Effect of high-dose steroid therapy on T-cell subpopulations. A longitudinal study in MS patients

Corticosteroid-depending effects on peripheral immune cell subsets vary according to disease modifying strategies in multiple sclerosis

Background

The primary treatment for acute relapses in multiple sclerosis (MS) is the intravenous administration of high-dose methylprednisolone (IVMP). However, the mechanisms through which corticosteroid treatment impacts acute neuroinflammation in people with MS (pwMS) remain not fully understood. In particular, the changes induced by glucocorticoids (GCs) on cells of the innate immune system and the differences between patients with distinct immunotherapies have received little attention to date.

Methods

We conducted immunophenotyping using flow cytometry on peripheral blood mononuclear cells of pwMS who received IVMP treatment during a relapse. We compared the impact of an IVMP treatment on a broad variety of immune cell subsets within three groups: twelve patients who were treatment-naïve to disease modifying therapies (wDMT) to ten patients on platform therapies (PT) and eighteen patients on fingolimod therapy (FTY).

Results

We observed pronounced interindividual short- and intermediate-term effects of IVMP on distinct immune cells subsets. In addition to the well-documented decrease in T-helper cells (Th cells), we detected significant alterations after the first IVMP infusion within the innate immune response among neutrophil, eosinophil and basophil granulocytes, monocytes and plasmacytoid dendritic cells (pDCs). When comparing patients wDMT to the PT and FTY cohorts, we found that IVMP had a similar impact on innate immune cells across all treatment groups. However, we did not observe a significant further decline in T lymphocyte counts during IVMP in patients with pre-existing lymphopenia under FTY treatment. Although T cell apoptosis is considered the main mechanism of action of GCs, patients with FTY still reported symptom improvement following IVMP treatment.

Conclusion

In addition to T cell suppression, our data suggests that further immunoregulatory mechanisms of GC, particularly on cells of the innate immune response, are of greater significance than previously understood. Due to the regulation of the adaptive immune cells by DMTs, the impact of GC on these cells varies depending on the underlying DMT. Additional studies involving larger cohorts and cerebrospinal fluid samples are necessary to gain a deeper understanding of the immune response to GC in pwMS with different DMTs during relapse to define and explain differences in clinical response profiles.

Anti lingo 1 (opicinumab) a new monoclonal antibody tested in relapsing remitting multiple sclerosis

INTRODUCTION

Multiple sclerosis (MS) is a chronic demyelinating disease of the central nervous system (CNS). The modern treatment era for MS witnessed a growing pool of drugs now available for use in clinical practice. These therapies work at different levels, however there is a lack of treatments acting on the neurodegenerative component or improving mechanism of repair. Areas covered: The latest knowledge about the pathophysiological changes occurring in MS have translated into novel treatments at different stages of development. Drugs for MS work mainly through modulating the inflammatory factors of the disease, but enhancing remyelination may be more successful in reducing long-term disability. Anti-LINGO-1 (opicinumab) is the first investigational product that achieved phase I trial with the aim of remyelination and axonal protection and/or repair in MS. Expert commentary: Over the past decade considerable strength has been applied to find more reliable strategies to improve myelin repair. The anti-LINGO-1 trial showed that the drug is safe and tolerable. A future phase II trial will provide more insights regarding the compound. The greatest challenge for myelin repair therapies will be how to monitor their efficacy. Eventually research will need to focus on consistent tools to assess the grade of remyelination in vivo.

Pharmacology and clinical efficacy of dimethyl fumarate (BG-12) for treatment of relapsing-remitting multiple sclerosis

