(s)
- Michael Levy
- Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA.
| | - Kazuo Fujihara
- Department of Multiple Sclerosis Therapeutics, School of Medicine, Fukushima Medical University, Koriyama, Japan; Southern Tohoku Research Institute for Neuroscience, Koriyama, Japan
| | - Jacqueline Palace
- Department of Clinical Neurology, John Radcliffe Hospital and University of Oxford, Oxford, UK
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57
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Wang A, Rojas O, Lee D, Gommerman JL. Regulation of neuroinflammation by B cells and plasma cells. Immunol Rev 2020; 299:45-60. [PMID: 33107072 DOI: 10.1111/imr.12929] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 09/07/2020] [Indexed: 02/06/2023]
Abstract
The remarkable success of anti-CD20 B cell depletion therapies in reducing the burden of multiple sclerosis (MS) disease has prompted significant interest in how B cells contribute to neuroinflammation. Most focus has been on identifying pathogenic CD20+ B cells. However, an increasing number of studies have also identified regulatory functions of B lineage cells, particularly the production of IL-10, as being associated with disease remission in anti-CD20-treated MS patients. Moreover, IL-10-producing B cells have been linked to the attenuation of inflammation in experimental autoimmune encephalomyelitis (EAE), the animal model of MS. In addition to IL-10-producing B cells, antibody-producing plasma cells (PCs) have also been implicated in suppressing neuroinflammation. This review will examine regulatory roles for B cells and PCs in MS and EAE. In addition, we speculate on the involvement of regulatory PCs and the cytokine BAFF in the context of anti-CD20 treatment. Lastly, we explore how the microbiota could influence anti-inflammatory B cell behavior. A better understanding of the contributions of different B cell subsets to the regulation of neuroinflammation, and factors that impact the development, maintenance, and migration of such subsets, will be important for rationalizing next-generation B cell-directed therapies for the treatment of MS.
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Affiliation(s)
- Angela Wang
- Department of Immunology, University of Toronto, Toronto, ON, Canada
| | - Olga Rojas
- Department of Immunology, University of Toronto, Toronto, ON, Canada
| | - Dennis Lee
- Department of Immunology, University of Toronto, Toronto, ON, Canada
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58
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Abstract
Pemphigus is a rare autoimmune disease of the skin, characterized by autoantibodies targeting adhesion proteins of the epidermis, in particular desmoglein 3 and desmoglein 1, that cause the loss of cell-cell adhesion and the formation of intraepidermal blisters. Given that these autoantibodies are both necessary and sufficient for pemphigus to occur, the goal of pemphigus therapy is the elimination of autoreactive B-cells responsible for autoantibody production. Rituximab, an anti-CD20 monoclonal antibody, was the first targeted B-cell therapy approved for use in pemphigus and is now considered the frontline therapy for new onset disease. One limitation of this treatment is that it targets both autoreactive and non -autoreactive B-cells, which accounts for the increased risk of serious infections in treated patients. In addition, most rituximab-treated patients experience disease relapse, highlighting the need of new therapeutic options. This review provides a concise overview of rituximab use in pemphigus and discusses new B-cell and antibody-directed therapies undergoing investigation in clinical studies.
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Affiliation(s)
- Roberto Maglie
- Department of Health Sciences, Section of Dermatology, University of Florence, Florence, Italy -
| | - Emiliano Antiga
- Department of Health Sciences, Section of Dermatology, University of Florence, Florence, Italy
| | - Aimee S Payne
- Department of Dermatology, University of Pennsylvania, Philadelphia, PA, USA
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Holmøy T, Høglund RA, Illes Z, Myhr KM, Torkildsen Ø. Recent progress in maintenance treatment of neuromyelitis optica spectrum disorder. J Neurol 2020; 268:4522-4536. [PMID: 33011853 PMCID: PMC8563615 DOI: 10.1007/s00415-020-10235-5] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 09/16/2020] [Accepted: 09/17/2020] [Indexed: 02/07/2023]
Abstract
Background Treatment of neuromyelitis optica spectrum disorder (NMOSD) has so far been based on retrospective case series. The results of six randomized clinical trials including five different monoclonal antibodies targeting four molecules and three distinct pathophysiological pathways have recently been published. Methods Literature search on clinical trials and case studies in NMOSD up to July 10. 2020. Results We review mechanism of action, efficacy and side effects, and consequences for reproductive health from traditional immunosuppressants and monoclonal antibodies including rituximab, inebilizumab, eculizumab, tocilizumab and satralizumab. Conclusion In NMOSD patients with antibodies against aquaporin 4, monoclonal antibodies that deplete B cells (rituximab and inebilizumab) or interfere with interleukin 6 signaling (tocilizumab and satralizumab) or complement activation (eculizumab) have superior efficacy compared to placebo. Tocilizumab and rituximab were also superior to azathioprine in head-to-head studies. Rituximab, tocilizumab and to some extent eculizumab have well-known safety profiles for other inflammatory diseases, and rituximab and azathioprine may be safe during pregnancy.
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Affiliation(s)
- Trygve Holmøy
- Department of Neurology, Akershus University Hospital, Lørenskog, Norway. .,Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
| | - Rune Alexander Høglund
- Department of Neurology, Akershus University Hospital, Lørenskog, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Zsolt Illes
- Department of Neurology, Odense University Hospital, Odense, Denmark.,Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Kjell-Morten Myhr
- Department of Clinical Medicine, University of Bergen, Bergen, Norway.,Neuro-SysMed, Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Øivind Torkildsen
- Department of Clinical Medicine, University of Bergen, Bergen, Norway.,Neuro-SysMed, Department of Neurology, Haukeland University Hospital, Bergen, Norway
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Stevens MY, Cropper HC, Lucot KL, Chaney AM, Lechtenberg KJ, Jackson IM, Buckwalter MS, James ML. Development of a CD19 PET tracer for detecting B cells in a mouse model of multiple sclerosis. J Neuroinflammation 2020; 17:275. [PMID: 32948198 PMCID: PMC7501720 DOI: 10.1186/s12974-020-01880-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Accepted: 06/23/2020] [Indexed: 01/11/2023] Open
Abstract
Background B cells play a central role in multiple sclerosis (MS) through production of injurious antibodies, secretion of pro-inflammatory cytokines, and antigen presentation. The therapeutic success of monoclonal antibodies (mAbs) targeting B cells in some but not all individuals suffering from MS highlights the need for a method to stratify patients and monitor response to treatments in real-time. Herein, we describe the development of the first CD19 positron emission tomography (PET) tracer, and its evaluation in a rodent model of MS, experimental autoimmune encephalomyelitis (EAE). Methods Female C57BL/6 J mice were induced with EAE through immunization with myelin oligodendrocyte glycoprotein (MOG1–125). PET imaging of naïve and EAE mice was performed 19 h after administration of [64Cu]CD19-mAb. Thereafter, radioactivity in organs of interest was determined by gamma counting, followed by ex vivo autoradiography of central nervous system (CNS) tissues. Anti-CD45R (B220) immunostaining of brain tissue from EAE and naïve mice was also conducted. Results Radiolabelling of DOTA-conjugated CD19-mAb with 64Cu was achieved with a radiochemical purity of 99% and molar activity of 2 GBq/μmol. Quantitation of CD19 PET images revealed significantly higher tracer binding in whole brain of EAE compared to naïve mice (2.02 ± 0.092 vs. 1.68 ± 0.06 percentage of injected dose per gram, % ID/g, p = 0.0173). PET findings were confirmed by ex vivo gamma counting of perfused brain tissue (0.22 ± 0.020 vs. 0.12 ± 0.003 % ID/g, p = 0.0010). Moreover, ex vivo autoradiography of brain sections corresponded with PET imaging results and the spatial distribution of B cells observed in B220 immunohistochemistry—providing further evidence that [64Cu]CD19-mAb enables visualization of B cell infiltration into the CNS of EAE mice. Conclusion CD19-PET imaging can be used to detect elevated levels of B cells in the CNS of EAE mice, and has the potential to impact the way we study, monitor, and treat clinical MS.
