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Bhol NK, Bhanjadeo MM, Singh AK, Dash UC, Ojha RR, Majhi S, Duttaroy AK, Jena AB. The interplay between cytokines, inflammation, and antioxidants: mechanistic insights and therapeutic potentials of various antioxidants and anti-cytokine compounds. Biomed Pharmacother 2024; 178:117177. [PMID: 39053423 DOI: 10.1016/j.biopha.2024.117177] [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: 05/17/2024] [Revised: 07/03/2024] [Accepted: 07/22/2024] [Indexed: 07/27/2024] Open
Abstract
Cytokines regulate immune responses essential for maintaining immune homeostasis, as deregulated cytokine signaling can lead to detrimental outcomes, including inflammatory disorders. The antioxidants emerge as promising therapeutic agents because they mitigate oxidative stress and modulate inflammatory pathways. Antioxidants can potentially ameliorate inflammation-related disorders by counteracting excessive cytokine-mediated inflammatory responses. A comprehensive understanding of cytokine-mediated inflammatory pathways and the interplay with antioxidants is paramount for developing natural therapeutic agents targeting inflammation-related disorders and helping to improve clinical outcomes and enhance the quality of life for patients. Among these antioxidants, curcumin, vitamin C, vitamin D, propolis, allicin, and cinnamaldehyde have garnered attention for their anti-inflammatory properties and potential therapeutic benefits. This review highlights the interrelationship between cytokines-mediated disorders in various diseases and therapeutic approaches involving antioxidants.
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Affiliation(s)
- Nitish Kumar Bhol
- Post Graduate Department of Biotechnology, Utkal University, Bhubaneswar, Odisha 751004, India
| | | | - Anup Kumar Singh
- National Centre for Cell Science, Savitribai Phule Pune University Campus, Ganeshkhind, Pune, India
| | - Umesh Chandra Dash
- Environmental Biotechnology Laboratory, KIIT School of Biotechnology, KIIT Deemed to be University, Bhubaneswar, Odisha, India
| | - Rakesh Ranjan Ojha
- Department of Bioinformatics, BJB (A) College, Bhubaneswar, Odisha-751014, India
| | - Sanatan Majhi
- Post Graduate Department of Biotechnology, Utkal University, Bhubaneswar, Odisha 751004, India
| | - Asim K Duttaroy
- Department of Nutrition, Institute of Medical Sciences, Faculty of Medicine, University of Oslo, Norway.
| | - Atala Bihari Jena
- National Centre for Cell Science, Savitribai Phule Pune University Campus, Ganeshkhind, Pune, India.
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Hu J, Wang J, Wang Z. The efficacy and safety of chidamide in combination with etoposide and glucocorticoids for the treatment of hemophagocytic lymphohistiocytosis in adult patients: an open-label, single-center study. Front Immunol 2024; 15:1415597. [PMID: 39040100 PMCID: PMC11260630 DOI: 10.3389/fimmu.2024.1415597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2024] [Accepted: 06/26/2024] [Indexed: 07/24/2024] Open
Abstract
Background Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening condition characterized by hyperinflammation and organ failure, with a high mortality rate. Current first-line treatments for adult patients have limited efficacy and significant toxicity. The novel selective histone deacetylase inhibitor (HDACi), chidamide, has shown promise in preclinical studies for the potential treatment of HLH. Methods An open-label, single-center study was conducted to evaluate the efficacy and safety of chidamide in combination with etoposide and glucocorticoids for the treatment of HLH in adult patients. Seventeen patients who fulfilled at least five of the eight HLH-2004 criteria were enrolled and treated with the combination therapy. The primary outcome was overall response rate (ORR), and secondary outcomes included survival, safety and tolerability, and changes in laboratory indicators. Results A total of 17 HLH patients who met the inclusion criteria were enrolled in this study, with a male to female ratio of 1.8:1. The age range at enrollment was 31 to 71 years old, with a median age of 52 years old. The ORR was 76.5% (13/17 patients), with a complete response (CR) rate of 17.6% (3/17 patients) and a partial response (PR) rate of 58.8% (10/17 patients). The median overall survival (OS) was not achieved, with OS at 6 months and 12 months being 81% and 65%, respectively. The median progression free survival (PFS) was not achieved, with PFS at 6 months and 12 months being 68% and 55%, respectively. Hematologic toxicities is the most common. Safety profile was favorable, with very few cases of grade 3/4 toxicities observed. The results showed that the levels of sCD25, platelets, aspartate aminotransferase, lactate dehydrogenase, and albumin in these patients were significantly improved 3 weeks after treatment. Conclusion The addition of chidamide to etoposide and glucocorticoids may be a promising new treatment option for patients with HLH, with a high ORR, manageable safety profile, and significant improvement in laboratory indicators. Further research is needed to confirm these findings and determine the optimal dosing and duration of therapy.
