101
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Whiteside D, Barth S, Datta A, Trip SA. Pneumonitis secondary to alemtuzumab in a patient with multiple sclerosis - A non-infectious cause of breathlessness. Mult Scler Relat Disord 2018; 22:139-140. [PMID: 29684788 DOI: 10.1016/j.msard.2018.04.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Revised: 03/05/2018] [Accepted: 04/02/2018] [Indexed: 01/26/2023]
Abstract
The most common adverse events associated with the monoclonal antibody alemtuzumab are infusion associated reactions and secondary autoimmune disease. Respiratory complications are unusual following treatment with alemtuzumab, but can be precipitated by an infectious cause. We describe a case of a sub-acute steroid responsive non-infectious pneumonitis affecting a 51 year old woman, who presented one month after initiation of therapy for multiple sclerosis with alemtuzumab.
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Affiliation(s)
- D Whiteside
- Department of Neurology, Northwick Park Hospital, London, UK
| | - S Barth
- Department of Respiratory Medicine, Northwick Park Hospital, London, UK
| | - A Datta
- Department of Respiratory Medicine, Northwick Park Hospital, London, UK
| | - S A Trip
- Department of Neurology, Northwick Park Hospital, London, UK; Queen Square MS Centre, National Hospital for Neurology & Neurosurgery, London, UK.
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102
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An in vitro system of autologous lymphocytes culture that allows the study of homeostatic proliferation mechanisms in human naive CD4 T-cells. J Transl Med 2018; 98:500-511. [PMID: 29348565 DOI: 10.1038/s41374-017-0006-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Revised: 11/08/2017] [Accepted: 11/20/2017] [Indexed: 11/09/2022] Open
Abstract
The size of peripheral T-cell pool is kept constant throughout life. However, a decline in lymphocyte numbers is a feature of several human disorders, in which fast and slow homeostatic proliferation play a crucial role. Several in vitro and in vivo models have been developed to study such processes. Nevertheless, self- and commensal- antigens, well-known triggers of homeostatic proliferation, have not been examined in these models. We have designed an in vitro culture of human T-cells exposed to rIL7 and autologous antigen-presenting cells (aAPC) that allows the simultaneous characterization of the different types of homeostatic proliferation. Using our model, we first confirmed that both rIL7 and aAPC are survival signals ultimately leading to homeostatic proliferation. In addition, we explored the modulation of different anti-apoptotic, proliferative, activation and homing markers during fast and slow homeostatic proliferation. Finally, different subsets of Treg were generated during homeostatic proliferation in our model. In summary, our in vitro system is able to simultaneously reproduce both types of homeostatic proliferation of human naive CD4 T-cells, and allows the characterization of these processes. Our in vitro system is a useful tool to explore specific features of human homeostatic proliferation in different human lymphopenia-related disorders and could be used as a cell therapy approach.
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103
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Leussink VI, Reifenberger J, Hartung HP. Case of alopecia universalis associated with alemtuzumab treatment in MS. NEUROLOGY-NEUROIMMUNOLOGY & NEUROINFLAMMATION 2018. [DOI: 10.1212/nxi.0000000000000454] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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104
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Massey JC, Sutton IJ, Ma DDF, Moore JJ. Regenerating Immunotolerance in Multiple Sclerosis with Autologous Hematopoietic Stem Cell Transplant. Front Immunol 2018; 9:410. [PMID: 29593711 PMCID: PMC5857574 DOI: 10.3389/fimmu.2018.00410] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Accepted: 02/14/2018] [Indexed: 12/20/2022] Open
Abstract
Multiple sclerosis (MS) is an inflammatory disorder of the central nervous system where evidence implicates an aberrant adaptive immune response in the accrual of neurological disability. The inflammatory phase of the disease responds to immunomodulation to varying degrees of efficacy; however, no therapy has been proven to arrest progression of disability. Recently, more intensive therapies, including immunoablation with autologous hematopoietic stem cell transplantation (AHSCT), have been offered as a treatment option to retard inflammatory disease, prior to patients becoming irreversibly disabled. Empirical clinical observations support the notion that the immune reconstitution (IR) that occurs following AHSCT is associated with a sustained therapeutic benefit; however, neither the pathogenesis of MS nor the mechanism by which AHSCT results in a therapeutic benefit has been clearly delineated. Although the antigenic target of the aberrant immune response in MS is not defined, accumulated data suggest that IR following AHSCT results in an immunotolerant state through deletion of pathogenic clones by a combination of direct ablation and induction of a lymphopenic state driving replicative senescence and clonal attrition. Restoration of immunoregulation is evidenced by changes in regulatory T cell populations following AHSCT and normalization of genetic signatures of immune homeostasis. Furthermore, some evidence exists that AHSCT may induce a rebooting of thymic function and regeneration of a diversified naïve T cell repertoire equipped to appropriately modulate the immune system in response to future antigenic challenge. In this review, we discuss the immunological mechanisms of IR therapies, focusing on AHSCT, as a means of recalibrating the dysfunctional immune response observed in MS.
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Affiliation(s)
- Jennifer C Massey
- Haematology and Bone Marrow Transplantation, St Vincent's Hospital Sydney, Darlinghurst, NSW, Australia.,Neurology, St Vincent's Hospital Sydney, Darlinghurst, NSW, Australia.,Centre for Applied Medical Research, St Vincent's Hospital Sydney, Darlinghurst, NSW, Australia.,St Vincent's Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Ian J Sutton
- Neurology, St Vincent's Hospital Sydney, Darlinghurst, NSW, Australia.,St Vincent's Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - David D F Ma
- Haematology and Bone Marrow Transplantation, St Vincent's Hospital Sydney, Darlinghurst, NSW, Australia.,Centre for Applied Medical Research, St Vincent's Hospital Sydney, Darlinghurst, NSW, Australia.,St Vincent's Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - John J Moore
- Haematology and Bone Marrow Transplantation, St Vincent's Hospital Sydney, Darlinghurst, NSW, Australia.,Centre for Applied Medical Research, St Vincent's Hospital Sydney, Darlinghurst, NSW, Australia.,St Vincent's Clinical School, University of New South Wales, Sydney, NSW, Australia
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105
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Devonshire V, Phillips R, Wass H, Da Roza G, Senior P. Monitoring and management of autoimmunity in multiple sclerosis patients treated with alemtuzumab: practical recommendations. J Neurol 2018. [PMID: 29525836 PMCID: PMC6182701 DOI: 10.1007/s00415-018-8822-y] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Alemtuzumab is a humanized anti-CD52 monoclonal antibody approved in more than 65 countries for the treatment of relapsing–remitting multiple sclerosis (RRMS). Compared with subcutaneous interferon-beta-1a, alemtuzumab significantly reduced clinical disease activity and the rate of brain volume loss, and improved disability outcomes in patients with active RRMS who were either treatment naive (CARE-MS I study) or who had an inadequate response (≥ 1 relapse after ≥ 6 months of treatment) to prior therapy (CARE-MS II study). Adverse events (AEs) associated with alemtuzumab include infusion-associated reactions, infections, and autoimmunity. The most commonly reported autoimmune AEs observed with alemtuzumab involve the thyroid gland, followed by immune thrombocytopenia and nephropathies. A monitoring program was designed and implemented to facilitate the early detection of autoimmune events to ensure timely and adequate management. The aim of this article is to provide physicians (including neurologists, general practitioners, endocrinologists, hematologists, and nephrologists who may be less familiar with the symptoms and treatment of autoimmune events), with practical real-world recommendations for the monitoring and management of autoimmunity associated with alemtuzumab treatment.
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Affiliation(s)
- Virginia Devonshire
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada. .,Djavad Mowafaghian Centre for Brain Health, Vancouver, BC, Canada.
| | - Richard Phillips
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | | | - Gerald Da Roza
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Peter Senior
- Division of Endocrinology and Metabolism, Department of Medicine, University of Alberta, Edmonton, AB, Canada
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106
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McCaughan G, Massey J, Sutton I, Curnow J. Acquired haemophilia A complicating alemtuzumab therapy for multiple sclerosis. BMJ Case Rep 2017; 2017:bcr-2017-223016. [PMID: 29212866 DOI: 10.1136/bcr-2017-223016] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Alemtuzumab is a highly efficacious therapy used in the treatment of multiple sclerosis (MS), but uncoupling of T and B cell repopulation during immune reconstitution associates with an increasing range of secondary B cell-mediated autoimmune complications. A 34-year-old woman developed Graves' disease 11 months following an initial course of alemtuzumab treatment for MS. Nine months following the second treatment with alemtuzumab, the patient presented with spontaneous intramuscular and subcutaneous haemorrhage due to development of an inhibitory autoantibody to coagulation factor VIII. Acquired haemophilia A (AHA) is an extremely rare complication in patients treated with alemtuzumab. Treatment with rituximab may induce a rapid remission of AHA; however, the patient's high John Cunningham virus (JCV) antibody index and alemtuzumab-induced T cell lymphopenia may lead to an increased risk of progressive multifocal leucoencephalopathy, a potential complication which was unacceptable to the patient.
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Affiliation(s)
- Georgia McCaughan
- Haematology Department, Westmead Hospital, Sydney, New South Wales, Australia.,Sydney Medical School, Sydney, Australia
| | - Jennifer Massey
- Neurology Department, St Vincent's Hospital, Sydney, New South Wales, Australia.,UNSW Medical School, Sydney, New South Wales, Australia
| | - Ian Sutton
- Neurology Department, St Vincent's Hospital, Sydney, New South Wales, Australia
| | - Jennifer Curnow
- Haematology Department, Westmead Hospital, Sydney, New South Wales, Australia.,Sydney Centres for Thrombosis and Haemostasis, Sydney, New South Wales, Australia
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107
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Abstract
Type 1 diabetes mellitus (T1DM) is an autoimmune disorder that affects an estimated 30 million people worldwide. It is characterized by the destruction of pancreatic β cells by the immune system, which leads to lifelong dependency on exogenous insulin and imposes an enormous burden on patients and health-care resources. T1DM is also associated with an increased risk of comorbidities, such as cardiovascular disease, retinopathy, and diabetic kidney disease (DKD), further contributing to the burden of this disease. Although T cells are largely considered to be responsible for β-cell destruction in T1DM, increasing evidence points towards a role for B cells in disease pathogenesis. B cell-depletion, for example, delays disease progression in patients with newly diagnosed T1DM. Loss of tolerance of islet antigen-reactive B cells occurs early in disease and numbers of pancreatic CD20+ B cells correlate with β-cell loss. Although the importance of B cells in T1DM is increasingly apparent, exactly how these cells contribute to disease and its comorbidities, such as DKD, is not well understood. Here we discuss the role of B cells in the pathogenesis of T1DM and how these cells are activated during disease development. Finally, we speculate on how B cells might contribute to the development of DKD.
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108
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Roman C, Menning K. Treatment and disease management of multiple sclerosis patients: A review for nurse practitioners. J Am Assoc Nurse Pract 2017; 29:629-638. [PMID: 29029375 DOI: 10.1002/2327-6924.12514] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Revised: 07/31/2017] [Accepted: 08/01/2017] [Indexed: 11/09/2022]
Abstract
BACKGROUND AND PURPOSE This review discusses the role of the nurse practitioner (NP) in evaluating the clinical effects, potential side effects, and monitoring requirements for treatment options in multiple sclerosis (MS) and provides guidance on how to help patients understand these issues. METHODS A literature search was conducted on PubMed to identify publications on monitoring and disease management of MS patients. Additional resources included drug information web sites and package inserts. CONCLUSIONS NPs play an active role in the management of MS patients via effective monitoring and communication throughout the patient's treatment regimen and disease course. In the shared decision-making model of MS treatment, NPs ensure that patients understand the implications of their disease-modifying therapies (DMTs). As patients move through treatments during the course of their disease, the importance of this role increases, and it is critical that NPs follow the guidelines in each medication's product label and take into account any potential lingering effects of prior medications. IMPLICATIONS FOR PRACTICE It is critical for NPs to promote patient adherence, to ensure that patients understand treatment side effects and monitoring requirements, and to take sequencing and reversibility implications of DMTs into account when making clinical decisions.
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109
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Baker D, Herrod SS, Alvarez-Gonzalez C, Giovannoni G, Schmierer K. Interpreting Lymphocyte Reconstitution Data From the Pivotal Phase 3 Trials of Alemtuzumab. JAMA Neurol 2017; 74:961-969. [PMID: 28604916 DOI: 10.1001/jamaneurol.2017.0676] [Citation(s) in RCA: 179] [Impact Index Per Article: 25.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Importance Alemtuzumab, a CD52-depleting monoclonal antibody, effectively inhibits relapsing multiple sclerosis (MS) but is associated with a high incidence of secondary B-cell autoimmunities that limit use. These effects may be avoided through control of B-cell hyperproliferation. Objective To investigate whether the data describing the effect of alemtuzumab on lymphocyte subsets collected during the phase 3 trial program reveal mechanisms explaining efficacy and the risk for secondary autoimmunity with treatment of MS. Design, Setting, and Participants Lymphocyte reconstitution data from regulatory submissions of the pivotal Comparison of Alemtuzumab and Rebif Efficacy in Multiple Sclerosis I and II (CARE-MS I and II) trials were obtained from the European Medicines Agency via Freedom of Information requests. Data used in this study were reported from June 22 to October 12, 2016. Main Outcomes and Measures Tabulated data from T- and B-lymphocyte subset analysis and antidrug antibody responses were extracted from the supplied documents. Results Alemtuzumab depleted CD4+ T cells by more than 95%, including regulatory cells (-80%) and CD8+ T cells (>80% depletion), which remained well below reference levels throughout the trials. However, although CD19+ B cells were initially also depleted (>85%), marked (180% increase) hyperrepopulation of immature B cells occurred with conversion to mature B cells over time. These lymphocyte kinetics were associated with rapid development of alemtuzumab-binding and -neutralizing antibodies and subsequent occurrence of secondary B-cell autoimmunity. Hyperrepopulation of B cells masked a marked, long-term depletion of CD19+ memory B cells that may underpin efficacy in MS. Conclusions and Relevance Although blockade of memory T and B cells may limit MS, rapid CD19+ B-cell subset repopulation in the absence of effective T-cell regulation has implications for the safety and efficacy of alemtuzumab. Controlling B-cell proliferation until T-cell regulation recovers may limit secondary autoimmunity, which does not occur with other B-cell-depleting agents.
