1
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Tang B, Yang X. Clinical advances in immunotherapy for immune-mediated glomerular diseases. Clin Exp Med 2023; 23:4091-4105. [PMID: 37889398 PMCID: PMC10725396 DOI: 10.1007/s10238-023-01218-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 10/09/2023] [Indexed: 10/28/2023]
Abstract
BACKGROUND AND OBJECTIVE Due to the suboptimal therapeutic efficacy and potential adverse effects associated with traditional immunosuppressive medications, there has been an increasing emphasis on the development and utilization of immunotherapies. This paper aims to provide clinicians with valuable insights for selecting appropriate therapeutic approaches and contribute to the development of novel immunotherapeutic drugs. MAIN BODY This paper categorizes the immunotherapeutic drugs that are used for the treatment of immune-mediated glomerular diseases into three groups: immunotherapies targeting antigen-presenting cells (anti-CD80), immunotherapies targeting T/B cells (anti-CD20, anti-CD22, BAFF and APRIL inhibitors, CD40-CD40L inhibitors, proteasome inhibitors, Syk inhibitors, and Btk inhibitors), and immunotherapies targeting the complement system (C5 inhibitors, C5a/C5aR inhibitors, C3 inhibitors, MASP2 inhibitors, factor B inhibitors, and factor D inhibitors). The article then provides a comprehensive overview of advances related to these immunotherapeutic drugs in clinical research. CONCLUSION Certain immunotherapeutic drugs, such as rituximab, belimumab, and eculizumab, have exhibited notable efficacy in treating specific immune-mediated glomerular diseases, thereby providing novel therapeutic approaches for patients. Nonetheless, the efficacy of numerous immunotherapeutic drugs remains to be substantiated.
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Affiliation(s)
- Bihui Tang
- Department of Nephrology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, Hubei, China
| | - Xiao Yang
- Department of Nephrology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, Hubei, China.
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2
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Chan J, Walters GD, Puri P, Jiang SH. Safety and efficacy of biological agents in the treatment of Systemic Lupus Erythematosus (SLE). BMC Rheumatol 2023; 7:37. [PMID: 37807057 PMCID: PMC10561476 DOI: 10.1186/s41927-023-00358-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 09/15/2023] [Indexed: 10/10/2023] Open
Abstract
BACKGROUND To determine the safety and efficacy of biological agents used in the treatment of systemic lupus erythematosus (SLE) in adults. METHODS Systematic review and meta-analysis following PRISMA guidelines. DATA SOURCES MEDLINE (through Pubmed), EMBASE, Cochrane library, Clinicaltrials.gov, Australianclinicaltrials.gov.au, ANZCTR.org.au and WHO International Clinical Trials Registry Platform for studies published from 20 May 2021 and 15 years prior. A grey literature search was performed and completed on 31 May 2021. STUDY CRITERIA Phase II, III or quasi randomised controlled trials, studies with only cerebral or cutaneous lupus were excluded. DATA EXTRACTION Two authors independently screened studies for eligibility, extracted, reviewed data for accuracy, and used the Cochrane tool to assess risk of bias. RESULTS Forty-four studies were identified, consisting of 15 groups of drugs and 25 different biological agents, totalling 16,889 patients. The main outcomes assessed included Systemic Lupus Erythematosus Responder Index (SRI), BILAG-Based Composite Lupus Assessment (BICLA) and combined combined/partial renal remission (CRR/PRR). Four groups of biologics were found to improve outcomes. Anti-interferons: Anifrolumab increased BICLA response and SRI 5 to 8, decreased prednisone dosages, with increased herpes zoster infections, but fewer serious adverse events. Sifalimumab improved SRI but also increased herpes zoster infections. Anti BAFF/BLyS and/or APRIL: Belimumab consistently improved SRI 4, decreased prednisone dosages, increased combined CRR/PRR, and had no adverse safety outcomes. Tabalumab increased SRI 5 at 52 weeks with no steroid sparing effect but was associated with increased infusion related adverse events. Telitacicept improved SRI 4 at 52 weeks, with no increased adverse events, though data was rather sparse. Anti CD-20 monoclonal antibody, Obinutuzumab increased combined CRR/PRR at 1 and 2 years. Anti IL12/23 monoclonal antibody, Ustekinumab, increased SRI 4 to 6, but not BICLA at 24 weeks, with no concerning safety outcomes. CONCLUSION Multiple biologic agents are shown in high quality studies to have a significant therapeutic impact on outcomes in SLE.
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Affiliation(s)
- Justin Chan
- John Curtin School of Medical Research, Australian National University, Canberra, Australian Capital Territory, Australia.
- Department of Renal Medicine, Canberra Hospital, Canberra, Australian Capital Territory, Australia.
| | - Giles D Walters
- John Curtin School of Medical Research, Australian National University, Canberra, Australian Capital Territory, Australia
- Department of Renal Medicine, Canberra Hospital, Canberra, Australian Capital Territory, Australia
| | - Prianka Puri
- Department of Nephrology, Royal Brisbane and Woman's Hospital Health Service District, Herston, QLD, Australia
| | - Simon H Jiang
- John Curtin School of Medical Research, Australian National University, Canberra, Australian Capital Territory, Australia
- Department of Renal Medicine, Canberra Hospital, Canberra, Australian Capital Territory, Australia
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3
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Parodis I, Long X, Karlsson MCI, Huang X. B Cell Tolerance and Targeted Therapies in SLE. J Clin Med 2023; 12:6268. [PMID: 37834911 PMCID: PMC10573616 DOI: 10.3390/jcm12196268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 09/02/2023] [Accepted: 09/22/2023] [Indexed: 10/15/2023] Open
Abstract
Systemic Lupus Erythematosus (SLE) is a chronic systemic autoimmune disease of high clinical and molecular heterogeneity, and a relapsing-remitting pattern. The disease is currently without cure and more prevalent in women. B cell tolerance and production of autoantibodies are critical mechanisms that drive SLE pathophysiology. However, how the balance of the immune system is broken and how the innate and adaptive immune systems are interacting during lupus-specific autoimmune responses are still largely unknown. Here, we review the latest knowledge on B cell development, maturation, and central versus peripheral tolerance in connection to SLE and treatment options. We also discuss the regulation of B cells by conventional T cells, granulocytes, and unconventional T cells, and how effector B cells exert their functions in SLE. We also discuss mechanisms of action of B cell-targeted therapies, as well as possible future directions based on current knowledge of B cell biology.
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Affiliation(s)
- Ioannis Parodis
- Division of Rheumatology, Department of Medicine Solna, Karolinska Institutet, 17177 Stockholm, Sweden;
- Department of Gastroenterology, Dermatology and Rheumatology, Karolinska University Hospital, 17176 Stockholm, Sweden
- Department of Rheumatology, Faculty of Medicine and Health, Örebro University, 70281 Örebro, Sweden
| | - Xuan Long
- Department of Dermatology, Hunan Key Laboratory of Medical Epigenomics, Second Xiangya Hospital, Central South University, Changsha 410011, China;
| | - Mikael C. I. Karlsson
- Department of Microbiology, Tumor and Cell Biology, Karolinska Institutet, 17177 Stockholm, Sweden;
| | - Xin Huang
- Department of Dermatology, Hunan Key Laboratory of Medical Epigenomics, Second Xiangya Hospital, Central South University, Changsha 410011, China;
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4
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Neves A, Viveiros L, Venturelli V, Isenberg DA. Promising Experimental Treatments for Lupus Nephritis: Key Talking Points and Potential Opportunities. Res Rep Urol 2023; 15:333-353. [PMID: 37456804 PMCID: PMC10348374 DOI: 10.2147/rru.s385836] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 07/03/2023] [Indexed: 07/18/2023] Open
Abstract
Lupus nephritis (LN) is a frequent and serious complication of systemic lupus erythematosus (SLE), impairing patients' quality of life and significantly increasing mortality. Despite optimizing the use of conventional immunosuppressants and other biological drugs, its management remains unsatisfactory. This is mainly due to the heterogeneity of SLE, but also to insufficiently effective treatment regimens and clinical trial limitations (strict criteria, low number of patients included, and side effects). Most clinical trials of new biological therapies have failed to meet their primary endpoints in both general SLE and LN, with only two biological drugs (belimumab and anifrolumab) being approved by the Food and Drug Administration (FDA) for the treatment of SLE. Recently, several Phase II randomized controlled trials have evaluated the efficacy and safety of new biologics in LN, and some of them have demonstrated an improvement in clinical and laboratory measures. Multi-target therapies are also being successfully developed and encourage a belief that there will be an improvement in LN outcomes.
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Affiliation(s)
- Ana Neves
- Internal Medicine Department, Centro Hospitalar Universitário de São João, Oporto, Portugal
| | - Luísa Viveiros
- Internal Medicine Department, Centro Hospitalar Universitário de Santo António, Oporto, Portugal
| | - Veronica Venturelli
- Rheumatology Unit, Department of Medical Sciences, Università degli Studi di Ferrara, Azienda Ospedaliero-Universitaria S. Anna, Cona, Italy
| | - David A Isenberg
- Centre for Rheumatology, Department of Medicine, University College London, London, UK
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5
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Han Y, Liu L, Zang B, Liang R, Zhao X, Liu B. Advances in natural products and antibody drugs for SLE: new therapeutic ideas. Front Pharmacol 2023; 14:1235440. [PMID: 37492083 PMCID: PMC10363611 DOI: 10.3389/fphar.2023.1235440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 07/03/2023] [Indexed: 07/27/2023] Open
Abstract
Systemic Lupus Erythematosus (SLE) is a chronic autoimmune systemic disease with a wide range of clinical symptoms, complex development processes, and uncertain prognosis. The clinical treatment of SLE is mainly based on hormones and immunosuppressants. Research on novel therapy strategies for SLE has flourished in recent years, especially the emergence of new targeted drugs and natural products that can modulate related symptoms. This review discusses the current experience including B-cell targeted drugs (belimumab, tabalumab, blisibimod, atacicept, rituximab, ofatumumab, ocrelizumab, obexelimab, and epratuzumab), T-cell targeted drugs (abatacept, dapirolizumab, and inhibitor of syk and CaMKIV), cytokines targeted drugs (anifrolumab and sifalimumab), and natural products (curcumin, oleuropein, punicalagin, sulforaphane, icariin, apigenin, and resveratrol). The aim of this paper is to combine the existing in vitro and in vivo models and clinical research results to summarize the efficacy and mechanism of natural drugs and targeted drugs in SLE for the reference and consideration of researchers.
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Affiliation(s)
| | | | | | | | | | - Bin Liu
- Department of Rheumatology, The Affiliated Hospital of Qingdao University, Shandong, China
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6
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Katarzyna PB, Wiktor S, Ewa D, Piotr L. Current treatment of systemic lupus erythematosus: a clinician's perspective. Rheumatol Int 2023:10.1007/s00296-023-05306-5. [PMID: 37171669 DOI: 10.1007/s00296-023-05306-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 03/04/2023] [Indexed: 05/13/2023]
Abstract
Systemic lupus erythematosus (SLE) is a chronic autoimmune disease. Its variable course makes it difficult to standardize patient treatment. This article aims at a literature review on available drugs for treating SLE and on drugs that have shown therapeutic effects in this disease. The PubMed/MEDLINE electronic search engine was used to identify relevant studies. This review presents the current therapeutic options, new biological therapies, and combination therapies of biologics with standard immunosuppressive and immunomodulating drugs. We have also underlined the importance to implement the treat-to-target strategy aimed at reducing or discontinuing therapy with glucocorticosteroids (GCs). The awareness of the benefits and risks of using GCs helps in refining their dosage and thereby obtaining a better safety profile. The advent of biological targeted therapies, and more recently, low-molecular-weight compounds such as kinase inhibitors, initiated numerous clinical trials in SLE patients and led to the approval of two biological drugs, belimumab, and anifrolumab, for SLE treatment. Progress in the treatment of SLE was reflected in the 2019 and 2021 recommendations of the European Alliance of Associations for Rheumatology (EULAR). However, a mass of recent clinical research data requires continuous consolidation to optimize patient outcomes.
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Affiliation(s)
- Pawlak-Buś Katarzyna
- Department of Internal Medicine, Poznań University of Medical Sciences, Poznań, Poland.
