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Sguigna PV, Hussain RZ, Okai A, Blackburn KM, Tardo L, Madinawala M, Korich J, Lebson LA, Kaplan J, Salter A, Manouchehri N, Stuve O. Cladribine tablets after treatment with natalizumab (CLADRINA) - rationale and design. Ther Adv Neurol Disord 2024; 17:17562864241233858. [PMID: 38585373 PMCID: PMC10996356 DOI: 10.1177/17562864241233858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 02/02/2024] [Indexed: 04/09/2024] Open
Abstract
Background Individual disease modifying therapies approved for multiple sclerosis (MS) have limited effectiveness and potentially serious side effects, especially when administered over long periods. Sequential combination therapy is a plausible alternative approach. Natalizumab is a monoclonal therapeutic antibody that reduces leukocyte access to the central nervous system that is associated with an increased risk of progressive multifocal leukoencephalopathy and disease reactivation after its discontinuation. Cladribine tablets act as a synthetic adenosine analog, disrupting DNA synthesis and repair, thereby reducing the number of lymphocytes. The generation of prospective, rigorous safety, and efficacy data in transitioning from natalizumab to cladribine is an unmet clinical need. Objectives To test the feasibility of transitioning patients with relapsing forms of MS natalizumab to cladribine tablets. Design Cladribine tablets after treatment with natalizumab (CLADRINA) is an open-label, single-arm, multicenter, collaborative phase IV, research study that will generate hypothesis regarding the safety, efficacy, and immunological impact of transition from natalizumab to cladribine tablets in patients with relapsing forms of MS. Methods and analysis Participants will be recruited from three different sites. The primary endpoint is the absolute and percent change from baseline of lymphocytes and myeloid cell subsets, as well as blood neurofilament light levels. The secondary endpoint is the annualized relapse rate over the 12- and 24-month trial periods. Exploratory endpoints include the expanded disability status scale, and magnetic resonance imaging outcomes. Discussion The CLADRINA trial will generate data regarding the safety, efficacy, and immunological impact of the transition from natalizumab to cladribine. As the pace of immunological knowledge of MS continues, insight into disease modifying therapy transition strategies is needed.
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Affiliation(s)
- Peter V. Sguigna
- Department of Neurology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Rehana Z. Hussain
- Department of Neurology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Annette Okai
- North Texas Institute of Neurology & Headache, Plano, TX, USA
| | - Kyle M. Blackburn
- Department of Neurology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Lauren Tardo
- Department of Neurology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Mariam Madinawala
- Department of Neurology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Julie Korich
- EMD Serono, Inc., Rockland, MA, USA, an affiliate of Merck KGaA, Darmstadt, Germany
| | - Lori A. Lebson
- EMD Serono, Inc., Rockland, MA, USA, an affiliate of Merck KGaA, Darmstadt, Germany
| | - Jeffrey Kaplan
- Kansas City Multiple Sclerosis and Headache Center, Overland Park, KS, USA
| | - Amber Salter
- Department of Neurology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Navid Manouchehri
- Department of Neurology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Olaf Stuve
- Department of Neurology, University of Texas Southwestern Medical Center, 6000 Harry Hines Blvd, Dallas, TX 75390-8813, USA
- Neurology Section, VA North Texas Health Care System, Dallas, TX, USA
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Vakrakou AG, Brinia ME, Alexaki A, Koumasopoulos E, Stathopoulos P, Evangelopoulos ME, Stefanis L, Stadelmann-Nessler C, Kilidireas C. Multiple faces of multiple sclerosis in the era of highly efficient treatment modalities: Lymphopenia and switching treatment options challenges daily practice. Int Immunopharmacol 2023; 125:111192. [PMID: 37951198 DOI: 10.1016/j.intimp.2023.111192] [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: 09/03/2023] [Revised: 10/25/2023] [Accepted: 11/03/2023] [Indexed: 11/13/2023]
Abstract
The expanded treatment landscape in relapsing-remitting multiple sclerosis (MS) has resulted in highly effective treatment options and complexity in managing disease- or drug-related events during disease progression. Proper decision-making requires thorough knowledge of the immunobiology of MS itself and an understanding of the main principles behind the mechanisms that lead to secondary autoimmunity affecting organs other than the central nervous system as well as opportunistic infections. The immune system is highly adapted to both environmental and disease-modifying agents. Immune reconstitution following cell depletion or cell entrapment therapies eliminates pathogenic aspects of the disease but can also lead to distorted immune responses with harmful effects. Atypical relapses occur with second-line treatments or after their discontinuation and require appropriate clinical decisions. Lymphopenia is a result of the mechanism of action of many drugs used to treat MS. However, persistent lymphopenia and cell-specific lymphopenia could result in disease exacerbation, secondary autoimmunity, or the emergence of opportunistic infections. Clinicians treating patients with MS should be aware of the multiple faces of MS under novel, efficient treatment modalities and understand the intricate brain-immune cell interactions in the context of an altered immune system. MS relapses and disease progression still occur despite the current treatment modalities and are mediated either by failure to control effector mechanisms inherent to MS pathophysiology or by new drug-related mechanisms. The multiple faces of MS due to the highly adapted immune system of patients impose the need for appropriate switching therapies that safeguard disease remission and further clinical improvement.
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Affiliation(s)
- Aigli G Vakrakou
- Demyelinating Diseases Unit, 1st Department of Neurology, School of Medicine, Aiginition Hospital, National and Kapodistrian University of Athens, Athens, Greece; Department of Neuropathology, University of Göttingen Medical Center, Göttingen, Germany.
| | - Maria-Evgenia Brinia
- Demyelinating Diseases Unit, 1st Department of Neurology, School of Medicine, Aiginition Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Anastasia Alexaki
- Demyelinating Diseases Unit, 1st Department of Neurology, School of Medicine, Aiginition Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Evangelos Koumasopoulos
- Demyelinating Diseases Unit, 1st Department of Neurology, School of Medicine, Aiginition Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Panos Stathopoulos
- Demyelinating Diseases Unit, 1st Department of Neurology, School of Medicine, Aiginition Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Maria-Eleftheria Evangelopoulos
- Demyelinating Diseases Unit, 1st Department of Neurology, School of Medicine, Aiginition Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Leonidas Stefanis
- Demyelinating Diseases Unit, 1st Department of Neurology, School of Medicine, Aiginition Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Constantinos Kilidireas
- Demyelinating Diseases Unit, 1st Department of Neurology, School of Medicine, Aiginition Hospital, National and Kapodistrian University of Athens, Athens, Greece; Department of Neurology, Henry Dunant Hospital Center, Athens, Greece
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Tanasescu R, Frakich N, Chou IJ, Filippini P, Podda G, Xin G, Muraleedharan R, Jerca O, Onion D, Constantinescu CS. Natalizumab Treatment of Relapsing Remitting Multiple Sclerosis Has No Long-Term Effects on the Proportion of Circulating Regulatory T Cells. Neurol Ther 2023; 12:2041-2052. [PMID: 37715885 PMCID: PMC10630259 DOI: 10.1007/s40120-023-00539-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 08/17/2023] [Indexed: 09/18/2023] Open
Abstract
INTRODUCTION Natalizumab (NTZ), a monoclonal antibody against the integrin α4β1 (VLA-4) found on activated T cells and B cells, blocks the interaction of this integrin with adhesion molecules of central nervous system (CNS) endothelial cells and lymphocyte migration through the blood-brain barrier, effectively preventing new lesion formation and relapses in multiple sclerosis (MS). Whether NTZ treatment has additional effects on the peripheral immune system cells, and how its actions compare with other MS disease-modifying treatments, have not been extensively investigated. In particular, its effect on the proportions of circulating regulatory T cells (Treg) is unclear. METHODS In this study, we investigated the effect of NTZ treatment in 12 patients with relapsing MS, at 6 and 12 months after the start of treatment. We evaluated the proportions of regulatory T cells (Treg), defined by flow cytometry as CD4+ CD25++ FoxP3+ cells and CD4+ CD25++ CD127- cells at these intervals. As an exploratory study, we also investigated the NTZ effects on the proportions of bulk T and B lymphocyte populations, and of those expressing novel the markers CD195 (CCR5), CD196 (CCR6), or CD161 (KLRB1), which are involved in MS pathogenesis but have been studied less in the context of MS treatment. The effects of NTZ were compared to those obtained with 11 patients under interferon-beta-1a (IFN-β1a) treatment, and against 9 healthy volunteers. RESULTS We observed a transient increment in the proportion of Treg cells at 6 months, which was not sustained at 12 months. We observed a reduction in the proportion of T cells expressing CD195 (CCR5) and CD161 (KLRB1) subsets of T cells. CONCLUSION We conclude that NTZ does not have an effect on the proportion of Treg cells over 1 year, but it may affect the expression of molecules important for some aspects MS pathogenesis, in a manner that is not shared with IFN-β1a.
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Affiliation(s)
- Radu Tanasescu
- Academic Unit of Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, NG7 2UH, UK
- Department of Neurology, Nottingham University Hospitals NHS Trust, Nottingham, UK
- Nottingham Centre for MS and Neuroinflammation, Nottingham University Hospital NHS Trust, Nottingham, NG7 2UH, UK
| | - Nanci Frakich
- Academic Unit of Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, NG7 2UH, UK
| | - I-Jun Chou
- Academic Unit of Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, NG7 2UH, UK
- Department of Neurology, Chang Gung Memorial Hospital, Linko Branch, Taoyuan, Taiwan
| | - Perla Filippini
- Academic Unit of Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, NG7 2UH, UK
| | - Giulio Podda
- Academic Unit of Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, NG7 2UH, UK
- Wye Valley NHS Trust, Hereford, England, UK
| | - Gao Xin
- Academic Unit of Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, NG7 2UH, UK
| | - Ranjithmenon Muraleedharan
- Academic Unit of Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, NG7 2UH, UK
- Broad Institute of Massachusetts Institute of Technology and Harvard University, Cambridge, MA, USA
| | - Oltita Jerca
- Academic Unit of Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, NG7 2UH, UK
- Medizinisches Zentrum Harz, Halberstadt, Germany
| | - David Onion
- School of Life Sciences, University of Nottingham, Nottingham, NG7 2UH, UK
| | - Cris S Constantinescu
- Academic Unit of Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, NG7 2UH, UK.
- Nottingham Centre for MS and Neuroinflammation, Nottingham University Hospital NHS Trust, Nottingham, NG7 2UH, UK.
- Department of Neurology, Cooper Neurological Institute, Cooper Medical School of Rowan University, 2339 Route 70 West, Cherry Hill, Camden, NJ, 08002, USA.