The last two decades have seen the introduction of several therapies for multiple sclerosis (MS). These therapies are intended to work at different levels of the disease, typically targeting direct symptom management, brief corticosteroid administration for acute exacerbations, and the regular use of disease-modifying drugs. Nevertheless, in clinical practice, disease-modifying drugs or immunosuppressive treatments are frequently associated with suboptimal response in terms of efficacy and several side effects leading to poor patient adherence, so the proportion of relapsing–remitting MS patients not adequately responding to disease-modifying therapy have been reported to range from 7% to 49%. Natalizumab and fingolimod are the newest US Food and Drug Administration-approved agents that have been added to the MS treatment armamentarium, but their use is limited by a less known safety profile and recognized specific risk. Thus, there is an important need for new therapeutic strategies, especially those that may offer greater patient satisfaction and safer risk profile in order to optimize therapeutic outcomes. A number of potential therapies for MS are now in late-stage development. Effective, safe, and well-tolerated therapies may improve compliance and empower patients with a level of independence not presently possible. To meet these characteristics, most of these therapies are oral compounds. Herein, we review the pharmacology and efficacy of dimethyl fumarate (BG-12) to date and its role in the evolving marketplace.

Immunopathogenesis and immunotherapeutic approaches in multiple sclerosis

Multiple sclerosis is an organ-specific autoimmune disease, characterized pathologically by cell-mediated inflammation, demyelination and variable degrees of axonal loss. Although inflammation is considered central to the pathogenesis of multiple sclerosis, to date, the only licensed and hence widely used multiple sclerosis immunotherapies are interferon-beta, glatiramer acetate and mitoxantrone. This review discusses the immunopathogenesis of multiple sclerosis, focusing on a number of emerging immunotherapies. A number of new approaches likely to manipulate the immunopathogenesis of multiple sclerosis and which may ultimately allow for the development of more effective immunotherapy are also highlighted.

Drugs in clinical development for multiple sclerosis: focusing on anti-CD20 antibodies

INTRODUCTION

Multiple sclerosis (MS) is a chronic inflammatory disease of the central nervous system (CNS), traditionally considered to be an autoimmune disease. Despite the standard of care for patients with MS is significantly improved in recent years, there is still room for improvement in terms of effectiveness and also compliance.

AREAS COVERED

The continuous improvements of our understanding of the pathophysiological changes that occur in MS have translated into many novel therapeutic agents at different stages of development. A number of therapies for MS are in advanced development and likely to be available soon. Along with these, we have also seen the appearance of a group of drugs considered together as a consequence of their similar design: the monoclonal antibodies (mAbs). Here, the focus will be on reviewing results that have emerged from a better clarification of MS pathogenesis to clinical trials of different anti-CD20 mAbs.

EXPERT OPINION

The decision to switch established patients from well-known drugs to either new formulations or new agents will be made on balancing efficacy and tolerability of the existing treatments. Safety seems increasingly likely to become a key factor.

Methylprednisolone treatment increases the proportion of the highly suppressive HLA-DR(+)-Treg-cells in transplanted patients

Methylprednisolone is widely used to improve immune suppression in transplanted patients threatened by acute rejection. Recently, we showed that the suppressive activity of a Treg cell population depends decisively on their percentage of highly suppressive HLA-DR(high+)-Treg cells, which are strongly reduced in rejecting transplant patients. In order to examine whether the composition of the total CD4(+)CD127(low+/-)FoxP3(+)-Treg cell pool with different Treg-subsets (DR(high+)CD45RA(-)-Tregs, DR(low+)CD45RA(-)-Tregs, DR(-)CD45RA(-)-Tregs, DR(-)CD45RA(+)-Tregs) is affected by methylprednisolone bolus therapy we compared the percentages of these four different Treg cell subsets in transplant patients with biopsy proven rejection before and after steroid bolus therapy (n=23). In patients treated with steroid bolus therapy, the percentage of the naïve DR(-)CD45RA(+)-Tregs was significantly decreased, whereas the percentage of the DR(+)CD45RA(-)-Tregs was significantly increased. By that, the strongest increase was detected for the most suppressive DR(high+)CD45RA(-)-Tregs. However, these effects were only temporarily and closely associated to the duration of the bolus therapy. Our results suggest that besides various anti-inflammatory effects on cells of the adaptive and innate immune system, methylprednisolone also has the capacity to enhance the suppressive activity of the total Treg cell pool by increasing its percentage of highly differentiated and highly suppressive DR(high+)CD45RA(-)-Tregs.