- Department of Rheumatology, Systemic Connective Tissue Diseases and Immunotherapy of Rheumatic Diseases, J. Struś Municipal Hospital, Poznań, Poland.
| | - Schmidt Wiktor
- Department of Rheumatology, Systemic Connective Tissue Diseases and Immunotherapy of Rheumatic Diseases, J. Struś Municipal Hospital, Poznań, Poland
- Doctoral School, Poznań University of Medical Sciences, Poznań, Poland
| | - Dudziec Ewa
- Department of Internal Medicine, Poznań University of Medical Sciences, Poznań, Poland
| | - Leszczyński Piotr
- Department of Internal Medicine, Poznań University of Medical Sciences, Poznań, Poland
- Department of Rheumatology, Systemic Connective Tissue Diseases and Immunotherapy of Rheumatic Diseases, J. Struś Municipal Hospital, Poznań, Poland
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7
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Lorenzo-Vizcaya A, Isenberg DA. Clinical trials in systemic lupus erythematosus: the dilemma-Why have phase III trials failed to confirm the promising results of phase II trials? Ann Rheum Dis 2023; 82:169-174. [PMID: 36202589 DOI: 10.1136/ard-2022-222839] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 08/04/2022] [Indexed: 01/26/2023]
Abstract
Systemic lupus erythematosus (SLE) is an autoimmune rheumatic disease of unknown aetiology, characterised by the production of auto-antibodies and formation of immune complexes against self-antigens and complement activation. This inflammatory response can lead to tissue infiltration and eventually, to organ damage.Patients with SLE invariably have periods of relapse and remission. Flares can occur even when the patient is on seemingly adequate treatment, which suggests that more effective therapies are necessary for the management of SLE. Thus, trials with many drugs against different targets, such as CD22, IL-12 and IL-23 or tyrosine kinases, have been carried out in recent years.A frustrating feature of some of the biologic drugs used to treat SLE has been the reporting of successful phase II trials followed by failures of the phase III trials.In this review, we will focus on phase II and III trials carried out with epratuzumab (anti CD22), baricitinib (Janus kinases inhibitor), rigerimod (P140 peptide) and ustekinumab (IL-12 and IL-23 inhibitor) and consider the reasons for their ultimate failure to 'make the grade'. Likewise, we will try to explain the possible reasons that can influence why good results may be obtained in phase II trials and lead to undue optimism.
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8
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Merino-Vico A, Frazzei G, van Hamburg JP, Tas SW. Targeting B cells and plasma cells in autoimmune diseases: From established treatments to novel therapeutic approaches. Eur J Immunol 2023; 53:e2149675. [PMID: 36314264 PMCID: PMC10099814 DOI: 10.1002/eji.202149675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 09/27/2022] [Accepted: 10/27/2022] [Indexed: 02/02/2023]
Abstract
Autoimmune diseases are characterized by the recognition of self-antigens by the immune system, which leads to inflammation and tissue damage. B cells are directly and indirectly involved in the pathophysiology of autoimmunity, both via antigen-presentation to T cells and production of proinflammatory cytokines and/or autoantibodies. Consequently, B lineage cells have been identified as therapeutic targets in autoimmune diseases. B cell depleting strategies have proven beneficial in the treatment of rheumatoid arthritis (RA), systemic lupus erythematous (SLE), ANCA-associated vasculitis (AAV), multiple sclerosis (MS), and a wide range of other immune-mediated inflammatory diseases (IMIDs). However, not all patients respond to treatment or may not reach (drug-free) remission. Moreover, B cell depleting therapies do not always target all B cell subsets, such as short-lived and long-lived plasma cells. These cells play an active role in autoimmunity and in certain diseases their depletion would be beneficial to achieve disease remission. In the current review article, we provide an overview of novel strategies to target B lineage cells in autoimmune diseases, with the focus on rheumatic diseases. Both advanced therapies that have recently become available and more experimental treatments that may reach the clinic in the near future are discussed.
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Affiliation(s)
- Ana Merino-Vico
- Department of Experimental Immunology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands.,Department of Clinical Immunology and Rheumatology, Amsterdam Rheumatology and Immunology Center, Amsterdam University Medical Centers, University of Amsterdam, Netherlands
| | - Giulia Frazzei
- Department of Experimental Immunology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands.,Department of Clinical Immunology and Rheumatology, Amsterdam Rheumatology and Immunology Center, Amsterdam University Medical Centers, University of Amsterdam, Netherlands
| | - Jan Piet van Hamburg
- Department of Experimental Immunology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands.,Department of Clinical Immunology and Rheumatology, Amsterdam Rheumatology and Immunology Center, Amsterdam University Medical Centers, University of Amsterdam, Netherlands
| | - Sander W Tas
- Department of Experimental Immunology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands.,Department of Clinical Immunology and Rheumatology, Amsterdam Rheumatology and Immunology Center, Amsterdam University Medical Centers, University of Amsterdam, Netherlands
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9
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Gomez A, Parodis I. Do biological agents improve health-related quality of life in patients with systemic lupus erythematosus? Results from a systematic search of the literature. Autoimmun Rev 2022; 21:103188. [PMID: 36089249 DOI: 10.1016/j.autrev.2022.103188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Accepted: 09/04/2022] [Indexed: 11/29/2022]
Abstract
Despite an unprecedented rise in the number of biological therapies developed for systemic lupus erythematosus (SLE) during the last decades, most randomised clinical trials (RCTs) have failed to reach their primary efficacy endpoint. These endpoints mainly constitute composite outcomes that encompass disease activity indices derived from clinician-reported and laboratory data and do not necessarily reflect the patient perspective, as symptoms that represent major concerns to patients, such as fatigue, are seldom part of the evaluation. To overcome this limitation, patient-reported outcomes (PROs) constitute useful tools for evaluating the effect of an intervention on facets that are particularly relevant for the patients. In the present review, we performed a systematic literature search aiming to examine the effect of biological therapies on SLE patients' health-related quality of life (HRQoL) and fatigue in RCT and real-life settings. We summarised results concerning 14 different biological agents, the majority of which targeting B cells or type I interferons, and discuss strategies that have been used to analyse HRQoL data, putting emphasis on minimal clinically important differences and the potential use of PROs as distinct targets in treat-to-target approaches. Lastly, we discuss differences between generic and disease-specific PRO measures and highlight the need of using a combination thereof aiming to capture the patient perspective in a comprehensive manner.
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Affiliation(s)
- Alvaro Gomez
- Division of Rheumatology, Department of Medicine Solna, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Ioannis Parodis
- Division of Rheumatology, Department of Medicine Solna, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden; Department of Rheumatology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
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10
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Joy A, Muralidharan A, Alfaraj M, Shantharam D, Cherukuri ASS, Muthukumar A. The Role of Belimumab in Systemic Lupus Erythematosis: A Systematic Review. Cureus 2022; 14:e25887. [PMID: 35844357 PMCID: PMC9277571 DOI: 10.7759/cureus.25887] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/13/2022] [Indexed: 12/14/2022] Open
Abstract
Systemic lupus erythematosus (SLE) is a chronic autoimmune disease involving multiple systems with a range of clinical presentations caused by the production of antibodies, activation of complements, and deposition of immune complexes. The exact cause of SLE is still unknown. The effectiveness of traditional treatment methods for SLE is very little. Nowadays, resistance to conventional therapy, steroids, and immunosuppressants is common among SLE patients. Patients with refractory disease and nephritis generally have severe drug-induced toxicity which contributes to organ dysfunction, despite available therapies. Different biologic agents and therapeutic antibodies have become an alternative and have been under experiment in clinical trials, enrolling patients whose disease is inadequately controlled by conventional treatment. Belimumab is the only targeted therapy approved for SLE treatment. This systematic review discusses one such biological agent for treating systemic lupus erythematosus, namely, belimumab. The systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies included randomized clinical trials (RCTs) from 2005 to 2021 on adult SLE. patients treated with monoclonal antibodies to assess the efficacy and safety. Methodological quality was assessed using PubMed, PMC, the Cochrane Risk of Bias tool, and the QUality In Prognosis Studies Tool (QUIPS) for RCTs. Two independent reviewers performed an electronic search on MEDLINE, Cochrane Library, SCIELO, Scopus, and ResearchGate. Based on a systematic review of articles we found that belimumab appears to be efficacious and generally well-tolerated in the treatment of SLE as compared to other drugs. The long-term use of belimumab combined with standard therapy showed a low incidence of organ damage. A lower incidence of organ damage was seen after initiating treatment in patients with a high risk for organ dysfunction. Patients who test for antinuclear antibody or anti-dsDNA-positive SLE, with moderate symptoms in the skin and musculoskeletal systems despite immunosuppressants, are treated with belimumab as an adjunct therapy. Patients with severe lupus nephritis or active CNS lupus cannot be treated with belimumab. Belimumab is effective in most races, as a clinical trial done in North-East Asia showed improvement in SLE symptoms and decreased dependence on prednisone. Belimumab also decreased disease activity and severe flares. Belimumab had greater efficacy in children.
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Affiliation(s)
- Ashna Joy
- Internal Medicine, AP Varkey Mission Hospital, Ernakulam, IND
| | | | - Marwa Alfaraj
- Internal Medicine, LaSante Health Center, New York, USA
| | | | | | - Arun Muthukumar
- Anaesthesiology, Calcutta National Medical College & Hospital (CNMCH), Kolkata, IND
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11
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Touma Z, Gladman DD, Zandy M, Su J, Anderson N, Urowitz MB. Identifying a Response for the Systemic Lupus Erythematosus Disease Activity 2000 Glucocorticoid Index. Arthritis Care Res (Hoboken) 2021; 73:1243-1249. [DOI: 10.1002/acr.24261] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Revised: 04/02/2020] [Accepted: 05/12/2020] [Indexed: 11/08/2022]
Affiliation(s)
- Zahi Touma
- University of Toronto Lupus Clinic Centre for Prognosis Studies in Rheumatic Diseases Toronto Western Hospital Toronto Ontario Canada
| | - Dafna D. Gladman
- University of Toronto Lupus Clinic Centre for Prognosis Studies in Rheumatic Diseases Toronto Western Hospital Toronto Ontario Canada
| | - Moe Zandy
- University of Toronto Lupus Clinic Centre for Prognosis Studies in Rheumatic Diseases Toronto Western Hospital Toronto Ontario Canada
| | - Jiandong Su
- University of Toronto Lupus Clinic Centre for Prognosis Studies in Rheumatic Diseases Toronto Western Hospital Toronto Ontario Canada
| | - Nicole Anderson
- University of Toronto Lupus Clinic Centre for Prognosis Studies in Rheumatic Diseases Toronto Western Hospital Toronto Ontario Canada
| | - Murray B. Urowitz
- University of Toronto Lupus Clinic Centre for Prognosis Studies in Rheumatic Diseases Toronto Western Hospital Toronto Ontario Canada
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12
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Atisha-Fregoso Y, Toz B, Diamond B. Meant to B: B cells as a therapeutic target in systemic lupus erythematosus. J Clin Invest 2021; 131:149095. [PMID: 34128474 PMCID: PMC8203443 DOI: 10.1172/jci149095] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
B cells have a prominent role in the pathogenesis of systemic lupus erythematosus (SLE). They are mediators of inflammation through the production of pathogenic antibodies that augment inflammation and cause direct tissue and cell damage. Multiple therapeutic agents targeting B cells have been successfully used in mouse models of SLE; however, these preclinical studies have led to approval of only one new agent to treat patients with SLE: belimumab, a monoclonal antibody targeting B cell-activating factor (BAFF). Integrating the experience acquired from previous clinical trials with the knowledge generated by new studies about mechanisms of B cell contributions to SLE in specific groups of patients is critical to the development of new treatment strategies that will help to improve outcomes in patients with SLE. In particular, a sharper focus on B cell differentiation to plasma cells is warranted.