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Affiliation(s)
| | | | - Zhao Wang
- Department of Hematology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
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Liang L, Wang B, Zhang Q, Zhang S, Zhang S. Antibody drugs targeting SARS-CoV-2: Time for a rethink? Biomed Pharmacother 2024; 176:116900. [PMID: 38861858 DOI: 10.1016/j.biopha.2024.116900] [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: 02/14/2024] [Revised: 04/20/2024] [Accepted: 06/06/2024] [Indexed: 06/13/2024] Open
Abstract
The coronavirus disease 2019 (COVID-19) pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) heavily burdens human health. Multiple neutralizing antibodies (nAbs) have been issued for emergency use or tested for treating infected patients in the clinic. However, SARS-CoV-2 variants of concern (VOC) carrying mutations reduce the effectiveness of nAbs by preventing neutralization. Uncoding the mutation profile and immune evasion mechanism of SARS-CoV-2 can improve the outcome of Ab-mediated therapies. In this review, we first outline the development status of anti-SARS-CoV-2 Ab drugs and provide an overview of SARS-CoV-2 variants and their prevalence. We next focus on the failure causes of anti-SARS-CoV-2 Ab drugs and rethink the design strategy for developing new Ab drugs against COVID-19. This review provides updated information for the development of therapeutic Ab drugs against SARS-CoV-2 variants.
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Affiliation(s)
- Likeng Liang
- Department of Cell Biology, School of Medicine, Nankai University, Tianjin 300071, China
| | - Bo Wang
- Department of Cell Biology, School of Medicine, Nankai University, Tianjin 300071, China
| | - Qing Zhang
- Department of Laboratory Medicine, Tianjin Medical University Cancer Institute and Hospital, Tianjin 300060, China
| | - Shiwu Zhang
- Department of Pathology, Tianjin Union Medical Center, Nankai University, Tianjin 300121, China
| | - Sihe Zhang
- Department of Cell Biology, School of Medicine, Nankai University, Tianjin 300071, China.
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Brossard P, Laveille C. Population Pharmacokinetics of the Anti-Interferon-Gamma Monoclonal Antibody Emapalumab: An Updated Analysis. Rheumatol Ther 2024; 11:869-880. [PMID: 38662147 PMCID: PMC11111609 DOI: 10.1007/s40744-024-00669-y] [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: 02/01/2024] [Accepted: 03/22/2024] [Indexed: 04/26/2024] Open
Abstract
INTRODUCTION Emapalumab is a fully human monoclonal antibody that targets free and receptor-bound interferon-gamma (IFNγ), neutralizing its biological activity. IFNγ levels differ by orders of magnitude between patients with primary hemophagocytic lymphohistiocytosis (HLH) and macrophage activation syndrome (MAS; a form of secondary HLH) in systemic juvenile idiopathic arthritis (sJIA). Therefore, this study aimed to develop a population pharmacokinetic model for emapalumab across a patient population with a wide range of total (free and emapalumab-bound) IFNγ levels using observations from patients with primary HLH or MAS in sJIA in clinical trials. METHODS Pharmacokinetic data were pooled (n = 58; 2709 observations) from studies enrolling patients administered emapalumab for primary HLH or MAS in sJIA. Patients with primary HLH were administered emapalumab 1 mg/kg (potentially increasing to 3, 6, and up to 10 mg/kg based on clinical response) every 3 days. Patients with MAS in sJIA were administered emapalumab 6 mg/kg, followed by 3 mg/kg every 3 days until day 15 and twice weekly until day 28. An earlier population PK model was re-parameterized using this data. RESULTS The final model for emapalumab comprised a 2-compartment model with first-order elimination. Emapalumab clearance remains constant when the total IFNγ concentration (free and emapalumab-bound) is < ~ 10,000 pg/ml but increases proportionally to total IFNγ concentration above this threshold. Emapalumab clearance was estimated to be 0.00218, 0.00308, 0.00623 and 0.01718 l/h at total serum IFNγ concentrations of 103, 104, 105 and 106 pg/ml, respectively, with corresponding terminal half-lives of 19.2, 13.8, 7.18 and 3.12 days for a 1-year-old patient weighing 10 kg with primary HLH. The median terminal half-life for emapalumab in patients with MAS in sJIA was estimated to be 24.0 (range, 6.13-32.4) days, which is similar to observations in healthy volunteers. CONCLUSIONS Emapalumab pharmacokinetics in patients with primary HLH and MAS in sJIA were described by a two-compartment model with fixed allometric exponents and an age-related effect. Differences in total IFNγ levels between patients with primary HLH and MAS may affect emapalumab pharmacokinetics, suggesting that each indication may require different dosing to rapidly control hyperinflammation. TRIAL REGISTRATION Clinicaltrials.gov identifiers: NCT01818492, NCT03311854 and NCT02069899.