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Affiliation(s)
- David Baker
- Centre for Neuroscience and Trauma, Blizard Institute, Queen Mary University of London, England
| | - Samuel S Herrod
- Centre for Neuroscience and Trauma, Blizard Institute, Queen Mary University of London, England
| | - Cesar Alvarez-Gonzalez
- Centre for Neuroscience and Trauma, Blizard Institute, Queen Mary University of London, England
| | - Gavin Giovannoni
- Centre for Neuroscience and Trauma, Blizard Institute, Queen Mary University of London, England.,Emergency Care and Acute Medicine, Clinical Academic Group Neuroscience, Barts Health NHS (National Health Service) Trust, The Royal London Hospital, London, England
| | - Klaus Schmierer
- Centre for Neuroscience and Trauma, Blizard Institute, Queen Mary University of London, England.,Emergency Care and Acute Medicine, Clinical Academic Group Neuroscience, Barts Health NHS (National Health Service) Trust, The Royal London Hospital, London, England
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110
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Pekalski ML, García AR, Ferreira RC, Rainbow DB, Smyth DJ, Mashar M, Brady J, Savinykh N, Dopico XC, Mahmood S, Duley S, Stevens HE, Walker NM, Cutler AJ, Waldron-Lynch F, Dunger DB, Shannon-Lowe C, Coles AJ, Jones JL, Wallace C, Todd JA, Wicker LS. Neonatal and adult recent thymic emigrants produce IL-8 and express complement receptors CR1 and CR2. JCI Insight 2017; 2:93739. [PMID: 28814669 PMCID: PMC5621870 DOI: 10.1172/jci.insight.93739] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Accepted: 07/18/2017] [Indexed: 12/21/2022] Open
Abstract
The maintenance of peripheral naive T lymphocytes in humans is dependent on their homeostatic division, not continuing emigration from the thymus, which undergoes involution with age. However, postthymic maintenance of naive T cells is still poorly understood. Previously we reported that recent thymic emigrants (RTEs) are contained in CD31+CD25− naive T cells as defined by their levels of signal joint T cell receptor rearrangement excision circles (sjTRECs). Here, by differential gene expression analysis followed by protein expression and functional studies, we define that the naive T cells having divided the least since thymic emigration express complement receptors (CR1 and CR2) known to bind complement C3b- and C3d-decorated microbial products and, following activation, produce IL-8 (CXCL8), a major chemoattractant for neutrophils in bacterial defense. We also observed an IL-8–producing memory T cell subpopulation coexpressing CR1 and CR2 and with a gene expression signature resembling that of RTEs. The functions of CR1 and CR2 on T cells remain to be determined, but we note that CR2 is the receptor for Epstein-Barr virus, which is a cause of T cell lymphomas and a candidate environmental factor in autoimmune disease. Complement receptors (CR1 and CR2) and IL-8 production identify T cells that have recently left the thymus.
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Affiliation(s)
- Marcin L Pekalski
- JDRF/Wellcome Trust Diabetes and Inflammation Laboratory, Wellcome Trust Centre for Human Genetics, Nuffield Department of Medicine, National Institute for Health Research (NIHR) Oxford Biomedical Research Centre, University of Oxford, Oxford, United Kingdom.,JDRF/Wellcome Trust Diabetes and Inflammation Laboratory, Wellcome Trust/MRC Building, Cambridge Institute for Medical Research, NIHR Cambridge Biomedical Research Centre, University of Cambridge, Cambridge, United Kingdom
| | - Arcadio Rubio García
- JDRF/Wellcome Trust Diabetes and Inflammation Laboratory, Wellcome Trust Centre for Human Genetics, Nuffield Department of Medicine, National Institute for Health Research (NIHR) Oxford Biomedical Research Centre, University of Oxford, Oxford, United Kingdom.,JDRF/Wellcome Trust Diabetes and Inflammation Laboratory, Wellcome Trust/MRC Building, Cambridge Institute for Medical Research, NIHR Cambridge Biomedical Research Centre, University of Cambridge, Cambridge, United Kingdom
| | - Ricardo C Ferreira
- JDRF/Wellcome Trust Diabetes and Inflammation Laboratory, Wellcome Trust Centre for Human Genetics, Nuffield Department of Medicine, National Institute for Health Research (NIHR) Oxford Biomedical Research Centre, University of Oxford, Oxford, United Kingdom.,JDRF/Wellcome Trust Diabetes and Inflammation Laboratory, Wellcome Trust/MRC Building, Cambridge Institute for Medical Research, NIHR Cambridge Biomedical Research Centre, University of Cambridge, Cambridge, United Kingdom
| | - Daniel B Rainbow
- JDRF/Wellcome Trust Diabetes and Inflammation Laboratory, Wellcome Trust Centre for Human Genetics, Nuffield Department of Medicine, National Institute for Health Research (NIHR) Oxford Biomedical Research Centre, University of Oxford, Oxford, United Kingdom.,JDRF/Wellcome Trust Diabetes and Inflammation Laboratory, Wellcome Trust/MRC Building, Cambridge Institute for Medical Research, NIHR Cambridge Biomedical Research Centre, University of Cambridge, Cambridge, United Kingdom
| | - Deborah J Smyth
- JDRF/Wellcome Trust Diabetes and Inflammation Laboratory, Wellcome Trust/MRC Building, Cambridge Institute for Medical Research, NIHR Cambridge Biomedical Research Centre, University of Cambridge, Cambridge, United Kingdom
| | - Meghavi Mashar
- JDRF/Wellcome Trust Diabetes and Inflammation Laboratory, Wellcome Trust/MRC Building, Cambridge Institute for Medical Research, NIHR Cambridge Biomedical Research Centre, University of Cambridge, Cambridge, United Kingdom
| | - Jane Brady
- JDRF/Wellcome Trust Diabetes and Inflammation Laboratory, Wellcome Trust/MRC Building, Cambridge Institute for Medical Research, NIHR Cambridge Biomedical Research Centre, University of Cambridge, Cambridge, United Kingdom
| | - Natalia Savinykh
- JDRF/Wellcome Trust Diabetes and Inflammation Laboratory, Wellcome Trust/MRC Building, Cambridge Institute for Medical Research, NIHR Cambridge Biomedical Research Centre, University of Cambridge, Cambridge, United Kingdom
| | - Xaquin Castro Dopico
- JDRF/Wellcome Trust Diabetes and Inflammation Laboratory, Wellcome Trust/MRC Building, Cambridge Institute for Medical Research, NIHR Cambridge Biomedical Research Centre, University of Cambridge, Cambridge, United Kingdom
| | - Sumiyya Mahmood
- JDRF/Wellcome Trust Diabetes and Inflammation Laboratory, Wellcome Trust/MRC Building, Cambridge Institute for Medical Research, NIHR Cambridge Biomedical Research Centre, University of Cambridge, Cambridge, United Kingdom
| | - Simon Duley
- JDRF/Wellcome Trust Diabetes and Inflammation Laboratory, Wellcome Trust/MRC Building, Cambridge Institute for Medical Research, NIHR Cambridge Biomedical Research Centre, University of Cambridge, Cambridge, United Kingdom
| | - Helen E Stevens
- JDRF/Wellcome Trust Diabetes and Inflammation Laboratory, Wellcome Trust/MRC Building, Cambridge Institute for Medical Research, NIHR Cambridge Biomedical Research Centre, University of Cambridge, Cambridge, United Kingdom
| | - Neil M Walker
- JDRF/Wellcome Trust Diabetes and Inflammation Laboratory, Wellcome Trust/MRC Building, Cambridge Institute for Medical Research, NIHR Cambridge Biomedical Research Centre, University of Cambridge, Cambridge, United Kingdom
| | - Antony J Cutler
- JDRF/Wellcome Trust Diabetes and Inflammation Laboratory, Wellcome Trust Centre for Human Genetics, Nuffield Department of Medicine, National Institute for Health Research (NIHR) Oxford Biomedical Research Centre, University of Oxford, Oxford, United Kingdom.,JDRF/Wellcome Trust Diabetes and Inflammation Laboratory, Wellcome Trust/MRC Building, Cambridge Institute for Medical Research, NIHR Cambridge Biomedical Research Centre, University of Cambridge, Cambridge, United Kingdom
| | - Frank Waldron-Lynch
- JDRF/Wellcome Trust Diabetes and Inflammation Laboratory, Wellcome Trust/MRC Building, Cambridge Institute for Medical Research, NIHR Cambridge Biomedical Research Centre, University of Cambridge, Cambridge, United Kingdom
| | - David B Dunger
- Department of Paediatrics, MRL Wellcome Trust-MRC Institute of Metabolic Science, NIHR Cambridge Comprehensive Biomedical Research Centre, University of Cambridge, Cambridge, United Kingdom
| | - Claire Shannon-Lowe
- Institute for Immunology and Immunotherapy and Centre for Human Virology, The University of Birmingham, Birmingham, United Kingdom
| | - Alasdair J Coles
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Joanne L Jones
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Chris Wallace
- JDRF/Wellcome Trust Diabetes and Inflammation Laboratory, Wellcome Trust/MRC Building, Cambridge Institute for Medical Research, NIHR Cambridge Biomedical Research Centre, University of Cambridge, Cambridge, United Kingdom.,Department of Medicine, University of Cambridge, Addenbrooke's Hospital, Cambridge, United Kingdom, and MRC Biostatistics Unit, Cambridge Institute of Public Health, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - John A Todd
- JDRF/Wellcome Trust Diabetes and Inflammation Laboratory, Wellcome Trust Centre for Human Genetics, Nuffield Department of Medicine, National Institute for Health Research (NIHR) Oxford Biomedical Research Centre, University of Oxford, Oxford, United Kingdom.,JDRF/Wellcome Trust Diabetes and Inflammation Laboratory, Wellcome Trust/MRC Building, Cambridge Institute for Medical Research, NIHR Cambridge Biomedical Research Centre, University of Cambridge, Cambridge, United Kingdom
| | - Linda S Wicker
- JDRF/Wellcome Trust Diabetes and Inflammation Laboratory, Wellcome Trust Centre for Human Genetics, Nuffield Department of Medicine, National Institute for Health Research (NIHR) Oxford Biomedical Research Centre, University of Oxford, Oxford, United Kingdom.,JDRF/Wellcome Trust Diabetes and Inflammation Laboratory, Wellcome Trust/MRC Building, Cambridge Institute for Medical Research, NIHR Cambridge Biomedical Research Centre, University of Cambridge, Cambridge, United Kingdom
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111
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Abstract
Alemtuzumab is a humanised anti-CD52 monoclonal antibody approved for use in active, relapsing multiple sclerosis (MS). Administration results in a rapid depletion of circulating lymphocytes with a subsequent beneficial immune reconstitution. Early open-label experience and recent clinical trials have demonstrated a dramatic effect on relapse rates as well as a positive effect on radiological disease outcomes and disability measures. Despite a mechanism of action that results in profound lymphopaenia, opportunistic infections are rarely seen and no excess association with malignancy has been identified. However, acquired autoimmune disease (AID) is a common adverse event following treatment, necessitating rigorous monitoring in order to facilitate prompt detection and management. Despite this issue, a unique dosing schedule and durability of effect make alemtuzumab a welcome addition to currently available treatment options for MS.
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Affiliation(s)
- Mark D Willis
- Institute of Psychological Medicine and Clinical Neuroscience, University Hospital of Wales, Cardiff University, Heath Park, Cardiff, CF14 4XN, UK
| | - Neil P Robertson
- Institute of Psychological Medicine and Clinical Neuroscience, University Hospital of Wales, Cardiff University, Heath Park, Cardiff, CF14 4XN, UK.
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112
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Landmann S, Preuss N, Behn U. Self-tolerance and autoimmunity in a minimal model of the idiotypic network. J Theor Biol 2017; 426:17-39. [DOI: 10.1016/j.jtbi.2017.05.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Revised: 03/31/2017] [Accepted: 05/03/2017] [Indexed: 10/19/2022]
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113
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Ayasoufi K, Fan R, Valujskikh A. Depletion-Resistant CD4 T Cells Enhance Thymopoiesis During Lymphopenia. Am J Transplant 2017; 17:2008-2019. [PMID: 28397358 PMCID: PMC5519419 DOI: 10.1111/ajt.14309] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Revised: 03/08/2017] [Accepted: 04/01/2017] [Indexed: 01/25/2023]
Abstract
Lymphoablation is routinely used in transplantation, and its success is defined by the balance of pathogenic versus protective T cells within reconstituted repertoire. While homeostatic proliferation and thymopoiesis may both cause T cell recovery during lymphopenia, the relative contributions of these mechanisms remain unclear. The goal of this study was to investigate the role of the thymus during T cell reconstitution in adult allograft recipients subjected to lymphoablative induction therapy. Compared with euthymic mice, thymectomized heart allograft recipients demonstrated severely impaired CD4 and CD8 T cell recovery and prolonged heart allograft survival after lymphoablation with murine anti-thymocyte globulin (mATG). The injection with agonistic anti-CD40 mAb or thymus transplantation only partially restored T cell reconstitution in mATG-treated thymectomized mice. After mATG depletion, residual CD4 T cells migrated into the thymus and enhanced thymopoiesis. Conversely, depletion of CD4 T cells before lymphoablation inhibited thymopoiesis at the stage of CD4- CD8- CD44hi CD25+ immature thymocytes. This is the first demonstration that the thymus and peripheral CD4 T cells cooperate to ensure optimal T cell reconstitution after lymphoablation. Targeting thymopoiesis through manipulating functions of depletion-resistant helper T cells may thus improve therapeutic benefits and minimize the risks of lymphoablation in clinical settings.