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Affiliation(s)
- Yemil Atisha-Fregoso
- Institute of Molecular Medicine, Feinstein Institutes for Medical Research, Manhasset, New York, USA
- Elmezzi Graduate School of Molecular Medicine at Northwell Health, Manhasset, New York, USA
| | - Bahtiyar Toz
- Department of Medicine, Icahn School of Medicine at Mount Sinai, Queens Hospital Center, New York, New York, USA
| | - Betty Diamond
- Institute of Molecular Medicine, Feinstein Institutes for Medical Research, Manhasset, New York, USA
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13
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Hannon CW, McCourt C, Lima HC, Chen S, Bennett C. Interventions for cutaneous disease in systemic lupus erythematosus. Cochrane Database Syst Rev 2021; 3:CD007478. [PMID: 33687069 PMCID: PMC8092459 DOI: 10.1002/14651858.cd007478.pub2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Lupus erythematosus is an autoimmune disease with significant morbidity and mortality. Cutaneous disease in systemic lupus erythematosus (SLE) is common. Many interventions are used to treat SLE with varying efficacy, risks, and benefits. OBJECTIVES To assess the effects of interventions for cutaneous disease in SLE. SEARCH METHODS We searched the following databases up to June 2019: the Cochrane Skin Specialised Register, CENTRAL, MEDLINE, Embase, Wiley Interscience Online Library, and Biblioteca Virtual em Saude (Virtual Health Library). We updated our search in September 2020, but these results have not yet been fully incorporated. SELECTION CRITERIA We included randomised controlled trials (RCTs) of interventions for cutaneous disease in SLE compared with placebo, another intervention, no treatment, or different doses of the same intervention. We did not evaluate trials of cutaneous lupus in people without a diagnosis of SLE. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. Primary outcomes were complete and partial clinical response. Secondary outcomes included reduction (or change) in number of clinical flares; and severe and minor adverse events. We used GRADE to assess the quality of evidence. MAIN RESULTS Sixty-one RCTs, involving 11,232 participants, reported 43 different interventions. Trials predominantly included women from outpatient clinics; the mean age range of participants was 20 to 40 years. Twenty-five studies reported baseline severity, and 22 studies included participants with moderate to severe cutaneous lupus erythematosus (CLE); duration of CLE was not well reported. Studies were conducted mainly in multi-centre settings. Most often treatment duration was 12 months. Risk of bias was highest for the domain of reporting bias, followed by performance/detection bias. We identified too few studies for meta-analysis for most comparisons. We limited this abstract to main comparisons (all administered orally) and outcomes. We did not identify clinical trials of other commonly used treatments, such as topical corticosteroids, that reported complete or partial clinical response or numbers of clinical flares. Complete clinical response Studies comparing oral hydroxychloroquine against placebo did not report complete clinical response. Chloroquine may increase complete clinical response at 12 months' follow-up compared with placebo (absence of skin lesions) (risk ratio (RR) 1.57, 95% confidence interval (CI) 0.95 to 2.61; 1 study, 24 participants; low-quality evidence). There may be little to no difference between methotrexate and chloroquine in complete clinical response (skin rash resolution) at 6 months' follow-up (RR 1.13, 95% CI 0.84 to 1.50; 1 study, 25 participants; low-quality evidence). Methotrexate may be superior to placebo with regard to complete clinical response (absence of malar/discoid rash) at 6 months' follow-up (RR 3.57, 95% CI 1.63 to 7.84; 1 study, 41 participants; low-quality evidence). At 12 months' follow-up, there may be little to no difference between azathioprine and ciclosporin in complete clinical response (malar rash resolution) (RR 0.83, 95% CI 0.46 to 1.52; 1 study, 89 participants; low-quality evidence). Partial clinical response Partial clinical response was reported for only one key comparison: hydroxychloroquine may increase partial clinical response at 12 months compared to placebo, but the 95% CI indicates that hydroxychloroquine may make no difference or may decrease response (RR 7.00, 95% CI 0.41 to 120.16; 20 pregnant participants, 1 trial; low-quality evidence). Clinical flares Clinical flares were reported for only two key comparisons: hydroxychloroquine is probably superior to placebo at 6 months' follow-up for reducing clinical flares (RR 0.49, 95% CI 0.28 to 0.89; 1 study, 47 participants; moderate-quality evidence). At 12 months' follow-up, there may be no difference between methotrexate and placebo, but the 95% CI indicates there may be more or fewer flares with methotrexate (RR 0.77, 95% CI 0.32 to 1.83; 1 study, 86 participants; moderate-quality evidence). Adverse events Data for adverse events were limited and were inconsistently reported, but hydroxychloroquine, chloroquine, and methotrexate have well-documented adverse effects including gastrointestinal symptoms, liver problems, and retinopathy for hydroxychloroquine and chloroquine and teratogenicity during pregnancy for methotrexate. AUTHORS' CONCLUSIONS Evidence supports the commonly-used treatment hydroxychloroquine, and there is also evidence supporting chloroquine and methotrexate for treating cutaneous disease in SLE. Evidence is limited due to the small number of studies reporting key outcomes. Evidence for most key outcomes was low or moderate quality, meaning findings should be interpreted with caution. Head-to-head intervention trials designed to detect differences in efficacy between treatments for specific CLE subtypes are needed. Thirteen further trials are awaiting classification and have not yet been incorporated in this review; they may alter the review conclusions.
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Affiliation(s)
- Cora W Hannon
- Dermatologist, Masters of Public Health Program, Harvard School of Public Health, Boston, Massachusetts, USA
| | | | - Hermenio C Lima
- Department of Dermatology, Clinical Unit for Research Trials and Outcomes in Skin (CURTIS), Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Suephy Chen
- Emory University Hospital, Emory Healthcare, Atlanta, Georgia, USA
| | - Cathy Bennett
- Office of Research and Innovation, Royal College of Surgeons in Ireland Coláiste Ríoga na Máinleá in Éirinn, Dublin, Ireland
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14
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B Cell Aberrance in Lupus: the Ringleader and the Solution. Clin Rev Allergy Immunol 2021; 62:301-323. [PMID: 33534064 DOI: 10.1007/s12016-020-08820-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/02/2020] [Indexed: 12/18/2022]
Abstract
Systemic lupus erythematosus (SLE) is a prototypical autoimmune disease with high heterogeneity but the common characterization of numerous autoantibodies and systemic inflammation which lead to the damage of multiple organs. Aberrance of B cells plays a pivotal role in the immunopathogenesis of SLE via both antibody-dependent and antibody-independent manners. Escape of autoreactive B cells from the central and peripheral tolerance checkpoints, over-activation of B cells and their excessive cytokines release which drive T cells and dendritic cells stimulation, and dysregulated surface molecules, as well as intracellular signal pathways involved in B cell biology, are all contributing to B cell aberrance and participating in the pathogenesis of SLE. Based on that rationale, targeting aberrance of B cells and relevant molecules and pathways is expected to be a promising strategy for lupus control. Multiple approaches targeting B cells through different mechanisms have been attempted, including B-cell depletion via monoclonal antibodies against B-cell-specific molecules, blockade of B-cell survival and activation factors, suppressing T-B crosstalk by interrupting costimulatory molecules and inhibiting intracellular activation signaling cascade by targeting pathway molecules in B cells. Though most attempts ended in failure, the efficacy of B-cell targeting has been encouraged by the FDA approval of belimumab that blocks B cell-activating factor (BAFF) and the recommended use of anti-CD20 as a remedial therapy in refractory lupus. Still, quantities of clinical trials targeting B cells or relevant molecules are ongoing and some of them have displayed promising preliminary results. Additionally, advances in multi-omics studies help deepen our understandings of B cell biology in lupus and may promote the discovery of novel potential therapeutic targets. The combination of real-world data with basic research achievements may pave the road to conquering lupus.
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15
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Klavdianou K, Lazarini A, Fanouriakis A. Targeted Biologic Therapy for Systemic Lupus Erythematosus: Emerging Pathways and Drug Pipeline. BioDrugs 2021; 34:133-147. [PMID: 32002918 DOI: 10.1007/s40259-020-00405-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Following the approval of belimumab, the first drug to be approved for systemic lupus erythematosus (SLE) in over 50 years, advances in our understanding of the pathogenesis of the disease have led to a remarkable number of clinical trials for investigational drugs, each with a unique mechanism of action. These include, but are not limited to, antibodies targeting B or T cells or their interaction, dendritic cells, interferon, and other cytokines. Frustratingly, this boost of studies has not been accompanied by a corresponding success and subsequent approval of novel agents, for reasons only partly attributed to the efficacy of the drugs per se. Successful phase II trials are often followed by failed phase III studies, which typically require many more patients. Nevertheless, recent successes, such as the ustekinumab and baricitinib trials and the positive results from the phase III TULIP-2 study of anifrolumab, provide room for cautious optimism. In this review, we attempt to draw the current landscape of the drug pipeline in SLE, focusing on the rationale behind each drug development, its mechanism of action, and the available preclinical and clinical data. We also highlight lessons learned from failed attempts that have helped to optimize clinical trial design for this challenging disease. We conclude with a look into the future, commenting on the surge of studies in the field of biomarkers and the use of omics technologies in lupus, which aim to pinpoint different disease phenotypes and, ideally, identify subsets of patients with disease that will respond to different biologic drugs.
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Affiliation(s)
- Kalliopi Klavdianou
- Department of Rheumatology, "Asklepieion" General Hospital, 1 Vasileos Pavlou Str., Voula, 16673, Athens, Greece
| | - Argyro Lazarini
- Department of Rheumatology, "Asklepieion" General Hospital, 1 Vasileos Pavlou Str., Voula, 16673, Athens, Greece
| | - Antonis Fanouriakis
- Department of Rheumatology, "Asklepieion" General Hospital, 1 Vasileos Pavlou Str., Voula, 16673, Athens, Greece.
- Rheumatology and Clinical Immunology, 4th Department of Internal Medicine, "Attikon" University Hospital, Athens, Greece.
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16
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Bacalao MA, Satterthwaite AB. Recent Advances in Lupus B Cell Biology: PI3K, IFNγ, and Chromatin. Front Immunol 2021; 11:615673. [PMID: 33519824 PMCID: PMC7841329 DOI: 10.3389/fimmu.2020.615673] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 11/26/2020] [Indexed: 12/18/2022] Open
Abstract
In the autoimmune disease Systemic Lupus Erythematosus (SLE), autoantibodies are formed that promote inflammation and tissue damage. There has been significant interest in understanding the B cell derangements involved in SLE pathogenesis. The past few years have been particularly fruitful in three domains: the role of PI3K signaling in loss of B cell tolerance, the role of IFNγ signaling in the development of autoimmunity, and the characterization of changes in chromatin accessibility in SLE B cells. The PI3K pathway coordinates various downstream signaling molecules involved in B cell development and activation. It is governed by the phosphatases PTEN and SHIP-1. Murine models lacking either of these phosphatases in B cells develop autoimmune disease and exhibit defects in B cell tolerance. Limited studies of human SLE B cells demonstrate reduced expression of PTEN or increased signaling events downstream of PI3K in some patients. IFNγ has long been known to be elevated in both SLE patients and mouse models of lupus. New data suggests that IFNγR expression on B cells is required to develop autoreactive germinal centers (GC) and autoantibodies in murine lupus. Furthermore, IFNγ promotes increased transcription of BCL6, IL-6 and T-bet in B cells, which also promote GC and autoantibody formation. IFNγ also induces epigenetic changes in human B cells. SLE B cells demonstrate significant epigenetic reprogramming, including enhanced chromatin accessibility at transcription factor motifs involved in B cell activation and plasma cell (PC) differentiation as well as alterations in DNA methylation and histone modifications. Histone deacetylase inhibitors limit disease development in murine lupus models, at least in part via their ability to prevent B cell class switching and differentiation into plasma cells. This review will discuss relevant discoveries of the past several years pertaining to these areas of SLE B cell biology.
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Affiliation(s)
- Maria A. Bacalao
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Anne B. Satterthwaite
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, United States
- Department of Immunology, University of Texas Southwestern Medical Center, Dallas, TX, United States
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17
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Bag-Ozbek A, Hui-Yuen JS. Emerging B-Cell Therapies in Systemic Lupus Erythematosus. Ther Clin Risk Manag 2021; 17:39-54. [PMID: 33488082 PMCID: PMC7814238 DOI: 10.2147/tcrm.s252592] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 12/29/2020] [Indexed: 12/11/2022] Open
Abstract
Systemic lupus erythematosus (SLE) is a chronic, multisystem, autoimmune disease of unknown etiology, whose hallmark is the production of autoantibodies. B cells are promising targets for novel SLE therapies. In 2011, belimumab (Benlysta®), a fully humanized monoclonal antibody inhibiting B-cell activation and proliferation, was the first medication in 50 years to be approved by the US Food and Drug Administration to treat adult SLE. This review discusses the current experience with B-cell-targeted therapies, including those targeting B-cell-surface antigens (rituximab, ocrelizumab, ofatumumab, obinutuzumab, obexelimab, epratuzumab, daratumumab), B-cell survival factors (belimumab, tabalumab, atacicept, blisibimod), or B-cell intracellular functions (ibrutinib, fenebrutinib, proteasome inhibitors), for the management of SLE. It focuses on ongoing clinical trials and real-world post-marketing use, where available, including their safety profiles, and concludes with our recommendations for B-cell-centric approaches to the management of SLE.