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Chandrakasan S, Jordan MB, Baker A, Behrens EM, Bhatla D, Chien M, Eckstein OS, Henry MM, Hermiston ML, Hinson AP, Leiding JW, Oladapo A, Patel SA, Pednekar P, Ray AK, Dávila Saldaña B, Sarangi SN, Walkovich KJ, Yee JD, Zoref-Lorenz A, Allen CE. Real-world treatment patterns and outcomes in patients with primary hemophagocytic lymphohistiocytosis treated with emapalumab. Blood Adv 2024; 8:2248-2258. [PMID: 38429096 PMCID: PMC11117018 DOI: 10.1182/bloodadvances.2023012217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 01/19/2024] [Accepted: 02/09/2024] [Indexed: 03/03/2024] Open
Abstract
ABSTRACT Hemophagocytic lymphohistiocytosis (HLH) is a rare, life-threatening, hyperinflammatory syndrome. Emapalumab, a fully human monoclonal antibody that neutralizes the proinflammatory cytokine interferon gamma, is approved in the United States to treat primary HLH (pHLH) in patients with refractory, recurrent, or progressive disease, or intolerance with conventional HLH treatments. REAL-HLH, a retrospective study, conducted across 33 US hospitals, evaluated real-world treatment patterns and outcomes in patients treated with ≥1 dose of emapalumab between 20 November 2018 and 31 October 2021. In total, 46 patients met the pHLH classification criteria. Median age at diagnosis was 1.0 year (range, 0.3-21.0). Emapalumab was initiated for treating refractory (19/46), recurrent (14/46), or progressive (7/46) pHLH. At initiation, 15 of 46 patients were in the intensive care unit, and 35 of 46 had received prior HLH-related therapies. Emapalumab treatment resulted in normalization of key laboratory parameters, including chemokine ligand 9 (24/33, 72.7%), ferritin (20/45, 44.4%), fibrinogen (37/38, 97.4%), platelets (39/46, 84.8%), and absolute neutrophil count (40/45, 88.9%). Forty-two (91.3%) patients were considered eligible for transplant. Pretransplant survival was 38 of 42 (90.5%). Thirty-one (73.8%) transplant-eligible patients proceeded to transplant, and 23 of 31 (74.2%) of those who received transplant were alive at the end of the follow-up period. Twelve-month survival probability from emapalumab initiation for the entire cohort (N = 46) was 73.1%. There were no discontinuations because of adverse events. In conclusion, results from the REAL-HLH study, which describes treatment patterns, effectiveness, and outcomes in patients with pHLH treated with emapalumab in real-world settings, are consistent with the emapalumab pivotal phase 2/3 pHLH trial.
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Affiliation(s)
- Shanmuganathan Chandrakasan
- Division of Bone Marrow Transplant, Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Emory University, Atlanta, GA
| | - Michael B. Jordan
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Ashley Baker
- Department of Pediatrics, Division of Hematology Oncology, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Edward M. Behrens
- Division of Rheumatology, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Deepika Bhatla
- Department of Pediatric Hematology Oncology, Saint Louis University, St. Louis, MO
| | - May Chien
- Department of Hematology-Oncology, Lucile Packard Children's Hospital at Stanford University, Palo Alto, CA
| | - Olive S. Eckstein
- Division of Pediatric Hematology and Oncology, Baylor College of Medicine, Houston, TX
| | - Michael M. Henry
- Department of Pediatric Hematology-Oncology, Phoenix Children’s, Phoenix, AZ
| | - Michelle L. Hermiston
- Department of Pediatric Hematology-Oncology, University of California San Francisco, San Francisco, CA
| | - Ashley P. Hinson
- Department of Pediatric Hematology-Oncology, Atrium Health, Levine Children's Hospital, Charlotte, NC
| | - Jennifer W. Leiding
- Division of Allergy and Immunology, Department of Pediatrics, Johns Hopkins University, Baltimore, MD
| | | | - Sachit A. Patel
- Department of Pediatrics, University of Nebraska Medical Center, Omaha, NE
| | | | - Anish K. Ray
- Department of Pediatric Hematology-Oncology, Cook Children's Medical Center, Fort Worth, TX
| | - Blachy Dávila Saldaña
- Division of Blood and Marrow Transplantation, Children's National Medical Center, Washington, DC
| | - Susmita N. Sarangi
- Department of Pediatric Hematology-Oncology, MedStar Georgetown University Hospital, Washington, DC
| | - Kelly J. Walkovich
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, University of Michigan Medical School, Ann Arbor, MI
| | | | - Adi Zoref-Lorenz
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
- Division of Hematology, Hematology Institute, Meir Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Carl E. Allen
- Division of Pediatric Hematology and Oncology, Baylor College of Medicine, Houston, TX