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Nguyen Ky M, Duran A, Hasantari I, Bru A, Deloire M, Brochet B, Ruet A, Schmitt N. Natalizumab Treatment Induces Proinflammatory CD4 T Cells Preferentially in the Integrin β7+ Compartment. NEUROLOGY(R) NEUROIMMUNOLOGY & NEUROINFLAMMATION 2023; 10:e200166. [PMID: 37739811 PMCID: PMC10519437 DOI: 10.1212/nxi.0000000000200166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 07/19/2023] [Indexed: 09/24/2023]
Abstract
BACKGROUND AND OBJECTIVES Natalizumab, a monoclonal humanized antibody targeting integrin α4, inhibits the transmigration of lymphocytes into the CNS by preventing the interaction of integrin α4β1 with V-CAM expressed on brain vascular endothelial cells. Although natalizumab treatment reduces the clinical relapse rate in patients with relapsing-remitting MS, its discontinuation after reactivation of the JC virus is associated with a rebound of the disease in 20% of patients. The mechanisms of this rebound are not elucidated, but natalizumab increases the frequencies of circulating CD4 T cells expressing proinflammatory cytokines as well as the proportion of circulating Th17/Th1 cells (Th1-like Th17 cells). Gut-derived memory CD4 T cells are a population of growing interest in the pathogenesis of MS, but whether and how their properties are affected by natalizumab is not known. Here, we studied the phenotype and cytokine expression profile of circulating gut-derived memory CD4 T cells in patients with relapsing-remitting MS under natalizumab. METHODS We identified gut-derived memory CD4 T cells by their expression of integrin β7 and compared their properties and those of integrin β7- memory CD4 T cells across healthy donors and patients with relapsing-remitting MS treated or not with natalizumab. We also compared the capacity of integrin β7- and integrin β7+ CD4 T-cell subsets to transmigrate in vitro across a model of blood-brain barrier. RESULTS The proportions of proinflammatory Th17/Th1 cells as well as of IL-17A+IFNγ+ and IL-17A+GM-CSF+ cells were higher in memory CD4 T cells expressing integrin β7 in patients receiving natalizumab compared with healthy donors and patients with relapsing-remitting MS not receiving natalizumab. By contrast, integrin β7 negative memory CD4 T cells only presented a modest increased in their proportion of Th17/Th1 cells under natalizumab. We further observed that integrin β7+ Th17/Th1 cells migrated as efficiently as integrin β7- Th17/Th1 across a monolayer of brain microvascular endothelial cells. DISCUSSION Our study shows that circulating integrin β7+ memory CD4 T cells of patients with relapsing-remitting MS under natalizumab are enriched in proinflammatory cells supporting the hypothesis that integrin β7+ memory CD4 T cells could play a pathogenic role in the disease rebound observed at natalizumab discontinuation.
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Affiliation(s)
- Mélanie Nguyen Ky
- From the Immunoconcept (M.N.K., A.D., I.H., A.B., N.S.), CNRS UMR 5164, University of Bordeaux; Service de Neurologie (M.D., A.R.), CRC SEP, Centre Hospitalier Universitaire (CHU) de Bordeaux; and INSERM U 1215 (B.B., A.R.), Neurocentre Magendie, University of Bordeaux, France
| | - Adrien Duran
- From the Immunoconcept (M.N.K., A.D., I.H., A.B., N.S.), CNRS UMR 5164, University of Bordeaux; Service de Neurologie (M.D., A.R.), CRC SEP, Centre Hospitalier Universitaire (CHU) de Bordeaux; and INSERM U 1215 (B.B., A.R.), Neurocentre Magendie, University of Bordeaux, France
| | - Iris Hasantari
- From the Immunoconcept (M.N.K., A.D., I.H., A.B., N.S.), CNRS UMR 5164, University of Bordeaux; Service de Neurologie (M.D., A.R.), CRC SEP, Centre Hospitalier Universitaire (CHU) de Bordeaux; and INSERM U 1215 (B.B., A.R.), Neurocentre Magendie, University of Bordeaux, France
| | - Agnès Bru
- From the Immunoconcept (M.N.K., A.D., I.H., A.B., N.S.), CNRS UMR 5164, University of Bordeaux; Service de Neurologie (M.D., A.R.), CRC SEP, Centre Hospitalier Universitaire (CHU) de Bordeaux; and INSERM U 1215 (B.B., A.R.), Neurocentre Magendie, University of Bordeaux, France
| | - Mathilde Deloire
- From the Immunoconcept (M.N.K., A.D., I.H., A.B., N.S.), CNRS UMR 5164, University of Bordeaux; Service de Neurologie (M.D., A.R.), CRC SEP, Centre Hospitalier Universitaire (CHU) de Bordeaux; and INSERM U 1215 (B.B., A.R.), Neurocentre Magendie, University of Bordeaux, France
| | - Bruno Brochet
- From the Immunoconcept (M.N.K., A.D., I.H., A.B., N.S.), CNRS UMR 5164, University of Bordeaux; Service de Neurologie (M.D., A.R.), CRC SEP, Centre Hospitalier Universitaire (CHU) de Bordeaux; and INSERM U 1215 (B.B., A.R.), Neurocentre Magendie, University of Bordeaux, France
| | - Aurélie Ruet
- From the Immunoconcept (M.N.K., A.D., I.H., A.B., N.S.), CNRS UMR 5164, University of Bordeaux; Service de Neurologie (M.D., A.R.), CRC SEP, Centre Hospitalier Universitaire (CHU) de Bordeaux; and INSERM U 1215 (B.B., A.R.), Neurocentre Magendie, University of Bordeaux, France
| | - Nathalie Schmitt
- From the Immunoconcept (M.N.K., A.D., I.H., A.B., N.S.), CNRS UMR 5164, University of Bordeaux; Service de Neurologie (M.D., A.R.), CRC SEP, Centre Hospitalier Universitaire (CHU) de Bordeaux; and INSERM U 1215 (B.B., A.R.), Neurocentre Magendie, University of Bordeaux, France.
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Ma X, Ma R, Zhang M, Qian B, Wang B, Yang W. Recent Progress in Multiple Sclerosis Treatment Using Immune Cells as Targets. Pharmaceutics 2023; 15:pharmaceutics15030728. [PMID: 36986586 PMCID: PMC10057470 DOI: 10.3390/pharmaceutics15030728] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Revised: 02/02/2023] [Accepted: 02/16/2023] [Indexed: 02/24/2023] Open
Abstract
Multiple sclerosis (MS) is an autoimmune-mediated demyelinating disease of the central nervous system. The main pathological features are inflammatory reaction, demyelination, axonal disintegration, reactive gliosis, etc. The etiology and pathogenesis of the disease have not been clarified. The initial studies believed that T cell-mediated cellular immunity is the key to the pathogenesis of MS. In recent years, more and more evidence has shown that B cells and their mediated humoral immune and innate immune cells (such as microglia, dendritic cells, macrophages, etc.) also play an important role in the pathogenesis of MS. This article mainly reviews the research progress of MS by targeting different immune cells and analyzes the action pathways of drugs. The types and mechanisms of immune cells related to the pathogenesis are introduced in detail, and the mechanisms of drugs targeting different immune cells are discussed in depth. This article aims to clarify the pathogenesis and immunotherapy pathway of MS, hoping to find new targets and strategies for the development of therapeutic drugs for MS.
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Affiliation(s)
- Xiaohong Ma
- Department of Neuroscience, The First Affiliated Hospital of Henan University of Chinese Medicine, Zhengzhou 450000, China
- The First Clinical Medical School, Henan University of Chinese Medicine, Zhengzhou 450046, China
| | - Rong Ma
- School of Pharmaceutical Sciences, Henan Key Laboratory of Targeting Therapy and Diagnosis for Critical Diseases, Zhengzhou University, Zhengzhou 450001, China
| | - Mengzhe Zhang
- School of Pharmaceutical Sciences, Henan Key Laboratory of Targeting Therapy and Diagnosis for Critical Diseases, Zhengzhou University, Zhengzhou 450001, China
| | - Baicheng Qian
- Department of Neuroscience, The First Affiliated Hospital of Henan University of Chinese Medicine, Zhengzhou 450000, China
| | - Baoliang Wang
- Department of Neuroscience, The First Affiliated Hospital of Henan University of Chinese Medicine, Zhengzhou 450000, China
- Correspondence: (B.W.); (W.Y.)
| | - Weijing Yang
- School of Pharmaceutical Sciences, Henan Key Laboratory of Targeting Therapy and Diagnosis for Critical Diseases, Zhengzhou University, Zhengzhou 450001, China
- Correspondence: (B.W.); (W.Y.)
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6
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Peptide Mimotope-Enabled Quantification of Natalizumab Arm Exchange During Multiple Sclerosis Treatment. Ther Drug Monit 2023; 45:55-60. [PMID: 36201847 DOI: 10.1097/ftd.0000000000001038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Natalizumab, a therapeutic antibody used to treat multiple sclerosis, undergoes in vivo Fab arm exchange to form a monovalent bispecific antibody. Although highly efficacious, the immunosuppressive activity of natalizumab has been associated with JC polyomavirus-driven progressive multifocal leukoencephalopathy (PML). Development of assays that can distinguish between and quantify bivalent (unexchanged) and monovalent (exchanged) forms of natalizumab in clinical samples may be useful for optimizing extended interval dosing and reducing the risk of PML. METHODS In vitro natalizumab arm exchange was conducted, along with peptide mimotope and anti-idiotype surface capture chemistry, to enable the development of enzyme-linked immunosorbent assays. RESULTS An assay using a unique peptide Veritope TM was developed, which can exclusively bind to bivalent natalizumab. In combination with enzyme-linked immunosorbent assays that quantifies total natalizumab, the assay system allows quantification of both natalizumab forms. CONCLUSIONS In this article, a novel assay for the quantification of unexchanged and exchanged natalizumab variants in clinical samples was developed. This assay will enable investigations into the clinical significance of the relationship of PK/PD with the monovalent-to-bivalent ratio, as it relates to the efficacy of the drug and risk of PML.
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Kim JS, Soto-Diaz K, Bingham TW, Steelman AJ, Das A. Role of omega-3 endocannabinoids in the modulation of T-cell activity in a multiple sclerosis experimental autoimmune encephalomyelitis (EAE) model. J Biol Chem 2023; 299:102886. [PMID: 36626985 PMCID: PMC9926309 DOI: 10.1016/j.jbc.2023.102886] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 12/26/2022] [Accepted: 12/29/2022] [Indexed: 01/09/2023] Open
Abstract
Epidemiological studies show that omega-3 fatty acid consumption is associated with improved conditions in neurodegenerative diseases such as multiple sclerosis (MS). However, the mechanism of this association is not well understood. Emerging evidence suggests that parent molecules such as docosahexaenoic acid are converted into downstream metabolites that are capable of directly modulating immune responses. In vitro, we found that docosahexaenoyl ethanolamide (DHEA), another dietary component and its epoxide metabolite, reduced the polarization of naïve T-cells toward proinflammatory Th1 and Th17 phenotypes. Furthermore, we identified that DHEA and related endocannabinoids are changing during the disease progression in mice undergoing relapse-remitting experimental autoimmune encephalomyelitis (RR-EAE). In addition, daily administration of DHEA to mice delayed the onset of disease, the rate of relapse, and the severity of clinical scores at relapse in RR-EAE, an animal model of MS. Collectively, these data indicate that DHEA and their downstream metabolites reduce the disease severity in the RR-EAE model of MS and can be potential dietary adjuvants to existing MS therapeutics.