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Affiliation(s)
- Ayse Bag-Ozbek
- Division of Rheumatology, Renaissance School of Medicine, Stony Brook University Medical Center, Stony Brook, NY, USA
| | - Joyce S Hui-Yuen
- Division of Pediatric Rheumatology, Steven and Alexandra Cohen Children Medical Center, New Hyde Park, NY, USA
- Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
- Center for Autoimmune, Musculoskeletal, and Hematopoietic Diseases Research, Feinstein Institute for Medical Research, Manhasset, NY, USA
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18
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Tselios K, Wakani L, Gladman DD, Su J, Urowitz MB. Response to placebo in non-renal, non-neuropsychiatric systemic lupus erythematosus: a systematic review and pooled analysis. Rheumatology (Oxford) 2021; 60:73-80. [PMID: 33140092 DOI: 10.1093/rheumatology/keaa655] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 08/31/2020] [Accepted: 09/07/2020] [Indexed: 01/20/2023] Open
Abstract
OBJECTIVES Most randomized controlled trials (RCTs) in SLE have failed to reach their respective end points, with the rates of response to placebo (plus standard-of-care treatment) being unexpectedly high. The aim of this systematic review was to quantify the response to placebo in non-renal, non-neuropsychiatric lupus. METHODS The PubMed database was searched (from 2000 to December 2019) for phase II/III RCTs assessing the efficacy and safety of biologics in non-renal, non-neuropsychiatric SLE. Data on the efficacy and safety of the placebo-treated patients were collected in a pre-established data retrieval form. Descriptive statistics were used. RESULTS A total of 24 RCTs (n = 11128 in total) were included. Placebo-treated patients (n = 3899) were mostly females (93.5%), Caucasians (60.2%), of mean age 39.7 years, and having a mean disease duration of 7.4 years. Their mean initial SLEDAI 2000 was 10.4, whereas 60.5% had positive anti-dsDNA antibodies, 41.9% low C3 and 35.6% low C4 at randomization. Standard-of-care treatment included glucocorticosteroids in 85.9%, antimalarials in 72.8% and immunosuppressives in 48.5%. The response to placebo was 36.2% for the primary end point (as defined in each study), 39.8% for the SLE Responder Index-4 (SRI-4), 29.2% for SRI-5, 28.4% for SRI-6 and 30.9% for BILAG-based Combined Lupus Assessment response. Regarding safety, there were serious adverse events in 16.3% of patients, serious infections in 5.5% and malignancies in 0.3%, and death occurred in 0.56% of patients. CONCLUSION More than one-third of the placebo-treated patients achieved their respective primary end points in RCTs with biologics in non-renal, non-neuropsychiatric SLE. The response rate was higher for certain end points, such as the SRI-4, while it decreased with more stringent end points.
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Affiliation(s)
- Konstantinos Tselios
- Centre for Prognosis Studies in Rheumatic Diseases, Toronto Lupus Clinic, University Health Network, Toronto, Canada
| | - Laura Wakani
- Centre for Prognosis Studies in Rheumatic Diseases, Toronto Lupus Clinic, University Health Network, Toronto, Canada
| | - Dafna D Gladman
- Centre for Prognosis Studies in Rheumatic Diseases, Toronto Lupus Clinic, University Health Network, Toronto, Canada
| | - Jiandong Su
- Centre for Prognosis Studies in Rheumatic Diseases, Toronto Lupus Clinic, University Health Network, Toronto, Canada
| | - Murray B Urowitz
- Centre for Prognosis Studies in Rheumatic Diseases, Toronto Lupus Clinic, University Health Network, Toronto, Canada
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19
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B Cell Abnormalities in Systemic Lupus Erythematosus and Lupus Nephritis-Role in Pathogenesis and Effect of Immunosuppressive Treatments. Int J Mol Sci 2019; 20:ijms20246231. [PMID: 31835612 PMCID: PMC6940927 DOI: 10.3390/ijms20246231] [Citation(s) in RCA: 80] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Revised: 12/02/2019] [Accepted: 12/03/2019] [Indexed: 12/19/2022] Open
Abstract
Abnormalities in B cells play pivotal roles in the pathogenesis of systemic lupus erythematosus (SLE) and lupus nephritis (LN). Breach in central and peripheral tolerance mechanisms generates autoreactive B cells which contribute to the pathogenesis of SLE and LN. Dysregulation of B cell transcription factors, cytokines and B cell-T cell interaction can result in aberrant B cell maturation and autoantibody production. These immunological abnormalities also lead to perturbations in circulating and infiltrating B cells in SLE and LN patients. Conventional and novel immunosuppressive medications confer differential effects on B cells which have important clinical implications. While cyclophosphamide and mycophenolate mofetil (MMF) showed comparable clinical efficacy in active LN, MMF induction was associated with earlier reduction in circulating plasmablasts and plasma cells. Accumulating evidence suggests that MMF maintenance is associated with lower risk of disease relapse than azathioprine, which may be explained by its more potent and selective suppression of B cell proliferation. Novel therapeutic approaches targeting the B cell repertoire include B cell depletion with monoclonal antibodies binding to cell surface markers, inhibition of B cell cytokines, and modulation of costimulatory signals in B cell-T cell interaction. These biologics, despite showing improvements in serological parameters and proteinuria, did not achieve primary endpoints when used as add-on therapy to standard treatments in active LN patients. Other emerging treatments such as calcineurin inhibitors, mammalian target of rapamycin inhibitors and proteasome inhibitors also show distinct inhibitory effects on the B cell repertoire. Advancement in the knowledge on B cell biology has fueled the development of new therapeutic strategies in SLE and LN. Modification in background treatments, study endpoints and selective recruitment of subjects showing aberrant B cells or its signaling pathways when designing future clinical trials may better elucidate the roles of these novel therapies for SLE and LN patients.
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20
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Lee WS, Amengual O. B cells targeting therapy in the management of systemic lupus erythematosus. Immunol Med 2019; 43:16-35. [PMID: 32107989 DOI: 10.1080/25785826.2019.1698929] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Systemic lupus erythematosus (SLE) is a chronic autoimmune disease which affects the majority of organs and systems. Traditional therapies do not lead to complete remission of disease but only relieve symptoms and inflammation. B cells are the most important effector cell types in the pathogenesis of SLE. Therefore, therapies targeting B cells and their related cytokines are a very important milestone for SLE treatment. Several biologics that modulate B cells, either depleting B cells or blocking B cell functions, have been developed and evaluated in clinical trials. Belimumab, a fully humanized monoclonal antibody that specifically binds B cells activating factor (BAFF), was the first of these agents approved for SLE treatment. In this review, we explore the currently available evidence in B cell targeted therapies in SLE including agents that target B cell surface antigens (CD19, CD20, CD22), B cell survival factors (BAFF and a proliferation-inducing ligand, APRIL), cytokines (interleukin-1 and type 1 interferons) and co-stimulatory molecules (CD40 ligand). We highlighted the mechanisms of action and the individual characteristics of these biologics, and present an update on the clinical trials that have evaluated their efficacy and safety. Finally, we describe some of the emerging and promising therapies for SLE treatment.
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Affiliation(s)
- Wen Shi Lee
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Olga Amengual
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
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21
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Magro R. Biological therapies and their clinical impact in the treatment of systemic lupus erythematosus. Ther Adv Musculoskelet Dis 2019; 11:1759720X19874309. [PMID: 31565077 PMCID: PMC6755633 DOI: 10.1177/1759720x19874309] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Accepted: 08/12/2019] [Indexed: 12/15/2022] Open
Abstract
The development of biological therapies has had an impact on the management of several medical conditions. Their use in systemic lupus erythematosus (SLE), however, remains very limited. This review has summarized the evidence on the clinical effect of biologicals in SLE. Biological drugs with a number of targets have been studied in several phase II and III randomized controlled trials (RCTs). Positive results have been obtained in phase III RCTs with belimumab and this led to its license for active SLE. The clinical experience with belimumab has confirmed the efficacy and safety of belimumab in SLE. Promising results have been noted in phase II trials for blisibimod, sifalimumab, anifrolumab, and ustekinumab. Despite the fact that the RCTs with rituximab did not achieve their primary endpoint, clinical experience with rituximab is extensive and shows favorable clinical response in refractory renal and non-renal SLE. It is hoped that further ongoing phase III RCTs on a number of biological agents in SLE will highlight the potential role of other biologicals in the management of this challenging and heterogeneous condition.
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Affiliation(s)
- Rosalie Magro
- Rheumatology Department, Mater Dei Hospital, Tal-Qroqq, Msida, MSD 2090, Malta
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22
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Li J, Wei MM, Song Q, Guo XH, Shao L, Liu Y. Anti-CD22 epratuzumab for systemic lupus erythematosus: A systematic review and meta-analysis of randomized controlled trials. Exp Ther Med 2019; 18:1500-1506. [PMID: 31316634 DOI: 10.3892/etm.2019.7630] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Accepted: 01/23/2018] [Indexed: 01/09/2023] Open
Abstract
Systemic lupus erythematosus (SLE) is a remarkable and challenging autoimmune disorder that is characterized by a broad range of clinical manifestations, such as flares and remissions. Recently, the humanized anti-CD22 antibody epratuzumab for SLE has been extensively studied. The aim of the present study was to perform a meta-analysis on the findings of associated randomized controlled trials in order to evaluate the effects of epratuzumab on SLE. Data from publications in PubMed, EMBASE and the Cochrane Library were collected up to March 2017. To calculate the risk ratio or standardized mean differences (SMDs) with 95% confidence intervals (CIs), a random effect model was applied when heterogeneity was significant and a fixed effect model was used when heterogeneity was negligible. All statistical tests were performed using Review Manager 5.3 software. A total of 1,921 participants in 4 studies (5 trials) that met the selection criteria were analyzed in this meta-analysis. Analyses of the BILAG-based Combined Lupus Assessment (BICLA) response and SLE Disease Activity Index 2000 (SLEDA-2K) score revealed that epratuzumab (720-3,600 mg) significantly improved the BICLA response (RR=1.09; 95% CI, 1.04 to 1.14) and decreased the SLEDA-2K score (SMD=-0.31; 95% CI, -0.67 to 0.06; P=0.10). While the British Isles Lupus Assessment Group index score was not significantly altered between the epratuzumab and control groups. For safety analyses, no statistically significant differences were identified between the two groups, which were proved by the pooled results (all P-values >0.05). These findings suggested that epratuzumab may be relatively safe and may have better therapeutic effectiveness than placebo control conditions in patients with SLE.
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Affiliation(s)
- Jian Li
- Department of Rheumatology and Immunology, Affiliated Hospital of Jining Medical University, Jining, Shandong 272000, P.R. China
| | - Ming-Ming Wei
- Department of Nephrology, Affiliated Hospital of Jining Medical University, Jining, Shandong 272000, P.R. China
| | - Qin Song
- Department of Rheumatology and Immunology, Affiliated Hospital of Jining Medical University, Jining, Shandong 272000, P.R. China
| | - Xiang-Hua Guo
- Department of Rheumatology and Immunology, Affiliated Hospital of Jining Medical University, Jining, Shandong 272000, P.R. China
| | - Li Shao
- Department of Rheumatology and Immunology, Affiliated Hospital of Jining Medical University, Jining, Shandong 272000, P.R. China
| | - Yan Liu
- Department of Rheumatology and Immunology, Affiliated Hospital of Jining Medical University, Jining, Shandong 272000, P.R. China
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23
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Abstract
Purpose of Review: The standard treatment options for systemic lupus erythematosus (SLE) are focused on non-specific immunosuppression. Over the past few years, scientific studies and ongoing clinical trials have shifted the paradigm with rapid advances in developing biologics and small molecules. A number of monoclonal antibodies and small molecule inhibitors have been developed to target specific pathways involved in SLE. Many of these novel therapeutic agents are already being tested in clinical trials and they may 1 day reshape the landscape of SLE treatment. Herein we review potential future therapeutic options for SLE.