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Jordan MB. Hemophagocytic lymphohistiocytosis: A disorder of T cell activation, immune regulation, and distinctive immunopathology. Immunol Rev 2024; 322:339-350. [PMID: 38100247 DOI: 10.1111/imr.13298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2023]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a disorder that has been recognized since the middle of the last century. In recent decades, increasing understanding of the genetic roots and pathophysiology of HLH has led to improved diagnosis and treatment of this once universally fatal disorder. HLH is best conceptualized as a maladaptive state of excessive T cell activation driving life-threatening myeloid cell activation, largely via interferon-gamma (IFN-γ). In familial forms of HLH (F-HLH), inherited defects of lymphocyte cytotoxic biology underlie excessive T cell activation, demonstrating the importance of the perforin/granzyme pathway as a negative feedback loop limiting acute T cell activation in response to environmental factors. HLH occurring in other contexts and without apparent inherited genetic predisposition remains poorly understood, though it may share some downstream aspects of pathophysiology including excessive IFN-γ action and activation of innate immune effectors. Iatrogenic forms of HLH occurring after immune-activating therapies for cancer are providing new insights into the potential toxicities of inadequately controlled T cell activation. Diagnosing HLH increasingly relies on context-specific measures of T cell activation, IFN-γ activity, and inflammation. Treatment of HLH largely relies on cytotoxic chemotherapy, though targeted therapies against T cells, IFN-γ, and other cytokines are increasingly utilized.
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Affiliation(s)
- Michael B Jordan
- Division of Immunobiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Division of Bone Marrow Transplantation and Immune Deficiency, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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Jordan MB, Locatelli F. Exposure-safety relationship for patients with primary hemophagocytic lymphohistiocytosis treated with emapalumab. Pediatr Blood Cancer 2024; 71:e30778. [PMID: 38014905 DOI: 10.1002/pbc.30778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 11/06/2023] [Accepted: 11/08/2023] [Indexed: 11/29/2023]
Abstract
Primary hemophagocytic lymphohistiocytosis (pHLH) is an immune-mediated, hyperinflammatory disorder. Interferon-γ (IFNγ) plays a key role in the pathophysiology of pHLH. Emapalumab, a fully human, anti-IFNγ monoclonal antibody neutralizes both free and receptor-bound IFNγ. However, inhibiting IFNγ-mediated signaling could result in immune dysfunction and immunosuppression. This exploratory exposure-safety analysis investigated the relationship between emapalumab and the incidence of adverse events in patients with pHLH. Increased exposure to emapalumab was not associated with an increased predicted risk of severe adverse events, infection, or infusion-related reactions. Emapalumab was associated with a favorable and manageable safety profile across all assessed doses and treatment durations.
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Affiliation(s)
- Michael B Jordan
- Divisions of Immunobiology and Bone Marrow Transplantation and Immune Deficiency, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Franco Locatelli
- IRCCS, Ospedale Pediatrico Bambino Gesù, Catholic University of the Sacred Heart, Rome, Italy
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Hahn TJ, McKeone DJ, Beal JW, Ericson JE, Halstead ES. Case Report: Successful avoidance of etoposide for primary hemophagocytic lymphohistiocytosis-induced multiple organ dysfunction syndrome using emapalumab. Front Pediatr 2024; 11:1340360. [PMID: 38304439 PMCID: PMC10830683 DOI: 10.3389/fped.2023.1340360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 12/18/2023] [Indexed: 02/03/2024] Open
Abstract
We describe the case of an infant who presented with simple rhinovirus/enterovirus bronchiolitis whose condition worsened with rapid progression to multiple organ dysfunction syndrome (MODS). The patient was presumed to have either primary or secondary hemophagocytic lymphohistiocytosis (HLH), and treatment was initiated using dexamethasone, anakinra, and intravenous immunoglobulin to modulate the immune system. Due to the organ dysfunction, the use of etoposide was avoided and instead, emapalumab, an interferon gamma antagonist, was administered at a dose of 6 mg/kg. The patient's organ failure improved, and the levels of inflammatory markers decreased. The flow cytometry analysis revealed that cytotoxic cells lacked perforin expression, and subsequent genetic analysis confirmed homozygous pathogenic mutations in the perforin gene. This case highlights the potential avoidance of etoposide in cases of primary HLH, the possible benefit of an elevated initial dose of emapalumab, and the contribution offered by a multi-specialty team approach to complex diagnosis.