The mechanism of action of methylprednisolone in the treatment of multiple sclerosis

Methylprednisolone plays an important role in the current treatment of multiple sclerosis (MS), particularly in the acute phase of relapse. It acts in various ways to decrease the inflammatory cycle including: dampening the inflammatory cytokine cascade, inhibiting the activation of T cells, decreasing the extravasation of immune cells into the central nervous system, facilitating the apoptosis of activated immune cells, and indirectly decreasing the cytotoxic effects of nitric oxide and tumor necrosis factor alpha. This paper reviews the most recent observations on these mechanisms both to understand the disease mechanism and its treatment. As more becomes known about these mechanisms, it may become possible to design treatment regimes that are more specific towards both the individual and the disease state.

Suppression of immune system genes by methylprednisolone in exacerbations of multiple sclerosis. Preliminary results

Acute relapses of multiple sclerosis (MS) are treated with intravenous methylprednisolone (IVMP), which speeds recovery from exacerbation. It is known that IVMP suppresses the immunological activation which occurs during an acute attack of MS. However, the specific target genes affected by this therapy remain obscure. A cDNA microarray for 448 genes was used to identify the target genes in IVMP therapy. Total RNA was isolated from peripheral blood mononuclear cells derived from six MS patients immediately before and after completion of therapy. IVMP significantly reduced mRNA levels for T-cell-specific transcription factor 7 (p=0.02), T-cell-specific protein-tyrosine kinase (p=0.02), T-cell surface glycoprotein CD5 (p=0.05) and interferon-stimulated gene factor 3 gamma subunit (p=0.04). Significantly increased expression was found for eosinophil-derived neurotoxin (p=0.05). The suppression of expression of genes associated with T-cell differentiation and antigen-specific T-cell activation detected in this study may contribute to the beneficial effect of MP in relapses of MS.

Immune parameters associated with early treatment effects of high-dose intravenous methylprednisolone in multiple sclerosis

To determine the immunological effects of high-dose intravenous methylprednisolone (IVMP) and elucidate immune measurements used for evaluation of its therapeutic effect, we analyzed lymphocyte subsets and humoral immune parameters in peripheral blood and cerebrospinal fluid (CSF) samples, before and within 2 weeks of treatment during 19 acute exacerbations in 16 relapsing-remitting multiple sclerosis (MS) patients. In addition to decreases in CSF albumin and IgG levels, treatment resulted in an increase of CD8(+)CXCR3(+) cells as well as a decrease in CD4(+) subsets expressing CD25, CD29, and CCR4 in the CSF. Further, the percentage of circulating CD4(+)CXCR3(+) Th1 cells also decreased. Clinical improvement was achieved following 15 of the 19 treatment occasions. Early (<2 weeks of treatment) clinical improvement was significantly associated with a decrease in CSF CD4(+)CD29(+) helper inducer T cells, whereas they were nearly unchanged in four patients who showed no improvement. Changes in other parameters following IVMP treatment were not different between the responder and non-responder groups.

Treatment with methylprednisolone in relapses of multiple sclerosis patients: immunological evidence of immediate and short-term but not long-lasting effects

Relapses of multiple sclerosis (MS) are treated commonly with high-dose intravenous methylprednisolone (MP) given over a period of 3-5 days. The mechanisms responsible for the beneficial effects of MP in attacks are not clearly established. It is also controversial whether this treatment may have a long-term effect. Here, peripheral blood samples from relapsing--remitting MS patients in acute relapse were analysed by flow cytometry just before steroid treatment and at different time points after initiation of the therapy. We observed an immediate (day 3) decrease in the percentage of CD4+ lymphocytes, with a relative increase in the memory (CD4+CD45R0+) subpopulation. A longer standing effect of MP on IFN-gamma production, CD54, CCR5, CXCR3 and CD95 (Fas) expression was also observed on CD4+ cells after 1 month of treatment initiation. Six months after the therapy, during clinical remission, no changes due to ivMP therapy were detected. These results support that MP treatment of relapses induces immediate post-treatment and short-term effects on the immune system that could partly account for the clinical and radiological improvement observed in MS patients. However, no conclusion can be drawn as to a possible long-term or even intermediate influence of ivMP treatment on the course of the disease.