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Affiliation(s)
- Milena Vukelic
- Division of Rheumatology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States
| | - Yi Li
- Division of Rheumatology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States
| | - Vasileios C Kyttaris
- Division of Rheumatology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States
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24
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Systematic review, and meta-analysis of steroid-sparing effect, of biologic agents in randomized, placebo-controlled phase 3 trials for systemic lupus erythematosus. Semin Arthritis Rheum 2018; 48:221-239. [DOI: 10.1016/j.semarthrit.2018.01.001] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Revised: 12/07/2017] [Accepted: 01/02/2018] [Indexed: 01/13/2023]
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25
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Sciascia S, Radin M, Roccatello D, Sanna G, Bertolaccini ML. Recent advances in the management of systemic lupus erythematosus. F1000Res 2018; 7:F1000 Faculty Rev-970. [PMID: 30026918 PMCID: PMC6039948 DOI: 10.12688/f1000research.13941.1] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/21/2018] [Indexed: 12/11/2022] Open
Abstract
Systemic lupus erythematosus (SLE) is a chronic autoimmune disease presenting highly heterogeneous clinical manifestations and multi-systemic involvement. Patients are susceptible to relapse- and remission, thus making management challenging. Moreover, a considerable number of side effects may occur with conventional therapies; therefore, there is clearly a need for new therapeutic strategies. Since the pathogenesis of SLE is highly complex, it is far from being fully understood. However, greater understanding of the pathways and of the cellular and molecular mediators involved in SLE is being achieved. Emerging evidence has allowed the development of new biological therapeutic options targeting crucial molecular mediators involved in the pathogenesis of SLE. This literature review analyzes the availability of biological and target-directed treatments, phase II and III trials, and new therapies that are being developed for the treatment of SLE.
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Affiliation(s)
- Savino Sciascia
- Center of Research of Immunopathology and Rare Diseases, Coordinating Center of Piemonte and Valle d’Aosta Network for Rare Diseases, Department of Clinical and Biological Sciences, and SCDU Nephrology and Dialysis, S. Giovanni Bosco Hospital, Turin, Italy
| | - Massimo Radin
- Center of Research of Immunopathology and Rare Diseases, Coordinating Center of Piemonte and Valle d’Aosta Network for Rare Diseases, Department of Clinical and Biological Sciences, and SCDU Nephrology and Dialysis, S. Giovanni Bosco Hospital, Turin, Italy
| | - Dario Roccatello
- Center of Research of Immunopathology and Rare Diseases, Coordinating Center of Piemonte and Valle d’Aosta Network for Rare Diseases, Department of Clinical and Biological Sciences, and SCDU Nephrology and Dialysis, S. Giovanni Bosco Hospital, Turin, Italy
| | - Giovanni Sanna
- Louise Coote Lupus Unit, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - Maria Laura Bertolaccini
- Academic Department of Vascular Surgery, School of Cardiovascular Medicine & Sciences, King’s College London, London, UK
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26
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Drgona L, Gudiol C, Lanini S, Salzberger B, Ippolito G, Mikulska M. ESCMID Study Group for Infections in Compromised Hosts (ESGICH) Consensus Document on the safety of targeted and biological therapies: an infectious diseases perspective (Agents targeting lymphoid or myeloid cells surface antigens [II]: CD22, CD30, CD33, CD38, CD40, SLAMF-7 and CCR4). Clin Microbiol Infect 2018; 24 Suppl 2:S83-S94. [DOI: 10.1016/j.cmi.2018.03.022] [Citation(s) in RCA: 71] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Revised: 02/05/2018] [Accepted: 02/11/2018] [Indexed: 01/12/2023]
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27
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Musette P, Bouaziz JD. B Cell Modulation Strategies in Autoimmune Diseases: New Concepts. Front Immunol 2018; 9:622. [PMID: 29706952 PMCID: PMC5908887 DOI: 10.3389/fimmu.2018.00622] [Citation(s) in RCA: 76] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Accepted: 03/13/2018] [Indexed: 12/04/2022] Open
Abstract
B cells are major effector cells in autoimmunity through antibody production, T cell help and pro-inflammatory cytokine production. Major advances have been made in human B cell biology knowledge using rituximab and type II new anti-CD20 antibodies, anti-CD19 antibodies, anti-CD22 antibodies, autoantigen specific B cell depleting therapy (chimeric antigen receptor T cells), and B cell receptor signaling inhibition (Bruton’s tyrosine kinase inhibitors). However, in certain circumstances B cell depleting therapy may lead to the worsening of the autoimmune disease which is in accordance with the existence of a regulatory B cell population. Current concepts and future directions for B cell modulating therapies in autoimmune diseases with a special focus on pemphigus are discussed.
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Affiliation(s)
- Philippe Musette
- Dermatology Department, INSERM U976, Rouen University Hospital, Rouen, France
| | - Jean David Bouaziz
- Dermatology Department, INSERM U976, Saint Louis University Hospital, Paris, France
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Abstract
INTRODUCTION Systemic lupus erythematosus (SLE) is a multi-system autoimmune disease. There are three drugs licensed for the treatment of lupus: corticosteroids, hydroxychloroquine and belimumab. Immunosuppressants such as azathioprine, methotrexate and mycophenolate are also used. Despite these treatments there is still considerable morbidity. New treatments are needed for the management of active lupus. Epratuzumab a humanized IgG1 monoclonal antibody that targets CD22 resulting in selective B cell modulation that has been considered a potential treatment for SLE. Areas covered: Summary of the relevant pathogenesis and disease activity measurements used in SLE patients, current treatments and unmet needs in SLE, pharmacokinetics and pharmacodynamics of epratuzumab therapy, and a summary of the 7 clinical trials that have investigated the efficacy and safety of epratuzumab in SLE. Expert commentary: It is not clear why trials have failed to demonstrate efficacy but high placebo response rates from optimisation of standard of care and a sub-optimal dosing regimen may have played a role. Post-hoc analysis suggested that there may be subgroups that did respond, such as anti-SSA positive patients with features of Sjogren's syndrome. Further research is needed to explore this and other potential sub-groups that might respond.
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Affiliation(s)
- Daniel Geh
- a Rheumatology Department , City Hospital, Sandwell and West Birmingham Hospitals NHS Trust , Birmingham , UK.,b University of Birmingham Research Labs , University Hospitals Birmingham NHS Foundation Trust , Birmingham , UK
| | - Caroline Gordon
- a Rheumatology Department , City Hospital, Sandwell and West Birmingham Hospitals NHS Trust , Birmingham , UK.,b University of Birmingham Research Labs , University Hospitals Birmingham NHS Foundation Trust , Birmingham , UK.,c Rheumatology Research Group, Institute of Inflammation and Ageing, College of Medical and Dental Sciences , University of Birmingham , Birmingham , UK
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He J, Li Z. An era of biological treatment in systemic lupus erythematosus. Clin Rheumatol 2017; 37:1-3. [PMID: 29234909 PMCID: PMC5754454 DOI: 10.1007/s10067-017-3933-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Revised: 11/19/2017] [Accepted: 11/24/2017] [Indexed: 12/01/2022]
Affiliation(s)
- Jing He
- Department of Rheumatology & Immunology, Peking University People's Hospital, 11 Xizhimen South Street, Beijing, 100044, China
| | - Zhanguo Li
- Department of Rheumatology & Immunology, Peking University People's Hospital, 11 Xizhimen South Street, Beijing, 100044, China.
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Liossis SNC, Staveri C. B Cell-Based Treatments in SLE: Past Experience and Current Directions. Curr Rheumatol Rep 2017; 19:78. [DOI: 10.1007/s11926-017-0707-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Borba HHL, Funke A, Wiens A, Utiyama SRDR, Perlin CM, Pontarolo R. Update on Biologic Therapies for Systemic Lupus Erythematosus. Curr Rheumatol Rep 2017; 18:44. [PMID: 27299782 DOI: 10.1007/s11926-016-0589-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Systemic lupus erythematosus (SLE) is a chronic multisystemic autoimmune disease driven by genetic, hormonal, and environmental factors. Despite the advances in diagnostic and therapeutic approaches in the last decades, SLE still leads to significant morbidity and increased mortality. Although a cure for SLE is still unknown, treatment is required to control acute disease exacerbation episodes (flares), decrease the frequency and severity of subsequent lupus flares, address comorbidities, and prevent end-organ damage. While conventional SLE pharmacotherapy may exhibit suboptimal efficacy and substantial toxicity, a growing knowledge of the disease pathogenesis enabled the research on novel therapeutic agents directed at specific disease-related targets. In this paper, we review the recent progress in the clinical investigation of biologic agents targeting B cells, T cells, cytokines, innate immunity, and other immunologic or inflammatory pathways. Although many investigational agents exhibited insufficient efficacy or inadequate safety in clinical trials, one of them, belimumab, fulfilled the efficacy and safety regulatory requirements and was approved for the treatment of SLE in Europe and the USA, which confirms that, despite all difficulties, advances in this field are possible.
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Affiliation(s)
- Helena Hiemisch Lobo Borba
- Department of Pharmacy, Pharmaceutical Sciences Postgraduate Research Program, Federal University of Parana, Campus III, Av. Pref. Lothario Meissner, 632, Jardim Botanico, Curitiba, PR, 80210-170, Brazil
| | - Andreas Funke
- Rheumatology Service, Hospital de Clinicas, Federal University of Parana, Curitiba, PR, Brazil
| | - Astrid Wiens
- Department of Pharmacy, Pharmaceutical Sciences Postgraduate Research Program, Federal University of Parana, Campus III, Av. Pref. Lothario Meissner, 632, Jardim Botanico, Curitiba, PR, 80210-170, Brazil
| | - Shirley Ramos da Rosa Utiyama
- Department of Pharmacy, Pharmaceutical Sciences Postgraduate Research Program, Federal University of Parana, Campus III, Av. Pref. Lothario Meissner, 632, Jardim Botanico, Curitiba, PR, 80210-170, Brazil
| | - Cássio Marques Perlin
- Department of Pharmacy, Pharmaceutical Sciences Postgraduate Research Program, Federal University of Parana, Campus III, Av. Pref. Lothario Meissner, 632, Jardim Botanico, Curitiba, PR, 80210-170, Brazil
| | - Roberto Pontarolo
- Department of Pharmacy, Pharmaceutical Sciences Postgraduate Research Program, Federal University of Parana, Campus III, Av. Pref. Lothario Meissner, 632, Jardim Botanico, Curitiba, PR, 80210-170, Brazil.
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Abstract
PURPOSE OF REVIEW The treatment of systemic lupus erythematosus (SLE) still depends on non-specific immunosuppression. Herein, we review promising targeted therapies that have the potential to change this therapeutic paradigm. RECENT FINDINGS Besides the FDA-approved B lymphocyte stimulator (BLyS) inhibitor, belimumab, interferon-α represents a promising treatment target, albeit with modest effectiveness primarily in non-renal SLE. Preclinical and early-phase clinical trials using biologics and small molecules targeting B and T cell activation as well as the cross-talk between these cells also show promise. BLyS and interferon targeting show the most promising results in challenging the current treatment status in non-renal SLE.
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Affiliation(s)
- Vasileios C Kyttaris
- Division of Rheumatology, Beth Israel Deaconess Medical Center and Harvard Medical School, 330 Brookline Ave, CLS-936, Boston, MA, 02215, USA.
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Kim YY, Park KT, Jang SY, Lee KH, Byun JY, Suh KH, Lee YM, Kim YH, Hwang KW. HM71224, a selective Bruton's tyrosine kinase inhibitor, attenuates the development of murine lupus. Arthritis Res Ther 2017; 19:211. [PMID: 28950886 PMCID: PMC5615432 DOI: 10.1186/s13075-017-1402-1] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Accepted: 08/01/2017] [Indexed: 01/16/2023] Open
Abstract
Background Systemic lupus erythematosus (SLE) is associated with B cell hyperactivity, and lupus nephritis (LN), in particular, is promoted by the production of autoantibodies and immune complex deposition. Bruton’s tyrosine kinase (BTK) plays critical roles in B cell receptor-related and Fc receptor-related signaling. We aimed to investigate the impact of therapeutic intervention with HM71224 (LY3337641), a selective BTK inhibitor, on the development of murine SLE-like disease features. Methods We examined the therapeutic effects of HM71224 on SLE-like disease features in MRL/lpr and NZB/W F1 mice. The disease-related skin lesion was macroscopically observed in MRL/lpr mice, and the impact on splenomegaly and lymphadenopathy was determined by the weight of the spleen and cervical lymph node. The renal function was evaluated by measuring blood urea nitrogen, serum creatinine, and urine protein, and the renal damage was assessed by histopathological grading. Survival rate was observed during the administration period. The impact of B cell inhibition was investigated in splenocytes from both mice using flow cytometry. Autoantibody was measured in serum by ELISA. Results HM71224 effectively suppressed splenic B220+GL7+, B220+CD138+, and B220+CD69+ B cell counts, and anti-dsDNA IgG and reduced splenomegaly and lymph node enlargement. The compound also prevented skin lesions caused by lupus development, ameliorated renal inflammation and damage with increased blood urea nitrogen and creatinine, and decreased proteinuria. Furthermore, HM71224 also decreased mortality from lupus development in both mouse models. Conclusion Our results indicate that inhibition of BTK by HM71224 effectively reduced B cell hyperactivity and significantly attenuated the development of SLE and LN in rodent SLE models.