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Affiliation(s)
- Marc Y Stevens
- Department of Radiology, Molecular Imaging Program at Stanford, 1201 Welch Rd, Stanford, CA, 94305, USA
| | - Haley C Cropper
- Department of Radiology, Molecular Imaging Program at Stanford, 1201 Welch Rd, Stanford, CA, 94305, USA
| | | | - Aisling M Chaney
- Department of Radiology, Molecular Imaging Program at Stanford, 1201 Welch Rd, Stanford, CA, 94305, USA
| | - Kendra J Lechtenberg
- Department of Neurology & Neurological Sciences, Stanford University, Stanford, CA, USA
| | - Isaac M Jackson
- Department of Radiology, Molecular Imaging Program at Stanford, 1201 Welch Rd, Stanford, CA, 94305, USA
| | - Marion S Buckwalter
- Department of Neurology & Neurological Sciences, Stanford University, Stanford, CA, USA
| | - Michelle L James
- Department of Radiology, Molecular Imaging Program at Stanford, 1201 Welch Rd, Stanford, CA, 94305, USA. .,Department of Neurology & Neurological Sciences, Stanford University, Stanford, CA, USA.
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Abboud H, Zheng C, Kar I, Chen CK, Sau C, Serra A. Current and emerging therapeutics for neuromyelitis optica spectrum disorder: Relevance to the COVID-19 pandemic. Mult Scler Relat Disord 2020; 44:102249. [PMID: 32526698 PMCID: PMC7265855 DOI: 10.1016/j.msard.2020.102249] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Revised: 05/27/2020] [Accepted: 05/28/2020] [Indexed: 02/07/2023]
Abstract
Neuromyelitis optica spectrum disorder (NMOSD) can lead to immobility and bulbar weakness. This, in addition to the older age of onset and the higher rate of hospitalization compared to multiple sclerosis, makes this patient group a potential target for complicated COVID-19 infection. Moreover, many of the commonly used preventive therapies for NMOSD are cell-depleting immunouppsressants with increased risk of viral and bacterial infections. The emergence of several new NMOSD therapeutics, including immune-modulating agents, concurrently with the worldwide spread of the COVID-19 global pandemic call for careful therapeutic planning and add to the complexity of NMOSD management. Altering the common therapeutic approach to NMOSD during the pandemic may be necessary to balance both efficacy and safety of treatment. Selection of preventive therapy should take in consideration the viral exposure risk related to the route and frequency of administration and, most importantly, the immunological properties of each therapeutic agent and its potential impact on the risk of SARS-CoV-2 susceptibility and severity of infection. The impact of the therapeutic agent on the immune response against the future SARS-CoV-2 vaccine should also be considered in the clinical decision-making. In this review, we will discuss the immune response against SARS-CoV-2 and evaluate the potential impact of the current and emerging NMOSD therapeutics on infection risk, infection severity, and future SARS-CoV-2 vaccination. We propose a therapeutic approach to NMOSD during the COVID-19 pandemic based on analysis of the mechanism of action, route of administration, and side effect profile of each therapeutic agent.
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Affiliation(s)
- Hesham Abboud
- Multiple Sclerosis and Neuroimmunology Program, University Hospitals of Cleveland, Case Western Reserve University School of Medicine, Cleveland, OH, USA.
| | - Crystal Zheng
- Ohio Northern University School of Pharmacy, Ada, OH, USA
| | - Indrani Kar
- System Pharmacy Services, University Hospitals of Cleveland, Cleveland, OH, USA
| | - Claire Kaori Chen
- System Pharmacy Services, University Hospitals of Cleveland, Cleveland, OH, USA
| | - Crystal Sau
- Multiple Sclerosis and Neuroimmunology Program, University Hospitals of Cleveland, Case Western Reserve University School of Medicine, Cleveland, OH, USA; System Pharmacy Services, University Hospitals of Cleveland, Cleveland, OH, USA
| | - Alessandro Serra
- Multiple Sclerosis and Neuroimmunology Program, University Hospitals of Cleveland, Case Western Reserve University School of Medicine, Cleveland, OH, USA; VA Multiple Sclerosis Center of Excellence, Cleveland VA Medical Center, Cleveland, OH, USA
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The ocrelizumab phase II extension trial suggests the potential to improve the risk: Benefit balance in multiple sclerosis. Mult Scler Relat Disord 2020; 44:102279. [DOI: 10.1016/j.msard.2020.102279] [Citation(s) in RCA: 52] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2020] [Revised: 06/01/2020] [Accepted: 06/08/2020] [Indexed: 02/01/2023]
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63
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Davis JS, Ferreira D, Paige E, Gedye C, Boyle M. Infectious Complications of Biological and Small Molecule Targeted Immunomodulatory Therapies. Clin Microbiol Rev 2020; 33:e00035-19. [PMID: 32522746 PMCID: PMC7289788 DOI: 10.1128/cmr.00035-19] [Citation(s) in RCA: 63] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
The past 2 decades have seen a revolution in our approach to therapeutic immunosuppression. We have moved from relying on broadly active traditional medications, such as prednisolone or methotrexate, toward more specific agents that often target a single receptor, cytokine, or cell type, using monoclonal antibodies, fusion proteins, or targeted small molecules. This change has transformed the treatment of many conditions, including rheumatoid arthritis, cancers, asthma, and inflammatory bowel disease, but along with the benefits have come risks. Contrary to the hope that these more specific agents would have minimal and predictable infectious sequelae, infectious complications have emerged as a major stumbling block for many of these agents. Furthermore, the growing number and complexity of available biologic agents makes it difficult for clinicians to maintain current knowledge, and most review articles focus on a particular target disease or class of agent. In this article, we review the current state of knowledge about infectious complications of biologic and small molecule immunomodulatory agents, aiming to create a single resource relevant to a broad range of clinicians and researchers. For each of 19 classes of agent, we discuss the mechanism of action, the risk and types of infectious complications, and recommendations for prevention of infection.
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Affiliation(s)
- Joshua S Davis
- Department of Infectious Diseases and Immunology, John Hunter Hospital, Newcastle, NSW, Australia
- Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, NT, Australia
- School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia
| | - David Ferreira
- School of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Emma Paige
- Department of Infectious Diseases, Alfred Hospital, Melbourne, VIC, Australia
| | - Craig Gedye
- School of Medicine, University of New South Wales, Sydney, NSW, Australia
- Department of Oncology, Calvary Mater Hospital, Newcastle, NSW, Australia
| | - Michael Boyle
- Department of Infectious Diseases and Immunology, John Hunter Hospital, Newcastle, NSW, Australia
- School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia
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64
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Monoclonal Antibody-Based Treatments for Neuromyelitis Optica Spectrum Disorders: From Bench to Bedside. Neurosci Bull 2020; 36:1213-1224. [PMID: 32533450 DOI: 10.1007/s12264-020-00525-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2019] [Accepted: 04/10/2020] [Indexed: 12/20/2022] Open
Abstract
Neuromyelitis optica (NMO)/NMO spectrum disorder (NMOSD) is a chronic, recurrent, antibody-mediated, inflammatory demyelinating disease of the central nervous system, characterized by optic neuritis and transverse myelitis. The binding of NMO-IgG with astrocytic aquaporin-4 (AQP4) functions directly in the pathogenesis of >60% of NMOSD patients, and causes astrocyte loss, secondary inflammatory infiltration, demyelination, and neuron death, potentially leading to paralysis and blindness. Current treatment options, including immunosuppressive agents, plasma exchange, and B-cell depletion, are based on small retrospective case series and open-label studies. It is noteworthy that monoclonal antibody (mAb) therapy is a better option for autoimmune diseases due to its high efficacy and tolerability. Although the pathophysiological mechanisms of NMOSD remain unknown, increasingly, therapeutic studies have focused on mAbs, which target B cell depletion, complement and inflammation cascade inactivation, blood-brain-barrier protection, and blockade of NMO-IgG-AQP4 binding. Here, we review the targets, characteristics, mechanisms of action, development, and potential efficacy of mAb trials in NMOSD, including preclinical and experimental investigations.