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Affiliation(s)
- Timothy J. Hahn
- Division of Pediatric Rheumatology, Department of Pediatrics, Penn State University College of Medicine, Hershey, PA, United States
- Dysregulated Immune Response Team (DIRT), Department of Pediatrics, Penn State University College of Medicine, Hershey, PA, United States
| | - Daniel J. McKeone
- Dysregulated Immune Response Team (DIRT), Department of Pediatrics, Penn State University College of Medicine, Hershey, PA, United States
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Penn State University College of Medicine, Hershey, PA, United States
| | - James W. Beal
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Penn State University College of Medicine, Hershey, PA, United States
| | - Jessica E. Ericson
- Dysregulated Immune Response Team (DIRT), Department of Pediatrics, Penn State University College of Medicine, Hershey, PA, United States
- Division of Pediatric Infectious Disease, Department of Pediatrics, Penn State University College of Medicine, Hershey, PA, United States
| | - E. Scott Halstead
- Dysregulated Immune Response Team (DIRT), Department of Pediatrics, Penn State University College of Medicine, Hershey, PA, United States
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Penn State University College of Medicine, Hershey, PA, United States
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Ahmed MA, Burnham J, Dwivedi G, AbuAsal B. Achieving big with small: quantitative clinical pharmacology tools for drug development in pediatric rare diseases. J Pharmacokinet Pharmacodyn 2023; 50:429-444. [PMID: 37140724 DOI: 10.1007/s10928-023-09863-x] [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: 03/04/2023] [Accepted: 04/26/2023] [Indexed: 05/05/2023]
Abstract
Pediatric populations represent a major fraction of rare diseases and compound the intrinsic challenges of pediatric drug development and drug development for rare diseases. The intertwined complexities of pediatric and rare disease populations impose unique challenges to clinical pharmacologists and require integration of novel clinical pharmacology and quantitative tools to overcome multiple hurdles during the discovery and development of new therapies. Drug development strategies for pediatric rare diseases continue to evolve to meet the inherent challenges and produce new medicines. Advances in quantitative clinical pharmacology research have been a key component in advancing pediatric rare disease research to accelerate drug development and inform regulatory decisions. This article will discuss the evolution of the regulatory landscape in pediatric rare diseases, the challenges encountered during the design of rare disease drug development programs and will highlight the use of innovative tools and potential solutions for future development programs.
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Affiliation(s)
- Mariam A Ahmed
- Takeda Development Center Americas Inc, 125 Binney St, Cambridge, MA, 02142-1123, USA.
| | | | - Gaurav Dwivedi
- Takeda Development Center Americas Inc, 125 Binney St, Cambridge, MA, 02142-1123, USA
| | - Bilal AbuAsal
- US Food and Drug Administration, 10903, New Hampshire Ave, Silver Spring, MD, 20993, USA
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Logan BR, Fu D, Howard A, Fei M, Kou J, Little MR, Adom D, Mohamed FA, Blazar BR, Gafken PR, Paczesny S. Validated graft-specific biomarkers identify patients at risk for chronic graft-versus-host disease and death. J Clin Invest 2023; 133:e168575. [PMID: 37526081 PMCID: PMC10378149 DOI: 10.1172/jci168575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 06/16/2023] [Indexed: 08/02/2023] Open
Abstract
BACKGROUNDChronic graft-versus-host disease (cGVHD) is a serious complication of allogeneic hematopoietic cell transplantation (HCT). More accurate information regarding the risk of developing cGVHD is required. Bone marrow (BM) grafts contribute to lower cGVHD, which creates a dispute over whether risk biomarker scores should be used for peripheral blood (PB) and BM.METHODSDay 90 plasma proteomics from PB and BM recipients developing cGVHD revealed 5 risk markers that were added to 8 previous cGVHD markers to screen 982 HCT samples of 2 multicenter Blood and Marrow Transplant Clinical Trials Network (BMTCTN) cohorts. Each marker was tested for its association with cause-specific hazard ratios (HRs) of cGVHD using Cox-proportional-hazards models. We paired these clinical studies with biomarker measurements in a mouse model of cGVHD.RESULTSSpearman correlations between DKK3 and MMP3 were significant in both cohorts. In BMTCTN 0201 multivariate analyses, PB recipients with 1-log increase in CXCL9 and DKK3 were 1.3 times (95% CI: 1.1-1.4, P = 0.001) and 1.9 times (95%CI: 1.1-3.2, P = 0.019) and BM recipients with 1-log increase in CXCL10 and MMP3 were 1.3 times (95%CI: 1.0-1.6, P = 0.018 and P = 0.023) more likely to develop cGVHD. In BMTCTN 1202, PB patients with high CXCL9 and MMP3 were 1.1 times (95%CI: 1.0-1.2, P = 0.037) and 1.2 times (95%CI: 1.0-1.3, P = 0.009) more likely to develop cGVHD. PB patients with high biomarkers had increased likelihood to develop cGVHD in both cohorts (22%-32% versus 8%-12%, P = 0.002 and P < 0.001, respectively). Mice showed elevated circulating biomarkers before the signs of cGVHD.CONCLUSIONBiomarker levels at 3 months after HCT identify patients at risk for cGVHD occurrence.FUNDINGNIH grants R01CA168814, R21HL139934, P01CA158505, T32AI007313, and R01CA264921.