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Affiliation(s)
- Justin S. Kim
- School of Chemistry and Biochemistry, Georgia Institute of Technology, Atlanta, Georgia, USA,Division of Nutritional Sciences, University of Illinois at Urbana-Champaign, Urbana, Illinois, USA,Department of Comparative Biosciences, University of Illinois at Urbana-Champaign, Urbana, Illinois, USA
| | - Katiria Soto-Diaz
- Neuroscience Program, Beckman Institute, University of Illinois at Urbana-Champaign, Urbana, Illinois, USA
| | - Tanner W. Bingham
- Department of Chemistry, University of Illinois at Urbana-Champaign, Urbana, Illinois, USA
| | - Andrew J. Steelman
- Division of Nutritional Sciences, University of Illinois at Urbana-Champaign, Urbana, Illinois, USA,Neuroscience Program, Beckman Institute, University of Illinois at Urbana-Champaign, Urbana, Illinois, USA,Carl R. Woese Institute for Genomic Biology, University of Illinois at Urbana-Champaign, Urbana, Illinois, USA,Department of Bioengineering, Cancer Center at Illinois, Beckman Institute for Advanced Science and Technology, University of Illinois at Urbana-Champaign, Urbana, Illinois, USA,For correspondence: Aditi Das; Andrew J. Steelman
| | - Aditi Das
- School of Chemistry and Biochemistry, Georgia Institute of Technology, Atlanta, Georgia, USA; Division of Nutritional Sciences, University of Illinois at Urbana-Champaign, Urbana, Illinois, USA; Department of Comparative Biosciences, University of Illinois at Urbana-Champaign, Urbana, Illinois, USA; Department of Chemistry, University of Illinois at Urbana-Champaign, Urbana, Illinois, USA; Carl R. Woese Institute for Genomic Biology, University of Illinois at Urbana-Champaign, Urbana, Illinois, USA.
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Enhanced pathogenicity of Th17 cells due to natalizumab treatment: Implications for MS disease rebound. Proc Natl Acad Sci U S A 2023; 120:e2209944120. [PMID: 36574650 PMCID: PMC9910615 DOI: 10.1073/pnas.2209944120] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
After natalizumab (NAT) cessation, some multiple sclerosis (MS) patients experience a severe disease rebound. The rebound pathophysiology is still unclear; however, it has been linked to interleukin-17-producing T-helper (Th17) cells. We demonstrate that during NAT treatment, MCAM+CCR6+Th17 cells gradually acquire a pathogenic profile, including proinflammatory cytokine production, pathogenic transcriptional signatures, brain endothelial barrier impairment, and oligodendrocyte damage via induction of apoptotic pathways. This is accompanied by an increase in Th17 cell frequencies in the cerebrospinal fluid of NAT-treated patients. Notably, Th17 cells derived from NAT-treated patients, who later developed a disease rebound upon treatment cessation, displayed a distinct transcriptional pathogenicity profile associated with altered migratory properties. Accordingly, increased brain infiltration of patient Th17 cells was illustrated in a humanized mouse model and brain histology from a rebound patient. Therefore, peripheral blood-accumulated MCAM+CCR6+Th17 cells might be involved in rebound pathophysiology, and monitoring of changes in Th17 cell pathogenicity in patients before/during NAT treatment cessation might enable rebound risk assessment in the future.
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Reverchon F, Guillard C, Mollet L, Auzou P, Gosset D, Madouri F, Valéry A, Menuet A, Ozsancak C, Pallix-Guyot M, Morisset-Lopez S. T Lymphocyte Serotonin 5-HT7 Receptor Is Dysregulated in Natalizumab-Treated Multiple Sclerosis Patients. Biomedicines 2022; 10:biomedicines10102418. [PMID: 36289679 PMCID: PMC9599221 DOI: 10.3390/biomedicines10102418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 09/21/2022] [Accepted: 09/21/2022] [Indexed: 11/24/2022] Open
Abstract
Serotonin (5-HT) is known as a potent immune cell modulator in autoimmune diseases and should be protective in the pathogenesis of multiple sclerosis (MS). Nevertheless, there is limited knowledge about receptors involved in 5-HT effects as well as induced mechanisms. Among 5-HT receptors, the 5-HT7 receptor is able to activate naïve T cells and influence the inflammatory response; however, its involvement in the disease has never been studied so far. In this study, we collected blood sample from three groups: acute relapsing MS patients (ARMS), natalizumab-treated MS patients (NTZ), and control subjects. We investigated the 5-HT7 expression on circulating lymphocytes and evaluated the effects of its activation on cytokine production with peripheral blood mononuclear cell (PBMC) cultures. We found a significant increase in the 5-HT7 surface expression on T lymphocytes and on the different CD4+ T cell subsets exclusively in NTZ-treated patients. We also showed that the selective agonist 5-carboxamidotryptamine (5-CT)-induced 5-HT7R activation significantly promotes the production of IL-10, a potent immunosuppressive cytokine in PBMCs. This study provides for the first time a dysregulation of 5-HT7 expression in NTZ-MS patients and its ability to promote IL-10 release, suggesting its protective role. These findings strengthen the evidence that 5-HT7 may play a role in the immuno-protective mechanisms of NTZ in MS disease and could be considered as an interesting therapeutic target in MS.
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Affiliation(s)
- Flora Reverchon
- UMR7355, Experimental and Molecular Immunology and Neurogenetics, CNRS and University of Orléans, 45071 Orleans, France
- Correspondence: ; Tel.: +33-0238257974
| | - Colleen Guillard
- UPR4301, Center for Molecular Biophysics, CNRS, 45071 Orleans, France
| | - Lucile Mollet
- UPR4301, Center for Molecular Biophysics, CNRS, 45071 Orleans, France
| | - Pascal Auzou
- Neurology Department, Regional Hospital Orleans, 45100 Orleans, France
| | - David Gosset
- UPR4301, Center for Molecular Biophysics, CNRS, 45071 Orleans, France
| | - Fahima Madouri
- UPR4301, Center for Molecular Biophysics, CNRS, 45071 Orleans, France
| | - Antoine Valéry
- Medical Information Department, Regional Hospital Orleans, 45100 Orleans, France
| | - Arnaud Menuet
- UMR7355, Experimental and Molecular Immunology and Neurogenetics, CNRS and University of Orléans, 45071 Orleans, France
| | - Canan Ozsancak
- Neurology Department, Regional Hospital Orleans, 45100 Orleans, France
| | - Maud Pallix-Guyot
- Neurology Department, Regional Hospital Orleans, 45100 Orleans, France
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10
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To the editors: Impact of mass vaccination on SARS-CoV-2 infections among multiple sclerosis patients taking immunomodulatory disease-modifying therapies in England. Mult Scler Relat Disord 2022; 59:103541. [PMID: 35078128 PMCID: PMC8768009 DOI: 10.1016/j.msard.2022.103541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 01/17/2022] [Indexed: 11/23/2022]
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11
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Hussain RZ, Sguigna PV, Okai A, Wright C, Madinawala M, Bass AD, Cutter GR, Manouchehri N, Stuve O. The sequential natalizumab – alemtuzumab therapy in patients with relapsing forms of multiple sclerosis (SUPPRESS) trial – Part I: Rationale and objectives. J Cent Nerv Syst Dis 2022; 14:11795735221123911. [PMID: 36062026 PMCID: PMC9434668 DOI: 10.1177/11795735221123911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Background Natalizumab is a recombinant humanized monoclonal antibody (mAb) against α4-integrin
that is approved for relapsing forms of multiple sclerosis (MS). Natalizumab is
associated with an increased risk of developing progressive multifocal
leukoencephalopathy (PML), and with disease reactivation after cessation of treatment
that is likely mediated by an accumulation of pro-inflammatory lymphocytes in the blood
during therapy. Alemtuzumab is a mAb against CD52 that reduces the number of peripheral
lymphocytes. Rationale To determine if treatment with alemtuzumab after natalizumab reduces disease activity
in patients with relapsing forms of MS. This review article will outline the rationale
and objectives of the sequential natalizumab – alemtuzumab therapy in patients with
relapsing forms of multiple sclerosis (SUPPRESS; ClinicalTrials.gov ID: NCT03135249)
trial in greater detail than would be feasible in a manuscript that summarizes the study
results. Methods The SUPPRESS trial is single arm, open-label, multicenter, efficacy pilot study that
aims to establish a disease-free state over a 24-months period in patients who received
the natalizumab- alemtuzumab sequential therapy. Participants will be recruited from
four different sites. The primary endpoint is the annualized relapse rate (ARR) from the
time of cessation of natalizumab treatment. Key secondary endpoint is freedom of relapse
at 12-months, the number of new/enlarging T2 lesions on magnetic resonance imaging
(MRI), and the number of gadolinium (Gd)-enhancing lesions on MRI. An exploratory
endpoint is the Expanded Disability Status Scale (EDSS), retinal nerve fiber layer
(RNFL) thickness assessment by optic coherence tomography (OCT) and assessment of
quality of life (QoL) measures by a pre-defined, self-administered testing battery. To
evaluate immunological effects, blood leukocytes will be collected and immunophenotyped
by multi-parameter flow cytometry. Conclusion The SUPPRESS trial will provide clinical, imaging, and biological data to determine
whether sequential natalizumab to alemtuzumab combination therapy establish a
disease-free state in patients with relapsing forms of MS.
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Affiliation(s)
- Rehana Z Hussain
- Department of Neurology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Peter V Sguigna
- Department of Neurology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Annette Okai
- North Texas Institute of Neurology & Headache, Plano, TX, USA
| | - Crystal Wright
- Department of Neurology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Mariam Madinawala
- Department of Neurology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Ann D Bass
- Neurology Center of San Antonio, Dallas, TX, USA
| | - Gary R Cutter
- Department of Biostatistics, Section on Research Methods and Clinical Trials, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Navid Manouchehri
- Department of Neurology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Olaf Stuve
- Department of Neurology, University of Texas Southwestern Medical Center, Dallas, TX, USA
- Neurology Section, VA North Texas Health Care System, Dallas, TX, USA
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12
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Song L, Zhou R, Xiao J, He L, Zhu F, Li C, Dai F. Demineralized bone matrix combined with cytotoxic T-lymphocyte-associated protein 4 promotes osteogenic differentiation of human bone marrow mesenchymal stem cells and suppresses the activation of T lymphocytes in vitro. J Tissue Eng Regen Med 2021; 16:290-296. [PMID: 34965018 DOI: 10.1002/term.3281] [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: 10/22/2021] [Revised: 12/22/2021] [Accepted: 12/23/2021] [Indexed: 11/11/2022]
Abstract
Cytotoxic T-lymphocyte-associated protein 4 (CTLA4) can promote osteogenic differentiation of human bone marrow mesenchymal stem cells (hBMMSCs), and CTLA4-modified bone marrow mesenchymal stem cells possess immunoregulatory effects. In the present study, we aimed to construct a new tissue engineering bone using demineralized bone matrix and CTLA4 protein, designated as DBM-CTLA4 (+). The effects of DBM-CTLA4 (+) on the osteogenic differentiation of hBMMSCs and T lymphocyte activation were evaluated through in vitro experiments. The cumulative release of CTLA4 from DBM-CTLA4 (+) was determined using enzyme-linked immunosorbent assay. DBM-CTLA4 (+) was co-cultured in a Transwell chamber with either phytohemagglutinin-treated hBMMSCs or human peripheral blood mononuclear cells (hPBMCs). Osteogenic differentiation of hBMMSCs was assessed by calcium deposition, ALP activity, and the protein levels of COL1A1, RUNX2, BMP2, and OPN. T lymphocyte activity was assessed by measuring the protein levels of IL-2, L-17, HLA-DRA1, IFN-γ, and RANKL. Our results showed that the cumulative release rates of CTLA4 at 7, 14, 21, and 28 days were 12.6% ± 1.4%, 30.2% ± 2.3%, 49.8% ± 3.8%, and 60.5% ± 2.7%, respectively. Compared to the negative control, DBM-CTLA4 (+) promoted the proliferation of hBMMSCs, and enhanced calcium deposition, ALP activity, and protein levels of COL1A1, RUNX2, BMP2, and OPN. Moreover, DBM-CTLA4 (+) decreased the levels of IL-2, IL-17, HLA-DR, IFN-γ, and RANKL in hPBMCs treated with phytohemagglutinin. In conclusion, DBM-CTLA4 (+) promoted proliferation and osteogenic differentiation of hBMMSCs and suppressed T lymphocyte activation.