Decreased CD57 lymphocyte subset in patients with chronic Lyme disease

BACKGROUND

Chronic Lyme disease (LD) is a debilitating illness caused by tickborne infection with the spirochete Borrelia burgdorferi. Although immunologic abnormalities appear to play a role in this disease, specific immunologic markers of chronic LD have not been identified.

METHODS

We evaluated 73 patients with chronic LD for lymphocyte subset abnormalities using flow cytometry. Of these, 53 patients had predominant musculoskeletal symptoms, while 20 patients had predominant neurologic symptoms. The estimated duration of infection ranged from 3 months to 15 years, and all patients had positive serologic tests for B. burgdorferi. Ten patients with acute LD (infection less than 1 month) and 22 patients with acquired immunodeficiency syndrome (AIDS) served as disease controls.

RESULTS

All 31 chronic LD patients who were tested prior to antibiotic treatment had significantly decreased CD57 lymphocyte counts (mean, 30+/-16 cells per microl; normal, 60-360 cells per microl, P<0.001). Nineteen of 37 patients (51%) who were tested after initiating antibiotic therapy had decreased CD57 levels (mean, 66+/-39 cells per microl), and all five patients tested after completing antibiotic treatment had normal CD57 counts (mean, 173+/-98 cells per microl). In contrast, all 10 patients with acute LD and 82% of AIDS patients had normal CD57 levels, and the difference between these groups and the pre-treatment patients with chronic LD was significant (P<0.001). Patients with chronic LD and predominant neurologic symptoms had significantly lower mean CD57 levels than patients with predominant musculoskeletal symptoms (30+/-21 vs. 58+/-37 cells per microl, P=0.002). CD57 levels increased in chronic LD patients whose symptoms improved, while patients with refractory disease had persistently low CD57 counts.

CONCLUSIONS

A decrease in the CD57 lymphocyte subset may be an important marker of chronic LD. Changes in the CD57 subset may be useful to monitor the response to therapy in this disease.

Functional activity of immune cells in female MS-patients

Since the well documented immunological disturbances in patients suffering from multiple sclerosis are especially attributed to T-cells we felt it expedient to look also for the functional activity of lymphocytes, monocytes, granulocytes and natural killer cells in the peripheral blood of female MS-patients (n = 17) and healthy controls (n = 17). While MS-patients showed decreased levels of total lymphocytes, CD2(+)- and CD8(+)-cells the percentage of HLA-DR(+)-monocytes was increased, indicating a high activity level of these immune cells, whereas we could find no differences in the functional tests of monocytes, granulocytes and natural killer cells between MS-patients and healthy controls. The percentage of HLA-DR(+)-T-lymphocytes increased with the duration of the illness and support the stronger consideration of clinical staging.

Effect of high-dose methylprednisolone administration on immune functions in multiple sclerosis patients

OBJECTIVES

To investigate the in vivo effect of corticosteroid pulse therapy on immunocompetent cells in 18 patients given methylprednisolone to treat an acute episode of MS.

MATERIAL AND METHODS

Blood was sampled before and after 3 days of methylprednisolone administration at doses of 1 g/day. Lymphocyte subtyping was performed and whole blood cell cultures were used to measure the cytokine producing capacity for interleukin-1 (IL-1), interleukin-2 (IL-2), interferon-gamma (IFN-gamma), tumor necrosis factor-alpha (TNF-alpha) and interferon-alpha (IFN-alpha). In addition, serum levels of the immunoglobulin classes IgG, IgA and IgM were determined.

RESULTS

Before treatment, production of IL-1 was significantly increased in MS patients as compared to healthy controls. After therapy, production of all cytokines was significantly decreased, whereas there were significant increases in the numbers of monocytes, neutrophils and T and B lymphocytes. Treatment had no effect on serum immunoglobulin levels.

CONCLUSION

An important mechanism for the antiinflammatory effect of corticosteroids in MS results from a suppression of the activation of the peripheral immune compartment through inhibition of cytokine production and lymphocyte endothelial adhesiveness.