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Affiliation(s)
- Brent R. Logan
- Division of Biostatistics and Center for International Blood and Marrow Transplant Research, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Denggang Fu
- Department of Microbiology and Immunology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Alan Howard
- Be The Match and Center for International Blood and Marrow Transplant Research, Minneapolis, Minnesota, USA
| | - Mingwei Fei
- Be The Match and Center for International Blood and Marrow Transplant Research, Minneapolis, Minnesota, USA
| | - Jianqun Kou
- Division of Biostatistics and Center for International Blood and Marrow Transplant Research, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Morgan R. Little
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Djamilatou Adom
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Fathima A. Mohamed
- Department of Pediatrics, Division of Blood & Marrow Transplant & Cellular Therapy, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Bruce R. Blazar
- Department of Pediatrics, Division of Blood & Marrow Transplant & Cellular Therapy, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Philip R. Gafken
- Proteomics & Metabolomics shared resource, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Sophie Paczesny
- Department of Microbiology and Immunology, Medical University of South Carolina, Charleston, South Carolina, USA
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA
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Manni S, Del Bufalo F, Merli P, Silvestris DA, Guercio M, Caruso S, Reddel S, Iaffaldano L, Pezzella M, Di Cecca S, Sinibaldi M, Ottaviani A, Quadraccia MC, Aurigemma M, Sarcinelli A, Ciccone R, Abbaszadeh Z, Ceccarelli M, De Vito R, Lodi MC, Cefalo MG, Mastronuzzi A, De Angelis B, Locatelli F, Quintarelli C. Neutralizing IFNγ improves safety without compromising efficacy of CAR-T cell therapy in B-cell malignancies. Nat Commun 2023; 14:3423. [PMID: 37296093 PMCID: PMC10256701 DOI: 10.1038/s41467-023-38723-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 05/10/2023] [Indexed: 06/12/2023] Open
Abstract
Chimeric antigen receptor T (CAR-T) cell therapy may achieve long-lasting remission in patients with B-cell malignancies not responding to conventional therapies. However, potentially severe and hard-to-manage side effects, including cytokine release syndrome (CRS), neurotoxicity and macrophage activation syndrome, and the lack of pathophysiological experimental models limit the applicability and development of this form of therapy. Here we present a comprehensive humanized mouse model, by which we show that IFNγ neutralization by the clinically approved monoclonal antibody, emapalumab, mitigates severe toxicity related to CAR-T cell therapy. We demonstrate that emapalumab reduces the pro-inflammatory environment in the model, thus allowing control of severe CRS and preventing brain damage, characterized by multifocal hemorrhages. Importantly, our in vitro and in vivo experiments show that IFNγ inhibition does not affect the ability of CD19-targeting CAR-T (CAR.CD19-T) cells to eradicate CD19+ lymphoma cells. Thus, our study provides evidence that anti-IFNγ treatment might reduce immune related adverse effect without compromising therapeutic success and provides rationale for an emapalumab-CAR.CD19-T cell combination therapy in humans.