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Affiliation(s)
- Katayoun Ayasoufi
- Department of Immunology, Lerner Research Institute, Cleveland Clinic, Cleveland, OH,Department of Molecular Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH
| | - Ran Fan
- Department of Immunology, Lerner Research Institute, Cleveland Clinic, Cleveland, OH
| | - Anna Valujskikh
- Department of Immunology, Lerner Research Institute, Cleveland Clinic, Cleveland, OH
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114
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Baker D, Herrod SS, Alvarez-Gonzalez C, Zalewski L, Albor C, Schmierer K. Both cladribine and alemtuzumab may effect MS via B-cell depletion. NEUROLOGY-NEUROIMMUNOLOGY & NEUROINFLAMMATION 2017. [PMID: 28626781 PMCID: PMC5459792 DOI: 10.1212/nxi.0000000000000360] [Citation(s) in RCA: 110] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective: To understand the efficacy of cladribine (CLAD) treatment in MS through analysis of lymphocyte subsets collected, but not reported, in the pivotal phase III trials of cladribine and alemtuzumab induction therapies. Methods: The regulatory submissions of the CLAD Tablets Treating Multiple Sclerosis Orally (CLARITY) (NCT00213135) cladribine and Comparison of Alemtuzumab and Rebif Efficacy in Multiple Sclerosis, study one (CARE-MS I) (NCT00530348) alemtuzumab trials were obtained from the European Medicine Agency through Freedom of Information requests. Data were extracted and statistically analyzed. Results: Either dose of cladribine (3.5 mg/kg; 5.25 mg/kg) tested in CLARITY reduced the annualized relapse rate to 0.16–0.18 over 96 weeks, and both doses were similarly effective in reducing the risk of MRI lesions and disability. Surprisingly, however, T-cell depletion was rather modest. Cladribine 3.5 mg/kg depleted CD4+ cells by 40%–45% and CD8+ cells by 15%–30%, whereas alemtuzumab suppressed CD4+ cells by 70%–95% and CD8+ cells by 47%–55%. However, either dose of cladribine induced 70%–90% CD19+ B-cell depletion, similar to alemtuzumab (90%). CD19+ cells slowly repopulated to 15%–25% of baseline before cladribine redosing. However, alemtuzumab induced hyperrepopulation of CD19+ B cells 6–12 months after infusion, which probably forms the substrate for B-cell autoimmunities associated with alemtuzumab. Conclusions: Cladribine induced only modest depletion of T cells, which may not be consistent with a marked influence on MS, based on previous CD4+ T-cell depletion studies. The therapeutic drug-response relationship with cladribine is more consistent with lasting B-cell depletion and, coupled with the success seen with monoclonal CD20+ depletion, suggests that B-cell suppression could be the major direct mechanism of action.
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Affiliation(s)
- David Baker
- BartsMS (D.B., S.S.H., C.A.G., C.A., K.S.), Blizard Institute, ITS Research (L.Z.), Queen Mary University of London; and Barts Health NHS Trust (K.S.), Emergency Care & Acute Medicine Neuroscience Clinical Academic Group, London, UK
| | - Samuel S Herrod
- BartsMS (D.B., S.S.H., C.A.G., C.A., K.S.), Blizard Institute, ITS Research (L.Z.), Queen Mary University of London; and Barts Health NHS Trust (K.S.), Emergency Care & Acute Medicine Neuroscience Clinical Academic Group, London, UK
| | - Cesar Alvarez-Gonzalez
- BartsMS (D.B., S.S.H., C.A.G., C.A., K.S.), Blizard Institute, ITS Research (L.Z.), Queen Mary University of London; and Barts Health NHS Trust (K.S.), Emergency Care & Acute Medicine Neuroscience Clinical Academic Group, London, UK
| | - Lukasz Zalewski
- BartsMS (D.B., S.S.H., C.A.G., C.A., K.S.), Blizard Institute, ITS Research (L.Z.), Queen Mary University of London; and Barts Health NHS Trust (K.S.), Emergency Care & Acute Medicine Neuroscience Clinical Academic Group, London, UK
| | - Christo Albor
- BartsMS (D.B., S.S.H., C.A.G., C.A., K.S.), Blizard Institute, ITS Research (L.Z.), Queen Mary University of London; and Barts Health NHS Trust (K.S.), Emergency Care & Acute Medicine Neuroscience Clinical Academic Group, London, UK
| | - Klaus Schmierer
- BartsMS (D.B., S.S.H., C.A.G., C.A., K.S.), Blizard Institute, ITS Research (L.Z.), Queen Mary University of London; and Barts Health NHS Trust (K.S.), Emergency Care & Acute Medicine Neuroscience Clinical Academic Group, London, UK
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Misbah SA. Progressive multi-focal leucoencephalopathy - driven from rarity to clinical mainstream by iatrogenic immunodeficiency. Clin Exp Immunol 2017; 188:342-352. [PMID: 28245526 PMCID: PMC5422720 DOI: 10.1111/cei.12948] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/22/2017] [Indexed: 12/21/2022] Open
Abstract
Advances in immune-mediated targeted therapies have proved to be a double-edged sword for patients by highlighting the risk of iatrogenic infective complications. This has been exemplified by progressive multi-focal leucoencephalopathy (PML), a hitherto rare devastating viral infection of the brain caused by the neurotrophic JC polyoma virus. While PML achieved prominence during the first two decades of the HIV epidemic, effective anti-retroviral treatment and restitution of T cell function has led to PML being less prominent in this population. HIV infection as a predisposing factor has now been supplanted by T cell immunodeficiency induced by a range of immune-mediated therapies as a major cause of PML. This review focuses on PML in the context of therapeutic immunosuppression and encompasses therapeutic monoclonal antibodies, novel immunomodulatory agents such as Fingolimod and dimethyl fumarate, as well as emerging data on PML in primary immune deficiency.
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Affiliation(s)
- S A Misbah
- Department of Clinical Immunology, Oxford University Hospitals, John Radcliffe Hospital, Oxford, UK
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Gallo P, Centonze D, Marrosu MG. Alemtuzumab for multiple sclerosis: the new concept of immunomodulation. ACTA ACUST UNITED AC 2017. [DOI: 10.1186/s40893-017-0024-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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The emerging role of ECM crosslinking in T cell mobility as a hallmark of immunosenescence in humans. Ageing Res Rev 2017; 35:322-335. [PMID: 27876574 DOI: 10.1016/j.arr.2016.11.005] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Revised: 10/26/2016] [Accepted: 11/07/2016] [Indexed: 02/07/2023]
Abstract
Immunosenescence is thought to result from cellular aging and to reflect exposure to environmental stressors and antigens, including cytomegalovirus (CMV). However, not all of the features of immunosenescence are consistent with this view, and this has led to the emergence of the sister theory of "inflammaging". The recently discovered diffuse tissue distribution of resident memory T cells (TRM) which don't recirculate, calls these theories into question. These cells account for most T cells residing in barrier epithelia which sit in and travel through the extracellular matrix (ECM). With almost all studies to date carried out on peripheral blood, the age-related changes of the ECM and their consequences for T cell mobility, which is crucial for the function of these cells, have been largely ignored. We propose an update of the theoretical framework of immunosenescence, based on a novel hypothesis: the increasing stiffness and cross-linking of the senescent ECM lead to a progressive immunodeficiency due to an age-related decrease in T cell mobility and eventually the death of these cells. A key element of this mechanism is the mechanical stress to which the cell cytoplasm and nucleus are subjected during passage through the ECM. This hypothesis is based on an "evo-devo" perspective bringing together some major characteristics of aging, to create a single interpretive framework for immunosenescence.
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Blinkenberg M, Soelberg Sørensen P. Monoclonal Antibodies for Relapsing Multiple Sclerosis: A Review of Recently Marketed and Late-Stage Agents. CNS Drugs 2017; 31:357-371. [PMID: 28285378 DOI: 10.1007/s40263-017-0414-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Treatment of multiple sclerosis (MS) has improved considerably over the last decade because of new insights into MS pathology and biotechnological advances. This has led to the development of new potent pharmaceutical compounds targeting different processes in the complex autoimmune pathology leading to chronic central nervous system (CNS) demyelination, neural loss, and, finally, neurological disability. Although a number of disease-modifying treatments are available for the treatment of the inflammatory phase of MS, there is still a need for highly efficacious therapies with an acceptable safety profile in order to gain therapeutic control early in the disease course. Monoclonal antibodies have proven to be some of the most efficacious disease-modifying therapies in the field of MS, and recent developments in clinical research hold promise for new compounds fulfilling the need for improved safety and high efficacy. We review recent developments in the field of therapeutic monoclonal antibodies used for the treatment of MS and current information on the mode of action, efficacy, and safety of existing and emerging therapeutic monoclonal antibodies as well as their place within the context of different treatment strategies. Finally, we consider the most important future developments.
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Affiliation(s)
- Morten Blinkenberg
- Danish Multiple Sclerosis Center, Department of Neurology 2082, Rigshospitalet and University of Copenhagen, 2100, Copenhagen, Denmark
| | - Per Soelberg Sørensen
- Danish Multiple Sclerosis Center, Department of Neurology 2082, Rigshospitalet and University of Copenhagen, 2100, Copenhagen, Denmark.
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Ramesh M, Hamm D, Simchoni N, Cunningham-Rundles C. Clonal and constricted T cell repertoire in Common Variable Immune Deficiency. Clin Immunol 2017; 178:1-9. [PMID: 25596453 PMCID: PMC4501913 DOI: 10.1016/j.clim.2015.01.002] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2014] [Revised: 12/22/2014] [Accepted: 01/04/2015] [Indexed: 01/08/2023]
Abstract
We used high throughput sequencing to examine the structure and composition of the T cell receptor β chain in Common Variable Immune Deficiency (CVID). TCRβ CDR3 regions were amplified and sequenced from genomic DNA of 44 adult CVID subjects and 22 healthy adults, using a high-throughput multiplex PCR. CVID TCRs had significantly less junctional diversity, fewer n-nucleotide insertions and deletions, and completely lacked a population of highly modified TCRs, with 13 or more V-gene nucleotide deletions, seen in healthy controls. The CVID CDR3 sequences were significantly more clonal than control DNA, and displayed unique V gene usage. Despite reduced junctional diversity, increased clonality and similar infectious exposures, DNA of CVID subjects shared fewer TCR sequences as compared to controls. These abnormalities are pervasive, found in out-of-frame sequences and thus independent of selection and were not associated with specific clinical complications. These data support an inherent T cell defect in CVID.
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Affiliation(s)
| | | | - Noa Simchoni
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Goropevšek A, Gorenjak M, Gradišnik S, Dai K, Holc I, Hojs R, Krajnc I, Pahor A, Avčin T. STAT5 phosphorylation in CD4 T cells from patients with SLE is related to changes in their subsets and follow-up disease severity. J Leukoc Biol 2017; 101:1405-1418. [DOI: 10.1189/jlb.5a0416-194r] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Revised: 01/27/2017] [Accepted: 02/13/2017] [Indexed: 11/24/2022] Open
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Willis M, Pearson O, Illes Z, Sejbaek T, Nielsen C, Duddy M, Petheram K, van Munster C, Killestein J, Malmeström C, Tallantyre E, Robertson N. An observational study of alemtuzumab following fingolimod for multiple sclerosis. NEUROLOGY-NEUROIMMUNOLOGY & NEUROINFLAMMATION 2017; 4:e320. [PMID: 28101520 PMCID: PMC5226279 DOI: 10.1212/nxi.0000000000000320] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Accepted: 12/05/2016] [Indexed: 11/16/2022]
Abstract
Objective: To describe a series of patients with relapsing multiple sclerosis (MS) who experienced significant and unexpected disease activity within the first 12 months after switching from fingolimod to alemtuzumab. Methods: Patients with relapsing MS treated sequentially with fingolimod then alemtuzumab who experienced significant subsequent disease activity were identified by personal communication with 6 different European neuroscience centers. Results: Nine patients were identified. Median disease duration to alemtuzumab treatment was 94 (39–215) months and follow-up from time of first alemtuzumab cycle 20 (14–21) months. Following first alemtuzumab infusion cycle, 8 patients were identified by at least 1 clinical relapse and radiologic disease activity and 1 by significant radiologic disease activity alone. Conclusions: We acknowledge the potential for ascertainment bias; however, these cases may illustrate an important cause of reduced efficacy of alemtuzumab in a vulnerable group of patients with MS most in need of disease control. We suggest that significant and unexpected subsequent disease activity after alemtuzumab induction results from prolonged sequestration of autoreactive lymphocytes following fingolimod withdrawal, allowing these cells to be concealed from the usual biological effect of alemtuzumab. Subsequent lymphocyte egress then provokes disease reactivation. Further animal studies and clinical trials are required to confirm these phenomena and in the meantime careful consideration should be given to mode of action of individual therapies and sequential treatment effects in MS when designing personalized treatment regimens.