CD4 subsets (CD45RA/RO) exhibit differences in proliferative responses, IL-2 and gamma-interferon production during intravenous methylprednisolone treatment of multiple sclerosis

Phytohaemagglutinin (PHA)-induced proliferative responses, interleukin 2 (IL-2) and gamma-interferon production were determined in purified CD4CD45RA and CD4CD45RO lymphocytes isolated by immunomagnetic bead separations from normal subjects and multiple sclerosis (MS) patients. Significantly higher proliferative activities were observed for CD4CD45RA cells compared with the corresponding CD4CD45RO cell population in normal subjects and MS patients. CD4CD45RA lymphocyte proliferative responses declined by 50% 3 h following a single dose (500 mg) of intravenous methylprednisolone (IVMP). At 24 h, levels were similar to those determined pre-therapy, as were the levels observed 24 h after a 5-day course (500 mg daily) of IVMP. In contrast, CD4CD45RO cells were unaffected by IVMP. In vitro incorporation of methylprednisolone (10(-6) M) to cell cultures resulted in a modest reduction in proliferative activities of both CD4 subsets. In MS patients subnormal levels of IL-2 and gamma-interferon were observed in PHA-stimulated cultures of CD4CD45RA and CD4CD45RO cells. Following 5 days of IVMP therapy, IL-2 and gamma-interferon production was similar to that observed in CD4CD45RA and CD4CD45RO cells from normal subjects. IVMP therapy causes selective, but transient, inhibition of CD4CD45RA lymphocyte proliferative responses and enhancement of PHA-induced IL-2 and gamma-interferon production by both CD4CD45RA and CD4CD45RO cells.

The immune profile of multiple sclerosis: T-lymphocyte effects predominate over all other factors in cyclophosphamide-treated patients

It is widely believed that multiple sclerosis is a T-cell mediated autoimmune disease associated with abnormalities in immunoregulation. This large, prospective study evaluated the lymphocyte immunophenotypic profile of 246 MS patients, divided clinically into a remitting/relapsing group (n = 176) and a progressive group (n = 70), and compared their results to those of 117 healthy controls. All patients were found to have significantly elevated percentage and absolute numbers of IL2R+CD3+ cells as well as depressed percentages of CD45RA+CD4+ cells. However, when the factor of treatment with cyclophosphamide (CY) versus no treatment or treatment with other agents was used to group patients, dramatic declines in both percentages and absolute numbers of CD45RA+CD4+ cells were discovered. These declines were associated specifically with CY and and could be explained by this factor independent of the clinical state of the patient. The effects were seen in patients undergoing current treatment or in those exposed to CY in the near or remote past. These findings highlight the confounding effect of specific treatments on the immune profile of MS patients groups and suggest that there may be important implications for cellular function and clinical outcome in these and other patient groups.

Transient immunomodulation by intravenous methylprednisolone treatment of multiple sclerosis

The extent and duration of immunomodulation induced by high-dose corticosteroid treatment of clinical relapse of multiple sclerosis was investigated. Ten patients treated with a 5 day course of intravenous methylprednisolone (IVMP) (500 mg daily) were studied. Circulating lymphocyte subpopulations and mitogen-induced interleukin 2 (IL-2) and gamma-interferon (gamma-IFN) production were determined immediately before initiation of therapy (day 1), during therapy (24 h after first dose, day 2) and at 24 h and 1 week post therapy (days 6 and 12 respectively). T-cell subpopulation (CD3, CD4, CD8, CD4CD45RA, CD4CD45RO) levels fell within 24 h of initiation of therapy, rebounded above pretreatment levels at day 6 and normalised 1 week post therapy. Despite a reduction in total T-cell numbers during treatment, the gamma delta T-cell subpopulation was not significantly altered. HLA-DR expression on B cells and monocytes declined transiently on day 2 to approximately 50% of pretherapy levels. IL-2 and gamma-IFN production were reduced during therapy but returned to baseline levels by 24 h post therapy. The effects of IVMP on lymphocyte distribution and function appear to be short-lived and, therefore, may not be responsible for the rapid improvement associated with this form of treatment.