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65
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Fichtner ML, Jiang R, Bourke A, Nowak RJ, O'Connor KC. Autoimmune Pathology in Myasthenia Gravis Disease Subtypes Is Governed by Divergent Mechanisms of Immunopathology. Front Immunol 2020; 11:776. [PMID: 32547535 PMCID: PMC7274207 DOI: 10.3389/fimmu.2020.00776] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Accepted: 04/06/2020] [Indexed: 12/13/2022] Open
Abstract
Myasthenia gravis (MG) is a prototypical autoantibody mediated disease. The autoantibodies in MG target structures within the neuromuscular junction (NMJ), thus affecting neuromuscular transmission. The major disease subtypes of autoimmune MG are defined by their antigenic target. The most common target of pathogenic autoantibodies in MG is the nicotinic acetylcholine receptor (AChR), followed by muscle-specific kinase (MuSK) and lipoprotein receptor-related protein 4 (LRP4). MG patients present with similar symptoms independent of the underlying subtype of disease, while the immunopathology is remarkably distinct. Here we highlight these distinct immune mechanisms that describe both the B cell- and autoantibody-mediated pathogenesis by comparing AChR and MuSK MG subtypes. In our discussion of the AChR subtype, we focus on the role of long-lived plasma cells in the production of pathogenic autoantibodies, the IgG1 subclass mediated pathology, and contributions of complement. The similarities underlying the immunopathology of AChR MG and neuromyelitis optica (NMO) are highlighted. In contrast, MuSK MG is caused by autoantibody production by short-lived plasmablasts. MuSK MG autoantibodies are mainly of the IgG4 subclass which can undergo Fab-arm exchange (FAE), a process unique to this subclass. In FAE IgG4, molecules can dissociate into two halves and recombine with other half IgG4 molecules resulting in bispecific antibodies. Similarities between MuSK MG and other IgG4-mediated autoimmune diseases, including pemphigus vulgaris (PV) and chronic inflammatory demyelinating polyneuropathy (CIDP), are highlighted. Finally, the immunological distinctions are emphasized through presentation of biological therapeutics that provide clinical benefit depending on the MG disease subtype.
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Affiliation(s)
- Miriam L Fichtner
- Department of Neurology, School of Medicine, Yale University, New Haven, CT, United States.,Department of Immunobiology, School of Medicine, Yale University, New Haven, CT, United States
| | - Ruoyi Jiang
- Department of Immunobiology, School of Medicine, Yale University, New Haven, CT, United States
| | - Aoibh Bourke
- Trinity Hall, University of Cambridge, Cambridge, United Kingdom
| | - Richard J Nowak
- Department of Neurology, School of Medicine, Yale University, New Haven, CT, United States
| | - Kevin C O'Connor
- Department of Neurology, School of Medicine, Yale University, New Haven, CT, United States.,Department of Immunobiology, School of Medicine, Yale University, New Haven, CT, United States
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66
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Duchow A, Paul F, Bellmann-Strobl J. Current and emerging biologics for the treatment of neuromyelitis optica spectrum disorders. Expert Opin Biol Ther 2020; 20:1061-1072. [DOI: 10.1080/14712598.2020.1749259] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Ankelien Duchow
- Neurocure Clinical Research Center, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Experimental and Clinical Research Center, Charité - Universitätsmedizin Berlin Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health and Max Delbrück Center for Molecular Medicine, Berlin, Germany
| | - Friedemann Paul
- Neurocure Clinical Research Center, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Experimental and Clinical Research Center, Charité - Universitätsmedizin Berlin Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health and Max Delbrück Center for Molecular Medicine, Berlin, Germany
| | - Judith Bellmann-Strobl
- Neurocure Clinical Research Center, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Experimental and Clinical Research Center, Charité - Universitätsmedizin Berlin Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health and Max Delbrück Center for Molecular Medicine, Berlin, Germany
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Mao-Draayer Y, Thiel S, Mills EA, Chitnis T, Fabian M, Katz Sand I, Leite MI, Jarius S, Hellwig K. Neuromyelitis optica spectrum disorders and pregnancy: therapeutic considerations. Nat Rev Neurol 2020; 16:154-170. [PMID: 32080393 DOI: 10.1038/s41582-020-0313-y] [Citation(s) in RCA: 59] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/15/2020] [Indexed: 12/18/2022]
Abstract
Neuromyelitis optica spectrum disorders (NMOSD) are a type of neurological autoimmune disease characterized by attacks of CNS inflammation that are often severe and predominantly affect the spinal cord and optic nerve. The majority of individuals with NMOSD are women, many of whom are of childbearing age. Although NMOSD are rare, several small retrospective studies and case reports have indicated that pregnancy can worsen disease activity and might contribute to disease onset. NMOSD disease activity seems to negatively affect pregnancy outcomes. Moreover, some of the current NMOSD treatments are known to pose risks to the developing fetus and only limited safety data are available for others. Here, we review published studies regarding the relationship between pregnancy outcomes and NMOSD disease activity. We also assess the risks associated with using disease-modifying therapies for NMOSD during the course of pregnancy and breastfeeding. On the basis of the available evidence, we offer recommendations regarding the use of these therapies in the course of pregnancy planning in individuals with NMOSD.
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Affiliation(s)
- Yang Mao-Draayer
- Department of Neurology, University of Michigan Medical School, Ann Arbor, MI, USA.,Graduate Program in Immunology, Program in Biomedical Sciences, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Sandra Thiel
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Bochum, Germany
| | - Elizabeth A Mills
- Department of Neurology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Tanuja Chitnis
- Department of Neurology, Brigham and Women's Hospital and Massachusetts General Hospital, Boston, MA, USA
| | - Michelle Fabian
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ilana Katz Sand
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - M Isabel Leite
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Sven Jarius
- Molecular Neuroimmunology Group, Department of Neurology, University of Heidelberg, Heidelberg, Germany
| | - Kerstin Hellwig
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Bochum, Germany.
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68
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Rubin SJS, Bloom MS, Robinson WH. B cell checkpoints in autoimmune rheumatic diseases. Nat Rev Rheumatol 2020; 15:303-315. [PMID: 30967621 DOI: 10.1038/s41584-019-0211-0] [Citation(s) in RCA: 57] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
B cells have important functions in the pathogenesis of autoimmune diseases, including autoimmune rheumatic diseases. In addition to producing autoantibodies, B cells contribute to autoimmunity by serving as professional antigen-presenting cells (APCs), producing cytokines, and through additional mechanisms. B cell activation and effector functions are regulated by immune checkpoints, including both activating and inhibitory checkpoint receptors that contribute to the regulation of B cell tolerance, activation, antigen presentation, T cell help, class switching, antibody production and cytokine production. The various activating checkpoint receptors include B cell activating receptors that engage with cognate receptors on T cells or other cells, as well as Toll-like receptors that can provide dual stimulation to B cells via co-engagement with the B cell receptor. Furthermore, various inhibitory checkpoint receptors, including B cell inhibitory receptors, have important functions in regulating B cell development, activation and effector functions. Therapeutically targeting B cell checkpoints represents a promising strategy for the treatment of a variety of autoimmune rheumatic diseases.
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Affiliation(s)
- Samuel J S Rubin
- Immunology Program, Stanford University School of Medicine, Stanford, CA, USA.,Division of Immunology and Rheumatology, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA.,VA Palo Alto Health Care System, Palo Alto, CA, USA
| | - Michelle S Bloom
- Immunology Program, Stanford University School of Medicine, Stanford, CA, USA.,Division of Immunology and Rheumatology, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA.,VA Palo Alto Health Care System, Palo Alto, CA, USA
| | - William H Robinson
- Immunology Program, Stanford University School of Medicine, Stanford, CA, USA. .,Division of Immunology and Rheumatology, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA. .,VA Palo Alto Health Care System, Palo Alto, CA, USA.
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69
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Abstract
Passive antibody therapies have a long history of use. In the 19th century, antibodies from xenographic sources of polyclonal antibodies were used to treat infections (diphtheria). They were used often as protection from infectious agents and toxins. Complications related to their use involved development of immune complexes and severe allergic reactions. As a result, human source plasma for polyclonal antibodies became the preferential source for antibodies. They are used to treat infection, remove toxins, prevent hemolytic disease of the newborn, modify inflammatory reactions, and control autoimmune diseases. Continued improvements in processing decreased the transfusion/infusion transmission of infections. In the late 20th century (∼1986), monoclonal antibodies were developed. The first monoclonal antibodies were of xenographic source and were wrought with problems of immunogenicity. These forms of antibodies did not gain favor until chimerization took pace in the mid-1990s and in 1998 two monoclonal antibodies were approved one to treat respiratory syncytial virus and the other for breast cancers. Further development of humanized and then fully human monoclonal antibodies has led to an evolution of therapies with these agents. Monoclonal antibodies are being researched or approved to treat a multitude of diseases to include oncologic, inflammatory, autoimmune, cardiovascular, respiratory, neurologic, allergic, benign hematologic, infections, orthopedic, coagulopathy, metabolic and to decrease morbidity of disease (diminution of pain), modify disease progression, and potentially anatomic development. In this chapter, we will review the history of use of these passive antibody therapies, their mechanism of action, pharmacologic-therapeutic classification, particular medical indication, adverse reactions, and potential future use of these medications.