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Affiliation(s)
- Mark Willis
- Department of Neurology (M.W., E.T., N.R.), Institute of Psychological Medicine and Clinical Neuroscience, Cardiff University, University Hospital of Wales; Department of Neurology (O.P.), Morriston Hospital, Heol Maes Eglwys, Morriston, Swansea, UK; Departments of Neurology (Z.I., T.S.) and Clinical Immunology (C.N.), Odense University Hospital, University of Southern Denmark; Department of Neurology (M.D.), The Royal Victoria Infirmary, Newcastle upon Tyne; Department of Neurology (K.P.), Sunderland Royal Hospital, UK; VU University Medical Center (C.v.M., J.K.), Amsterdam, the Netherlands; and Department of Neurology (C.M.), Sahlgrenska Academy at the University of Gothenburg, Institute of Clinical Neuroscience and Physiology, Gothenburg, Sweden
| | - Owen Pearson
- Department of Neurology (M.W., E.T., N.R.), Institute of Psychological Medicine and Clinical Neuroscience, Cardiff University, University Hospital of Wales; Department of Neurology (O.P.), Morriston Hospital, Heol Maes Eglwys, Morriston, Swansea, UK; Departments of Neurology (Z.I., T.S.) and Clinical Immunology (C.N.), Odense University Hospital, University of Southern Denmark; Department of Neurology (M.D.), The Royal Victoria Infirmary, Newcastle upon Tyne; Department of Neurology (K.P.), Sunderland Royal Hospital, UK; VU University Medical Center (C.v.M., J.K.), Amsterdam, the Netherlands; and Department of Neurology (C.M.), Sahlgrenska Academy at the University of Gothenburg, Institute of Clinical Neuroscience and Physiology, Gothenburg, Sweden
| | - Zsolt Illes
- Department of Neurology (M.W., E.T., N.R.), Institute of Psychological Medicine and Clinical Neuroscience, Cardiff University, University Hospital of Wales; Department of Neurology (O.P.), Morriston Hospital, Heol Maes Eglwys, Morriston, Swansea, UK; Departments of Neurology (Z.I., T.S.) and Clinical Immunology (C.N.), Odense University Hospital, University of Southern Denmark; Department of Neurology (M.D.), The Royal Victoria Infirmary, Newcastle upon Tyne; Department of Neurology (K.P.), Sunderland Royal Hospital, UK; VU University Medical Center (C.v.M., J.K.), Amsterdam, the Netherlands; and Department of Neurology (C.M.), Sahlgrenska Academy at the University of Gothenburg, Institute of Clinical Neuroscience and Physiology, Gothenburg, Sweden
| | - Tobias Sejbaek
- Department of Neurology (M.W., E.T., N.R.), Institute of Psychological Medicine and Clinical Neuroscience, Cardiff University, University Hospital of Wales; Department of Neurology (O.P.), Morriston Hospital, Heol Maes Eglwys, Morriston, Swansea, UK; Departments of Neurology (Z.I., T.S.) and Clinical Immunology (C.N.), Odense University Hospital, University of Southern Denmark; Department of Neurology (M.D.), The Royal Victoria Infirmary, Newcastle upon Tyne; Department of Neurology (K.P.), Sunderland Royal Hospital, UK; VU University Medical Center (C.v.M., J.K.), Amsterdam, the Netherlands; and Department of Neurology (C.M.), Sahlgrenska Academy at the University of Gothenburg, Institute of Clinical Neuroscience and Physiology, Gothenburg, Sweden
| | - Christian Nielsen
- Department of Neurology (M.W., E.T., N.R.), Institute of Psychological Medicine and Clinical Neuroscience, Cardiff University, University Hospital of Wales; Department of Neurology (O.P.), Morriston Hospital, Heol Maes Eglwys, Morriston, Swansea, UK; Departments of Neurology (Z.I., T.S.) and Clinical Immunology (C.N.), Odense University Hospital, University of Southern Denmark; Department of Neurology (M.D.), The Royal Victoria Infirmary, Newcastle upon Tyne; Department of Neurology (K.P.), Sunderland Royal Hospital, UK; VU University Medical Center (C.v.M., J.K.), Amsterdam, the Netherlands; and Department of Neurology (C.M.), Sahlgrenska Academy at the University of Gothenburg, Institute of Clinical Neuroscience and Physiology, Gothenburg, Sweden
| | - Martin Duddy
- Department of Neurology (M.W., E.T., N.R.), Institute of Psychological Medicine and Clinical Neuroscience, Cardiff University, University Hospital of Wales; Department of Neurology (O.P.), Morriston Hospital, Heol Maes Eglwys, Morriston, Swansea, UK; Departments of Neurology (Z.I., T.S.) and Clinical Immunology (C.N.), Odense University Hospital, University of Southern Denmark; Department of Neurology (M.D.), The Royal Victoria Infirmary, Newcastle upon Tyne; Department of Neurology (K.P.), Sunderland Royal Hospital, UK; VU University Medical Center (C.v.M., J.K.), Amsterdam, the Netherlands; and Department of Neurology (C.M.), Sahlgrenska Academy at the University of Gothenburg, Institute of Clinical Neuroscience and Physiology, Gothenburg, Sweden
| | - Kate Petheram
- Department of Neurology (M.W., E.T., N.R.), Institute of Psychological Medicine and Clinical Neuroscience, Cardiff University, University Hospital of Wales; Department of Neurology (O.P.), Morriston Hospital, Heol Maes Eglwys, Morriston, Swansea, UK; Departments of Neurology (Z.I., T.S.) and Clinical Immunology (C.N.), Odense University Hospital, University of Southern Denmark; Department of Neurology (M.D.), The Royal Victoria Infirmary, Newcastle upon Tyne; Department of Neurology (K.P.), Sunderland Royal Hospital, UK; VU University Medical Center (C.v.M., J.K.), Amsterdam, the Netherlands; and Department of Neurology (C.M.), Sahlgrenska Academy at the University of Gothenburg, Institute of Clinical Neuroscience and Physiology, Gothenburg, Sweden
| | - Caspar van Munster
- Department of Neurology (M.W., E.T., N.R.), Institute of Psychological Medicine and Clinical Neuroscience, Cardiff University, University Hospital of Wales; Department of Neurology (O.P.), Morriston Hospital, Heol Maes Eglwys, Morriston, Swansea, UK; Departments of Neurology (Z.I., T.S.) and Clinical Immunology (C.N.), Odense University Hospital, University of Southern Denmark; Department of Neurology (M.D.), The Royal Victoria Infirmary, Newcastle upon Tyne; Department of Neurology (K.P.), Sunderland Royal Hospital, UK; VU University Medical Center (C.v.M., J.K.), Amsterdam, the Netherlands; and Department of Neurology (C.M.), Sahlgrenska Academy at the University of Gothenburg, Institute of Clinical Neuroscience and Physiology, Gothenburg, Sweden
| | - Joep Killestein
- Department of Neurology (M.W., E.T., N.R.), Institute of Psychological Medicine and Clinical Neuroscience, Cardiff University, University Hospital of Wales; Department of Neurology (O.P.), Morriston Hospital, Heol Maes Eglwys, Morriston, Swansea, UK; Departments of Neurology (Z.I., T.S.) and Clinical Immunology (C.N.), Odense University Hospital, University of Southern Denmark; Department of Neurology (M.D.), The Royal Victoria Infirmary, Newcastle upon Tyne; Department of Neurology (K.P.), Sunderland Royal Hospital, UK; VU University Medical Center (C.v.M., J.K.), Amsterdam, the Netherlands; and Department of Neurology (C.M.), Sahlgrenska Academy at the University of Gothenburg, Institute of Clinical Neuroscience and Physiology, Gothenburg, Sweden
| | - Clas Malmeström
- Department of Neurology (M.W., E.T., N.R.), Institute of Psychological Medicine and Clinical Neuroscience, Cardiff University, University Hospital of Wales; Department of Neurology (O.P.), Morriston Hospital, Heol Maes Eglwys, Morriston, Swansea, UK; Departments of Neurology (Z.I., T.S.) and Clinical Immunology (C.N.), Odense University Hospital, University of Southern Denmark; Department of Neurology (M.D.), The Royal Victoria Infirmary, Newcastle upon Tyne; Department of Neurology (K.P.), Sunderland Royal Hospital, UK; VU University Medical Center (C.v.M., J.K.), Amsterdam, the Netherlands; and Department of Neurology (C.M.), Sahlgrenska Academy at the University of Gothenburg, Institute of Clinical Neuroscience and Physiology, Gothenburg, Sweden
| | - Emma Tallantyre
- Department of Neurology (M.W., E.T., N.R.), Institute of Psychological Medicine and Clinical Neuroscience, Cardiff University, University Hospital of Wales; Department of Neurology (O.P.), Morriston Hospital, Heol Maes Eglwys, Morriston, Swansea, UK; Departments of Neurology (Z.I., T.S.) and Clinical Immunology (C.N.), Odense University Hospital, University of Southern Denmark; Department of Neurology (M.D.), The Royal Victoria Infirmary, Newcastle upon Tyne; Department of Neurology (K.P.), Sunderland Royal Hospital, UK; VU University Medical Center (C.v.M., J.K.), Amsterdam, the Netherlands; and Department of Neurology (C.M.), Sahlgrenska Academy at the University of Gothenburg, Institute of Clinical Neuroscience and Physiology, Gothenburg, Sweden
| | - Neil Robertson
- Department of Neurology (M.W., E.T., N.R.), Institute of Psychological Medicine and Clinical Neuroscience, Cardiff University, University Hospital of Wales; Department of Neurology (O.P.), Morriston Hospital, Heol Maes Eglwys, Morriston, Swansea, UK; Departments of Neurology (Z.I., T.S.) and Clinical Immunology (C.N.), Odense University Hospital, University of Southern Denmark; Department of Neurology (M.D.), The Royal Victoria Infirmary, Newcastle upon Tyne; Department of Neurology (K.P.), Sunderland Royal Hospital, UK; VU University Medical Center (C.v.M., J.K.), Amsterdam, the Netherlands; and Department of Neurology (C.M.), Sahlgrenska Academy at the University of Gothenburg, Institute of Clinical Neuroscience and Physiology, Gothenburg, Sweden
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Bachelet D, Hässler S, Mbogning C, Link J, Ryner M, Ramanujam R, Auer M, Hyldgaard Jensen PE, Koch-Henriksen N, Warnke C, Ingenhoven K, Buck D, Grummel V, Lawton A, Donnellan N, Hincelin-Mery A, Sikkema D, Pallardy M, Kieseier B, Hemmer B, Hartung HP, Soelberg Sorensen P, Deisenhammer F, Dönnes P, Davidson J, Fogdell-Hahn A, Broët P. Occurrence of Anti-Drug Antibodies against Interferon-Beta and Natalizumab in Multiple Sclerosis: A Collaborative Cohort Analysis. PLoS One 2016; 11:e0162752. [PMID: 27806057 PMCID: PMC5091903 DOI: 10.1371/journal.pone.0162752] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Accepted: 08/26/2016] [Indexed: 11/20/2022] Open
Abstract
Immunogenicity of biopharmaceutical products in multiple sclerosis is a frequent side effect which has a multifactorial etiology. Here we study associations between anti-drug antibody (ADA) occurrence and demographic and clinical factors. Retrospective data from routine ADA test laboratories in Sweden, Denmark, Austria and Germany (Dusseldorf group) and from one research study in Germany (Munich group) were gathered to build a collaborative multi-cohort dataset within the framework of the ABIRISK project. A subset of 5638 interferon-beta (IFNβ)-treated and 3440 natalizumab-treated patients having data on at least the first two years of treatment were eligible for interval-censored time-to-event analysis. In multivariate Cox regression, IFNβ-1a subcutaneous and IFNβ-1b subcutaneous treated patients were at higher risk of ADA occurrence compared to IFNβ-1a intramuscular-treated patients (pooled HR = 6.4, 95% CI 4.9-8.4 and pooled HR = 8.7, 95% CI 6.6-11.4 respectively). Patients older than 50 years at start of IFNβ therapy developed ADA more frequently than adult patients younger than 30 (pooled HR = 1.8, 95% CI 1.4-2.3). Men developed ADA more frequently than women (pooled HR = 1.3, 95% CI 1.1-1.6). Interestingly we observed that in Sweden and Germany, patients who started IFNβ in April were at higher risk of developing ADA (HR = 1.6, 95% CI 1.1-2.4 and HR = 2.4, 95% CI 1.5-3.9 respectively). This result is not confirmed in the other cohorts and warrants further investigations. Concerning natalizumab, patients older than 45 years had a higher ADA rate (pooled HR = 1.4, 95% CI 1.0-1.8) and women developed ADA more frequently than men (pooled HR = 1.4, 95% CI 1.0-2.0). We confirmed previously reported differences in immunogenicity of the different types of IFNβ. Differences in ADA occurrence by sex and age are reported here for the first time. These findings should be further investigated taking into account other exposures and biomarkers.
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Affiliation(s)
- Delphine Bachelet
- CESP, Université Pa ris-Sud, UVSQ, INSERM, Université Paris-Saclay, Villejuif, France
| | - Signe Hässler
- CESP, Université Pa ris-Sud, UVSQ, INSERM, Université Paris-Saclay, Villejuif, France
| | - Cyprien Mbogning
- CESP, Université Pa ris-Sud, UVSQ, INSERM, Université Paris-Saclay, Villejuif, France
| | - Jenny Link
- Karolinska Institutet, Department of Clinical Neuroscience, Clinical Neuroimmunology, Stockholm, Sweden
| | - Malin Ryner
- Karolinska Institutet, Department of Clinical Neuroscience, Clinical Neuroimmunology, Stockholm, Sweden
| | - Ryan Ramanujam
- Karolinska Institutet, Department of Clinical Neuroscience, Clinical Neuroimmunology, Stockholm, Sweden
- KTH—Royal Institute of Technology, Stockholm, Sweden
| | - Michael Auer
- Department of Neurology, Innsbruck Medical University, Innsbruck, Austria
| | - Poul Erik Hyldgaard Jensen
- Danish MS Center, Department of Neurology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Nils Koch-Henriksen
- Danish Multiple Sclerosis Registry, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Epidemiology, University of Aarhus, Aarhus, Denmark
| | - Clemens Warnke
- University of Düsseldorf, Medical Faculty, Department of Neurology, Düsseldorf, Germany
| | - Kathleen Ingenhoven
- University of Düsseldorf, Medical Faculty, Department of Neurology, Düsseldorf, Germany
| | - Dorothea Buck
- Department of Neurology, Technische Universität München, Munich, Germany
| | - Verena Grummel
- Department of Neurology, Technische Universität München, Munich, Germany
| | - Andy Lawton
- GlaxoSmithKline, Uxbridge, Middlesex, United Kingdom
| | | | | | - Dan Sikkema
- GlaxoSmithKline, Uxbridge, Middlesex, United Kingdom
| | - Marc Pallardy
- INSERM UMR 996, Univ. Paris-Sud, Faculty of Pharmacy, Université Paris-Saclay, Châtenay-Malabry, France
| | - Bernd Kieseier
- University of Düsseldorf, Medical Faculty, Department of Neurology, Düsseldorf, Germany
| | - Bernard Hemmer
- Department of Neurology, Technische Universität München, Munich, Germany
- Munich Cluster for Systems Neurology (SyNergy), Munich, Germany
| | - Hans Peter Hartung
- University of Düsseldorf, Medical Faculty, Department of Neurology, Düsseldorf, Germany
| | - Per Soelberg Sorensen
- Danish MS Center, Department of Neurology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | | | | | | | - Anna Fogdell-Hahn
- Karolinska Institutet, Department of Clinical Neuroscience, Clinical Neuroimmunology, Stockholm, Sweden
| | - Philippe Broët
- CESP, Université Pa ris-Sud, UVSQ, INSERM, Université Paris-Saclay, Villejuif, France
- Assistance Publique—Hôpitaux de Paris, Hôpital Paul Brousse, Villejuif, France
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Dörr J, Baum K. Alemtuzumab in the treatment of multiple sclerosis: patient selection and special considerations. DRUG DESIGN DEVELOPMENT AND THERAPY 2016; 10:3379-3386. [PMID: 27799738 PMCID: PMC5076850 DOI: 10.2147/dddt.s97956] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Multiple sclerosis (MS) is among the most common chronic inflammatory diseases of the central nervous system. Although not curable, the constantly increasing armamentarium of disease-modifying drugs now allows control of disease activity in many patients. The humanized monoclonal antibody alemtuzumab is a powerful drug licensed for the treatment of MS. Upon binding to the CD52 surface protein on CD4+ and CD8+ T cells, B cells, and monocytes, circulating CD52+ cells are eliminated via antibody- and complement-mediated lysis, and a less autoreactive adaptive immune system is reconstituted. The efficacy of alemtuzumab in terms of both clinical and magnetic resonance imaging outcomes has been demonstrated in several phase II/III trials including long-term extensions and follow-up studies. Treatment response to alemtuzumab is strongest as long as active inflammation is the predominant pathophysiological feature, and it is becoming less efficacious in neurodegeneration-dominated later stages of the disease. Thus, the optimal placement of alemtuzumab within treatment algorithms of MS is crucial. The impressive efficacy of alemtuzumab is counteracted by a less favorable safety profile. Besides usually manageable infusion-associated side effects, development of secondary autoimmunity in almost half of treated patients is the most disconcerting risk of alemtuzumab. The high frequency, the delayed occurrence, and the potentially severe course of secondary autoimmune diseases require awareness and a close long-term monitoring of patients treated with alemtuzumab. Biomarkers that would allow prediction of treatment response to alemtuzumab on the one hand and identification of patients at risk for the development of secondary autoimmune diseases on the other are not yet available. Thus, the overall success of alemtuzumab treatment critically depends on the patient selection. The aim of this article is therefore, to characterize the significance of alemtuzumab in the treatment of MS with a focus on the selection of the optimal patient.