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Affiliation(s)
- Lei Song
- Department of Orthopedics, First Affiliated Hospital, Army Medical University, Chongqing, China
| | - Rui Zhou
- Department of Orthopedics, First Affiliated Hospital, Army Medical University, Chongqing, China
| | - Jun Xiao
- Department of Orthopedics, First Affiliated Hospital, Army Medical University, Chongqing, China
| | - Lei He
- Department of Orthopedics, First Affiliated Hospital, Army Medical University, Chongqing, China
| | - Fang Zhu
- Department of Orthopedics, First Affiliated Hospital, Army Medical University, Chongqing, China
| | - Congcan Li
- Department of Orthopedics, First Affiliated Hospital, Army Medical University, Chongqing, China
| | - Fei Dai
- Department of Orthopedics, First Affiliated Hospital, Army Medical University, Chongqing, China
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13
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Barbour M, Wood R, Harte T, Bushell TJ, Jiang HR. Anti-CD52 antibody treatment in murine experimental autoimmune encephalomyelitis induces dynamic and differential modulation of innate immune cells in peripheral immune and central nervous systems. Immunology 2021; 165:312-327. [PMID: 34826154 PMCID: PMC9426620 DOI: 10.1111/imm.13437] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 10/31/2021] [Accepted: 11/22/2021] [Indexed: 12/18/2022] Open
Abstract
Anti‐CD52 antibody (anti‐CD52‐Ab) leads to a rapid depletion of T and B cells, followed by reconstitution of immune cells with tolerogenic characteristics. However, very little is known about its effect on innate immune cells. In this study, experimental autoimmune encephalomyelitis mice were administered murine anti‐CD52‐Ab to investigate its effect on dendritic cells and monocytes/macrophages in the periphery lymphoid organs and the central nervous system (CNS). Our data show that blood and splenic innate immune cells exhibited significantly increased expression of MHC‐II and costimulatory molecules, which was associated with increased capacity of activating antigen‐specific T cells, at first day but not three weeks after five daily treatment with anti‐CD52‐Ab in comparison with controls. In contrast to the periphery, microglia and infiltrating macrophages in the CNS exhibited reduced expression levels of MHC‐II and costimulatory molecules after antibody treatment at both time‐points investigated when compared to controls. Furthermore, the transit response of peripheral innate immune cells to anti‐CD52‐Ab treatment was also observed in the lymphocyte‐deficient SCID mice, suggesting the changes are not a direct consequence of the mass depletion of lymphocytes in the periphery. Our study demonstrates a dynamic and tissue‐specific modulation of the innate immune cells in their phenotype and function following the antibody treatment. The findings of differential modulation of the microglia and infiltrating macrophages in the CNS in comparison with the innate immune cells in the peripheral organs support the CNS‐specific beneficial effect of alemtuzumab treatment on inhibiting neuroinflammation in multiple sclerosis patients.
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Affiliation(s)
- Mark Barbour
- Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow, UK
| | - Rachel Wood
- Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow, UK
| | - Tanith Harte
- Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow, UK
| | - Trevor J Bushell
- Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow, UK
| | - Hui-Rong Jiang
- Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow, UK
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14
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Veroni C, Aloisi F. The CD8 T Cell-Epstein-Barr Virus-B Cell Trialogue: A Central Issue in Multiple Sclerosis Pathogenesis. Front Immunol 2021; 12:665718. [PMID: 34305896 PMCID: PMC8292956 DOI: 10.3389/fimmu.2021.665718] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 06/07/2021] [Indexed: 12/11/2022] Open
Abstract
The cause and the pathogenic mechanisms leading to multiple sclerosis (MS), a chronic inflammatory disease of the central nervous system (CNS), are still under scrutiny. During the last decade, awareness has increased that multiple genetic and environmental factors act in concert to modulate MS risk. Likewise, the landscape of cells of the adaptive immune system that are believed to play a role in MS immunopathogenesis has expanded by including not only CD4 T helper cells but also cytotoxic CD8 T cells and B cells. Once the key cellular players are identified, the main challenge is to define precisely how they act and interact to induce neuroinflammation and the neurodegenerative cascade in MS. CD8 T cells have been implicated in MS pathogenesis since the 80's when it was shown that CD8 T cells predominate in MS brain lesions. Interest in the role of CD8 T cells in MS was revived in 2000 and the years thereafter by studies showing that CNS-recruited CD8 T cells are clonally expanded and have a memory effector phenotype indicating in situ antigen-driven reactivation. The association of certain MHC class I alleles with MS genetic risk implicates CD8 T cells in disease pathogenesis. Moreover, experimental studies have highlighted the detrimental effects of CD8 T cell activation on neural cells. While the antigens responsible for T cell recruitment and activation in the CNS remain elusive, the high efficacy of B-cell depleting drugs in MS and a growing number of studies implicate B cells and Epstein-Barr virus (EBV), a B-lymphotropic herpesvirus that is strongly associated with MS, in the activation of pathogenic T cells. This article reviews the results of human studies that have contributed to elucidate the role of CD8 T cells in MS immunopathogenesis, and discusses them in light of current understanding of autoreactivity, B-cell and EBV involvement in MS, and mechanism of action of different MS treatments. Based on the available evidences, an immunopathological model of MS is proposed that entails a persistent EBV infection of CNS-infiltrating B cells as the target of a dysregulated cytotoxic CD8 T cell response causing CNS tissue damage.
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Affiliation(s)
| | - Francesca Aloisi
- Department of Neuroscience, Istituto Superiore di Sanità, Rome, Italy
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15
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Small noncoding RNA profiling across cellular and biofluid compartments and their implications for multiple sclerosis immunopathology. Proc Natl Acad Sci U S A 2021; 118:2011574118. [PMID: 33879606 PMCID: PMC8092379 DOI: 10.1073/pnas.2011574118] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Dysregulation of microRNAs (miRNAs), a type of small noncoding RNAs (sncRNAs), has frequently been associated with multiple sclerosis (MS). However, most studies have focused on peripheral blood, and few investigated other classes of sncRNAs. To address this, we analyzed all classes of sncRNAs in matching peripheral blood mononuclear cells, plasma, cerebrospinal fluid (CSF) cells, and cell-free CSF from MS patients and controls. We demonstrate widespread alterations of small nuclear (snRNA)–derived RNAs, small nucleolar-derived RNAs (sdRNAs), transfer RNA–derived fragments, and miRNAs, particularly in CSF cells. The striking contrast between the periphery and central nervous system and between relapse and remission phases of disease highlights the importance of sncRNA-mediated mechanisms in MS, in particular alternative splicing and mRNA translation. Multiple sclerosis (MS) is a chronic inflammatory demyelinating disease affecting the central nervous system (CNS). Small non-coding RNAs (sncRNAs) and, in particular, microRNAs (miRNAs) have frequently been associated with MS. Here, we performed a comprehensive analysis of all classes of sncRNAs in matching samples of peripheral blood mononuclear cells (PBMCs), plasma, cerebrospinal fluid (CSF) cells, and cell-free CSF from relapsing-remitting (RRMS, n = 12 in relapse and n = 11 in remission) patients, secondary progressive (SPMS, n = 6) MS patients, and noninflammatory and inflammatory neurological disease controls (NINDC, n = 11; INDC, n = 5). We show widespread changes in miRNAs and sncRNA-derived fragments of small nuclear, nucleolar, and transfer RNAs. In CSF cells, 133 out of 133 and 115 out of 117 differentially expressed sncRNAs were increased in RRMS relapse compared to remission and RRMS compared to NINDC, respectively. In contrast, 65 out of 67 differentially expressed PBMC sncRNAs were decreased in RRMS compared to NINDC. The striking contrast between the periphery and CNS suggests that sncRNA-mediated mechanisms, including alternative splicing, RNA degradation, and mRNA translation, regulate the transcriptome of pathogenic cells primarily in the CNS target organ.
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16
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Zanghì A, Gallo A, Avolio C, Capuano R, Lucchini M, Petracca M, Bonavita S, Lanzillo R, Ferraro D, Curti E, Buccafusca M, Callari G, Barone S, Pontillo G, Abbadessa G, Di Francescantonio V, Signoriello E, Lus G, Sola P, Granella F, Valentino P, Mirabella M, Patti F, D'Amico E. Exit Strategies in Natalizumab-Treated RRMS at High Risk of Progressive Multifocal Leukoencephalopathy: a Multicentre Comparison Study. Neurotherapeutics 2021; 18:1166-1174. [PMID: 33844155 PMCID: PMC8423885 DOI: 10.1007/s13311-021-01037-2] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/09/2021] [Indexed: 11/27/2022] Open
Abstract
The main aim of the study is to evaluate the efficacy and safety profile of ocrelizumab (OCR), rituximab (RTX), and cladribine (CLA), employed as natalizumab (NTZ) exit strategies in relapsing-remitting multiple sclerosis (RRMS) patients at high-risk for progressive multifocal leukoencephalopathy (PML). This is a multicentre, retrospective, real-world study on consecutive RRMS patients from eleven tertiary Italian MS centres, who switched from NTZ to OCR, RTX, and CLA from January 1st, 2019, to December 31st, 2019. The primary study outcomes were the annualized relapse rate (ARR) and magnetic resonance imaging (MRI) outcome. Treatment effects were estimated by the inverse probability treatment weighting (IPTW), based on propensity-score (PS) approach. Additional endpoint included confirmed disability progression (CDP) as measured by Expanded Disability Status Scale and adverse events (AEs). Patients satisfying predefined inclusion and exclusion criteria were 120; 64 switched to OCR, 36 to RTX, and 20 to CLA. Patients from the 3 groups did not show differences for baseline characteristics, also after post hoc analysis. The IPTW PS-adjusted models revealed that patients on OCR had a lower risk for ARR than patients on CLA (ExpBOCR 0.485, CI 95% 0.264-0.893, p = 0.020). This result was confirmed also for 12-month MRI activity (ExpBOCR 0.248 CI 95% 0.065-0.948, p = 0.042). No differences were found in other pairwise comparisons (OCR vs RTX and RTX vs CLA) for the investigated outcomes. AEs were similar among the 3 groups. Anti-CD20 drugs were revealed to be effective and safe options as NTZ exit strategies. All investigated DMTs showed a good safety profile.