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70
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Kim W, Kim HJ. Monoclonal Antibody Therapies for Multiple Sclerosis and Neuromyelitis Optica Spectrum Disorder. J Clin Neurol 2020; 16:355-368. [PMID: 32657055 PMCID: PMC7354979 DOI: 10.3988/jcn.2020.16.3.355] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Revised: 12/01/2019] [Accepted: 12/02/2019] [Indexed: 12/21/2022] Open
Abstract
Considerable progress has been made in treatments for multiple sclerosis (MS) and neuromyelitis optica spectrum disorder (NMOSD) over the last several decades. However, the present treatments do not show satisfactory efficacy or safety in a considerable proportion of patients, who experience relapse or disability progression despite receiving treatment and suffer from side effects, which can be severe. Improvements in the understanding of the pathophysiologies of MS and NMOSD have led to numerous therapeutic approaches being proposed and developed. Monoclonal antibodies (mAbs) are receiving increasing attention because of their specificity of action and likelihood of high efficacy with fewer side effects. Many mAbs have been evaluated, and some have been approved for MS or NMOSD treatment. This article reviews the use of mAbs for treating MS and NMOSD, including summarizing their mechanisms of action, efficacy, and safety profiles.
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Affiliation(s)
- Woojun Kim
- Department of Neurology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Ho Jin Kim
- Department of Neurology, Research Institute and Hospital of National Cancer Center, Goyang, Korea.
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71
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Akaishi T, Nakashima I, Takahashi T, Abe M, Ishii T, Aoki M. Neuromyelitis optica spectrum disorders with unevenly clustered attack occurrence. NEUROLOGY-NEUROIMMUNOLOGY & NEUROINFLAMMATION 2019; 7:7/1/e640. [PMID: 31757816 PMCID: PMC6935841 DOI: 10.1212/nxi.0000000000000640] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Objective The aim of this study was to elucidate the characteristics of clinical attacks in neuromyelitis optica spectrum disorders (NMOSDs) with positive serum anti-aquaporin-4 antibody. Both the timing and sequential pattern of clinical types were analyzed. Methods A total of 69 patients with NMOSD were enrolled in this study, all of whom were treated at a single university hospital. All data regarding the clinical attacks (including types and date) together with other clinical information were collected. Results Analysis of clinical attacks from the enrolled patients showed that there were 2 distributional patterns of attack occurrence in each patient: (1) “clustered” occurrences, which occurred within 12 months from the previous attack, and (2) “nonclustered” intermittent occurrences, which occurred ≥12 months after the previous attack. These occurrences were regardless of the duration from the onset. During the “clustered” period, clinical attacks were more likely to show a similar clinical manifestation, such as optic neuritis or myelitis. After entering the “nonclustered” intermittent period, the relapses were of random clinical type, regardless of the previous clinical manifestation. Conclusions Patients with NMOSD showed mixed periods of “clustered” occurrence with frequent attacks presenting with similar manifestations and “nonclustered” intermittent periods with sparse relapses. Approximately half of the relapses occurred during the “clustered” period within 12 months of the last clinical attack. Clinicians should pay special attention to whether the patients are presently in the “clustered” or “nonclustered” period to decide optimal relapse-preventive strategies.
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Affiliation(s)
- Tetsuya Akaishi
- From the Department of Neurology (T.A., T.T., M.A.), Tohoku University School of Medicine, Sendai, Japan; Department of Education and Support for Regional Medicine (T.A., M.A., T.I.), Tohoku University Hospital, Sendai, Japan; Department of Neurology (I.N.), Tohoku Medical and Pharmaceutical University, Sendai, Japan; and Department of Neurology (T.T.), National Hospital Organization Yonezawa National Hospital, Yonezawa, Japan.
| | - Ichiro Nakashima
- From the Department of Neurology (T.A., T.T., M.A.), Tohoku University School of Medicine, Sendai, Japan; Department of Education and Support for Regional Medicine (T.A., M.A., T.I.), Tohoku University Hospital, Sendai, Japan; Department of Neurology (I.N.), Tohoku Medical and Pharmaceutical University, Sendai, Japan; and Department of Neurology (T.T.), National Hospital Organization Yonezawa National Hospital, Yonezawa, Japan
| | - Toshiyuki Takahashi
- From the Department of Neurology (T.A., T.T., M.A.), Tohoku University School of Medicine, Sendai, Japan; Department of Education and Support for Regional Medicine (T.A., M.A., T.I.), Tohoku University Hospital, Sendai, Japan; Department of Neurology (I.N.), Tohoku Medical and Pharmaceutical University, Sendai, Japan; and Department of Neurology (T.T.), National Hospital Organization Yonezawa National Hospital, Yonezawa, Japan
| | - Michiaki Abe
- From the Department of Neurology (T.A., T.T., M.A.), Tohoku University School of Medicine, Sendai, Japan; Department of Education and Support for Regional Medicine (T.A., M.A., T.I.), Tohoku University Hospital, Sendai, Japan; Department of Neurology (I.N.), Tohoku Medical and Pharmaceutical University, Sendai, Japan; and Department of Neurology (T.T.), National Hospital Organization Yonezawa National Hospital, Yonezawa, Japan
| | - Tadashi Ishii
- From the Department of Neurology (T.A., T.T., M.A.), Tohoku University School of Medicine, Sendai, Japan; Department of Education and Support for Regional Medicine (T.A., M.A., T.I.), Tohoku University Hospital, Sendai, Japan; Department of Neurology (I.N.), Tohoku Medical and Pharmaceutical University, Sendai, Japan; and Department of Neurology (T.T.), National Hospital Organization Yonezawa National Hospital, Yonezawa, Japan
| | - Masashi Aoki
- From the Department of Neurology (T.A., T.T., M.A.), Tohoku University School of Medicine, Sendai, Japan; Department of Education and Support for Regional Medicine (T.A., M.A., T.I.), Tohoku University Hospital, Sendai, Japan; Department of Neurology (I.N.), Tohoku Medical and Pharmaceutical University, Sendai, Japan; and Department of Neurology (T.T.), National Hospital Organization Yonezawa National Hospital, Yonezawa, Japan
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72
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Murphy KA, Bhamidipati K, Rubin SJS, Kipp L, Robinson WH, Lanz TV. Immunomodulatory receptors are differentially expressed in B and T cell subsets relevant to autoimmune disease. Clin Immunol 2019; 209:108276. [PMID: 31669582 DOI: 10.1016/j.clim.2019.108276] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 10/15/2019] [Accepted: 10/17/2019] [Indexed: 12/15/2022]
Abstract
Inhibitory cell-surface receptors on lymphocytes, often called immune checkpoints, are powerful targets for cancer therapy. Despite their direct involvement in autoimmune pathology, they are currently not exploited therapeutically for autoimmune diseases. Understanding the expression pattern of these receptors in health and disease is essential for targeted drug design. Here, we designed three 23-colour flow cytometry panels for peripheral-blood T cells, including 15 lineage-defining markers and 21 immunomodulatory cell-surface receptors, and a 22-marker panel for B cells. Blood samples from healthy individuals, multiple sclerosis (MS), and lupus (SLE) patients were included in the study. Several receptors show differential expression on regulatory T cells (Treg) compared to T helper (Th) 1 and Th17 cells, and functional relevance of this difference could be shown for BTLA and CD5. Unbiased multiparametric analysis revealed a subset of activated CD8+ T cells and a subset of unswitched memory B cells that are diminished in MS and SLE, respectively.