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Affiliation(s)
- Jan Dörr
- Multiple Sclerosis Center, Neurology Department, Klinik Hennigsdorf, Hennigsdorf; NeuroCure Clinical Research Center, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Karl Baum
- Multiple Sclerosis Center, Neurology Department, Klinik Hennigsdorf, Hennigsdorf
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125
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Merayo-Chalico J, Rajme-López S, Barrera-Vargas A, Alcocer-Varela J, Díaz-Zamudio M, Gómez-Martín D. Lymphopenia and autoimmunity: A double-edged sword. Hum Immunol 2016; 77:921-929. [DOI: 10.1016/j.humimm.2016.06.016] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2015] [Revised: 06/01/2016] [Accepted: 06/21/2016] [Indexed: 01/09/2023]
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126
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Assessment of lymphocyte proliferation for diagnostic purpose: Comparison of CFSE staining, Ki-67 expression and 3H-thymidine incorporation. Hum Immunol 2016; 77:1215-1222. [PMID: 27562802 DOI: 10.1016/j.humimm.2016.08.012] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Revised: 08/18/2016] [Accepted: 08/20/2016] [Indexed: 11/20/2022]
Abstract
The capability of lymphocytes to respond to antigenic or mitogenic stimulation is an important feature in the diagnosis of various immunodeficiencies and immune disorders. We used large cohorts of both immune compromised patients and healthy controls to measure lymphocyte proliferations by means of three methods: CFSE staining, Ki-67 expression and 3H-thymidine incorporation. The advantages and disadvantages of each method was then evaluated for use in routine clinical diagnostic. The statistical analysis was performed between the outcomes and the correlation between all three methods was computed. CFSE and Ki-67 assay correlated well with the r=0.767, correlation between Ki-67 expression and 3H-thymidine incorporation was 0.546 and correlation between CFSE staining and 3H-thymidine incorporation was 0.337. The differences between these three methods concerning complexity, sensitivity and reliability as well as the financial aspects are discussed hereafter. CFSE and its analogues provide the cheapest and reasonable choice for measuring lymphocyte proliferation, while Ki-67 represents a more expensive, but more sensitive and robust method. The original 3H-thymidine assay does not bring any advantages and cannot compare to the competition presented by modern flow cytometric methods available today.
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127
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Benjamin CL, Stowe RP, St. John L, Sams CF, Mehta SK, Crucian BE, Pierson DL, Komanduri KV. Decreases in thymopoiesis of astronauts returning from space flight. JCI Insight 2016; 1:e88787. [PMID: 27699228 PMCID: PMC5033888 DOI: 10.1172/jci.insight.88787] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Accepted: 06/30/2016] [Indexed: 12/23/2022] Open
Abstract
Following the advent of molecular assays that measure T cell receptor excision circles (TRECs) present in recent thymic emigrants, it has been conclusively shown that thymopoiesis persists in most adults, but that functional output decreases with age, influencing the maintenance of a diverse and functional T cell receptor (TCR) repertoire. Space flight has been shown to result in a variety of phenotypic and functional changes in human T cells and in the reactivation of latent viruses. While space flight has been shown to influence thymic architecture in rodents, thymopoiesis has not previously been assessed in astronauts. Here, we assessed thymopoiesis longitudinally over a 1-year period prior to and after long-term space flight (median duration, 184 days) in 16 astronauts. While preflight assessments of thymopoiesis remained quite stable in individual astronauts, we detected significant suppression of thymopoiesis in all subjects upon return from space flight. We also found significant increases in urine and plasma levels of endogenous glucocorticoids coincident with the suppression of thymopoiesis. The glucocorticoid induction and thymopoiesis suppression were transient, and they normalized shortly after return to Earth. This is the first report to our knowledge to prospectively demonstrate a significant change in thymopoiesis in healthy individuals in association with a defined physiologic emotional and physical stress event. These results suggest that suppression of thymopoiesis has the potential to influence the maintenance of the TCR repertoire during extended space travel. Further studies of thymopoiesis and endogenous glucocorticoids in other stress states, including illness, are warranted.
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Affiliation(s)
- Cara L. Benjamin
- Adult Stem Cell Transplant Program, University of Miami Sylvester Cancer Center, Miami, Florida, USA
| | | | - Lisa St. John
- University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | | | | | | | | | - Krishna V. Komanduri
- Adult Stem Cell Transplant Program, University of Miami Sylvester Cancer Center, Miami, Florida, USA
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128
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Smith C, Buhlmann JE, Wang X, Bartlett A, Lim B, Barrington RA. CD275-Independent IL-17-Producing T Follicular Helper-like Cells in Lymphopenic Autoimmune-Prone Mice. THE JOURNAL OF IMMUNOLOGY 2016; 196:4935-46. [PMID: 27183569 DOI: 10.4049/jimmunol.1402193] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/25/2014] [Accepted: 04/15/2016] [Indexed: 12/27/2022]
Abstract
T cells undergo homeostatic expansion and acquire an activated phenotype in lymphopenic microenvironments. Restoration of normal lymphocyte numbers typically re-establishes normal homeostasis, and proinflammatory cytokine production returns to baseline. Mice deficient in guanine nucleotide exchange factor RasGRP1 exhibit dysregulated homeostatic expansion, which manifests as lymphoproliferative disease with autoantibody production. Our previous work revealed that autoreactive B cells lacking RasGRP1 break tolerance early during development, as well as during germinal center responses, suggesting that T cell-independent and T cell-dependent mechanisms are responsible. Examination of whether a particular T cell subset is involved in the breach of B cell tolerance revealed increased Th17 cells in Rasgrp1-deficient mice relative to control mice. Rasgrp1-deficient mice lacking IL-17R had fewer germinal centers, and germinal centers that formed contained fewer autoreactive B cells, suggesting that IL-17 signaling is required for a break in B cell tolerance in germinal centers. Interestingly, a fraction of Th17 cells from Rasgrp1-deficient mice were CXCR5(+) and upregulated levels of CD278 coordinate with their appearance in germinal centers, all attributes of T follicular helper cells (Tfh17). To determine whether CD278-CD275 interactions were required for the development of Tfh17 cells and for autoantibody, Rasgrp1-deficient mice were crossed with CD275-deficient mice. Surprisingly, mice deficient in RasGRP1 and CD275 formed Tfh17 cells and germinal centers and produced similar titers of autoantibodies as mice deficient in only RasGRP1. Therefore, these studies suggest that requirements for Tfh cell development change in lymphopenia-associated autoimmune settings.
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Affiliation(s)
- Christopher Smith
- Department of Microbiology and Immunology, University of South Alabama, Mobile, AL 36688; and
| | - Janet E Buhlmann
- Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA 02115
| | - Xiaogan Wang
- Department of Microbiology and Immunology, University of South Alabama, Mobile, AL 36688; and
| | - Amber Bartlett
- Department of Microbiology and Immunology, University of South Alabama, Mobile, AL 36688; and
| | - Bing Lim
- Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA 02115
| | - Robert A Barrington
- Department of Microbiology and Immunology, University of South Alabama, Mobile, AL 36688; and
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129
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Ruck T, Afzali AM, Lukat KF, Eveslage M, Gross CC, Pfeuffer S, Bittner S, Klotz L, Melzer N, Wiendl H, Meuth SG. ALAIN01--Alemtuzumab in autoimmune inflammatory neurodegeneration: mechanisms of action and neuroprotective potential. BMC Neurol 2016; 16:34. [PMID: 26966029 PMCID: PMC4785638 DOI: 10.1186/s12883-016-0556-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2015] [Accepted: 03/02/2016] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Alemtuzumab (Lemtrada®) is a newly approved therapeutic agent for relapsing-remitting multiple sclerosis (RRMS). In previous phase II and III clinical trials, alemtuzumab has proven superior efficacy to subcutaneous interferon beta-1a concerning relapse rate and disability progression with unprecedented durability and long-lasting freedom of disease activity. The humanized monoclonal antibody targets CD52, leading to a rapid and long-lasting depletion, especially of B and T cells. Arising from hematopoietic precursor cells a fundamental reprogramming of the immune system restores tolerogenic networks effectively suppressing autoimmune inflammatory responses in the central nervous system (CNS). Despite its favourable effects alemtuzumab holds a severe risk of side effects with secondary autoimmunity being the most considerable. Markers for risk stratification and treatment response improving patient selection and therapy guidance are a big unmet need for MS patients and health care providers. METHODS/DESIGN This is a mono center, single arm, explorative phase IV study including 15 patients with highly active RRMS designed for 3 years. Patients will be studied by a high-resolution analysis comprising a repertoire of various immunological assays for the detection of immune cells and their function in peripheral blood as well as the cerebrospinal fluid (CSF). These assays encompass a number of experiments investigating immune cell subset composition, activation status, cytokine secretion, migratory capacity, potential neuroprotective properties and cytolytic activity complemented by instrument-based diagnostics like MRI scans, evoked potentials and optical coherence tomography (OCT). DISCUSSION Our study represents the first in-depth and longitudinal functional analysis of key immunological parameters in the periphery and the CNS compartment underlying the fundamental effects of alemtuzumab in MS patients. By combining clinical, experimental and MRI data our study will provide a deeper understanding of alemtuzumab's mechanisms of action (MOA) potentially identifying immune signatures associated with treatment response or the development of secondary autoimmunity. After validation in larger cohorts this might help to improve efficacy and safety of alemtuzumab therapy in RRMS patients. TRIAL REGISTRATION NCT02419378 (clinicaltrials.gov), registered 31 March 2015.
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Affiliation(s)
- Tobias Ruck
- Department of Neurology, University of Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany.
| | - Ali Maisam Afzali
- Department of Neurology, University of Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
| | | | - Maria Eveslage
- Institute of Biostatistics and Clinical Research, University of Münster, Münster, Germany
| | - Catharina C Gross
- Department of Neurology, University of Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
| | - Steffen Pfeuffer
- Department of Neurology, University of Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
| | - Stefan Bittner
- Department of Neurology, University of Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
| | - Luisa Klotz
- Department of Neurology, University of Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
| | - Nico Melzer
- Department of Neurology, University of Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
| | - Heinz Wiendl
- Department of Neurology, University of Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
| | - Sven G Meuth
- Department of Neurology, University of Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
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130
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Lossius A, Johansen JN, Vartdal F, Holmøy T. High-throughput sequencing of immune repertoires in multiple sclerosis. Ann Clin Transl Neurol 2016; 3:295-306. [PMID: 27081660 PMCID: PMC4818741 DOI: 10.1002/acn3.295] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2015] [Revised: 12/21/2015] [Accepted: 01/18/2016] [Indexed: 12/24/2022] Open
Abstract
T cells and B cells are crucial in the initiation and maintenance of multiple sclerosis (MS), and the activation of these cells is believed to be mediated through specific recognition of antigens by the T‐ and B‐cell receptors. The antigen receptors are highly polymorphic due to recombination (T‐ and B‐cell receptors) and mutation (B‐cell receptors) of the encoding genes, which can therefore be used as fingerprints to track individual T‐ and B‐cell clones. Such studies can shed light on mechanisms driving the immune responses and provide new insights into the pathogenesis. Here, we summarize studies that have explored the T‐ and B‐cell receptor repertoires using earlier methodological approaches, and we focus on how high‐throughput sequencing has provided new knowledge by surveying the immune repertoires in MS in even greater detail and with unprecedented depth.
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Affiliation(s)
- Andreas Lossius
- Department of Immunology and Transfusion Medicine Oslo University Hospital Rikshospitalet Oslo Norway; Department of Neurology Oslo University Hospital Rikshospitalet Oslo Norway; Institute of Clinical Medicine University of Oslo Oslo Norway
| | - Jorunn N Johansen
- Department of Immunology and Transfusion Medicine Oslo University Hospital Rikshospitalet Oslo Norway
| | - Frode Vartdal
- Department of Immunology and Transfusion Medicine Oslo University Hospital Rikshospitalet Oslo Norway; Institute of Clinical Medicine University of Oslo Oslo Norway
| | - Trygve Holmøy
- Institute of Clinical Medicine University of Oslo Oslo Norway; Department of Neurology Akershus University Hospital Lørenskog Norway
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131
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Fischer HJ, Witte AK, Walter L, Gröne HJ, van den Brandt J, Reichardt HM. Distinct roles of T-cell lymphopenia and the microbial flora for gastrointestinal and CNS autoimmunity. FASEB J 2016; 30:1724-32. [PMID: 26740263 DOI: 10.1096/fj.15-277384] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2015] [Accepted: 12/17/2015] [Indexed: 01/28/2023]
Abstract
T-cell lymphopenia is a major risk factor for autoimmunity. Here we describe congenic Lewis (LEW) rats with a loss-of-function mutation in the Gimap5 gene, leading to a 92% reduction in peripheral T-cell numbers. Gimap5-deficient LEW rats developed eosinophilic autoimmune gastroenteritis accompanied by a 40-fold increase in IgE serum levels. This phenotype was ameliorated by antibiotic treatment, indicating a critical role of the microbial flora in the development of inflammatory bowel disease. Interestingly, Gimap5-deficient LEW rats showed strongly aggravated experimental autoimmune encephalomyelitis (EAE) after immunization with guinea pig myelin basic protein. This phenotype, however, persisted after antibiosis, confirming that the enhanced CNS autoimmune response in T-cell lymphopenic Gimap5-deficient LEW rats was unrelated to the composition of the microbial flora. Rather, it seems that it was caused by the 7-fold increase in the percentage of activated T cells producing IL-17 and IFN-γ, and the skewed T-cell receptor (TCR) repertoire, both of which were the result of T-cell lymphopenia and not affected by antibiosis. This notion was supported by the observation that adoptive T-cell transfer corrected the TCR repertoire and improved EAE. Collectively, our findings confirm a critical albeit differential role of T-cell lymphopenia in the susceptibility to organ-specific autoimmune responses.-Fischer, H. J., Witte, A.-K., Walter, L., Gröne, H.-J., van den Brandt, J., Reichardt, H. M. Distinct roles of T-cell lymphopenia and the microbial flora for gastrointestinal and CNS autoimmunity.