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Affiliation(s)
- Aurora Zanghì
- Department "G.F. Ingrassia", MS Center, Organization University of Catania, Catania, Italy
| | - Antonio Gallo
- MS Center I Division of Neurology, University Della Campania "L. Vanvitelli", Naples, Italy
| | - Carlo Avolio
- Department of Medical and Surgical Sciences Head of Multiple Sclerosis Center Dept. of Neurosciences, University of Foggia, Foggia, Italy
| | - Rocco Capuano
- MS Center I Division of Neurology, University Della Campania "L. Vanvitelli", Naples, Italy
| | - Matteo Lucchini
- Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Istituto di Neurologia, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Maria Petracca
- Department of Neuroscience, Reproductive Sciences and Odontostomatology, University of Naples "Federico II", Naples, Italy
| | - Simona Bonavita
- Dipartimento Di Scienze Mediche E Chirurgiche Avanzate, Università Della Campania Luigi Vanvitelli, Piazza Miraglia, 2, 80138, Naples, Italy
| | - Roberta Lanzillo
- Department of Neuroscience, Reproductive Sciences and Odontostomatology, University of Naples "Federico II", Naples, Italy
| | - Diana Ferraro
- University of Modena and Reggio Emilia, Modena, Italy
| | - Erica Curti
- Multiple Sclerosis Centre, Department of General Medicine, Parma University Hospital, Parma, Italy
| | | | | | - Stefania Barone
- Azienda Ospedaliera Universitaria "Mater Domini", Catanzaro, Italy
| | - Giuseppe Pontillo
- Department of Advanced Biomedical Sciences, University "Federico II", Naples, Italy
- Department of Electrical Engineering and Information Technology, , University "Federico II", Naples, Italy
| | - Gianmarco Abbadessa
- Dipartimento Di Scienze Mediche E Chirurgiche Avanzate, Università Della Campania Luigi Vanvitelli, Piazza Miraglia, 2, 80138, Napoli, Italy
| | - Valeria Di Francescantonio
- Department of Medical and Surgical Sciences Head of Multiple Sclerosis Center Dept. of Neurosciences, University of Foggia, Foggia, Italy
| | - Elisabetta Signoriello
- Department of Clinical and Experimental Medicine, Multiple Sclerosis Center, II Division of Neurology, Second University of Naples, Naples, Italy
| | - Giacomo Lus
- Department of Clinical and Experimental Medicine, Multiple Sclerosis Center, II Division of Neurology, Second University of Naples, Naples, Italy
| | - Patrizia Sola
- University of Modena and Reggio Emilia, Modena, Italy
| | - Franco Granella
- Multiple Sclerosis Centre, Department of General Medicine, Parma University Hospital, Parma, Italy
- Unit of Neurosciences, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Paola Valentino
- Azienda Ospedaliera Universitaria "Mater Domini", Catanzaro, Italy
| | - Massimiliano Mirabella
- Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Istituto di Neurologia, Università Cattolica del Sacro Cuore, Rome, Italy
- Università Cattolica del Sacro Cuore, Rome, Italy
| | - Francesco Patti
- Department "G.F. Ingrassia", MS Center, Organization University of Catania, Catania, Italy
| | - Emanuele D'Amico
- Department "G.F. Ingrassia", MS Center, Organization University of Catania, Catania, Italy.
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Clinical Immunological Correlations in Patients with Multiple Sclerosis Treated with Natalizumab. Brain Sci 2020; 10:brainsci10110802. [PMID: 33143271 PMCID: PMC7692182 DOI: 10.3390/brainsci10110802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 10/22/2020] [Accepted: 10/29/2020] [Indexed: 11/17/2022] Open
Abstract
Natalizumab (NAT) was the first disease modifying therapy used for the treatment of relapsing-remitting multiple sclerosis (MS) that was designed with a specific mechanism of action that targets an important step of the MS immunopathology, directly blocking the T lymphocyte intrusion in the central nervous system. Initially, it was considered that NAT carried no biological effects on the peripheral immune response. The purpose of our study was to assess the effects of NAT on the peripheral pro and anti-inflammatory cytokines and to reveal possible correlations between them and the clinical activity of the disease. We noticed a significant decrease in interleukin (IL)-17, tumor necrosis factor-alpha (TNF-α) and IL-31 serum levels in treated patients. The lack of relapses during the study was associated with low baseline IL-17 level. The patients that had an increase in the disability score during the study had significantly lower IL-17 and higher IL-1β baseline levels. IL-17 can be used as a biomarker for disease activity but also for progression assessment in NAT treated patients. NAT has a far more complex mechanism compared to what was initially believed, besides modulating lymphocyte trafficking through the blood–brain barrier, it also changes the peripheral levels of pro and anti-inflammatory cytokines in MS patients.
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Jakimovski D, Vaughn CB, Eckert S, Zivadinov R, Weinstock-Guttman B. Long-term drug treatment in multiple sclerosis: safety success and concerns. Expert Opin Drug Saf 2020; 19:1121-1142. [PMID: 32744073 DOI: 10.1080/14740338.2020.1805430] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
INTRODUCTION The portfolio of multiple sclerosis (MS) disease modifying treatments (DMTs) has significantly expanded over the past two decades. Given the lifelong use of MS pharmacotherapy, understanding their long-term safety profiles is essential in determining suitable and personalized treatment. AREAS COVERED In this narrative review, we summarize the short-, mid-, and long-term safety profile of currently available MS DMTs categories. In addition to the initial trial findings, safety outcomes derived from long-term extension studies (≥5-20 years) and safety-based prescription programs have been reviewed. In order to better understand the risk-benefit ratio for each particular DMT group, a short description of the DMT-based efficacy outcomes has been included. EXPERT OPINION Long-term extension trials, large observational studies and real-world databases allow detection of rare and potentially serious adverse events. Two-year-long trials are unable to fully capture the positive and negative effects of immune system modulation and reconstitution. DMT-based monitoring programs can provide greater insights regarding safe use of MS medications in different patient populations and clinical settings. During the process of shared DMT decision, both MS care providers and their patients should be aware of an ever-expanding number of drug-based adverse events and their influence on the risk-benefit analysis.
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Affiliation(s)
- Dejan Jakimovski
- Buffalo Neuroimaging Analysis Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York , Buffalo, NY, USA
| | - Caila B Vaughn
- Jacobs Comprehensive MS Treatment and Research Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences University at Buffalo , Buffalo, NY, USA
| | - Svetlana Eckert
- Jacobs Comprehensive MS Treatment and Research Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences University at Buffalo , Buffalo, NY, USA
| | - Robert Zivadinov
- Buffalo Neuroimaging Analysis Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York , Buffalo, NY, USA.,Translational Imaging Center at Clinical Translational Research Center, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Stat37$e University of New York , Buffalo, NY, USA
| | - Bianca Weinstock-Guttman
- Jacobs Comprehensive MS Treatment and Research Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences University at Buffalo , Buffalo, NY, USA
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Moser T, Akgün K, Proschmann U, Sellner J, Ziemssen T. The role of TH17 cells in multiple sclerosis: Therapeutic implications. Autoimmun Rev 2020; 19:102647. [PMID: 32801039 DOI: 10.1016/j.autrev.2020.102647] [Citation(s) in RCA: 144] [Impact Index Per Article: 36.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 03/08/2020] [Indexed: 12/13/2022]
Abstract
Multiple sclerosis (MS) is an inflammatory demyelinating disease of the central nervous system (CNS) where immunopathology is thought to be mediated by myelin-reactive CD4+ T helper (TH) cells. The TH cells most commonly implicated in the pathogenesis of the disease are of TH1 and TH17 lineage, which are defined by the production of interferon-γ and interleukin-17, respectively. Moreover, there is emerging evidence for the involvement of TH17.1 cells, which share the hallmarks of TH1 and TH17 subsets. In this review, we summarise current knowledge about the potential role of TH17 subsets in the initiation and progression of the disease and put a focus on their response to approved immunomodulatory MS drugs. In this regard, TH17 cells are abundant in peripheral blood, cerebrospinal fluid and brain lesions of MS patients, and their counts and inflammatory mediators are further increased during relapses. Fingolimod and alemtuzumab induce a paramount decrease in central memory T cells, which harbour the majority of peripheral TH17 cells, while the efficacy of natalizumab, dimethyl fumarate and importantly hematopoietic stem cell therapy correlates with TH17.1 cell inhibition. Interestingly, also CD20 antibodies target highly inflammatory TH cells and hamper TH17 differentiation by IL-6 reductions. Moreover, recovery rates of TH cells best correlate with long-term efficacy after therapeutical immunodepletion. We conclude that central memory TH17.1 cells play a pivotal role in MS pathogenesis and they represent a major target of MS therapeutics.
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Affiliation(s)
- Tobias Moser
- Center of Clinical Neuroscience, University Hospital Carl Gustav Carus, Dresden University of Technical, Fetscherstrasse 74, 01307 Dresden, Germany; Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University, Ignaz-Harrer-Straße 79, 5020 Salzburg, Austria
| | - Katja Akgün
- Center of Clinical Neuroscience, University Hospital Carl Gustav Carus, Dresden University of Technical, Fetscherstrasse 74, 01307 Dresden, Germany
| | - Undine Proschmann
- Center of Clinical Neuroscience, University Hospital Carl Gustav Carus, Dresden University of Technical, Fetscherstrasse 74, 01307 Dresden, Germany
| | - Johann Sellner
- Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University, Ignaz-Harrer-Straße 79, 5020 Salzburg, Austria; Department of Neurology, Landesklinikum Mistelbach-Gänserndorf, Liechtensteinstrasse 67, 3120 Mistelbach, Austria; Department of Neurology, Klinikum rechts der Isar, Technische Universität München, Ismaninger Strasse 22, 81675 München, Germany
| | - Tjalf Ziemssen
- Center of Clinical Neuroscience, University Hospital Carl Gustav Carus, Dresden University of Technical, Fetscherstrasse 74, 01307 Dresden, Germany.
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20
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Rimmer K, Farber R, Thakur K, Braverman G, Podolsky D, Sutherland L, Migliore C, Ryu YK, Levin S, De Jager PL, Vargas W, Levine L, Riley CS. Fatal COVID-19 in an MS patient on natalizumab: A case report. Mult Scler J Exp Transl Clin 2020; 6:2055217320942931. [PMID: 32850133 PMCID: PMC7425275 DOI: 10.1177/2055217320942931] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Accepted: 06/22/2020] [Indexed: 01/20/2023] Open
Abstract
We report a fatal case of COVID-19 in a 51-year-old African American woman with multiple sclerosis on natalizumab. She had multiple risk factors for severe COVID-19 disease including race, obesity, hypertension, and elevated inflammatory markers, but the contribution of natalizumab to her poor outcome remains unknown. We consider whether altered dynamics of peripheral immune cells in the context of natalizumab treatment could worsen the cytokine storm syndrome associated with severe COVID-19. We discuss extended interval dosing as a risk-reduction strategy for multiple sclerosis patients on natalizumab, and the use of interleukin-6 inhibitors in such patients who contract COVID-19.