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Affiliation(s)
- Simona Manni
- Department of Haematology-Oncology and Cell and Gene Therapy, Bambino Gesù Children Hospital, IRCCS, Rome, Italy
| | - Francesca Del Bufalo
- Department of Haematology-Oncology and Cell and Gene Therapy, Bambino Gesù Children Hospital, IRCCS, Rome, Italy
| | - Pietro Merli
- Department of Haematology-Oncology and Cell and Gene Therapy, Bambino Gesù Children Hospital, IRCCS, Rome, Italy
| | | | - Marika Guercio
- Department of Haematology-Oncology and Cell and Gene Therapy, Bambino Gesù Children Hospital, IRCCS, Rome, Italy
| | - Simona Caruso
- Department of Haematology-Oncology and Cell and Gene Therapy, Bambino Gesù Children Hospital, IRCCS, Rome, Italy
| | - Sofia Reddel
- Department of Haematology-Oncology and Cell and Gene Therapy, Bambino Gesù Children Hospital, IRCCS, Rome, Italy
| | - Laura Iaffaldano
- Department of Haematology-Oncology and Cell and Gene Therapy, Bambino Gesù Children Hospital, IRCCS, Rome, Italy
| | - Michele Pezzella
- Department of Haematology-Oncology and Cell and Gene Therapy, Bambino Gesù Children Hospital, IRCCS, Rome, Italy
| | - Stefano Di Cecca
- Department of Haematology-Oncology and Cell and Gene Therapy, Bambino Gesù Children Hospital, IRCCS, Rome, Italy
| | - Matilde Sinibaldi
- Department of Haematology-Oncology and Cell and Gene Therapy, Bambino Gesù Children Hospital, IRCCS, Rome, Italy
| | - Alessio Ottaviani
- Department of Haematology-Oncology and Cell and Gene Therapy, Bambino Gesù Children Hospital, IRCCS, Rome, Italy
| | - Maria Cecilia Quadraccia
- Department of Haematology-Oncology and Cell and Gene Therapy, Bambino Gesù Children Hospital, IRCCS, Rome, Italy
| | - Mariasole Aurigemma
- Department of Haematology-Oncology and Cell and Gene Therapy, Bambino Gesù Children Hospital, IRCCS, Rome, Italy
| | - Andrea Sarcinelli
- Department of Haematology-Oncology and Cell and Gene Therapy, Bambino Gesù Children Hospital, IRCCS, Rome, Italy
| | - Roselia Ciccone
- Department of Haematology-Oncology and Cell and Gene Therapy, Bambino Gesù Children Hospital, IRCCS, Rome, Italy
| | - Zeinab Abbaszadeh
- Department of Haematology-Oncology and Cell and Gene Therapy, Bambino Gesù Children Hospital, IRCCS, Rome, Italy
| | - Manuela Ceccarelli
- Department of Haematology-Oncology and Cell and Gene Therapy, Bambino Gesù Children Hospital, IRCCS, Rome, Italy
| | - Rita De Vito
- Department of Pathological Anatomy, Bambino Gesù Children Hospital, IRCCS, Rome, Italy
| | - Maria Chiara Lodi
- Department of Haematology-Oncology and Cell and Gene Therapy, Bambino Gesù Children Hospital, IRCCS, Rome, Italy
| | - Maria Giuseppina Cefalo
- Department of Haematology-Oncology and Cell and Gene Therapy, Bambino Gesù Children Hospital, IRCCS, Rome, Italy
| | - Angela Mastronuzzi
- Department of Haematology-Oncology and Cell and Gene Therapy, Bambino Gesù Children Hospital, IRCCS, Rome, Italy
| | - Biagio De Angelis
- Department of Haematology-Oncology and Cell and Gene Therapy, Bambino Gesù Children Hospital, IRCCS, Rome, Italy.
| | - Franco Locatelli
- Department of Haematology-Oncology and Cell and Gene Therapy, Bambino Gesù Children Hospital, IRCCS, Rome, Italy.
- Department of Pediatrics, Catholic University of the Sacred Heart, Rome, Italy.
| | - Concetta Quintarelli
- Department of Haematology-Oncology and Cell and Gene Therapy, Bambino Gesù Children Hospital, IRCCS, Rome, Italy
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
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12
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De Benedetti F, Grom AA, Brogan PA, Bracaglia C, Pardeo M, Marucci G, Eleftheriou D, Papadopoulou C, Schulert GS, Quartier P, Antón J, Laveille C, Frederiksen R, Asnaghi V, Ballabio M, Jacqmin P, de Min C. Efficacy and safety of emapalumab in macrophage activation syndrome. Ann Rheum Dis 2023; 82:857-865. [PMID: 37001971 PMCID: PMC10314091 DOI: 10.1136/ard-2022-223739] [Citation(s) in RCA: 32] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Accepted: 02/02/2023] [Indexed: 04/03/2023]
Abstract
OBJECTIVES Macrophage activation syndrome (MAS) is a severe, life-threatening complication of systemic juvenile idiopathic arthritis (sJIA) and adult-onset Still's disease (AOSD). The objective of this study was to confirm the adequacy of an emapalumab dosing regimen in relation to interferon-γ (IFNγ) activity by assessing efficacy and safety. The efficacy outcome was MAS remission by week 8, based on clinical and laboratory criteria. METHODS We studied emapalumab, a human anti-IFNγ antibody, administered with background glucocorticoids, in a prospective single-arm trial involving patients who had MAS secondary to sJIA or AOSD and had previously failed high-dose glucocorticoids, with or without anakinra and/or ciclosporin. The study foresaw 4-week treatment that could be shortened or prolonged based on investigator's assessment of response. Patients entered a long-term (12 months) follow-up study. RESULTS Fourteen patients received emapalumab. All patients completed the trial, entered the long-term follow-up and were alive at the end of follow-up. The investigated dosing regimen, based on an initial loading dose followed by maintenance doses, was appropriate, as shown by rapid neutralisation of IFNγ activity, demonstrated by a prompt decrease in serum C-X-C motif chemokine ligand 9 (CXCL9) levels. By week 8, MAS remission was achieved in 13 of the 14 patients at a median time of 25 days. Viral infections and positive viral tests were observed. CONCLUSIONS Neutralisation of IFNγ with emapalumab was efficacious in inducing remission of MAS secondary to sJIA or AOSD in patients who had failed high-dose glucocorticoids. Screening for viral infections should be performed, particularly for cytomegalovirus. TRIAL REGISTRATION NUMBER NCT02069899 and NCT03311854.