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Affiliation(s)
- Yu-Yon Kim
- Host Defense Modulation Lab, College of Pharmacy, Chung-Ang University, 84 Heukseok-Ro, Dongjak-Gu, Seoul, 06974, Republic of Korea.,Hanmi Research Center, Hanmi Pharm. Co. Ltd, 550 Dongtangiheung-Ro, Hwaseong-Si, Gyeonggi-Do, 18469, Republic of Korea
| | - Ki Tae Park
- Hanmi Research Center, Hanmi Pharm. Co. Ltd, 550 Dongtangiheung-Ro, Hwaseong-Si, Gyeonggi-Do, 18469, Republic of Korea
| | - Sun Young Jang
- Hanmi Research Center, Hanmi Pharm. Co. Ltd, 550 Dongtangiheung-Ro, Hwaseong-Si, Gyeonggi-Do, 18469, Republic of Korea
| | - Kyu Hang Lee
- Hanmi Research Center, Hanmi Pharm. Co. Ltd, 550 Dongtangiheung-Ro, Hwaseong-Si, Gyeonggi-Do, 18469, Republic of Korea
| | - Joo-Yun Byun
- Hanmi Research Center, Hanmi Pharm. Co. Ltd, 550 Dongtangiheung-Ro, Hwaseong-Si, Gyeonggi-Do, 18469, Republic of Korea
| | - Kwee Hyun Suh
- Hanmi Research Center, Hanmi Pharm. Co. Ltd, 550 Dongtangiheung-Ro, Hwaseong-Si, Gyeonggi-Do, 18469, Republic of Korea
| | - Young-Mi Lee
- Hanmi Research Center, Hanmi Pharm. Co. Ltd, 550 Dongtangiheung-Ro, Hwaseong-Si, Gyeonggi-Do, 18469, Republic of Korea
| | - Young Hoon Kim
- Hanmi Research Center, Hanmi Pharm. Co. Ltd, 550 Dongtangiheung-Ro, Hwaseong-Si, Gyeonggi-Do, 18469, Republic of Korea.
| | - Kwang Woo Hwang
- Host Defense Modulation Lab, College of Pharmacy, Chung-Ang University, 84 Heukseok-Ro, Dongjak-Gu, Seoul, 06974, Republic of Korea.
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Abstract
PURPOSE OF REVIEW With advancement in our understanding of pathogenic mechanisms in systemic lupus erythematosus (SLE), there is tremendous enthusiasm in examining drugs, old and new, to improve outcomes. This review highlights recent trials' successes and impasses that have come to fore. RECENT FINDINGS Among B-cell therapies, belimumab continues its run of successes with sustained safety and tolerability documented in a long-term extension as well as the likely approval of a subcutaneous formulation in the near future. With greater antibody-dependent cytotoxicity and less immunogenicity, there is hope for obinituzumab to succeed where its anti-CD 20 predecessors have failed. Drugs targeting type I interferons - sifalimumab and anifrolumab - have been efficacious albeit with an increase in incidence of Herpes zoster infections. There is also renewed interest in evaluating the efficacy of calcineurin inhibitors, specifically tacrolimus in the induction and maintenance of lupus nephritis. Introspection into clinical trial designs have highlighted the effects of entry criteria, end points, background medications and geographical differences on study outcomes. SUMMARY There are at least 50 drugs and targets being evaluated in SLE. In addition to developing new drugs to treat lupus, future trials have to focus on more effective study designs to improve chances of trial success.
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Additional Improvements in Clinical Response From Adjuvant Biologic Response Modifiers in Adults With Moderate to Severe Systemic Lupus Erythematosus Despite Immunosuppressive Agents: A Systematic Review and Meta-analysis. Clin Ther 2017; 39:1479-1506.e45. [DOI: 10.1016/j.clinthera.2017.05.359] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Revised: 05/30/2017] [Accepted: 05/30/2017] [Indexed: 11/22/2022]
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Hui-Yuen JS, Nguyen SC, Askanase AD. Targeted B cell therapies in the treatment of adult and pediatric systemic lupus erythematosus. Lupus 2017; 25:1086-96. [PMID: 27497253 DOI: 10.1177/0961203316652491] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Belimumab (Benlysta) is a fully-humanized monoclonal antibody that inhibits B-lymphocyte stimulator (also known as B cell activating factor) and was approved by the U.S. Federal Drug Administration and European Medicines Evaluation Agency for treatment in adults with autoantibody-positive systemic lupus erythematosus (SLE). Rituximab (Rituxan) is a chimeric anti-CD20 monoclonal antibody targeting B lymphocytes. This review discusses the key findings of the phase III trials in adults with SLE and of real-world use of belimumab and rituximab in the care of both adult and pediatric SLE patients. It highlights the safety profile of belimumab and rituximab and gives insight into the consideration of these therapies for specific SLE disease states. It concludes with a discussion of the current clinical trials investigating B cell therapies in specific SLE disease states and a look to the future, with ongoing clinical trials.
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Affiliation(s)
- J S Hui-Yuen
- Division of Pediatric Rheumatology, Steven and Alexandra Cohen Children Medical Center, Hofstra Northwell School of Medicine, USA
| | - S C Nguyen
- Division of Rheumatology, New York-Presbyterian Hospital/Columbia University Medical Center, USA
| | - A D Askanase
- Division of Rheumatology, New York-Presbyterian Hospital/Columbia University Medical Center, USA
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Forbess LJ, Bresee C, Wallace DJ, Weisman MH. Failure of a systemic lupus erythematosus response index developed from clinical trial data: lessons examined and learned. Lupus 2017; 26:909-916. [PMID: 28173737 DOI: 10.1177/0961203317692433] [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] [Indexed: 11/15/2022]
Abstract
Background Our primary goal was to create an outcome change score index similar to a standard rheumatoid arthritis (RA) model utilizing real-world data in systemic lupus erythematosus (SLE) patients that occurred during their phase 3 trials with a Food and Drug Administration-approved drug. Methods We utilized raw data from trials of belimumab for the treatment of SLE. Data were split 80/20 into training/validation sets. Index variables present in a majority of patients and with face validity were selected. Variables were scored for each patient as percentage improvement from baseline after one year. The percentage of placebo- and drug-treated patients considered improved after the application of various criteria was ascertained. Logistic regression was employed to determine the ability of the new index to predict treatment assignment. Results A total of 1693 subjects had data for analyses. Eight variables were chosen: arthritis, rash, physician global assessment, fatigue, anti-double stranded DNA antibodies, C3, C4 and C-reactive protein. In the training dataset, ≥20% improvement in ≥4 of eight variables produced the largest difference between placebo- and drug-treated patients (22.1%) with an acceptable rate of improved placebo-treated patients (25%). This resulted in an odds ratio for belimumab (10 mg/kg) vs placebo of 2.7 (95% CI: 2.0-3.6; p < 0.001). However, in the validate dataset the odds ratio was not significant at 1.3 (95% CI: 0.8-2.2; p = 0.863). Conclusions The index created from training data did not achieve statistical significance when tested in the validation set. We have speculated why this happened. Is the lack of success of therapeutics for SLE caused by ineffective medications, study design and outcome instruments that fail to inform us, or is the heterogeneity of the disease too daunting? The lessons learned here can help direct future endeavors intended to improve SLE outcome instruments.
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Affiliation(s)
- L J Forbess
- 1 Cedars-Sinai Medical Center, Division of Rheumatology, USA
| | - C Bresee
- 2 Cedars-Sinai Medical Center, Department of Biostatistics and Bioinformatics, USA
| | - D J Wallace
- 1 Cedars-Sinai Medical Center, Division of Rheumatology, USA
| | - M H Weisman
- 1 Cedars-Sinai Medical Center, Division of Rheumatology, USA
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Clowse MEB, Wallace DJ, Furie RA, Petri MA, Pike MC, Leszczyński P, Neuwelt CM, Hobbs K, Keiserman M, Duca L, Kalunian KC, Galateanu C, Bongardt S, Stach C, Beaudot C, Kilgallen B, Gordon C. Efficacy and Safety of Epratuzumab in Moderately to Severely Active Systemic Lupus Erythematosus: Results From Two Phase III Randomized, Double-Blind, Placebo-Controlled Trials. Arthritis Rheumatol 2017; 69:362-375. [PMID: 27598855 PMCID: PMC5299488 DOI: 10.1002/art.39856] [Citation(s) in RCA: 146] [Impact Index Per Article: 20.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Accepted: 08/23/2016] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Epratuzumab, a monoclonal antibody that targets CD22, modulates B cell signaling without substantial reductions in the number of B cells. The aim of this study was to report the results of 2 phase III multicenter randomized, double-blind, placebo-controlled trials, the EMBODY 1 and EMBODY 2 trials, assessing the efficacy and safety of epratuzumab in patients with moderately to severely active systemic lupus erythematosus (SLE). METHODS Patients met ≥4 of the American College of Rheumatology revised classification criteria for SLE, were positive for antinuclear antibodies and/or anti-double-stranded DNA antibodies, had an SLE Disease Activity Index 2000 (SLEDAI-2K) score of ≥6 (increased disease activity), had British Isles Lupus Assessment Group 2004 index (BILAG-2004) scores of grade A (severe disease activity) in ≥1 body system or grade B (moderate disease activity) in ≥2 body systems (in the mucocutaneous, musculoskeletal, or cardiorespiratory domains), and were receiving standard therapy, including mandatory treatment with corticosteroids (5-60 mg/day). BILAG-2004 grade A scores in the renal and central nervous system domains were excluded. Patients were randomized 1:1:1 to receive either placebo, epratuzumab 600 mg every week, or epratuzumab 1,200 mg every other week, with infusions delivered for the first 4 weeks of each 12-week dosing cycle, for 4 cycles. Patients across all 3 treatment groups also continued with their standard therapy. The primary end point was the response rate at week 48 according to the BILAG-based Combined Lupus Assessment (BICLA) definition, requiring improvement in the BILAG-2004 score, no worsening in the BILAG-2004 score, SLEDAI-2K score, or physician's global assessment of disease activity, and no disallowed changes in concomitant medications. Patients who discontinued the study medication were classified as nonresponders. RESULTS In the EMBODY 1 and EMBODY 2 trials of epratuzumab, 793 patients and 791 patients, respectively, were randomized, 786 (99.1%) and 788 (99.6%), respectively, received study medication, and 528 (66.6%) and 533 (67.4%), respectively, completed the study. There was no statistically significant difference in the primary end point between the groups, with the week 48 BICLA response rates being similar between the epratuzumab groups and the placebo group (response rates ranging from 33.5% to 39.8%). No new safety signals were identified. CONCLUSION In patients with moderate or severely active SLE, treatment with epratuzumab + standard therapy did not result in improvements in response rates over that observed in the placebo + standard therapy group.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Caroline Gordon
- University of Birmingham and University Hospital Birmingham NHS Foundation TrustBirminghamUK
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Zhao Q, Chen X, Li J, Jiang J, Li M, Zhong W, Li Z, Leung SO, Zhang F, Hu P. Pharmacokinetics, Pharmacodynamics and Preliminary Observations for Clinical Activity and Safety of Multiple Doses of Human Mouse Chimeric Anti-CD22 Monoclonal Antibody (SM03) in Chinese Patients with Systemic Lupus Erythematosus. Clin Drug Investig 2017; 36:889-902. [PMID: 27424629 DOI: 10.1007/s40261-016-0426-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND AND OBJECTIVES SM03 is a novel recombinant, human/mouse chimeric immunoglobulin G1 monoclonal antibody directed against the CD22 antigen on human B lymphocytes. This was the first study to investigate the pharmacokinetics, pharmacodynamics, immunogenicity, safety and clinical activity of SM03 in patients with systemic lupus erythematosus (SLE). METHODS This study was an open, multiple-centre, parallel-group, multiple-ascending-dose, phase I study in 29 SLE patients. Pharmacokinetic assessment was conducted in 22 of these patients. Eligible patients received multiple intravenous infusions of SM03 for 4 weeks (240 mg/m2, 600 or 900 mg, once weekly) and were monitored over an 84-day observation period for pharmacokinetics, pharmacodynamics, immunogenicity, safety and clinical response. RESULTS After multiple-dose SM03, the maximal serum concentration of SM03 was reached within 3-7 h. The mean elimination half-life was 15 days. The average accumulation ratios of the area under the time-concentration curve and the maximum concentration after the fourth administration of SM03 were 2.0 and 1.5. CD19+ B-lymphocyte counts were decreased. Infections were the most common adverse events. No drug-related serious adverse events were reported. The therapeutic benefit of SM03 was observed mainly in patients with moderate-to-severe disease activity. CONCLUSION Pharmacokinetic exposure increased in a lower-than-dose-proportional manner up to 900 mg. SM03 was well tolerated at doses ranging from 240 mg/m2 to 900 mg, with no new safety signals identified. SM03 has potential efficacy in Chinese patients with SLE.