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Affiliation(s)
- Henrike J Fischer
- Institute for Cellular and Molecular Immunology, University Medical Center Göttingen, Göttingen, Germany
| | - Ann-Kathrin Witte
- Institute for Cellular and Molecular Immunology, University Medical Center Göttingen, Göttingen, Germany
| | - Lutz Walter
- Primate Genetics Laboratory, German Primate Center, Leibniz Institute for Primate Research, Göttingen, Germany; and
| | - Hermann-Josef Gröne
- Department of Molecular Pathology, German Cancer Research Center, Heidelberg, Germany
| | - Jens van den Brandt
- Institute for Cellular and Molecular Immunology, University Medical Center Göttingen, Göttingen, Germany
| | - Holger M Reichardt
- Institute for Cellular and Molecular Immunology, University Medical Center Göttingen, Göttingen, Germany;
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132
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Bittner S, Wiendl H. Neuroimmunotherapies Targeting T Cells: From Pathophysiology to Therapeutic Applications. Neurotherapeutics 2016; 13:4-19. [PMID: 26563391 PMCID: PMC4720668 DOI: 10.1007/s13311-015-0405-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
Therapeutic options for multiple sclerosis (MS) have significantly increased over the last few years. T lymphocytes are considered to play a central role in initiating and perpetuating the pathological immune response. Currently approved therapies for MS target T lymphocytes, either in an unspecific manner or directly by interference with specific T-cell pathways. While the concept of "T-cell-specific therapy" implies specificity and selectivity, currently approved approaches come from a general shaping of the immune system towards anti-inflammatory immune responses by non-T-cell-selective immune suppression or immune modulation (e.g., interferons-immune modulation approach) to a depletion of immune cell populations involving T cells (e.g., anti-CD52, alemtuzumab-immune selective depletion approach), or a selective inhibition of distinct molecular pathways in order to sequester leucocytes (e.g., natalizumab-leukocyte sequestration approach). This review will highlight the rationale and results of different T-cell-directed therapeutic approaches coming from basic animal experiments to clinical trials. We will first discuss the pathophysiological rationale for targeting T lymphocytes in MS leading to currently approved treatments acting on T lymphocytes. Furthermore, we will disuss previous promising concepts that have failed to show efficacy in clinical trials or were halted as a result of unexpected adverse events. Learning from the discrepancies between expectations and failures in practical outcomes helps to optimize future research approaches and clinical study designs. As our current view of MS pathogenesis and patient needs is rapidly evolving, novel therapeutic approaches targeting T lymphocytes will also be discussed, including specific molecular interventions such as cytokine-directed treatments or strategies enhancing immunoregulatory mechanisms. Based on clinical experience and novel pathophysiological approaches, T-cell-based strategies will remain a pillarstone of MS therapy.
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Affiliation(s)
- Stefan Bittner
- Department of Neurology, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
- Department of Neurology, University of Münster, Münster, Germany
| | - Heinz Wiendl
- Department of Neurology, University of Münster, Münster, Germany.
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133
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Salmond RJ, Brownlie RJ, Zamoyska R. Multifunctional roles of the autoimmune disease-associated tyrosine phosphatase PTPN22 in regulating T cell homeostasis. Cell Cycle 2015; 14:705-11. [PMID: 25715232 PMCID: PMC4671365 DOI: 10.1080/15384101.2015.1007018] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
The non-receptor tyrosine phosphatase PTPN22 has a vital function in inhibiting antigen-receptor signaling in T cells, while polymorphisms in the PTPN22 gene are important risk alleles in human autoimmune diseases. We recently reported that a key physiological function of PTPN22 was to prevent naïve T cell activation and effector cell responses in response to low affinity antigens. PTPN22 also has a more general role in limiting T cell receptor-induced proliferation. Here we present new data emphasizing this dual function for PTPN22 in T cells. Furthermore, we show that T cell activation modulates the expression of PTPN22 and additional inhibitory phosphatases. We discuss the implication of these findings for our understanding of the roles of PTPN22 in regulating T cell responses and in autoimmunity.
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Affiliation(s)
- Robert J Salmond
- a Institute of Immunology and Infection Research ; Ashworth Laboratories ; University of Edinburgh ; Edinburgh , UK
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134
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Alanio C, Nicoli F, Sultanik P, Flecken T, Perot B, Duffy D, Bianchi E, Lim A, Clave E, van Buuren MM, Schnuriger A, Johnsson K, Boussier J, Garbarg-Chenon A, Bousquet L, Mottez E, Schumacher TN, Toubert A, Appay V, Heshmati F, Thimme R, Pol S, Mallet V, Albert ML. Bystander hyperactivation of preimmune CD8+ T cells in chronic HCV patients. eLife 2015; 4. [PMID: 26568315 PMCID: PMC4752008 DOI: 10.7554/elife.07916] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2015] [Accepted: 11/12/2015] [Indexed: 01/21/2023] Open
Abstract
Chronic infection perturbs immune homeostasis. While prior studies have reported dysregulation of effector and memory cells, little is known about the effects on naïve T cell populations. We performed a cross-sectional study of chronic hepatitis C (cHCV) patients using tetramer-associated magnetic enrichment to study antigen-specific inexperienced CD8(+) T cells (i.e., tumor or unrelated virus-specific populations in tumor-free and sero-negative individuals). cHCV showed normal precursor frequencies, but increased proportions of memory-phenotype inexperienced cells, as compared to healthy donors or cured HCV patients. These observations could be explained by low surface expression of CD5, a negative regulator of TCR signaling. Accordingly, we demonstrated TCR hyperactivation and generation of potent CD8(+) T cell responses from the altered T cell repertoire of cHCV patients. In sum, we provide the first evidence that naïve CD8(+) T cells are dysregulated during cHCV infection, and establish a new mechanism of immune perturbation secondary to chronic infection.
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Affiliation(s)
- Cécile Alanio
- Unités de Recherche Internationales Mixtes Pasteur, Institut Pasteur, Paris, France.,Centre d'Immunologie Humaine, Institut Pasteur, Paris, France.,Immunobiology of Dendritic Cells, Institut Pasteur, Paris, France
| | - Francesco Nicoli
- Sorbonne Universités, UPMC Univ Paris 06, DNU FAST, CR7, Centre d'Immunologie et des Maladies Infectieuses (CIMI-Paris), Paris, France.,Emory, , United States
| | - Philippe Sultanik
- Unités de Recherche Internationales Mixtes Pasteur, Institut Pasteur, Paris, France.,Immunobiology of Dendritic Cells, Institut Pasteur, Paris, France
| | - Tobias Flecken
- The University Medical Center Freiburg, Department of Internal Medicine II, Albert-Ludwigs-Universität, Freiberg, Germany
| | - Brieuc Perot
- Unités de Recherche Internationales Mixtes Pasteur, Institut Pasteur, Paris, France.,Immunobiology of Dendritic Cells, Institut Pasteur, Paris, France
| | - Darragh Duffy
- Unités de Recherche Internationales Mixtes Pasteur, Institut Pasteur, Paris, France.,Centre d'Immunologie Humaine, Institut Pasteur, Paris, France.,Immunobiology of Dendritic Cells, Institut Pasteur, Paris, France
| | | | - Annick Lim
- Plateforme d'Immunoscope, Institut Pasteur, Paris, France
| | - Emmanuel Clave
- Hôpital Saint-Louis, Assistance publique - hôpitaux de Paris, Paris, France
| | - Marit M van Buuren
- Department of Immunology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Aurélie Schnuriger
- Laboratoire de virologie, Hôpital Armand-Trousseau, Assistance publique - hôpitaux de Paris, Paris, France
| | - Kerstin Johnsson
- Mathematics, Faculty of Engineering, Lunds University, Lund, Sweden
| | - Jeremy Boussier
- Unités de Recherche Internationales Mixtes Pasteur, Institut Pasteur, Paris, France.,Centre d'Immunologie Humaine, Institut Pasteur, Paris, France.,Immunobiology of Dendritic Cells, Institut Pasteur, Paris, France
| | - Antoine Garbarg-Chenon
- Laboratoire de virologie, Hôpital Armand-Trousseau, Assistance publique - hôpitaux de Paris, Paris, France
| | | | - Estelle Mottez
- Centre d'Immunologie Humaine, Institut Pasteur, Paris, France
| | - Ton N Schumacher
- Department of Immunology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Antoine Toubert
- Hôpital Saint-Louis, Assistance publique - hôpitaux de Paris, Paris, France
| | - Victor Appay
- Sorbonne Universités, UPMC Univ Paris 06, DNU FAST, CR7, Centre d'Immunologie et des Maladies Infectieuses (CIMI-Paris), Paris, France.,Emory, , United States
| | | | - Robert Thimme
- The University Medical Center Freiburg, Department of Internal Medicine II, Albert-Ludwigs-Universität, Freiberg, Germany
| | | | | | - Matthew L Albert
- Unités de Recherche Internationales Mixtes Pasteur, Institut Pasteur, Paris, France.,Centre d'Immunologie Humaine, Institut Pasteur, Paris, France.,Immunobiology of Dendritic Cells, Institut Pasteur, Paris, France
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135
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Reading JL, Vaes B, Hull C, Sabbah S, Hayday T, Wang NS, DiPiero A, Lehman NA, Taggart JM, Carty F, English K, Pinxteren J, Deans R, Ting AE, Tree TIM. Suppression of IL-7-dependent Effector T-cell Expansion by Multipotent Adult Progenitor Cells and PGE2. Mol Ther 2015. [PMID: 26216515 DOI: 10.1038/mt.2015.131] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
T-cell depletion therapy is used to prevent acute allograft rejection, treat autoimmunity and create space for bone marrow or hematopoietic cell transplantation. The evolved response to T-cell loss is a transient increase in IL-7 that drives compensatory homeostatic proliferation (HP) of mature T cells. Paradoxically, the exaggerated form of this process that occurs following lymphodepletion expands effector T-cells, often causing loss of immunological tolerance that results in rapid graft rejection, autoimmunity, and exacerbated graft-versus-host disease (GVHD). While standard immune suppression is unable to treat these pathologies, growing evidence suggests that manipulating the incipient process of HP increases allograft survival, prevents autoimmunity, and markedly reduces GVHD. Multipotent adult progenitor cells (MAPC) are a clinical grade immunomodulatory cell therapy known to alter γ-chain cytokine responses in T-cells. Herein, we demonstrate that MAPC regulate HP of human T-cells, prevent the expansion of Th1, Th17, and Th22 effectors, and block the development of pathogenic allograft responses. This occurs via IL-1β-primed secretion of PGE2 and activates T-cell intrinsic regulatory mechanisms (SOCS2, GADD45A). These data provide proof-of-principle that HP of human T-cells can be targeted by cellular and molecular therapies and lays a basis for the development of novel strategies to prevent immunopathology in lymphodepleted patients.
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Affiliation(s)
- James L Reading
- Department of Immunobiology, King's College London, London, UK.
| | | | - Caroline Hull
- Department of Immunobiology, King's College London, London, UK
| | - Shereen Sabbah
- Department of Immunobiology, King's College London, London, UK
| | - Thomas Hayday
- Department of Immunobiology, King's College London, London, UK
| | | | | | | | | | - Fiona Carty
- Department of Biology, Institute of Immunology, National University of Ireland, Maynooth, Ireland
| | - Karen English
- Department of Biology, Institute of Immunology, National University of Ireland, Maynooth, Ireland
| | | | | | | | - Timothy I M Tree
- Department of Immunobiology, King's College London, London, UK; NIHR Biomedical Research Centre at Guy's & St Thomas' NHS Foundation Trust and King's College London, London, UK
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136
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Abstract
Alemtuzumab is a humanized monoclonal antibody against CD52 (cluster of differentiation 52) and is approved for the therapy of relapsing-remitting multiple sclerosis. The application of alemtuzumab leads to a rapid, but long-lasting depletion predominantly of CD52-bearing B and T cells with reprogramming effects on immune cell composition resulting in the restoration of tolerogenic networks. Alemtuzumab has proven high efficacy in clinical phase II and III trials, where interferon β-1a was used as active comparator. However, alemtuzumab is associated with frequent and considerable risks. Most importantly secondary autoimmune disease affects 30%-40% of patients, predominantly impairing thyroid function. Extensive monitoring and early intervention allow for an appropriate risk management. However, new and reliable biomarkers for individual risk stratification and treatment response to improve patient selection and therapy guidance are a significant unmet need. Only a deeper understanding of the underlying mechanisms of action (MOA) will reveal such markers, maximizing the best potential risk-benefit ratio for the individual patient. This review provides and analyses the current knowledge on the MOA of alemtuzumab. Most recent data on efficacy and safety of alemtuzumab are presented and future research opportunities are discussed.
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137
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Abstract
Alemtuzumab (Lemtrada™) is a humanized therapeutic monoclonal antibody, which has been approved for use in patients with B-cell chronic lymphocytic leukaemia for several years, and has recently become approved in the EU and several other countries for use in adult patients with active relapsing-remitting multiple sclerosis. This article reviews the available pharmacological properties of intravenous infusions of alemtuzumab and its clinical efficacy and tolerability in adult patients with relapsing-remitting multiple sclerosis. Alemtuzumab is an effective treatment for patients with relapsing-remitting multiple sclerosis, and has a generally acceptable tolerability profile. In phase III trials, it was shown to be more effective than a current first-line treatment, subcutaneous interferon beta-1a, in decreasing relapse rate in treatment-naïve and previously treated patients and in decreasing disability progression in previously treated patients. Of note, these results appear to have extended into the long-term follow-up, despite no further treatment. There was an increased risk of autoimmunity and infection associated with alemtuzumab in these trials; while these adverse events were generally mild to moderate, some were severe. Alemtuzumab is a highly convenient treatment, requiring hospital attendance for an intravenous infusion for a handful of days on two consecutive years, with no treatment required in between; however, this convenience is counterbalanced by the need for regular monitoring for the increased risk of autoimmunity. More investigation is required before final conclusions can be drawn on the correct placement of alemtuzumab in multiple sclerosis treatment; however, it is of a certainty a welcome addition to the treatment options for these patients.