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Affiliation(s)
- Katherine A Murphy
- Division of Immunology and Rheumatology, Department of Medicine, Stanford University School of Medicine, Stanford, CA, United States
| | - Kartik Bhamidipati
- Division of Immunology and Rheumatology, Department of Medicine, Stanford University School of Medicine, Stanford, CA, United States
| | - Samuel J S Rubin
- Division of Immunology and Rheumatology, Department of Medicine, Stanford University School of Medicine, Stanford, CA, United States
| | - Lucas Kipp
- Division of Neuroimmunology, Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, CA, United States
| | - William H Robinson
- Division of Immunology and Rheumatology, Department of Medicine, Stanford University School of Medicine, Stanford, CA, United States.
| | - Tobias V Lanz
- Division of Immunology and Rheumatology, Department of Medicine, Stanford University School of Medicine, Stanford, CA, United States; Department of Neurology, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany.
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73
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Cree BAC, Bennett JL, Kim HJ, Weinshenker BG, Pittock SJ, Wingerchuk DM, Fujihara K, Paul F, Cutter GR, Marignier R, Green AJ, Aktas O, Hartung HP, Lublin FD, Drappa J, Barron G, Madani S, Ratchford JN, She D, Cimbora D, Katz E. Inebilizumab for the treatment of neuromyelitis optica spectrum disorder (N-MOmentum): a double-blind, randomised placebo-controlled phase 2/3 trial. Lancet 2019; 394:1352-1363. [PMID: 31495497 DOI: 10.1016/s0140-6736(19)31817-3] [Citation(s) in RCA: 394] [Impact Index Per Article: 78.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Revised: 07/01/2019] [Accepted: 07/05/2019] [Indexed: 11/27/2022]
Abstract
BACKGROUND No approved therapies exist for neuromyelitis optica spectrum disorder (NMOSD), a rare, relapsing, autoimmune, inflammatory disease of the CNS that causes blindness and paralysis. We aimed to assess the efficacy and safety of inebilizumab, an anti-CD19, B cell-depleting antibody, in reducing the risk of attacks and disability in NMOSD. METHODS We did a multicentre, double-blind, randomised placebo-controlled phase 2/3 study at 99 outpatient specialty clinics or hospitals in 25 countries. Eligible participants were adults (≥18 years old) with a diagnosis of NMOSD, an Expanded Disability Status Scale score of 8·0 or less, and a history of at least one attack requiring rescue therapy in the year before screening or at least two attacks requiring rescue therapy in the 2 years before screening. Participants were randomly allocated (3:1) to 300 mg intravenous inebilizumab or placebo with a central interactive voice response system or interactive web response system and permuted block randomisation. Inebilizumab or placebo was administered on days 1 and 15. Participants, investigators, and all clinical staff were masked to the treatments, and inebilizumab and placebo were indistinguishable in appearance. The primary endpoint was time to onset of an NMOSD attack, as determined by the adjudication committee. Efficacy endpoints were assessed in all randomly allocated patients who received at least one dose of study intervention, and safety endpoints were assessed in the as-treated population. The study is registered with ClinicalTrials.gov, number NCT02200770. FINDINGS Between Jan 6, 2015, and Sept 24, 2018, 230 participants were randomly assigned to treatment and dosed, with 174 participants receiving inebilizumab and 56 receiving placebo. The randomised controlled period was stopped before complete enrolment, as recommended by the independent data-monitoring committee, because of a clear demonstration of efficacy. 21 (12%) of 174 participants receiving inebilizumab had an attack versus 22 (39%) of 56 participants receiving placebo (hazard ratio 0·272 [95% CI 0·150-0·496]; p<0·0001). Adverse events occurred in 125 (72%) of 174 participants receiving inebilizumab and 41 (73%) of 56 participants receiving placebo. Serious adverse events occurred in eight (5%) of 174 participants receiving inebilizumab and five (9%) of 56 participants receiving placebo. INTERPRETATION Compared with placebo, inebilizumab reduced the risk of an NMOSD attack. Inebilizumab has potential application as an evidence-based treatment for patients with NMOSD. FUNDING MedImmune and Viela Bio.
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Affiliation(s)
- Bruce A C Cree
- UCSF Weill Institute for Neurosciences, Department of Neurology, University of California San Francisco, San Francisco, CA, USA.
| | - Jeffrey L Bennett
- School of Medicine, Anschutz Medical Campus, University of Colorado, Aurora, CO, USA
| | - Ho Jin Kim
- Research Institute and Hospital of National Cancer Center, Seoul, South Korea
| | | | | | | | - Kazuo Fujihara
- Department of Multiple Sclerosis Therapeutics, Fukushima Medical University, Fukushima, Japan; Multiple Sclerosis and Neuromyelitis Optica Center, Southern Tohoku Research Institute for Neuroscience, Koriyama, Japan
| | - Friedemann Paul
- Experimental and Clinical Research Center, Max Delbrueck Center for Molecular Medicine, Berlin, Germany; Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Gary R Cutter
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Romain Marignier
- Service de Neurologie, Sclérose en Plaques, Pathologies de la Myéline et Neuro-inflammation, Lyon University Hospital, Lyon, France
| | - Ari J Green
- UCSF Weill Institute for Neurosciences, Department of Neurology, University of California San Francisco, San Francisco, CA, USA; Department of Ophthalmology, University of California San Francisco, San Francisco, CA, USA
| | - Orhan Aktas
- Medical Faculty, Heinrich Heine University, Düsseldorf, Germany
| | | | - Fred D Lublin
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Ayzenberg I, Faissner S, Tomaske L, Richter D, Behrendt V, Gold R. General principles and escalation options of immunotherapy in autoantibody-associated disorders of the CNS. Neurol Res Pract 2019; 1:32. [PMID: 33324898 PMCID: PMC7650108 DOI: 10.1186/s42466-019-0037-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Accepted: 08/05/2019] [Indexed: 12/18/2022] Open
Abstract
Autoimmune diseases associated with antineuronal and antiglial autoantibodies (Abs) is one of the most rapidly expanding research fields in clinical neuroimmunology, with more than 30 autoantibodies described so far. Being associated with a wide range of clinical presentations these syndromes can be diagnostically challenging. Surface or intracellular antigen localizations are crucial for the treatment response and outcome. In the latter Abs are mostly of paraneoplastic cause and tumor management should be performed as soon as possible in order to stop peripheral antigen stimulation. Immunotherapy should be started early in both groups, before irreversible neuronal loss occurs. Despite serious prognosis, aggressive therapeutic approaches can be effective in many cases. In this article we review main pathogenic mechanisms leading to Abs-related syndromes and describe standard as well as emerging strategies of immunotherapy, including tocilizumab and bortezomib. Several special therapeutic approaches will be illustrated by clinical cases recently treated in our department.
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Affiliation(s)
- Ilya Ayzenberg
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Bochum, Germany.,Department of Neurology, Sechenov First Moscow State Medical University, Moscow, Russia
| | - Simon Faissner
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Bochum, Germany
| | - Laura Tomaske
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Bochum, Germany
| | - Daniel Richter
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Bochum, Germany
| | - Volker Behrendt
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Bochum, Germany
| | - Ralf Gold
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Bochum, Germany
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75
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Pharmacotherapy for Neuromyelitis Optica Spectrum Disorders: Current Management and Future Options. Drugs 2019; 79:125-142. [PMID: 30623348 DOI: 10.1007/s40265-018-1039-7] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Neuromyelitis optica (NMO) is an inflammatory and demyelinating disease of the central nervous system. Although the prevalence of NMO is low, the rapid and severe impairment observed in patients has led to extensive development of research in the fields of diagnostic criteria and therapy in the past 15 years. With improved understanding of the pathophysiology of NMO and the role of aquaporin-4 (AQP4) or myelin oligodendrocyte glycoprotein antibodies, numerous therapeutic approaches have been proposed and are currently undergoing evaluation. In this review, we describe the rationale for existing therapeutics and their benefit/risk ratio. We also discuss the pharmacological and clinical interest of future approaches targeting, among others, B or T cells, the blood-central nervous system barrier, complement, polynuclear cells, AQP4-antibody linkage and AQP4 activity. The numerous agents under development are the result of a major collaborative effort all over the world. After the considerable progress on diagnosis, we are now close to class I evidence for a therapeutic effect of several drugs in NMO spectrum disorders, most notably with the anti-interleukin-6 receptor antibody (satralizumab) and anti-complement-5 antibody (eculizumab).