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Affiliation(s)
| | - Alexei A Grom
- Division of Rheumatology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Paul A Brogan
- University College London Great Ormond Street Institute of Child Health, London, UK
| | - Claudia Bracaglia
- Division of Rheumatology, Ospedale Pediatrico Bambino Gesù, IRCCS, Rome, Italy
| | - Manuela Pardeo
- Division of Rheumatology, Ospedale Pediatrico Bambino Gesù, IRCCS, Rome, Italy
| | - Giulia Marucci
- Division of Rheumatology, Ospedale Pediatrico Bambino Gesù, IRCCS, Rome, Italy
| | - Despina Eleftheriou
- University College London Great Ormond Street Institute of Child Health, London, UK
| | | | - Grant S Schulert
- Division of Rheumatology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Pierre Quartier
- Pediatric Immuno-Hematology and Rheumatology Unit, RAISE Rare Disease Reference Centre, Hopital Universitaire Necker-Enfants Malades, Assistance Publique-Hopitaux de Paris, Paris, France
- Université Paris-Cité, Paris, France
| | - Jordi Antón
- Pediatric Rheumatology, Hospital Sant Joan de Deu, Barcelona, Spain
- Faculty of Medicine, Universitat de Barcelona, Barcelona, Spain
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13
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Pinto MV, Neves JF. Precision medicine: The use of tailored therapy in primary immunodeficiencies. Front Immunol 2022; 13:1029560. [PMID: 36569887 PMCID: PMC9773086 DOI: 10.3389/fimmu.2022.1029560] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2022] [Accepted: 11/17/2022] [Indexed: 12/13/2022] Open
Abstract
Primary immunodeficiencies (PID) are rare, complex diseases that can be characterised by a spectrum of phenotypes, from increased susceptibility to infections to autoimmunity, allergy, auto-inflammatory diseases and predisposition to malignancy. With the introduction of genetic testing in these patients and wider use of next-Generation sequencing techniques, a higher number of pathogenic genetic variants and conditions have been identified, allowing the development of new, targeted treatments in PID. The concept of precision medicine, that aims to tailor the medical interventions to each patient, allows to perform more precise diagnosis and more importantly the use of treatments directed to a specific defect, with the objective to cure or achieve long-term remission, minimising the number and type of side effects. This approach takes particular importance in PID, considering the nature of causative defects, disease severity, short- and long-term complications of disease but also of the available treatments, with impact in life-expectancy and quality of life. In this review we revisit how this approach can or is already being implemented in PID and provide a summary of the most relevant treatments applied to specific diseases.
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Affiliation(s)
- Marta Valente Pinto
- Primary Immunodeficiencies Unit, Hospital Dona Estefânia, CHULC-EPE, Lisbon, Portugal
- Centro de Investigação Egas Moniz (CiiEM), Instituto Universitário Egas Moniz (IUEM), Quinta da Granja, Monte da Caparica, Caparica, Portugal
| | - João Farela Neves
- Primary Immunodeficiencies Unit, Hospital Dona Estefânia, CHULC-EPE, Lisbon, Portugal
- CHRC, Comprehensive Health Research Centre, Nova Medical School, Lisbon, Portugal
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14
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Interferon-γ blockade in CAR T-cell therapy-associated macrophage activation syndrome/hemophagocytic lymphohistiocytosis. Blood Adv 2022; 7:533-536. [PMID: 35917457 PMCID: PMC9979758 DOI: 10.1182/bloodadvances.2022008256] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 07/07/2022] [Accepted: 07/23/2022] [Indexed: 11/20/2022] Open
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