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Affiliation(s)
- Kathryn Rimmer
- Department of Neurology and Taub Institute for Research on Alzheimer's Disease and the Aging Brain, Multiple Sclerosis Center and Center for Translational and Computational Neuroimmunology, Columbia University Irving Medical Center, United States of America.,New York Presbyterian Hospital, United States of America
| | - Rebecca Farber
- Department of Neurology and Taub Institute for Research on Alzheimer's Disease and the Aging Brain, Multiple Sclerosis Center and Center for Translational and Computational Neuroimmunology, Columbia University Irving Medical Center, United States of America.,New York Presbyterian Hospital, United States of America
| | - Kiran Thakur
- Department of Neurology and Taub Institute for Research on Alzheimer's Disease and the Aging Brain, Multiple Sclerosis Center and Center for Translational and Computational Neuroimmunology, Columbia University Irving Medical Center, United States of America.,New York Presbyterian Hospital, United States of America
| | | | - Dina Podolsky
- New York Presbyterian Hospital, United States of America
| | | | | | - Yun Kyoung Ryu
- New York Presbyterian Hospital, United States of America
| | - Seth Levin
- Department of Neurology and Taub Institute for Research on Alzheimer's Disease and the Aging Brain, Multiple Sclerosis Center and Center for Translational and Computational Neuroimmunology, Columbia University Irving Medical Center, United States of America.,New York Presbyterian Hospital, United States of America
| | - Philip L De Jager
- Department of Neurology and Taub Institute for Research on Alzheimer's Disease and the Aging Brain, Multiple Sclerosis Center and Center for Translational and Computational Neuroimmunology, Columbia University Irving Medical Center, United States of America.,New York Presbyterian Hospital, United States of America
| | - Wendy Vargas
- Department of Neurology and Taub Institute for Research on Alzheimer's Disease and the Aging Brain, Multiple Sclerosis Center and Center for Translational and Computational Neuroimmunology, Columbia University Irving Medical Center, United States of America.,New York Presbyterian Hospital, United States of America
| | - Libby Levine
- Department of Neurology and Taub Institute for Research on Alzheimer's Disease and the Aging Brain, Multiple Sclerosis Center and Center for Translational and Computational Neuroimmunology, Columbia University Irving Medical Center, United States of America.,New York Presbyterian Hospital, United States of America
| | - Claire S Riley
- Department of Neurology and Taub Institute for Research on Alzheimer's Disease and the Aging Brain, Multiple Sclerosis Center and Center for Translational and Computational Neuroimmunology, Columbia University Irving Medical Center, United States of America.,New York Presbyterian Hospital, United States of America
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21
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Nair-Gupta P, Rudnick SI, Luistro L, Smith M, McDaid R, Li Y, Pillarisetti K, Joseph J, Heidrich B, Packman K, Attar R, Gaudet F. Blockade of VLA4 sensitizes leukemic and myeloma tumor cells to CD3 redirection in the bone marrow microenvironment. Blood Cancer J 2020; 10:65. [PMID: 32483120 PMCID: PMC7264144 DOI: 10.1038/s41408-020-0331-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 05/11/2020] [Accepted: 05/18/2020] [Indexed: 01/08/2023] Open
Abstract
Redirecting T cells to specifically kill malignant cells has been validated as an effective anti-cancer strategy in the clinic with the approval of blinatumomab for acute lymphoblastic leukemia. However, the immunosuppressive nature of the tumor microenvironment potentially poses a significant hurdle to T cell therapies. In hematological malignancies, the bone marrow (BM) niche is protective to leukemic stem cells and has minimized the efficacy of several anti-cancer drugs. In this study, we investigated the impact of the BM microenvironment on T cell redirection. Using bispecific antibodies targeting specific tumor antigens (CD123 and BCMA) and CD3, we observed that co-culture of acute myeloid leukemia or multiple myeloma cells with BM stromal cells protected tumor cells from bispecific antibody-T cell-mediated lysis in vitro and in vivo. Impaired CD3 redirection cytotoxicity was correlated with reduced T cell effector responses and cell-cell contact with stromal cells was implicated in reducing T cell activation and conferring protection of cancer cells. Finally, blocking the VLA4 adhesion pathway in combination with CD3 redirection reduced the stromal-mediated inhibition of cytotoxicity and T cell activation. Our results lend support to inhibiting VLA4 interactions along with administering CD3 redirection therapeutics as a novel combinatorial regimen for robust anti-cancer responses.
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MESH Headings
- Animals
- Antibodies, Bispecific/pharmacology
- Antibodies, Bispecific/therapeutic use
- Antineoplastic Agents, Immunological/pharmacology
- Antineoplastic Agents, Immunological/therapeutic use
- B-Cell Maturation Antigen/antagonists & inhibitors
- B-Cell Maturation Antigen/immunology
- Bone Marrow/drug effects
- Bone Marrow/immunology
- Bone Marrow/pathology
- CD3 Complex/antagonists & inhibitors
- CD3 Complex/immunology
- Cell Line, Tumor
- Female
- Humans
- Integrin alpha4beta1/antagonists & inhibitors
- Integrin alpha4beta1/immunology
- Interleukin-3 Receptor alpha Subunit/antagonists & inhibitors
- Interleukin-3 Receptor alpha Subunit/immunology
- Leukemia, Myeloid, Acute/drug therapy
- Leukemia, Myeloid, Acute/immunology
- Leukemia, Myeloid, Acute/pathology
- Mice
- Multiple Myeloma/drug therapy
- Multiple Myeloma/immunology
- Multiple Myeloma/pathology
- T-Lymphocytes/drug effects
- T-Lymphocytes/immunology
- T-Lymphocytes/pathology
- Tumor Microenvironment/drug effects
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Affiliation(s)
| | | | | | - Melissa Smith
- Janssen Research & Development LLC, Spring House, PA, USA
| | - Ronan McDaid
- Janssen Research & Development LLC, Spring House, PA, USA
| | - Yingzhe Li
- Janssen Research & Development LLC, Spring House, PA, USA
| | | | - Jocelin Joseph
- Janssen Research & Development LLC, Spring House, PA, USA
| | | | | | - Ricardo Attar
- Janssen Research & Development LLC, Spring House, PA, USA
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22
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Gross CC, Pawlitzki M, Schulte-Mecklenbeck A, Rolfes L, Ruck T, Hundehege P, Wiendl H, Herty M, Meuth SG. Generation of a Model to Predict Differentiation and Migration of Lymphocyte Subsets under Homeostatic and CNS Autoinflammatory Conditions. Int J Mol Sci 2020; 21:ijms21062046. [PMID: 32192056 PMCID: PMC7139518 DOI: 10.3390/ijms21062046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 03/12/2020] [Accepted: 03/13/2020] [Indexed: 12/15/2022] Open
Abstract
The central nervous system (CNS) is an immune-privileged compartment that is separated from the circulating blood and the peripheral organs by the blood–brain and the blood–cerebrospinal fluid (CSF) barriers. Transmigration of lymphocyte subsets across these barriers and their activation/differentiation within the periphery and intrathecal compartments in health and autoinflammatory CNS disease are complex. Mathematical models are warranted that qualitatively and quantitatively predict the distribution and differentiation stages of lymphocyte subsets in the blood and CSF. Here, we propose a probabilistic mathematical model that (i) correctly reproduces acquired data on location and differentiation states of distinct lymphocyte subsets under homeostatic and neuroinflammatory conditions, (ii) provides a quantitative assessment of differentiation and transmigration rates under these conditions, (iii) correctly predicts the qualitative behavior of immune-modulating therapies, (iv) and enables simulation-based prediction of distribution and differentiation stages of lymphocyte subsets in the case of limited access to biomaterial. Taken together, this model might reduce future measurements in the CSF compartment and allows for the assessment of the effectiveness of different immune-modulating therapies.
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Affiliation(s)
- Catharina C. Gross
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Albert-Schweitzer-Campus 1, Building A01, D-48149 Münster, Germany; (M.P.); (A.S.-M.); (L.R.); (T.R.); (P.H.); (H.W.); (S.G.M.)
- Correspondence:
| | - Marc Pawlitzki
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Albert-Schweitzer-Campus 1, Building A01, D-48149 Münster, Germany; (M.P.); (A.S.-M.); (L.R.); (T.R.); (P.H.); (H.W.); (S.G.M.)
| | - Andreas Schulte-Mecklenbeck
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Albert-Schweitzer-Campus 1, Building A01, D-48149 Münster, Germany; (M.P.); (A.S.-M.); (L.R.); (T.R.); (P.H.); (H.W.); (S.G.M.)
| | - Leoni Rolfes
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Albert-Schweitzer-Campus 1, Building A01, D-48149 Münster, Germany; (M.P.); (A.S.-M.); (L.R.); (T.R.); (P.H.); (H.W.); (S.G.M.)
| | - Tobias Ruck
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Albert-Schweitzer-Campus 1, Building A01, D-48149 Münster, Germany; (M.P.); (A.S.-M.); (L.R.); (T.R.); (P.H.); (H.W.); (S.G.M.)
| | - Petra Hundehege
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Albert-Schweitzer-Campus 1, Building A01, D-48149 Münster, Germany; (M.P.); (A.S.-M.); (L.R.); (T.R.); (P.H.); (H.W.); (S.G.M.)
| | - Heinz Wiendl
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Albert-Schweitzer-Campus 1, Building A01, D-48149 Münster, Germany; (M.P.); (A.S.-M.); (L.R.); (T.R.); (P.H.); (H.W.); (S.G.M.)
| | - Michael Herty
- Institute of Geometry and Applied Mathematics, RWTH Aachen University, Templergraben 55, D-52056 Aachen, Germany;
| | - Sven G. Meuth
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Albert-Schweitzer-Campus 1, Building A01, D-48149 Münster, Germany; (M.P.); (A.S.-M.); (L.R.); (T.R.); (P.H.); (H.W.); (S.G.M.)