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138
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Bluestone JA, Bour-Jordan H, Cheng M, Anderson M. T cells in the control of organ-specific autoimmunity. J Clin Invest 2015; 125:2250-60. [PMID: 25985270 DOI: 10.1172/jci78089] [Citation(s) in RCA: 102] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Immune tolerance is critical to the avoidance of unwarranted immune responses against self antigens. Multiple, non-redundant checkpoints are in place to prevent such potentially deleterious autoimmune responses while preserving immunity integral to the fight against foreign pathogens. Nevertheless, a large and growing segment of the population is developing autoimmune diseases. Deciphering cellular and molecular pathways of immune tolerance is an important goal, with the expectation that understanding these pathways will lead to new clinical advances in the treatment of these devastating diseases. The vast majority of autoimmune diseases develop as a consequence of complex mechanisms that depend on genetic, epigenetic, molecular, cellular, and environmental elements and result in alterations in many different checkpoints of tolerance and ultimately in the breakdown of immune tolerance. The manifestations of this breakdown are harmful inflammatory responses in peripheral tissues driven by innate immunity and self antigen-specific pathogenic T and B cells. T cells play a central role in the regulation and initiation of these responses. In this Review we summarize our current understanding of the mechanisms involved in these fundamental checkpoints, the pathways that are defective in autoimmune diseases, and the therapeutic strategies being developed with the goal of restoring immune tolerance.
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Shah PD, Zhong Q, Lendermon EA, Pipeling MR, McDyer JF. Hyperexpansion of Functional Viral-Specific CD8+ T Cells in Lymphopenia-Associated MCMV Pneumonitis. Viral Immunol 2015; 28:255-64. [PMID: 26046830 DOI: 10.1089/vim.2015.0005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Cytomegalovirus (CMV) is a significant cause of morbidity and mortality in immunocompromised hosts, many of whom undergo significant periods of lymphopenia. However, the impact of lymphopenia and subsequent immune reconstitution on T cell responses and pulmonary pathology are poorly understood. Using a model of primary murine CMV infection in mice treated with cyclophosphamide (CY), the relationship of CD8+ T cell reconstitution to pneumonitis pathology was studied. Female BALB/c mice were infected with murine CMV (MCMV) with/without CY on day 1 post-infection. Lung pathology and viral specific T cell responses were assessed on days 7-28. T cell lymphocyte subsets, effector responses, and MCMV specificity were assessed at baseline and after in vitro stimulation of cells with immediate-early peptide pp89. CY treatment of MCMV-infected mice resulted in interstitial pneumonitis not seen with MCMV alone. Compared to MCMV alone, on day 14, MCMV/CY mice had greater number of CD8+ T cells, a fourfold increase in absolute number of pp89 tetramer-specific CD8+ cells, and an eightfold increase in MCMV specific T cell effector responses (IFN-γ; p<0.001). This expansion was preceded by transient lymphopenia, increased viral titers, and, most strikingly, a 10-fold increased proliferative capacity in MCMV/CY mice. In the setting of CY-associated lymphopenia, concurrent MCMV infection alters immune reconstitution toward a hyperexpanded MCMV-specific CD8+ effector T cell pool that correlates with significant lung immunopathology.
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Affiliation(s)
- Pali D Shah
- 1Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Qiong Zhong
- 1Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Elizabeth A Lendermon
- 2Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Matthew R Pipeling
- 2Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - John F McDyer
- 2Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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Affiliation(s)
- Mark D Willis
- Institute of Psychological Medicine and Clinical Neuroscience, Cardiff University, University Hospital of Wales, Heath Park, Cardiff, UK
| | - Neil P Robertson
- Institute of Psychological Medicine and Clinical Neuroscience, Cardiff University, University Hospital of Wales, Heath Park, Cardiff, UK
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Tuohy O, Costelloe L, Hill-Cawthorne G, Bjornson I, Harding K, Robertson N, May K, Button T, Azzopardi L, Kousin-Ezewu O, Fahey MT, Jones J, Compston DAS, Coles A. Alemtuzumab treatment of multiple sclerosis: long-term safety and efficacy. J Neurol Neurosurg Psychiatry 2015; 86:208-15. [PMID: 24849515 DOI: 10.1136/jnnp-2014-307721] [Citation(s) in RCA: 185] [Impact Index Per Article: 20.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVES Alemtuzumab is a newly licensed treatment of active relapsing-remitting multiple sclerosis (RRMS) in Europe, which in phase II and III studies demonstrated superior efficacy over β-interferon in reducing disability progression over 2-3 years. In this observational cohort study, we sought to describe our longer-term experience of the efficacy and safety of alemtuzumab in active RRMS. METHODS Clinical and laboratory data including serial Expanded Disability Status Scale (EDSS) assessments, from all 87 patients treated with alemtuzumab on investigator-led studies in Cambridge, UK, from 1999 to 2012, were collected. The occurrence of adverse events including secondary autoimmunity, malignancy and death, and pregnancy outcomes was recorded. Baseline variables including age, disease duration and relapse rate were compared in univariate and logistic regression analyses between groups with different disability outcomes. RESULTS Over a median 7-year follow-up (range 33-144 months), most patients (52%) required just two cycles of alemtuzumab. In the remaining patients, relapses triggered re-treatment to a total of three cycles (36%), four cycles (8%) or five cycles (1%). Using a 6-month sustained accumulation of disability definition, 59/87 (67.8%) of patients had an improved or unchanged disability compared with baseline. By an area under the curve analysis, 52/87 (59.8%) patients had an overall improvement or stabilisation of disability. Higher baseline relapse rate was associated with worse long-term disability outcomes, with trends for longer disease duration and older age at first treatment. Secondary autoimmunity was the most frequent adverse event occurring in 41/86 (47.7%) patients, most commonly involving the thyroid gland. CONCLUSIONS Alemtuzumab is associated with disease stabilisation in the majority of patients with highly active RRMS over an average seven-year follow-up. No new safety concerns arose over this extended follow-up.
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Affiliation(s)
- Orla Tuohy
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Lisa Costelloe
- Department of Neurology, Beaumont Hospital, Dublin, Ireland
| | - Grant Hill-Cawthorne
- Sydney Institute of Emerging Infectious Diseases and Biosecurity, University of Sydney, Sydney, Australia
| | - Ingunn Bjornson
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Katharine Harding
- Institute of Psychological Medicine and Clinical Neuroscience, Cardiff University, Cardiff, Wales, UK
| | - Neil Robertson
- Institute of Psychological Medicine and Clinical Neuroscience, Cardiff University, Cardiff, Wales, UK
| | - Karen May
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Tom Button
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Laura Azzopardi
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | | | - Michael T Fahey
- Biostatistics Unit, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Joanne Jones
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | | | - Alasdair Coles
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
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Villar LM, Costa-Frossard L, Masterman T, Fernandez O, Montalban X, Casanova B, Izquierdo G, Coret F, Tumani H, Saiz A, Arroyo R, Fink K, Leyva L, Espejo C, Simó-Castelló M, García-Sánchez MI, Lauda F, Llufriú S, Álvarez-Lafuente R, Olascoaga J, Prada A, Oterino A, de Andrés C, Tintoré M, Ramió-Torrentà L, Rodríguez-Martín E, Picón C, Comabella M, Quintana E, Agüera E, Díaz S, Fernandez-Bolaños R, García-Merino JA, Landete L, Menéndez-González M, Navarro L, Pérez D, Sánchez-López F, Serrano-Castro PJ, Tuñón A, Espiño M, Muriel A, Bar-Or A, Álvarez-Cermeño JC. Lipid-specific immunoglobulin M bands in cerebrospinal fluid are associated with a reduced risk of developing progressive multifocal leukoencephalopathy during treatment with natalizumab. Ann Neurol 2015; 77:447-57. [PMID: 25581547 DOI: 10.1002/ana.24345] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2014] [Revised: 12/16/2014] [Accepted: 12/24/2014] [Indexed: 02/05/2023]
Affiliation(s)
- Luisa M. Villar
- Department of Immunology; Ramón y Cajal University Hospital, Institute Ramon y Cajal for Biomedical Research; Madrid Spain
- Spanish Network for the Research in Multiple Sclerosis; Spain
| | - Lucienne Costa-Frossard
- Spanish Network for the Research in Multiple Sclerosis; Spain
- Department of Neurology; Ramon y Cajal University Hospital; Institute Ramon y Cajal for Biomedical Research; Madrid Spain
| | - Thomas Masterman
- Department of Clinical Neuroscience; Karolinska Institute; Karolinska University Hospital; Huddinge Sweden
| | - Oscar Fernandez
- Spanish Network for the Research in Multiple Sclerosis; Spain
- Department of Neurology; Regional University Hospital of Malaga; Malaga Spain
| | - Xavier Montalban
- Spanish Network for the Research in Multiple Sclerosis; Spain
- Department of Neurology-Neuroimmunology; Catalunya Center for Multiple Sclerosis; Vall d'Hebron Institute of Research; Vall d'Hebron University Hospital; Autonomous University of Barcelona; Barcelona Spain
| | - Bonaventura Casanova
- Spanish Network for the Research in Multiple Sclerosis; Spain
- Department of Neurology; La Fe University Hospital; Valencia Spain
| | - Guillermo Izquierdo
- Spanish Network for the Research in Multiple Sclerosis; Spain
- Department of Neurology; Virgen Macarena University Hospital; Seville Spain
| | - Francisco Coret
- Spanish Network for the Research in Multiple Sclerosis; Spain
- Department of Neurology; Clinic University Hospital of Valencia; Valencia Spain
| | | | - Albert Saiz
- Spanish Network for the Research in Multiple Sclerosis; Spain
- Department of Neurology; Clinic Hospital and Institute August Pi i Sunyer for Biomedical Research of; University of Barcelona; Barcelona Spain
| | - Rafael Arroyo
- Spanish Network for the Research in Multiple Sclerosis; Spain
- Department of Neurology; San Carlos Clinic University Hospital; Institute for Biomedical Research of San Carlos Clinic University Hospital; Madrid Spain
| | - Katharina Fink
- Department of Clinical Neuroscience; Karolinska Institute; Karolinska University Hospital; Huddinge Sweden
| | - Laura Leyva
- Spanish Network for the Research in Multiple Sclerosis; Spain
- Department of Neurology; Regional University Hospital of Malaga; Malaga Spain
| | - Carmen Espejo
- Spanish Network for the Research in Multiple Sclerosis; Spain
- Department of Neurology-Neuroimmunology; Catalunya Center for Multiple Sclerosis; Vall d'Hebron Institute of Research; Vall d'Hebron University Hospital; Autonomous University of Barcelona; Barcelona Spain
| | - María Simó-Castelló
- Spanish Network for the Research in Multiple Sclerosis; Spain
- Department of Neurology; La Fe University Hospital; Valencia Spain
| | - María I. García-Sánchez
- Spanish Network for the Research in Multiple Sclerosis; Spain
- Department of Neurology; Virgen Macarena University Hospital; Seville Spain
| | - Florian Lauda
- Department of Neurology; University of Ulm; Ulm Germany
| | - Sara Llufriú
- Spanish Network for the Research in Multiple Sclerosis; Spain
- Department of Neurology; Clinic Hospital and Institute August Pi i Sunyer for Biomedical Research of; University of Barcelona; Barcelona Spain
| | - Roberto Álvarez-Lafuente
- Spanish Network for the Research in Multiple Sclerosis; Spain
- Department of Neurology; San Carlos Clinic University Hospital; Institute for Biomedical Research of San Carlos Clinic University Hospital; Madrid Spain
| | - Javier Olascoaga
- Spanish Network for the Research in Multiple Sclerosis; Spain
- Department of Neurology; Donostia University Hospital; San Sebastián Spain
| | - Alvaro Prada
- Spanish Network for the Research in Multiple Sclerosis; Spain
- Department of Immunology; Donostia University Hospital; San Sebastián Spain
| | - Agustín Oterino
- Department of Neurology; Marqués de Valdecilla University Hospital; Santander Spain
| | - Clara de Andrés
- Spanish Network for the Research in Multiple Sclerosis; Spain
- Department of Neurology; Gregorio Marañón University Hospital; Madrid Spain
| | - Mar Tintoré
- Spanish Network for the Research in Multiple Sclerosis; Spain
- Department of Neurology-Neuroimmunology; Catalunya Center for Multiple Sclerosis; Vall d'Hebron Institute of Research; Vall d'Hebron University Hospital; Autonomous University of Barcelona; Barcelona Spain
| | - Lluis Ramió-Torrentà
- Spanish Network for the Research in Multiple Sclerosis; Spain
- Department of Neurology; Doctor Josep Trueta University Hospital; Institute for Biomedical Research of Girona; Girona Spain
| | - Eulalia Rodríguez-Martín
- Department of Immunology; Ramón y Cajal University Hospital, Institute Ramon y Cajal for Biomedical Research; Madrid Spain
- Spanish Network for the Research in Multiple Sclerosis; Spain
| | - Carmen Picón
- Department of Immunology; Ramón y Cajal University Hospital, Institute Ramon y Cajal for Biomedical Research; Madrid Spain
- Spanish Network for the Research in Multiple Sclerosis; Spain
| | - Manuel Comabella
- Spanish Network for the Research in Multiple Sclerosis; Spain
- Department of Neurology-Neuroimmunology; Catalunya Center for Multiple Sclerosis; Vall d'Hebron Institute of Research; Vall d'Hebron University Hospital; Autonomous University of Barcelona; Barcelona Spain
| | - Ester Quintana
- Department of Neurology; Doctor Josep Trueta University Hospital; Institute for Biomedical Research of Girona; Girona Spain
| | - Eduardo Agüera
- Institute Maimónides for Biomedical Research, Reina Sofía University Hospital, University of Córdoba; Córdoba Spain
| | - Santiago Díaz
- Department of Neurology; Doctor Negrin University Hospital, Las Palmas de Gran Canaria; Spain
| | | | - Juan A. García-Merino
- Spanish Network for the Research in Multiple Sclerosis; Spain
- Department of Neurology; Puerta de Hierro University Hospital; Madrid Spain
| | - Lamberto Landete
- Department of Neurology; Doctor Peset University Hospital; Valencia Spain
| | | | - Laura Navarro
- Department of Neurology; Elche General Hospital; Elche Spain
| | - Domingo Pérez
- Department of Neurology; Hospital of El Bierzo, Ponferrada; Ponferrada Spain
| | - Fernando Sánchez-López
- Institute Maimónides for Biomedical Research, Reina Sofía University Hospital, University of Córdoba; Córdoba Spain
| | | | - Alberto Tuñón
- Department of Neurology; Central University Hospital of Asturias; Oviedo Spain
| | - Mercedes Espiño
- Department of Immunology; Ramón y Cajal University Hospital, Institute Ramon y Cajal for Biomedical Research; Madrid Spain
- Spanish Network for the Research in Multiple Sclerosis; Spain
| | - Alfonso Muriel
- Biostatistics Unit; Ramón y Cajal University Hospital; Institute Ramon y Cajal for Biomedical Research; CIBERESP; Madrid Spain
| | - Amit Bar-Or
- Montreal Neurological Institute and Hospital; McGill University; Montreal Quebec Canada
| | - José C. Álvarez-Cermeño
- Spanish Network for the Research in Multiple Sclerosis; Spain
- Department of Neurology; Ramon y Cajal University Hospital; Institute Ramon y Cajal for Biomedical Research; Madrid Spain
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143
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Abstract
PURPOSE OF REVIEW Following lymphodepletion, lymphocytes repopulate the immune space both through enhanced thymopoiesis and proliferation of residual nondepleted peripheral lymphocytes. The term homeostatic proliferation (alternatively homeostatic expansion or lymphopenia-induced proliferation) refers to the latter process. Homeostatic proliferation is especially relevant to reconstitution of the lymphocyte compartment following immunodepletion therapy in transplantation. Repopulating lymphocytes can skew toward an effector memory type capable of inducing graft rejection, autoimmunity, or, in the case of allogeneic bone marrow transplantation, graft versus host disease. Here we review recent studies exploring the biologic mechanisms underlying homeostatic proliferation and explore implications for therapy in transplantation. RECENT FINDINGS Two immune-depleting agents, alemtuzumab and rabbit antithymocyte globulin, have been well characterized in their abilities to induce an effector-memory phenotype in repopulating lymphocytes. Additionally, we have gained new understandings of the mechanisms by which the cytokines interleukin-7 and interleukin-15 regulate this process. Recent studies have also explored the functions of noncytokine and signaling molecules in lymphopenia-induced proliferation. Finally, we have seen the promise and limitations of several therapeutic approaches, including recombinant interleukin-7 therapy, CD8-targeted antibodies, and peri-transplant cyclophosphamide, to treat posttransplant lymphopenia and reduce the risks of immune dysregulation following homeostatic proliferation. SUMMARY Immune dysfunction following homeostatic proliferation is a special challenge in transplantation. A deeper understanding of the underlying biology has led to a number of promising new therapies to overcome this problem.