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76
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Abstract
Increasing evidence suggests that B cells contribute both to the regulation of normal autoimmunity and to the pathogenesis of immune mediated diseases, including multiple sclerosis (MS). B cells in MS are skewed toward a pro-inflammatory profile, and contribute to MS pathogenesis by antibody production, antigen presentation, T cells stimulation and activation, driving autoproliferation of brain-homing autoreactive CD4+ T cells, production of pro-inflammatory cytokines, and formation of ectopic meningeal germinal centers that drive cortical pathology and contribute to neurological disability. The recent interest in the key role of B cells in MS has been evoked by the profound anti-inflammatory effects of rituximab, a chimeric monoclonal antibody (mAb) targeting the B cell surface marker CD20, observed in relapsing-remitting MS. This has been reaffirmed by clinical trials with less immunogenic and more potent B cell-depleting mAbs targeting CD20 – ocrelizumab, ofatumumab and ublituximab. Ocrelizumab is also the first disease-modifying drug that has shown efficacy in primary-progressive MS, and is currently approved for both indications. Another promising approach is the inhibition of Bruton's tyrosine kinase, a key enzyme that mediates B cell activation and survival, by agents such as evobrutinib. On the other hand, targeting B cell cytokines with the fusion protein atacicept increased MS activity, highlighting the complex and not fully understood role of B cells and humoral immunity in MS. Finally, all other approved therapies for MS, some of which have been designed to target T cells, have some effects on the frequency, phenotype, or homing of B cells, which may contribute to their therapeutic activity.
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Affiliation(s)
- Ron Milo
- Ron Milo, Department of Neurology, Barzilai Medical Center, Ha-Histadrut St 2, Ashkelon 7308604, Israel,
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77
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Osherov M, Milo R. B Cell-based Therapies for Multiple Sclerosis. EMERGING DRUGS AND TARGETS FOR MULTIPLE SCLEROSIS 2019. [DOI: 10.1039/9781788016070-00134] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
The traditional view of multiple sclerosis (MS) as a T cell mediated autoimmune disease of the central nervous system (CNS) has evolved into a concept of an immune-mediated disease where complex bi-directional interactions between T cells, B cells and myeloid cells underlie and shape CNS-directed autoimmunity. B cells are now recognized as major contributors to the pathogenesis of MS, largely due to increased understanding of their biology and the profound anti-inflammatory effects demonstrated by B cell depletion in MS. In this chapter we discuss the fundamental roles B cells play in the pathogenesis of MS and review current and future therapeutic strategies targeting B cells in MS, including B cell depletion with various monoclonal antibodies (mAbs) against the B cell surface markers CD20 and CD19, anti-B cell cytokine therapies, blocking Bruton's tyrosine kinase (BTK) in B cells, and various immunomodulatory and immunosuppressive effects exerted on B cells by virtually all other approved therapies for MS.
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Affiliation(s)
- Michael Osherov
- Department of Neurology, Barzilai University Medical Center 2 Hahistadrut St. Ashkelon 7830604 Israel
| | - Ron Milo
- Department of Neurology, Barzilai University Medical Center 2 Hahistadrut St. Ashkelon 7830604 Israel
- Faculty of Health Sciences, Ben-Gurion University of the Negev Beer-Sheva Israel
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78
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D'Amico E, Zanghì A, Gastaldi M, Patti F, Zappia M, Franciotta D. Placing CD20-targeted B cell depletion in multiple sclerosis therapeutic scenario: Present and future perspectives. Autoimmun Rev 2019; 18:665-672. [PMID: 31059839 DOI: 10.1016/j.autrev.2019.05.003] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2019] [Accepted: 01/18/2019] [Indexed: 12/26/2022]
Abstract
Multiple sclerosis (MS) is an acquired demyelinating disease of the central nervous system (CNS) that traditionally has been considered to be mediated primarily by T cells. Increasing evidence, however, suggests the fundamental role of B cells in the pathogenesis and development of the disease. Recently, anti-CD20 B cell-based therapies have demonstrated impressive and somewhat surprising results in MS, showing profound anti-inflammatory effects with a favorable risk-benefit ratio. Moreover, for the first time in the MS therapeutic scenario, the anti-CD20 monoclonal antibody ocrelizumab has been granted for the treatment of the primary progressive form of the disease. In this review, we provide a brief overview about anti-CD20 B cell-based therapies in MS, in the perspective of their influence on the future management of the disease, and of their possible positioning in a new wider therapeutic scenario.
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Affiliation(s)
| | - Aurora Zanghì
- Department G.F.Ingrassia, University of Catania, Italy
| | - Matteo Gastaldi
- Neuroimmunology Laboratory, IRCCS Mondino Foundation, Pavia, Italy
| | | | - Mario Zappia
- Department G.F.Ingrassia, University of Catania, Italy
| | - Diego Franciotta
- Neuroimmunology Laboratory, IRCCS Mondino Foundation, Pavia, Italy
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79
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Milo R. Therapies for multiple sclerosis targeting B cells. Croat Med J 2019; 60:87-98. [PMID: 31044580 PMCID: PMC6509632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2019] [Accepted: 04/14/2019] [Indexed: 10/12/2023] Open
Abstract
Increasing evidence suggests that B cells contribute both to the regulation of normal autoimmunity and to the pathogenesis of immune mediated diseases, including multiple sclerosis (MS). B cells in MS are skewed toward a pro-inflammatory profile, and contribute to MS pathogenesis by antibody production, antigen presentation, T cells stimulation and activation, driving autoproliferation of brain-homing autoreactive CD4+ T cells, production of pro-inflammatory cytokines, and formation of ectopic meningeal germinal centers that drive cortical pathology and contribute to neurological disability. The recent interest in the key role of B cells in MS has been evoked by the profound anti-inflammatory effects of rituximab, a chimeric monoclonal antibody (mAb) targeting the B cell surface marker CD20, observed in relapsing-remitting MS. This has been reaffirmed by clinical trials with less immunogenic and more potent B cell-depleting mAbs targeting CD20 - ocrelizumab, ofatumumab and ublituximab. Ocrelizumab is also the first disease-modifying drug that has shown efficacy in primary-progressive MS, and is currently approved for both indications. Another promising approach is the inhibition of Bruton's tyrosine kinase, a key enzyme that mediates B cell activation and survival, by agents such as evobrutinib. On the other hand, targeting B cell cytokines with the fusion protein atacicept increased MS activity, highlighting the complex and not fully understood role of B cells and humoral immunity in MS. Finally, all other approved therapies for MS, some of which have been designed to target T cells, have some effects on the frequency, phenotype, or homing of B cells, which may contribute to their therapeutic activity.
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Affiliation(s)
- Ron Milo
- Ron Milo, Department of Neurology, Barzilai Medical Center, Ha-Histadrut St 2, Ashkelon 7308604, Israel,
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80
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Patel SY, Carbone J, Jolles S. The Expanding Field of Secondary Antibody Deficiency: Causes, Diagnosis, and Management. Front Immunol 2019; 10:33. [PMID: 30800120 PMCID: PMC6376447 DOI: 10.3389/fimmu.2019.00033] [Citation(s) in RCA: 118] [Impact Index Per Article: 23.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Accepted: 01/08/2019] [Indexed: 12/11/2022] Open
Abstract
Antibody deficiency or hypogammaglobulinemia can have primary or secondary etiologies. Primary antibody deficiency (PAD) is the result of intrinsic genetic defects, whereas secondary antibody deficiency may arise as a consequence of underlying conditions or medication use. On a global level, malnutrition, HIV, and malaria are major causes of secondary immunodeficiency. In this review we consider secondary antibody deficiency, for which common causes include hematological malignancies, such as chronic lymphocytic leukemia or multiple myeloma, and their treatment, protein-losing states, and side effects of a number of immunosuppressive agents and procedures involved in solid organ transplantation. Secondary antibody deficiency is not only much more common than PAD, but is also being increasingly recognized with the wider and more prolonged use of a growing list of agents targeting B cells. SAD may thus present to a broad range of specialties and is associated with an increased risk of infection. Early diagnosis and intervention is key to avoiding morbidity and mortality. Optimizing treatment requires careful clinical and laboratory assessment and may involve close monitoring of risk parameters, vaccination, antibiotic strategies, and in some patients, immunoglobulin replacement therapy (IgRT). This review discusses the rapidly evolving list of underlying causes of secondary antibody deficiency, specifically focusing on therapies targeting B cells, alongside recent advances in screening, biomarkers of risk for the development of secondary antibody deficiency, diagnosis, monitoring, and management.