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23
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Cathérine D, Annelien DP, Anne S, Luc A, Liesbeth VH, Gerlo S, Guy L. End of dose interval symptoms in patients treated with natalizumab: A role for serum cytokines? Mult Scler Relat Disord 2020; 41:102020. [PMID: 32146430 DOI: 10.1016/j.msard.2020.102020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 01/22/2020] [Accepted: 02/21/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Many natalizumab treated patients experience end of dose interval (EDI) symptoms towards the end of the administration cycle. Natalizumab has previously shown to influence cytokine profiles in relapsing remitting MS patients. We hypothesize that EDI symptoms might be explained by variability in serum cytokine levels during natalizumab treatment. METHODS 42 relapsing remitting MS patients were included. Participants were evaluated before natalizumab administration (day 0) and 7 days afterwards (day 7). At both time points fatigue, depressed mood and cognition were evaluated using the fatigue severity scale (FSS), the visual analogue scale for fatigue (VAS-F), the symbol digit modality test (SDMT) and the inventory for depressive symptomatology (IDS-SR). Serum samples were tested for concentrations of IL-6, IFN-γ and TNF-α at both timepoints. On day 7 an additional EDI questionnaire was completed. Data were analyzed with SPSS by means of non-parametric tests. RESULTS EDI symptoms were reported by 59.5%. Although fatigue was most frequently reported, fatigue scales did not significantly change from day 0 to 7 in (fatigued) EDI patients. Mood and cognition significantly ameliorated in both EDI and non-EDI patients. Cytokines remained stable at day 0 vs 7 except for a significant increase in IFN-γ. On day 0, IFN-γ concentration was positively correlated with a depressed mood in the whole cohort, and with mood and fatigue in the EDI group. Depressed mood positively whilst cognition negatively correlated with IFN-γ concentration on day 0 in the EDI subgroup reporting fatigue. No significant correlations between IL-6 nor TNF-α and symptom scores could be found. CONCLUSION In our study EDI symptoms could not be objectified since EDI and non-EDI groups did not differ in terms of change in mood, cognition and fatigue between day 0 and 7 suggesting that symptom recrudescence could be a subjective experience. Although our results need to be interpreted cautiously, we found no clear correlation between studied serum cytokines concentrations and the occurrence of EDI symptoms.
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Affiliation(s)
- Dekeyser Cathérine
- Department of Neurology, UZ Gent, Corneel Heymanslaan 10, Gent, Belgium.
| | - De Pue Annelien
- Department of Neurology, AZ St. Lucas, Groenebriel 1, Gent, Belgium
| | - Sieben Anne
- Department of Neurology, UZ Gent, Corneel Heymanslaan 10, Gent, Belgium; Department of Neurology, AZ Jan Palfijn, Henri Dunantlaan 5, Gent, Belgium
| | - Algoed Luc
- Department of Neurology, AZ Maria Middelares, Buitenring-Sint-Denijs 30, Gent, Belgium
| | | | - Sarah Gerlo
- VIB Center for Medical Biotechnology, Albert Baertsoenkaai 3, Gent, Belgium; Department of Biomolecular Medicine, UGent, Albert Baertsoenkaai 3, Gent, Belgium
| | - Laureys Guy
- Department of Neurology, UZ Gent, Corneel Heymanslaan 10, Gent, Belgium.
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24
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Kunkl M, Frascolla S, Amormino C, Volpe E, Tuosto L. T Helper Cells: The Modulators of Inflammation in Multiple Sclerosis. Cells 2020; 9:cells9020482. [PMID: 32093011 PMCID: PMC7072830 DOI: 10.3390/cells9020482] [Citation(s) in RCA: 129] [Impact Index Per Article: 32.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Revised: 02/17/2020] [Accepted: 02/18/2020] [Indexed: 02/06/2023] Open
Abstract
Multiple sclerosis (MS) is a chronic neurodegenerative disease characterized by the progressive loss of axonal myelin in several areas of the central nervous system (CNS) that is responsible for clinical symptoms such as muscle spasms, optic neuritis, and paralysis. The progress made in more than one decade of research in animal models of MS for clarifying the pathophysiology of MS disease validated the concept that MS is an autoimmune inflammatory disorder caused by the recruitment in the CNS of self-reactive lymphocytes, mainly CD4+ T cells. Indeed, high levels of T helper (Th) cells and related cytokines and chemokines have been found in CNS lesions and in cerebrospinal fluid (CSF) of MS patients, thus contributing to the breakdown of the blood-brain barrier (BBB), the activation of resident astrocytes and microglia, and finally the outcome of neuroinflammation. To date, several types of Th cells have been discovered and designated according to the secreted lineage-defining cytokines. Interestingly, Th1, Th17, Th1-like Th17, Th9, and Th22 have been associated with MS. In this review, we discuss the role and interplay of different Th cell subpopulations and their lineage-defining cytokines in modulating the inflammatory responses in MS and the approved as well as the novel therapeutic approaches targeting T lymphocytes in the treatment of the disease.
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Affiliation(s)
- Martina Kunkl
- Department of Biology and Biotechnology Charles Darwin, Sapienza University, 00185 Rome, Italy
- Laboratory affiliated to Istituto Pasteur Italia-Fondazione Cenci Bolognetti, Sapienza University, 00185 Rome, Italy
| | - Simone Frascolla
- Department of Biology and Biotechnology Charles Darwin, Sapienza University, 00185 Rome, Italy
- Laboratory affiliated to Istituto Pasteur Italia-Fondazione Cenci Bolognetti, Sapienza University, 00185 Rome, Italy
| | - Carola Amormino
- Department of Biology and Biotechnology Charles Darwin, Sapienza University, 00185 Rome, Italy
- Laboratory affiliated to Istituto Pasteur Italia-Fondazione Cenci Bolognetti, Sapienza University, 00185 Rome, Italy
| | - Elisabetta Volpe
- Neuroimmunology Unit, IRCCS Santa Lucia Foundation, 00143 Rome, Italy
| | - Loretta Tuosto
- Department of Biology and Biotechnology Charles Darwin, Sapienza University, 00185 Rome, Italy
- Laboratory affiliated to Istituto Pasteur Italia-Fondazione Cenci Bolognetti, Sapienza University, 00185 Rome, Italy
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25
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Petersen E, Ammitzbøll C, Søndergaard H, Oturai A, Sørensen P, Nilsson A, Börnsen L, von Essen M, Sellebjerg F. Expression of melanoma cell adhesion molecule-1 (MCAM-1) in natalizumab-treated multiple sclerosis. J Neuroimmunol 2019; 337:577085. [DOI: 10.1016/j.jneuroim.2019.577085] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 10/06/2019] [Accepted: 10/07/2019] [Indexed: 12/21/2022]
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26
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Cohan SL, Edwards K, Lucas L, Gervasi-Follmar T, O'Connor J, Siuta J, Kamath V, Garten L, Chen C, Thomas J, Smoot K, Kresa-Reahl K, Spinelli KJ. Reducing return of disease activity in patients with relapsing multiple sclerosis transitioned from natalizumab to teriflunomide: 12-month interim results of teriflunomide therapy. Mult Scler J Exp Transl Clin 2019; 5:2055217318824618. [PMID: 30729028 PMCID: PMC6350141 DOI: 10.1177/2055217318824618] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Revised: 12/14/2018] [Accepted: 12/17/2018] [Indexed: 11/16/2022] Open
Abstract
Background Natalizumab is an effective treatment for relapsing multiple sclerosis.
Return of disease activity upon natalizumab discontinuance creates the need
for follow-up therapeutic strategies. Objective To assess the efficacy of teriflunomide following natalizumab discontinuance
in relapsing multiple sclerosis patients. Methods Clinically stable relapsing multiple sclerosis patients completing 12 or more
consecutive months of natalizumab, testing positive for anti-John Cunningham
virus antibody, started teriflunomide 14 mg/day, 28 ± 7 days after their
final natalizumab infusion. Physical examination, Expanded Disability Status
Scale, laboratory assessments, and brain magnetic resonance imaging were
performed at screening and multiple follow-up visits. Results Fifty-five patients were enrolled in the study. The proportion of patients
relapse-free was 0.94, restricted mean time to first gadolinium-enhancing
lesion was 10.9 months and time to 3-month sustained disability worsening
was 11.8 months. The mean number of new or enlarging T2 lesions per patient
at 12 months was 0.42. Exploratory analyses revealed an annualized relapse
rate of 0.08, and a proportion of patients with no evidence of disease
activity of 0.68. Forty-seven patients (85.5%) reported adverse events, 95%
of which were mild to moderate. Conclusions Teriflunomide therapy initiated without natalizumab washout resulted in a low
rate of return of disease activity. Clinicians may consider this a
worthwhile strategy when transitioning clinically stable patients off
natalizumab to another therapy. ClinicalTrials.gov Identifier: NCT01970410
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Affiliation(s)
- Stanley L Cohan
- Providence Multiple Sclerosis Center, Providence Brain and Spine Institute, USA
| | - Keith Edwards
- Multiple Sclerosis Center of Northeastern New York, USA
| | - Lindsay Lucas
- Providence Multiple Sclerosis Center, Providence Brain and Spine Institute, USA
| | | | - Judy O'Connor
- Multiple Sclerosis Center of Northeastern New York, USA
| | - Jessica Siuta
- Multiple Sclerosis Center of Northeastern New York, USA
| | | | - Lore Garten
- Multiple Sclerosis Center of Northeastern New York, USA
| | - Chiayi Chen
- Providence Multiple Sclerosis Center, Providence Brain and Spine Institute, USA
| | - James Thomas
- ImageCare, Medical Imaging of Community Care Physicians, USA
| | - Kyle Smoot
- Providence Multiple Sclerosis Center, Providence Brain and Spine Institute, USA
| | - Kiren Kresa-Reahl
- Providence Multiple Sclerosis Center, Providence Brain and Spine Institute, USA
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27
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Kaufmann M, Haase R, Proschmann U, Ziemssen T, Akgün K. Real-World Lab Data in Natalizumab Treated Multiple Sclerosis Patients Up to 6 Years Long-Term Follow Up. Front Neurol 2018; 9:1071. [PMID: 30581413 PMCID: PMC6292961 DOI: 10.3389/fneur.2018.01071] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Accepted: 11/23/2018] [Indexed: 12/12/2022] Open
Abstract
Natalizumab inhibits the transmigration of immune cells across the blood-brain barrier thus inhibiting inflammation in the central nervous system. Generally, this blockade at the blood-brain barrier has significant influence on the circulating lymphocytes. Up to date, only short-term data on peripheral blood parameters are available which are mostly from controlled clinical trials and not from real-world experience. Real-world lab data of 120 patients diagnosed with highly active disease course of relapsing-remitting multiple sclerosis (RRMS) were analyzed during natalizumab treatment. Patient sampling was performed by consecutive recruitment in the Multiple Sclerosis Center Dresden. Lab testing was performed before and at every third infusion up to 72 months follow-up. After first natalizumab infusion, absolute numbers of all major lymphocyte populations including CD4+ T-cells, CD8+ T-cells, CD19+ B-cells, and NK-cells significantly increased and remained stable during the whole observation period of 72 months. Upon lymphocyte subsets, CD19+ B-cells presented a disproportionate increase up to levels higher than normal level in most of the treated patients. Neutralizing antibodies to natalizumab abrogated the described changes. Intra-individual variation of lymphocytes and its subsets remained in a narrow range for the whole treatment period. CD4/CD8 ratio did not change compared to baseline measurement up to 6 years of natalizumab treatment. Monocytes, eosinophils, and basophils, but not neutrophils persistently increased during natalizumab treatment. Hematological parameters including erythrocyte, platelet count, hemoglobin, and hematocrit remained unchanged compared to baseline. Interestingly, immature precursor cells including erythroblasts were detectable in 36,8% of the treated patients during natalizumab therapy, but not in the pretreatment period. Asymptomatic elevations of liver enzymes were rare, mostly only transient and lower than 3x upper normal limit. Kidney function parameters remained stable within physiological ranges in most patients. CRP levels >20 mg/dl were recognized only in 10 patients during natalizumab therapy and were mostly linked to respiratory tract infections. In our present analysis, we report persistent, but stable increases of peripheral immune cell subtypes in natalizumab treated patients. Additional serological analyses confirm excellent tolerability and safety even 6 years after natalizumab initiation in post-marketing experience.