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144
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Havrdova E, Horakova D, Kovarova I. Alemtuzumab in the treatment of multiple sclerosis: key clinical trial results and considerations for use. Ther Adv Neurol Disord 2015; 8:31-45. [PMID: 25584072 DOI: 10.1177/1756285614563522] [Citation(s) in RCA: 114] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Alemtuzumab is a humanized monoclonal antibody therapy that has recently been approved in over 30 countries for patients with active relapsing-remitting multiple sclerosis. It acts by targeting CD52, an antigen primarily expressed on T and B lymphocytes, resulting in their depletion and subsequent repopulation. The alemtuzumab clinical development program used an active comparator, subcutaneous interferon beta-1a, to show that alemtuzumab is a highly efficacious disease-modifying therapy, with benefits on relapses, disability outcomes, and freedom from clinical disease and magnetic resonance imaging activity. The safety profile was consistent across studies and no new safety signals have emerged during follow-up in the extension study. Infusion-associated reactions are common with alemtuzumab, but rarely serious. Infection incidence was elevated with alemtuzumab in clinical studies; most infections were mild or moderate in severity. Autoimmune adverse events occurred in approximately a third of patients, manifesting mainly as thyroid disorders, and less frequently as immune thrombocytopenia or nephropathy. A comprehensive monitoring program lasting at least 4 years after the last alemtuzumab dose allows early detection and effective management of autoimmune adverse events. Further experience with alemtuzumab in the clinic will provide needed long-term data.
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Affiliation(s)
- Eva Havrdova
- Department of Neurology and Center for Clinical Neuroscience, First Medical Faculty, Charles University in Prague, Katerinska 30, Prague, 120 00, Czech Republic
| | - Dana Horakova
- Department of Neurology and Center for Clinical Neuroscience, First Medical Faculty, Charles University in Prague, Prague, Czech Republic
| | - Ivana Kovarova
- Department of Neurology and Center for Clinical Neuroscience, First Medical Faculty, Charles University in Prague, Prague, Czech Republic
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145
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Abstract
Alemtuzumab is a humanized monoclonal antibody directed against CD52 to deplete circulating T and B lymphocytes; lymphocyte depletion is followed by a distinctive pattern of T- and B-cell repopulation, changing the balance of the immune system. This review reports the efficacy and safety findings of the phase 2 CAMMS223 trial and the phase 3 CARE-MS I and II trials investigating alemtuzumab for the treatment of active relapsing–remitting MS. Alemtuzumab, administered intravenously, was shown to improve relapse rate versus subcutaneous interferon beta-1a in patients who were treatment-naive (CAMMS223 and CARE-MS I) or had relapsed on prior therapy (CARE-MS II), and to reduce sustained accumulation of disability (CAMMS223 and CARE-MS II). Important adverse events were infusion-associated reactions, serious infections and autoimmune events. A safety monitoring program allowed for early detection and management of autoimmune events. Recommendations for the monitoring of adverse events are made. Alemtuzumab’s mechanism of action, pharmacodynamics and opportunities for future research are discussed.
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Affiliation(s)
- Hans-Peter Hartung
- Department of Neurology and Center for Neuropsychiatry, Medical Faculty, Heinrich-Heine University, Germany
| | - Orhan Aktas
- Department of Neurology and Center for Neuropsychiatry, Medical Faculty, Heinrich-Heine University, Germany
| | - Alexey N Boyko
- Moscow City Center of Multiple Sclerosis, Russian Federation, Russia
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146
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Salmond RJ, Brownlie RJ, Morrison VL, Zamoyska R. The tyrosine phosphatase PTPN22 discriminates weak self peptides from strong agonist TCR signals. Nat Immunol 2014; 15:875-883. [PMID: 25108421 PMCID: PMC4148831 DOI: 10.1038/ni.2958] [Citation(s) in RCA: 85] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2014] [Accepted: 07/09/2014] [Indexed: 12/12/2022]
Abstract
T cells must be tolerant of self antigens to avoid autoimmunity but responsive to foreign antigens to provide protection against infection. We found that in both naive T cells and effector T cells, the tyrosine phosphatase PTPN22 limited signaling via the T cell antigen receptor (TCR) by weak agonists and self antigens while not impeding responses to strong agonist antigens. T cells lacking PTPN22 showed enhanced formation of conjugates with antigen-presenting cells pulsed with weak peptides, which led to activation of the T cells and their production of inflammatory cytokines. This effect was exacerbated under conditions of lymphopenia, with the formation of potent memory T cells in the absence of PTPN22. Our data address how loss-of-function PTPN22 alleles can lead to the population expansion of effector and/or memory T cells and a predisposition to human autoimmunity.
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Affiliation(s)
- Robert J. Salmond
- Institute of Immunology and Infection Research, Centre for Immunity, Infection and Evolution, Ashworth Laboratories, The King’s Buildings, University of Edinburgh, West Mains Road, Edinburgh, EH9 3JT, UK
| | - Rebecca J. Brownlie
- Institute of Immunology and Infection Research, Centre for Immunity, Infection and Evolution, Ashworth Laboratories, The King’s Buildings, University of Edinburgh, West Mains Road, Edinburgh, EH9 3JT, UK
| | - Vicky L. Morrison
- Medical Research Institute, Ninewells Hospital and Medical School, University of Dundee, Dundee, DD1 9SY, UK
| | - Rose Zamoyska
- Institute of Immunology and Infection Research, Centre for Immunity, Infection and Evolution, Ashworth Laboratories, The King’s Buildings, University of Edinburgh, West Mains Road, Edinburgh, EH9 3JT, UK
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147
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Diversity and clonal selection in the human T-cell repertoire. Proc Natl Acad Sci U S A 2014; 111:13139-44. [PMID: 25157137 DOI: 10.1073/pnas.1409155111] [Citation(s) in RCA: 460] [Impact Index Per Article: 46.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
T-cell receptor (TCR) diversity, a prerequisite for immune system recognition of the universe of foreign antigens, is generated in the first two decades of life in the thymus and then persists to an unknown extent through life via homeostatic proliferation of naïve T cells. We have used next-generation sequencing and nonparametric statistical analysis to estimate a lower bound for the total number of different TCR beta (TCRB) sequences in human repertoires. We arrived at surprisingly high minimal estimates of 100 million unique TCRB sequences in naïve CD4 and CD8 T-cell repertoires of young adults. Naïve repertoire richness modestly declined two- to fivefold in healthy elderly. Repertoire richness contraction with age was even less pronounced for memory CD4 and CD8 T cells. In contrast, age had a major impact on the inequality of clonal sizes, as estimated by a modified Gini-Simpson index clonality score. In particular, large naïve T-cell clones that were distinct from memory clones were found in the repertoires of elderly individuals, indicating uneven homeostatic proliferation without development of a memory cell phenotype. Our results suggest that a highly diverse repertoire is maintained despite thymic involution; however, peripheral fitness selection of T cells leads to repertoire perturbations that can influence the immune response in the elderly.
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148
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Jones DE, Goldman MD. Alemtuzumab for the treatment of relapsing-remitting multiple sclerosis: a review of its clinical pharmacology, efficacy and safety. Expert Rev Clin Immunol 2014; 10:1281-91. [PMID: 25148422 DOI: 10.1586/1744666x.2014.951332] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Multiple sclerosis (MS) is an inflammatory condition of the CNS presumably induced by an environmental trigger(s) in a genetically susceptible individual. Inflammation is prominent and most susceptible to intervention early in MS, so early treatment with disease-modifying therapies is recommended to reduce relapses and new MRI activity (both markers of inflammation) with the goal of delaying disability progression. Unfortunately, the response to the disease-modifying therapies is variable and often falls short of stopping observable disease activity, so the search for more effective agents continues. Alemtuzumab is a monoclonal antibody against CD52 that has exhibited significant efficacy throughout its clinical trial program in MS; uniquely, some of the studies have demonstrated a sustained reduction in disability in MS patients. Countering this impressive efficacy is an associated high risk of autoimmune events (especially thyroid) and concerns for infection or malignancy given prolonged immunosuppression after treatment with alemtuzumab.
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Affiliation(s)
- David E Jones
- Department of Neurology, James Q. Miller MS Clinic, University of Virginia Health System , 500 Ray C. Hunt Drive, Charlottesville, VA 22908 , USA
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149
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Abstract
INTRODUCTION Alemtuzumab is a humanised anti-CD52 mAb which has recently been licensed for the treatment of relapsing multiple sclerosis in Europe. AREAS COVERED The efficacy and safety of alemtuzumab from open label, Phase II and Phase III trials is reported. EXPERT OPINION Alemtuzumab causes rapid and profound complement mediated lysis of circulating lymphocytes and allows beneficial modulation of the immune system during a subsequent reconstitution phase. Clinical trials have demonstrated superior efficacy against an active comparator, with reduction in annualised relapse rates and sustained accumulation of disability at 3 years and sustained efficacy at 5 years. The main adverse effects are mild to moderate infusion reactions, an increased incidence of mild to moderate infections and autoimmune adverse events. Thyroid disorders are the most common form of autoimmune adverse events, occurring in approximately one third of patients. Overt Graves' hyperthyroidism represents approximately half of these cases. Careful patient selection and structured monitoring programs allow for effective patient management resulting in a favourable risk benefit profile.
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Affiliation(s)
- Mark Willis
- Institute of Psychological Medicine and Clinical Neuroscience, Cardiff University School of Medicine , Cardiff , UK
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150
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Vaz NM, Carvalho CR. On the origin of immunopathology. J Theor Biol 2014; 375:61-70. [PMID: 24937801 DOI: 10.1016/j.jtbi.2014.06.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2014] [Revised: 06/02/2014] [Accepted: 06/04/2014] [Indexed: 12/19/2022]
Abstract
Stranded between medicine and experimental biology, immunology is buried in its own problems and remains distant from important areas of current biology, such as evolutionary theory, developmental biology and cognitive sciences. Immunology has treated the living system merely as the place or dimension in which immune activity takes place, inserted on a misleading axis (progressive responsiveness versus no response; memory versus tolerance) which neglects the analysis of a robustly stable dynamics which is always present and is neither tolerance nor immunity-a problem currently approached as one of "regulatory" activity. However, a regulatory response also demands regulation, leading to an endless recursion and the adoption of a stimulus-response framework inevitably drives us away from the physiological processes in which lymphocytes are involved. Herein, we propose that immunological physiology, like everything else in the body is dynamic and conservative. Immunopathology, including inherited immunodeficiencies, severe forms of infectious diseases, allergy and autoimmune diseases, are interferences with this stability which frequently include oligoclonal expansions of T lymphocytes. We suggest that this decrease in clonal diversity results from a loss of the stabilizing connectivity among lymphocytes and are not simply markers of immunopathology, but are rather expressions of basic pathogenic mechanisms. The so-called autoimmune diseases are examples of this disequilibrium. In the last decade the characterization of an enormous and diversified commensal microbiota has posed a new and pressing problem: how to explain the harmonic conviviality with trillions of foreign macromolecules. In addition, robustly stable relations towards macromolecular diet can be established by simple ingestion, a state presently labeled as "oral tolerance", a problem that has been buffered for decades as anti-inflammatory protection of the gut. A major change in terminology is necessary to describe this new panorama. We focus on two important gaps in immunological discussions: (a) the organism, seen simultaneously as the medium with which the immune system is constantly in touch and as the entity that mediates the contact with external materials; and (b) the observer, the immunologist, who operates as a human being in human languaging with other human beings, and characterizes immunological specificity. We acknowledge that we are proposing radical departures from current dogma and that we should justify them. Most of what we propose stem form a way of seeing called Biology of Cognition and Language, that derives from ideas of the neurobiologist/philosopher Humberto Maturana, also known as "autopoiesis theory".
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Affiliation(s)
- Nelson M Vaz
- Departamento de Bioquímica e Imunologia, Instituto de Ciências Biológicas, Universidade Federal de Minas Gerais, Belo Horizonte 31270-901, MG, Brazil.
| | - Claudia R Carvalho
- Departamento de Morfologia, Instituto de Ciências Biológicas, Universidade Federal de Minas Gerais, Belo Horizonte, 31270-901, MG, Brazil
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