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Affiliation(s)
- Smita Y. Patel
- Clinical Immunology Department, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Javier Carbone
- Clinical Immunology Department, Hospital General Universitario Gregorio Marañon, Madrid, Spain
| | - Stephen Jolles
- Immunodeficiency Centre for Wales, University Hospital of Wales, Cardiff, United Kingdom
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81
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Abstract
B cells play a vital function in multiple sclerosis (MS) pathogenesis through an array of effector functions. All currently approved MS disease-modifying therapies alter the frequency, phenotype, or homing of B cells in one way or another. The importance of this mechanism of action has been reinforced with the successful development and clinical testing of B-cell-depleting monoclonal antibodies that target the CD20 surface antigen. Ocrelizumab, a humanized anti-CD20 monoclonal antibody, was approved by the Food and Drug Administration (FDA) in March 2017 after pivotal trials showed dramatic reductions in inflammatory disease activity in relapsing MS as well as lessening of disability progression in primary progressive MS. These and other clinical studies place B cells at the center of the inflammatory cascade in MS and provide a launching point for development of therapies that target selective pathogenic B-cell populations.
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Affiliation(s)
- Joseph J Sabatino
- Multiple Sclerosis Center, Department of Neurology, University of California, San Francisco, California 94158
| | - Scott S Zamvil
- Multiple Sclerosis Center, Department of Neurology, University of California, San Francisco, California 94158
| | - Stephen L Hauser
- Multiple Sclerosis Center, Department of Neurology, University of California, San Francisco, California 94158
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82
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Myhr KM, Torkildsen Ø, Lossius A, Bø L, Holmøy T. B cell depletion in the treatment of multiple sclerosis. Expert Opin Biol Ther 2019; 19:261-271. [PMID: 30632834 DOI: 10.1080/14712598.2019.1568407] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
INTRODUCTION Multiple sclerosis (MS) is a chronic inflammatory disease of the central nervous system. The latest development of B-cell depletion by anti-CD20 monoclonal antibodies has been a large step forward in the treatment of this devastating disease. AREAS COVERED In this manuscript, we review mechanisms of action, efficacy, safety, and tolerance of anti-CD20 therapies for MS, including rituximab, ocrelizumab, and ofatumumab. EXPERT OPINION B-cell depletion efficiently suppresses acute inflammatory disease activity in relapsing-remitting MS (RRMS), and may slowdown progression in primary progressive MS (PPMS). The treatment is generally well tolerated, with manageable adverse events related to infusion reactions and infections. Ocrelizumab, a humanized anti-CD20 monoclonal antibody, is the first therapy to be approved for the treatment of both RRMS and PPMS.
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Affiliation(s)
- Kjell-Morten Myhr
- a Department of Clinical Medicine , University of Bergen , Bergen , Norway.,b Department of Neurology , Haukeland University Hospital , Bergen , Norway
| | - Øivind Torkildsen
- a Department of Clinical Medicine , University of Bergen , Bergen , Norway.,b Department of Neurology , Haukeland University Hospital , Bergen , Norway
| | - Andreas Lossius
- c Department of Neurology , Akershus University Hospital , Lørenskog , Norway.,d Department of Immunology and Transfusion Medicine, Faculty of Medicine , University of Oslo and Oslo University Hospital Rikshospitalet , Oslo , Norway
| | - Lars Bø
- a Department of Clinical Medicine , University of Bergen , Bergen , Norway.,b Department of Neurology , Haukeland University Hospital , Bergen , Norway
| | - Trygve Holmøy
- c Department of Neurology , Akershus University Hospital , Lørenskog , Norway.,e Department of Clinical Medicine , University of Oslo , Oslo , Norway
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83
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Abstract
INTRODUCTION In the past decade, the role of B cells in the pathogenesis of multiple sclerosis (MS) is coming to the forefront. Depletion of B cells by anti-CD20 monoclonal antibodies (mAbs) has proved to decrease the activity of the relapsing-remitting MS (RRMS) and the progression of primary progressive MS (PPMS). Areas covered: In this review, the authors discuss the rationale of the depletion of B cells in RRMS and PPMS across recent studies on the role of B cells in the pathogenesis of MS; previous clinical trials with treatments targeting B cells; the mechanism of action of ocrelizumab - a second generation anti-CD20 mAb - and recent phase III clinical trials with ocrelizumab in RRMS and PPMS. Expert commentary: Ocrelizumab is the first anti-CD20 monoclonal antibody approved for RRMS and the first treatment approved for PPMS. The long-term effect and safety profile need to be evaluated in extension of clinical trials and in real-world studies.
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Affiliation(s)
- Kévin Bigaut
- a Département de Neurologie , Centre Hospitalier Universitaire de Strasbourg, Avenue Moliére , 67200 Strasbourg , France
| | - Jérôme De Seze
- a Département de Neurologie , Centre Hospitalier Universitaire de Strasbourg, Avenue Moliére , 67200 Strasbourg , France.,b Biopathologie de la Myéline,Neuroprotection et Stratégies Thérapeutiques, INSERM U1119, Fédération de Médecine Translationnelle de Strasbourg (FMTS) , Université de Strasbourg, Bâtiment 3 de la Faculté de Médecine , 11 rue Humann, 67000 Strasbourg , France.,c Centre d'investigation clinique , INSERM U1434, Centre Hospitalier Universitaire de Strasbourg , 1 Place de l'Hôpital, 67000 Strasbourg , France
| | - Nicolas Collongues
- a Département de Neurologie , Centre Hospitalier Universitaire de Strasbourg, Avenue Moliére , 67200 Strasbourg , France.,b Biopathologie de la Myéline,Neuroprotection et Stratégies Thérapeutiques, INSERM U1119, Fédération de Médecine Translationnelle de Strasbourg (FMTS) , Université de Strasbourg, Bâtiment 3 de la Faculté de Médecine , 11 rue Humann, 67000 Strasbourg , France.,c Centre d'investigation clinique , INSERM U1434, Centre Hospitalier Universitaire de Strasbourg , 1 Place de l'Hôpital, 67000 Strasbourg , France
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84
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Abstract
INTRODUCTION Autoimmune blistering skin diseases are a group of disorders subdivided according to the location of blister formation: intraepidermal blistering in the pemphigus group and subepidermal in the pemphigoid group. These conditions are clinically heterogeneous and are treated with systemic corticosteroids and/or other forms of immunosuppression on the basis of clinical subtype and disease severity. These approaches may not be effective for the induction and maintenance of clinical response or need to be stopped because of intolerable side effects. AREAS COVERED Biological therapies can represent a valid alternative strategy in various autoimmune blistering disorders and this review article will address this issue with a special focus on pemphigus vulgaris and bullous pemphigoid. These biological approaches are designed to target B cells, autoantibodies, complement proteins, and several cytokines. EXPERT OPINION Innovative strategies for the treatment of autoimmune blistering conditions primarily depend on the use of drugs with a high degree of specificity targeting crucial steps in the immunopathology of these disorders. Novel biological agents offer treatment alternatives to patients with autoimmune blistering conditions by targeting B cells, pathogenic autoantibodies, complement and cytokines.
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Affiliation(s)
- Mauro Alaibac
- a Unit of Dermatology , University of Padua , Padua , Italy
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85
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Negron A, Robinson RR, Stüve O, Forsthuber TG. The role of B cells in multiple sclerosis: Current and future therapies. Cell Immunol 2018; 339:10-23. [PMID: 31130183 DOI: 10.1016/j.cellimm.2018.10.006] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Revised: 10/19/2018] [Accepted: 10/20/2018] [Indexed: 02/07/2023]
Abstract
While it was long held that T cells were the primary mediators of multiple sclerosis (MS) pathogenesis, the beneficial effects observed in response to treatment with Rituximab (RTX), a monoclonal antibody (mAb) targeting CD20, shed light on a key contributor to MS that had been previously underappreciated: B cells. This has been reaffirmed by results from clinical trials testing the efficacy of subsequently developed B cell-depleting mAbs targeting CD20 as well as studies revisiting the effects of previous disease-modifying therapies (DMTs) on B cell subsets thought to modulate disease severity. In this review, we summarize current knowledge regarding the complex roles of B cells in MS pathogenesis and current and potential future B cell-directed therapies.