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Affiliation(s)
- Qian Zhao
- Clinical Pharmacology Research Center, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 41 Damucang, Xicheng District, Beijing, 100032, China
| | - Xia Chen
- Clinical Pharmacology Research Center, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 41 Damucang, Xicheng District, Beijing, 100032, China
| | - Jing Li
- Department of Rheumatology, Peking Union Medical College Hospital, 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China
| | - Ji Jiang
- Clinical Pharmacology Research Center, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 41 Damucang, Xicheng District, Beijing, 100032, China
| | - Mengtao Li
- Department of Rheumatology, Peking Union Medical College Hospital, 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China
| | - Wen Zhong
- Clinical Pharmacology Research Center, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 41 Damucang, Xicheng District, Beijing, 100032, China
| | - Zhengdong Li
- SinoMab BioScience, Ltd, BioIncubator No. 1-301, Science and Technology Park, Nanshan District, Shenzhen, 518057, Guangdong, China
| | - Shui-On Leung
- SinoMab BioScience, Ltd, BioIncubator No. 1-301, Science and Technology Park, Nanshan District, Shenzhen, 518057, Guangdong, China.
| | - Fengchun Zhang
- Department of Rheumatology, Peking Union Medical College Hospital, 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China.
| | - Pei Hu
- Clinical Pharmacology Research Center, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 41 Damucang, Xicheng District, Beijing, 100032, China.
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Mota P, Reddy V, Isenberg D. Improving B-cell depletion in systemic lupus erythematosus and rheumatoid arthritis. Expert Rev Clin Immunol 2016; 13:667-676. [PMID: 27841031 DOI: 10.1080/1744666x.2017.1259068] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
INTRODUCTION Rituximab-based B-cell depletion (BCD) therapy is effective in refractory rheumatoid arthritis (RA) and although used to treat patients with refractory systemic lupus erythematosus (SLE) in routine clinical practice, rituximab failed to meet the primary endpoints in two large randomised controlled trials (RCTs) of non-renal (EXPLORER) and renal (LUNAR) SLE. Areas covered: We review how BCD could be improved to achieve better clinical responses in RA and SLE. Insights into the variability in clinical response to BCD in RA and SLE may help develop new therapeutic strategies. To this end, a literature search was performed using the following terms: rheumatoid arthritis, systemic erythematosus lupus, rituximab and B-cell depletion. Expert commentary: Poor trial design may have, at least partly, contributed to the apparent lack of response to BCD in the two RCTs of patients with SLE. Enhanced B-cell depletion and/or sequential therapy with belimumab may improve clinical response at least in some patients with SLE.
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Affiliation(s)
- Pedro Mota
- a Department of Internal Medicine , Hospital da Luz , Lisbon , Portugal
| | - Venkat Reddy
- b Centre for Rheumatology, Division of Medicine , University College London , London , UK
| | - David Isenberg
- b Centre for Rheumatology, Division of Medicine , University College London , London , UK
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Radin M, Cecchi I, Schreiber K, Baldovino S, Rossi D, Menegatti E, Roccatello D, Sciascia S. Immunotherapies in phase II and III trials for the treatment of systemic lupus erythematosus. Expert Opin Orphan Drugs 2016. [DOI: 10.1080/21678707.2017.1257937] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Affiliation(s)
- Massimo Radin
- Center of Research of Immunopathology and Rare Diseases- Coordinating Center of Piemonte and Valle d’Aosta Network for Rare Diseases, Department of Rare, Immunologic, Hematologic and Immunohematologic Diseases, and SCDU Nephrology and Dialysis, S. Giovanni Bosco Hospital
| | - Irene Cecchi
- Center of Research of Immunopathology and Rare Diseases- Coordinating Center of Piemonte and Valle d’Aosta Network for Rare Diseases, Department of Rare, Immunologic, Hematologic and Immunohematologic Diseases, and SCDU Nephrology and Dialysis, S. Giovanni Bosco Hospital
| | - Karen Schreiber
- Department of Thrombosis and Thrombophilia, Guy’s and St Thomas’ Hospital, London, UK
- Department of Rheumatology, Copenhagen University Hospital at Rigshospitalet, Copenhagen, Denmark
| | - Simone Baldovino
- Center of Research of Immunopathology and Rare Diseases- Coordinating Center of Piemonte and Valle d’Aosta Network for Rare Diseases, Department of Rare, Immunologic, Hematologic and Immunohematologic Diseases, and SCDU Nephrology and Dialysis, S. Giovanni Bosco Hospital
| | - Daniela Rossi
- Center of Research of Immunopathology and Rare Diseases- Coordinating Center of Piemonte and Valle d’Aosta Network for Rare Diseases, Department of Rare, Immunologic, Hematologic and Immunohematologic Diseases, and SCDU Nephrology and Dialysis, S. Giovanni Bosco Hospital
| | - Elisa Menegatti
- Center of Research of Immunopathology and Rare Diseases- Coordinating Center of Piemonte and Valle d’Aosta Network for Rare Diseases, Department of Rare, Immunologic, Hematologic and Immunohematologic Diseases, and SCDU Nephrology and Dialysis, S. Giovanni Bosco Hospital
| | - Dario Roccatello
- Center of Research of Immunopathology and Rare Diseases- Coordinating Center of Piemonte and Valle d’Aosta Network for Rare Diseases, Department of Rare, Immunologic, Hematologic and Immunohematologic Diseases, and SCDU Nephrology and Dialysis, S. Giovanni Bosco Hospital
| | - Savino Sciascia
- Center of Research of Immunopathology and Rare Diseases- Coordinating Center of Piemonte and Valle d’Aosta Network for Rare Diseases, Department of Rare, Immunologic, Hematologic and Immunohematologic Diseases, and SCDU Nephrology and Dialysis, S. Giovanni Bosco Hospital
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Beyond pan-B-cell-directed therapy - new avenues and insights into the pathogenesis of SLE. Nat Rev Rheumatol 2016; 12:645-657. [PMID: 27733759 DOI: 10.1038/nrrheum.2016.158] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
New insights into the mechanisms of autoimmune diseases have been obtained not only from preclinical studies, but also from clinical trials of pan-B-cell-directed therapy. Overall, the results of these clinical trials suggest that more-specific approaches focusing on pathogenic B-cell functions, and perhaps sparing or even enhancing regulatory B-cell activity, might be attractive alternatives. Importantly, pathogenic B-cell subpopulations function within a network of cellular interactions, many of which might require additional interventions to restore immunologic balance and suppress autoimmune disease. Thus, approaches that simultaneously target innate immune cells as well as multiple nodes of T-cell and B-cell interactions might hold the promise of improved therapeutic efficacy. Interfering with B-cell intracellular signalling pathways, altering their intracellular metabolic pathways and perturbing transcription factors are additional options. This Review critically analyses these approaches, examines the role of cytokines and other functions of B-lineage cells separate from antibody secretion, and provides insights into the potential next generation of therapies targeting B-lineage cells.
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Mahieu MA, Strand V, Simon LS, Lipsky PE, Ramsey-Goldman R. A critical review of clinical trials in systemic lupus erythematosus. Lupus 2016; 25:1122-40. [PMID: 27497257 PMCID: PMC4978143 DOI: 10.1177/0961203316652492] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
One challenge in caring for patients with systemic lupus erythematosus (SLE) is a paucity of approved therapeutics for treatment of the diverse disease manifestations. In the last 60 years, only one drug, belimumab, has been approved for SLE treatment. Critical evaluation of investigator initiated and pharma-sponsored randomized controlled trials (RCTs) highlights barriers to successful drug development in SLE, including disease heterogeneity, inadequate trial size or duration, insufficient dose finding before initiation of large trials, handling of background medications, and choice of primary endpoint. Herein we examine lessons learned from landmark SLE RCTs and subsequent advances in trial design, as well as discuss efforts to address limitations in current SLE outcome measures that will improve detection of true therapeutic responses in future RCTs.
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Affiliation(s)
- M A Mahieu
- Department of Medicine, Division of Rheumatology, Northwestern University Feinberg School of Medicine, Chicago, USA
| | - V Strand
- Division of Immunology/Rheumatology, Stanford University School of Medicine, Palo Alto, USA
| | | | - P E Lipsky
- AMPEL BioSolutions, Charlottesville, USA
| | - R Ramsey-Goldman
- Department of Medicine, Division of Rheumatology, Northwestern University Feinberg School of Medicine, Chicago, USA
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Immune checkpoints and rheumatic diseases: what can cancer immunotherapy teach us? Nat Rev Rheumatol 2016; 12:593-604. [DOI: 10.1038/nrrheum.2016.131] [Citation(s) in RCA: 74] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Wallace DJ, Hobbs K, Clowse MEB, Petri M, Strand V, Pike M, Merrill JT, Leszczyński P, Neuwelt CM, Jeka S, Houssiau F, Keiserman M, Ordi-Ros J, Bongardt S, Kilgallen B, Galateanu C, Kalunian K, Furie R, Gordon C. Long-Term Safety and Efficacy of Epratuzumab in the Treatment of Moderate-to- Severe Systemic Lupus Erythematosus: Results From an Open-Label Extension Study. Arthritis Care Res (Hoboken) 2016; 68:534-43. [PMID: 26316325 DOI: 10.1002/acr.22694] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Revised: 07/17/2015] [Accepted: 08/11/2015] [Indexed: 12/20/2022]
Abstract
OBJECTIVE The primary objective was to assess the long-term safety of repeated courses of epratuzumab therapy in patients with moderate-to-severe systemic lupus erythematosus. Secondary objectives were to assess long-term efficacy and health-related quality of life (HRQOL). METHODS Eligible patients from the 12-week, phase IIb, randomized, placebo-controlled EMBLEM study enrolled into the open-label extension (OLE) study, SL0008. In the SL0008 study, patients received 1,200 mg epratuzumab infusions at weeks 0 and 2 of repeating 12-week cycles, plus standard of care. Safety measures included treatment-emergent adverse events (TEAEs) and serious TEAEs. Efficacy measures included combined treatment response, the British Isles Lupus Assessment Group score, the Systemic Lupus Erythematosus Disease Activity Index score, and the physician's and patient's global assessment of disease activity. Total daily corticosteroid dose and HRQOL (by the Short Form 36 health survey) were also assessed. RESULTS A total of 113 of the 203 patients (55.7%) who entered the SL0008 study continued epratuzumab therapy until study closure (total cumulative exposure: 381.3 patient-years, median exposure: 845 days, and maximum exposure: 1,185 days/approximately 3.2 years). TEAEs were reported in 192 patients (94.6%); most common were infections and infestations (68.0%, 138 patients). Serious TEAEs were reported in 51 patients (25.1%), and 14 patients (6.9%) had serious infections. In patients treated for 108 weeks (n = 116), the median corticosteroid dose was reduced from 10.0 mg/day at OLE screening to 5.0 mg/day at week 108. Improvements in efficacy and HRQOL measures in EMBLEM were maintained in the OLE, while placebo patients exhibited similar improvements in disease activity upon a switch to epratuzumab. CONCLUSION Open-label epratuzumab treatment was well tolerated for up to 3.2 years, and associated with sustained improvements in disease activity and HRQOL, while steroids were reduced.