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Affiliation(s)
- Austin Negron
- Department of Biology, University of Texas at San Antonio, TX 78249, USA
| | - Rachel R Robinson
- Department of Biology, University of Texas at San Antonio, TX 78249, USA
| | - Olaf Stüve
- Department of Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, Dallas, TX, USA; Neurology Section, VA North Texas Health Care System, Medical Service, Dallas, TX, USA
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86
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Li R, Patterson KR, Bar-Or A. Reassessing B cell contributions in multiple sclerosis. Nat Immunol 2018; 19:696-707. [PMID: 29925992 DOI: 10.1038/s41590-018-0135-x] [Citation(s) in RCA: 253] [Impact Index Per Article: 42.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Accepted: 05/09/2018] [Indexed: 02/06/2023]
Abstract
There is growing recognition that B cell contributions to normal immune responses extend well beyond their potential to become antibody-producing cells, including roles at the innate-adaptive interface and their potential to modulate the responses of other immune cells such as T cells and myeloid cells. These B cell functions can have both pathogenic and protective effects in the context of central nervous system (CNS) inflammation. Here, we review recent advances in the field of multiple sclerosis (MS), which has traditionally been viewed as primarily a T cell-mediated disease, and we consider antibody-dependent and, particularly, emerging antibody-independent functions of B cells that may be relevant in both the peripheral and CNS disease compartments.
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Affiliation(s)
- Rui Li
- Center for Neuroinflammation and Experimental Therapeutics (CNET) and Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Kristina R Patterson
- Center for Neuroinflammation and Experimental Therapeutics (CNET) and Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Amit Bar-Or
- Center for Neuroinflammation and Experimental Therapeutics (CNET) and Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
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87
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Musette P, Bouaziz JD. B Cell Modulation Strategies in Autoimmune Diseases: New Concepts. Front Immunol 2018; 9:622. [PMID: 29706952 PMCID: PMC5908887 DOI: 10.3389/fimmu.2018.00622] [Citation(s) in RCA: 76] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Accepted: 03/13/2018] [Indexed: 12/04/2022] Open
Abstract
B cells are major effector cells in autoimmunity through antibody production, T cell help and pro-inflammatory cytokine production. Major advances have been made in human B cell biology knowledge using rituximab and type II new anti-CD20 antibodies, anti-CD19 antibodies, anti-CD22 antibodies, autoantigen specific B cell depleting therapy (chimeric antigen receptor T cells), and B cell receptor signaling inhibition (Bruton’s tyrosine kinase inhibitors). However, in certain circumstances B cell depleting therapy may lead to the worsening of the autoimmune disease which is in accordance with the existence of a regulatory B cell population. Current concepts and future directions for B cell modulating therapies in autoimmune diseases with a special focus on pemphigus are discussed.
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Affiliation(s)
- Philippe Musette
- Dermatology Department, INSERM U976, Rouen University Hospital, Rouen, France
| | - Jean David Bouaziz
- Dermatology Department, INSERM U976, Saint Louis University Hospital, Paris, France
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88
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Gajofatto A, Turatti M. Investigational immunosuppressants in early-stage clinical trials for the treatment of multiple sclerosis. Expert Opin Investig Drugs 2018; 27:273-286. [DOI: 10.1080/13543784.2018.1442437] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Alberto Gajofatto
- Department of Neuroscience, Biomedicine and Movement Sciences, University of Verona, Italy
| | - Marco Turatti
- Neurology B Unit, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
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89
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Greenfield AL, Hauser SL. B-cell Therapy for Multiple Sclerosis: Entering an era. Ann Neurol 2018; 83:13-26. [PMID: 29244240 PMCID: PMC5876115 DOI: 10.1002/ana.25119] [Citation(s) in RCA: 155] [Impact Index Per Article: 25.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Revised: 12/01/2017] [Accepted: 12/09/2017] [Indexed: 12/12/2022]
Abstract
Monoclonal antibodies that target CD20 expressing B cells represent an important new treatment option for patients with multiple sclerosis (MS). B-cell-depleting therapy is highly effective against relapsing forms of the disease and is also the first treatment approach proven to protect against disability worsening in primary progressive MS. Moreover, evolving clinical experience with B-cell therapy, combined with a more sophisticated understanding of humoral immunity in preclinical models and in patients with MS, has led to major progress in deciphering the immune pathogenesis of MS. Here, we review the nuanced roles of B cells in MS autoimmunity, the clinical data supporting use of ocrelizumab and other anti-CD20 therapies in the treatment of MS, as well as safety and practical considerations for prescribing. Last, we summarize remaining unanswered questions regarding the proper role of anti-CD20 therapy in MS, its limitations, and the future landscape of B-cell-based approaches to treatment. Ann Neurol 2018;83:13-26.
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Affiliation(s)
- Ariele L. Greenfield
- Weill Institute for Neurosciences, Department of Neurology, University of California, San Francisco, San Francisco, California
| | - Stephen L. Hauser
- Weill Institute for Neurosciences, Department of Neurology, University of California, San Francisco, San Francisco, California
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90
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Deciphering the Role of B Cells in Multiple Sclerosis-Towards Specific Targeting of Pathogenic Function. Int J Mol Sci 2017; 18:ijms18102048. [PMID: 28946620 PMCID: PMC5666730 DOI: 10.3390/ijms18102048] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Revised: 09/19/2017] [Accepted: 09/20/2017] [Indexed: 12/25/2022] Open
Abstract
B cells, plasma cells and antibodies may play a key role in the pathogenesis of multiple sclerosis (MS). This notion is supported by various immunological changes observed in MS patients, such as activation and pro-inflammatory differentiation of peripheral blood B cells, the persistence of clonally expanded plasma cells producing immunoglobulins in the cerebrospinal fluid, as well as the composition of inflammatory central nervous system lesions frequently containing co-localizing antibody depositions and activated complement. In recent years, the perception of a respective pathophysiological B cell involvement was vividly promoted by the empirical success of anti-CD20-mediated B cell depletion in clinical trials; based on these findings, the first monoclonal anti-CD20 antibody—ocrelizumab—is currently in the process of being approved for treatment of MS. In this review, we summarize the current knowledge on the role of B cells, plasma cells and antibodies in MS and elucidate how approved and future treatments, first and foremost anti-CD20 antibodies, therapeutically modify these B cell components. We will furthermore describe regulatory functions of B cells in MS and discuss how the evolving knowledge of these therapeutically desirable B cell properties can be harnessed to improve future safety and efficacy of B cell-directed therapy in MS.
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91
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Memory B Cells are Major Targets for Effective Immunotherapy in Relapsing Multiple Sclerosis. EBioMedicine 2017; 16:41-50. [PMID: 28161400 PMCID: PMC5474520 DOI: 10.1016/j.ebiom.2017.01.042] [Citation(s) in RCA: 190] [Impact Index Per Article: 27.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Revised: 01/20/2017] [Accepted: 01/29/2017] [Indexed: 01/01/2023] Open
Abstract
Although multiple sclerosis (MS) is considered to be a CD4, Th17-mediated autoimmune disease, supportive evidence is perhaps circumstantial, often based on animal studies, and is questioned by the perceived failure of CD4-depleting antibodies to control relapsing MS. Therefore, it was interestingly to find that current MS-treatments, believed to act via T cell inhibition, including: beta-interferons, glatiramer acetate, cytostatic agents, dimethyl fumarate, fingolimod, cladribine, daclizumab, rituximab/ocrelizumab physically, or functionally in the case of natalizumab, also depleted CD19+, CD27+ memory B cells. This depletion was substantial and long-term following CD52 and CD20-depletion, and both also induced long-term inhibition of MS with few treatment cycles, indicating induction-therapy activity. Importantly, memory B cells were augmented by B cell activating factor (atacicept) and tumor necrosis factor (infliximab) blockade that are known to worsen MS. This creates a unifying concept centered on memory B cells that is consistent with therapeutic, histopathological and etiological aspects of MS.
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