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Affiliation(s)
- D J Wallace
- Cedars-Sinai Medical Center, Los Angeles, California
| | - K Hobbs
- Denver Arthritis Clinic, Denver, Colorado
| | - M E B Clowse
- Duke University Medical Center, Durham, North Carolina
| | - M Petri
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - V Strand
- Biopharmaceutical Consultant, Portola Valley, California
| | - M Pike
- MedPharm Consulting, Inc., Cambridge, Massachusetts
| | - J T Merrill
- Oklahoma Medical Research Foundation, University of Oklahoma Health Sciences Center, Oklahoma City
| | - P Leszczyński
- Poznan University of Medical Sciences, Poznan, Poland
| | - C M Neuwelt
- Alameda County Health System, Oakland, California
| | - S Jeka
- Clinic of Rheumatology and Connective Tissue Diseases, 2nd University Hospital, CM UMK, Bydgoszcz, Poland
| | - F Houssiau
- Clinique Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - M Keiserman
- Pontifical Catholic University, School of Medicine, Porto Alegre, Brazil
| | - J Ordi-Ros
- Universitari Vall d'Hebron, Barcelona, Spain
| | | | | | | | - K Kalunian
- University of California San Diego School of Medicine, La Jolla
| | - R Furie
- North Shore-Long Island Jewish Health System, New York, New York
| | - C Gordon
- School of Immunity and Infection, College of Medical and Dental Sciences, University of Birmingham, and NIHR/Wellcome Trust Clinical Research Facility, University Hospital Birmingham NHS Foundation Trust, Birmingham, UK
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Medina-Rosas J, Al-Rayes H, Moustafa AT, Touma Z. Recent advances in the biologic therapy of lupus: the 10 most important areas to look for common pitfalls in clinical trials. Expert Opin Biol Ther 2016; 16:1225-38. [PMID: 27429254 DOI: 10.1080/14712598.2016.1214263] [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] [Indexed: 12/22/2022]
Abstract
INTRODUCTION Systemic lupus erythematosus (SLE) is an autoimmune disease affecting different organs. The improved knowledge of the disease's pathogenesis has contributed to the emergence of immune targets and new biologic drugs directed at them. Although rheumatologists continue to use off-label biologics in SLE resistant to other immunosuppressants, only belimumab has been approved as a biological therapy since 2011. AREAS COVERED In this review, an overview is provided on: 1) the classification of the biologic drugs in clinical trials and of those under research; 2) the results of clinical trials of biologic therapy with an interpretation of pitfalls and syntheses of potential approaches to overcome these pitfalls and, 3) the commonly used disease activity metrics and composite indices for assessing response to drugs. EXPERT OPINION Some drugs that have failed in previous drug trials have shown to be efficacious in the treatment of lupus in observational studies. Moreover, the post-hoc analyses of the data of negative drug trials have shown that results of the same trials could be altered with the modification of some pitfalls. For future clinical trials, the consideration of these pitfalls is crucial when designing clinical trials. This could potentially enhance the approval of novel drugs for SLE.
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Affiliation(s)
- Jorge Medina-Rosas
- a Toronto Western Hospital, Centre for Prognosis Studies in the Rheumatic Diseases , University of Toronto Lupus Clinic , Toronto , Canada
| | - Hanan Al-Rayes
- a Toronto Western Hospital, Centre for Prognosis Studies in the Rheumatic Diseases , University of Toronto Lupus Clinic , Toronto , Canada
| | - Ahmed T Moustafa
- a Toronto Western Hospital, Centre for Prognosis Studies in the Rheumatic Diseases , University of Toronto Lupus Clinic , Toronto , Canada
| | - Zahi Touma
- a Toronto Western Hospital, Centre for Prognosis Studies in the Rheumatic Diseases , University of Toronto Lupus Clinic , Toronto , Canada
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Gatto M, Saccon F, Zen M, Bettio S, Iaccarino L, Punzi L, Doria A. Success and failure of biological treatment in systemic lupus erythematosus: A critical analysis. J Autoimmun 2016; 74:94-105. [PMID: 27373904 DOI: 10.1016/j.jaut.2016.06.014] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Accepted: 06/23/2016] [Indexed: 11/26/2022]
Abstract
Patients affected with systemic lupus erythematosus (SLE) still display increased mortality and decreased quality of life in respect to general population. The major determinant of poor long term prognosis is organ damage, which is predictive of more damage and death. Damage is in turn triggered by uncontrolled disease activity and especially by the long-standing corticosteroid use which often accompanies SLE patients over their disease course, owing both to the need of reaching disease remission and to the habit of keeping patients on a small steroid dose for an indefinite period of time. Hence, the need for new drugs and therapeutic strategies aiming at minimizing damage accrual through a better control of disease activity and a steroid-sparing potential is paramount. So far, however, the therapeutic strategy in SLE requires a multitarget approach which is not devoid of widespread immunesuppression. In fact, several studies have been carried out in recent years targeting both the adaptive and the innate immune system, the majority of which did not achieve their primary endpoint, being often divergent from successful clinical experience and thereby committing physician to off-label use of targeted therapies in face of refractory SLE manifestations. The study designs and the chosen endpoints were often blamed for inadequacy, being at least in part responsible for study failures. In this review, we go over major clinical trials conducted in SLE by analyzing any critical aspects related to study design, predefined endpoints and biological activity of novel compounds that may have hampered study outcome, despite the great effort of providing less toxic drugs within a targeted, pathogenic-based approach.
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Affiliation(s)
- Mariele Gatto
- Division of Rheumatology, Department of Medicine, University of Padova, Via Giustiniani 2, 35123, Padova, Italy
| | - Francesca Saccon
- Division of Rheumatology, Department of Medicine, University of Padova, Via Giustiniani 2, 35123, Padova, Italy
| | - Margherita Zen
- Division of Rheumatology, Department of Medicine, University of Padova, Via Giustiniani 2, 35123, Padova, Italy
| | - Silvano Bettio
- Division of Rheumatology, Department of Medicine, University of Padova, Via Giustiniani 2, 35123, Padova, Italy
| | - Luca Iaccarino
- Division of Rheumatology, Department of Medicine, University of Padova, Via Giustiniani 2, 35123, Padova, Italy
| | - Leonardo Punzi
- Division of Rheumatology, Department of Medicine, University of Padova, Via Giustiniani 2, 35123, Padova, Italy
| | - Andrea Doria
- Division of Rheumatology, Department of Medicine, University of Padova, Via Giustiniani 2, 35123, Padova, Italy.
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Durcan L, Petri M. Immunomodulators in SLE: Clinical evidence and immunologic actions. J Autoimmun 2016; 74:73-84. [PMID: 27371107 DOI: 10.1016/j.jaut.2016.06.010] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Revised: 06/16/2016] [Accepted: 06/21/2016] [Indexed: 01/08/2023]
Abstract
Systemic lupus erythematosus (SLE) is a potentially fatal autoimmune disease. Current treatment strategies rely heavily on corticosteroids, which are in turn responsible for a significant burden of morbidity, and immunosuppressives which are limited by suboptimal efficacy, increased infections and malignancies. There are significant deficiencies in our immunosuppressive armamentarium, making immunomodulatory therapies crucial, offering the opportunity to prevent disease flare and the subsequent accrual of damage. Currently available immunomodulators include prasterone (synthetic dehydroeipandrosterone), vitamin D, hydroxychloroquine and belimumab. These therapies, acting via numerous cellular and cytokine pathways, have been shown to modify the aberrant immune responses associated with SLE without overt immunosuppression. Vitamin D is important in SLE and supplementation appears to have a positive impact on disease activity particularly proteinuria. Belimumab has specific immunomodulatory properties and is an effective therapy in those with specific serological and clinical characteristics predictive of response. Hydroxychloroquine is a crucial background medication in SLE with actions in many molecular pathways. It has disease specific effects in reducing flare, treating cutaneous disease and inflammatory arthralgias in addition to other effects such as reduced thrombosis, increased longevity, improved lipids, better glycemic control and blood pressure. Dehydroeipandrosterone is also an immunomodulator in SLE which can have positive effects on disease activity and has bone protective properties. This review outlines the immunologic actions of these drugs and the clinical evidence supporting their use.
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Affiliation(s)
- L Durcan
- Division of Rheumatology, University of Washington, Seattle, USA.
| | - M Petri
- Division of Rheumatology, Johns Hopkins University, School of Medicine, Baltimore, USA
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Bruce IN, Urowitz M, van Vollenhoven R, Aranow C, Fettiplace J, Oldham M, Wilson B, Molta C, Roth D, Gordon D. Long-term organ damage accrual and safety in patients with SLE treated with belimumab plus standard of care. Lupus 2016; 25:699-709. [PMID: 26936891 PMCID: PMC4958991 DOI: 10.1177/0961203315625119] [Citation(s) in RCA: 72] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Accepted: 12/01/2015] [Indexed: 01/31/2023]
Abstract
OBJECTIVE To examine long-term organ damage and safety following treatment with belimumab plus standard of care (SoC) in patients with systemic lupus erythematosus (SLE). METHODS Pooled data were examined from two ongoing open-label studies that enrolled patients who completed BLISS-52 or BLISS-76. Patients received belimumab every four weeks plus SoC. SLICC Damage Index (SDI) values were assessed every 48 weeks (study years) following belimumab initiation (baseline). The primary endpoint was change in SDI from baseline at study years 5-6. Incidences of adverse events (AEs) were reported for the entire study period. RESULTS The modified intent-to-treat (MITT) population comprised 998 patients. At baseline, 940 (94.2%) were female, mean (SD) age was 38.7 (11.49) years, and disease duration was 6.7 (6.24) years. The mean (SD) SELENA-SLEDAI and SDI scores were 8.2 (4.18) and 0.7 (1.19), respectively; 411 (41.2%) patients had organ damage (SDI = 1: 235 (23.5%); SDI ≥ 2: 176 (17.6%)) prior to belimumab. A total of 427 (42.8%) patients withdrew overall; the most common reasons were patient request (16.8%) and AEs (8.5%).The mean (SD) change in SDI was +0.2 (0.48) at study years 5-6 (n = 403); 343 (85.1%) patients had no change from baseline in SDI score (SDI +1: 46 (11.4%), SDI +2: 13 (3.2%), SDI +3: 1 (0.2%)). Of patients without organ damage at baseline, 211/241 (87.6%) had no change in SDI and the mean change (SD) in SDI was +0.2 (0.44). Of patients with organ damage at baseline, 132/162 (81.5%) had no change in SDI and the mean (SD) change in SDI was +0.2 (0.53). The probability of not having a worsening in SDI score was 0.88 (95% CI: 0.85, 0.91) and 0.75 (0.67, 0.81) in those without and with baseline damage, respectively (post hoc analysis).Drug-related AEs were reported for 433 (43.4%) patients; infections/infestations (282, 28.3%) and gastrointestinal disorders (139, 13.9%) were the most common. CONCLUSION Patients with SLE treated with long-term belimumab plus SoC had a low incidence of organ damage accrual and no unexpected AEs. High-risk patients with pre-existing organ damage also had low accrual, suggesting a favorable effect on future damage development.
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Affiliation(s)
- I N Bruce
- Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal Research, Institute for Inflammation and Repair, University of Manchester, Manchester Academic Health Sciences Centre, Manchester, UK The Kellgren Centre for Rheumatology, NIHR Manchester Musculoskeletal Biomedical Research Unit, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - M Urowitz
- University of Toronto and Toronto Western Hospital, Toronto, ON, Canada
| | | | - C Aranow
- The Feinstein Institute for Medical Research, Manhasset, NY, USA
| | | | - M Oldham
- GSK, Stevenage, Hertfordshire, UK
| | - B Wilson
- GSK, Research Triangle Park, NC, USA
| | | | - D Roth
- GSK, Philadelphia, PA, USA
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Abstract
Systemic lupus erythematosus (SLE) is a rare, severe, multisystem autoimmune disorder. Childhood-onset SLE (cSLE) follows a more aggressive course with greater associated morbidity and mortality than adult-onset SLE. Its aetiology is yet to be fully elucidated. It is recognised to be the archetypal systemic autoimmune disease, arising from a complex interaction between the innate and adaptive immune systems. Its complexity is reflected by the fact that there has been only one new drug licensed for use in SLE in the last 50 years. However, biologic agents that specifically target aspects of the immune system are emerging. Immunosuppression remains the cornerstone of medical management, with glucocorticoids still playing a leading role. Treatment choices are led by disease severity. Immunosuppressants, including azathioprine and methotrexate, are used in mild to moderate manifestations. Mycophenolate mofetil is widely used for lupus nephritis. Cyclophosphamide remains the first-line treatment for patients with severe organ disease. No biologic therapies have yet been approved for cSLE, although they are being used increasingly as part of routine care of patients with severe lupus nephritis or with neurological and/or haematological involvement. Drugs influencing B cell survival, including belimumab and rituximab, are currently undergoing clinical trials in cSLE. Hydroxychloroquine is indicated for disease manifestations of all severities and can be used as monotherapy in mild disease. However, the management of cSLE is hampered by the lack of a robust evidence base. To date, it has been principally guided by best-practice guidelines, retrospective case series and adapted adult protocols. In this pharmacological review, we provide an overview of current practice for the management of cSLE, together with recent advances in new therapies, including biologic agents.
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