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Affiliation(s)
- Maxi Kaufmann
- MS Center Dresden, Center of Clinical Neuroscience, Carl Gustav Carus University Hospital, University of Technology Dresden, Dresden, Germany
| | - Rocco Haase
- MS Center Dresden, Center of Clinical Neuroscience, Carl Gustav Carus University Hospital, University of Technology Dresden, Dresden, Germany
| | - Undine Proschmann
- MS Center Dresden, Center of Clinical Neuroscience, Carl Gustav Carus University Hospital, University of Technology Dresden, Dresden, Germany
| | - Tjalf Ziemssen
- MS Center Dresden, Center of Clinical Neuroscience, Carl Gustav Carus University Hospital, University of Technology Dresden, Dresden, Germany
| | - Katja Akgün
- MS Center Dresden, Center of Clinical Neuroscience, Carl Gustav Carus University Hospital, University of Technology Dresden, Dresden, Germany
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28
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Predictors of relapse and disability progression in MS patients who discontinue disease-modifying therapy. J Neurol Sci 2018; 391:72-76. [DOI: 10.1016/j.jns.2018.06.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Revised: 05/30/2018] [Accepted: 06/01/2018] [Indexed: 11/22/2022]
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29
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Lohmann L, Janoschka C, Schulte-Mecklenbeck A, Klinsing S, Kirstein L, Hanning U, Wirth T, Schneider-Hohendorf T, Schwab N, Gross CC, Eveslage M, Meuth SG, Wiendl H, Klotz L. Immune Cell Profiling During Switching from Natalizumab to Fingolimod Reveals Differential Effects on Systemic Immune-Regulatory Networks and on Trafficking of Non-T Cell Populations into the Cerebrospinal Fluid-Results from the ToFingo Successor Study. Front Immunol 2018; 9:1560. [PMID: 30050529 PMCID: PMC6052886 DOI: 10.3389/fimmu.2018.01560] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Accepted: 06/25/2018] [Indexed: 11/13/2022] Open
Abstract
Leukocyte sequestration is an established therapeutic concept in multiple sclerosis (MS) as represented by the trafficking drugs natalizumab (NAT) and fingolimod (FTY). However, the precise consequences of targeting immune cell trafficking for immunoregulatory network functions are only incompletely understood. In the present study, we performed an in-depth longitudinal characterization of functional and phenotypic immune signatures in peripheral blood (PB) and cerebrospinal fluid (CSF) of 15 MS patients during switching from long-term NAT to FTY treatment after a defined 8-week washout period within a clinical trial (ToFingo successor study; ClinicalTrials.gov: NCT02325440). Unbiased visualization and analysis of high-dimensional single cell flow-cytometry data revealed that switching resulted in a profound alteration of more than 80% of investigated innate and adaptive immune cell subpopulations in the PB, revealing an unexpectedly broad effect of trafficking drugs on peripheral immune signatures. Longitudinal CSF analysis demonstrated that NAT and FTY both reduced T cell subset counts and proportions in the CSF of MS patients with equal potency; NAT however was superior with regard to sequestering non-T cell populations out of the CSF, including B cells, natural killer cells and inflammatory monocytes, suggesting that disease exacerbation in the context of switching might be driven by non-T cell populations. Finally, correlation of our immunological data with signs of disease exacerbation in this small cohort suggested that both (i) CD49d expression levels under NAT at the time of treatment cessation and (ii) swiftness of FTY-mediated effects on immune cell subsets in the PB together may predict stability during switching later on.
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Affiliation(s)
- Lisa Lohmann
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Muenster, Germany
| | - Claudia Janoschka
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Muenster, Germany
| | - Andreas Schulte-Mecklenbeck
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Muenster, Germany
| | - Svenja Klinsing
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Muenster, Germany
| | - Lucienne Kirstein
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Muenster, Germany
| | - Uta Hanning
- Department of Radiology, University Hospital Münster, Muenster, Germany
| | - Timo Wirth
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Muenster, Germany
| | - Tilman Schneider-Hohendorf
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Muenster, Germany
| | - Nicholas Schwab
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Muenster, Germany
| | - Catharina C Gross
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Muenster, Germany
| | - Maria Eveslage
- Institute of Biostatistics and Clinical Research, University of Münster, Muenster, Germany
| | - Sven G Meuth
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Muenster, Germany
| | - Heinz Wiendl
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Muenster, Germany
| | - Luisa Klotz
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Muenster, Germany
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30
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Mills EA, Mao-Draayer Y. Aging and lymphocyte changes by immunomodulatory therapies impact PML risk in multiple sclerosis patients. Mult Scler 2018; 24:1014-1022. [PMID: 29774781 DOI: 10.1177/1352458518775550] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
New potent immunomodulatory therapies for multiple sclerosis (MS) are associated with increased risk for progressive multifocal leukoencephalopathy (PML). It is unclear why a subset of treated patients develops PML, but patient age has emerged as an important risk factor. PML is caused by the JC virus and aging is associated with immune senescence, which increases susceptibility to infection. With the goal of improving PML risk stratification, we here describe the lymphocyte changes that occur with disease-modifying therapies (DMTs) associated with high or moderate risk toward PML in MS patients, how these changes compare to immune aging, and which measures best correlate with risk. We reviewed studies examining how these therapies alter patient immune profiles, which revealed the induction of changes to lymphocyte number and/or function that resemble immunosenescence. Therefore, the immunosuppressive activity of these MS DMTs may be enhanced in the context of an immune system that is already exhibiting features of senescence.
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Affiliation(s)
- Elizabeth A Mills
- Department of Neurology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Yang Mao-Draayer
- Department of Neurology, University of Michigan Medical School, Ann Arbor, MI, USA/Graduate Program in Immunology, Program in Biomedical Sciences, University of Michigan Medical School, Ann Arbor, MI, USA
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31
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van Langelaar J, van der Vuurst de Vries RM, Janssen M, Wierenga-Wolf AF, Spilt IM, Siepman TA, Dankers W, Verjans GMGM, de Vries HE, Lubberts E, Hintzen RQ, van Luijn MM. T helper 17.1 cells associate with multiple sclerosis disease activity: perspectives for early intervention. Brain 2018; 141:1334-1349. [DOI: 10.1093/brain/awy069] [Citation(s) in RCA: 109] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Accepted: 01/19/2018] [Indexed: 12/13/2022] Open
Affiliation(s)
- Jamie van Langelaar
- Department of Immunology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
- MS Center ErasMS at Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Roos M van der Vuurst de Vries
- MS Center ErasMS at Erasmus MC, University Medical Center, Rotterdam, The Netherlands
- Department of Neurology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Malou Janssen
- Department of Immunology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
- MS Center ErasMS at Erasmus MC, University Medical Center, Rotterdam, The Netherlands
- Department of Neurology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Annet F Wierenga-Wolf
- Department of Immunology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
- MS Center ErasMS at Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Isis M Spilt
- Department of Immunology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
- MS Center ErasMS at Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Theodora A Siepman
- MS Center ErasMS at Erasmus MC, University Medical Center, Rotterdam, The Netherlands
- Department of Neurology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Wendy Dankers
- Department of Rheumatology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Georges M G M Verjans
- Department of Viroscience, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
- Research Center for Emerging Infections and Zoonosis, University of Veterinary Medicine, Hannover, Germany
| | - Helga E de Vries
- Department of Molecular Cell Biology and Immunology; Neuroscience Campus Amsterdam, VU University Medical Center, Amsterdam, The Netherlands
| | - Erik Lubberts
- Department of Rheumatology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Rogier Q Hintzen
- Department of Immunology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
- MS Center ErasMS at Erasmus MC, University Medical Center, Rotterdam, The Netherlands
- Department of Neurology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Marvin M van Luijn
- Department of Immunology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
- MS Center ErasMS at Erasmus MC, University Medical Center, Rotterdam, The Netherlands
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32
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Wilson JJ, Foyle KL, Foeng J, Norton T, McKenzie DR, Payne N, Bernard CC, McColl SR, Comerford I. Redirecting adult mesenchymal stromal cells to the brain: a new approach for treating CNS autoimmunity and neuroinflammation? Immunol Cell Biol 2018; 96:347-357. [PMID: 29377354 DOI: 10.1111/imcb.12014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Revised: 01/22/2018] [Accepted: 01/23/2018] [Indexed: 12/15/2022]
Abstract
Mesenchymal stromal cells or stem cells (MSCs) have been shown to participate in tissue repair and are immunomodulatory in neuropathological settings. Given this, their potential use in developing a new generation of personalized therapies for autoimmune and inflammatory diseases of the central nervous system (CNS) will be explored. To effectively exert these effector functions, MSCs must first gain entry into damaged neural tissues, a process that has been demonstrated to be a limiting factor in their therapeutic efficacy. In this review, we discuss approaches to maximize the therapeutic efficacy of MSCs by altering their intrinsic trafficking programs to effectively enter neuropathological sites. To this end, we explore the significant role of chemokine receptors and adhesion molecules in directing cellular traffic to the inflamed CNS and the capacity of MSCs to adopt these molecular mechanisms to gain entry to this site. We postulate that understanding and exploiting these migratory mechanisms may be key to the development of cell-based therapies tailored to respond to the migratory cues unique to the nature and stage of progression of individual CNS disorders.
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Affiliation(s)
- Jasmine J Wilson
- The Chemokine Biology Laboratory, The University of Adelaide, Adelaide, SA, 5005, Australia
| | - Kerrie L Foyle
- The Chemokine Biology Laboratory, The University of Adelaide, Adelaide, SA, 5005, Australia
| | - Jade Foeng
- The Chemokine Biology Laboratory, The University of Adelaide, Adelaide, SA, 5005, Australia
| | - Todd Norton
- The Chemokine Biology Laboratory, The University of Adelaide, Adelaide, SA, 5005, Australia
| | - Duncan R McKenzie
- The Chemokine Biology Laboratory, The University of Adelaide, Adelaide, SA, 5005, Australia
| | - Natalie Payne
- Multiple Sclerosis Research Group, Australian Regenerative Medicine Institute, Monash University, Clayton, VIC, 3800, Australia
| | - Claude C Bernard
- Multiple Sclerosis Research Group, Australian Regenerative Medicine Institute, Monash University, Clayton, VIC, 3800, Australia
| | - Shaun R McColl
- The Chemokine Biology Laboratory, The University of Adelaide, Adelaide, SA, 5005, Australia
| | - Iain Comerford
- The Chemokine Biology Laboratory, The University of Adelaide, Adelaide, SA, 5005, Australia
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33
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Mills EA, Mao-Draayer Y. Understanding Progressive Multifocal Leukoencephalopathy Risk in Multiple Sclerosis Patients Treated with Immunomodulatory Therapies: A Bird's Eye View. Front Immunol 2018; 9:138. [PMID: 29456537 PMCID: PMC5801425 DOI: 10.3389/fimmu.2018.00138] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Accepted: 01/16/2018] [Indexed: 12/14/2022] Open
Abstract
The increased use of newer potent immunomodulatory therapies for multiple sclerosis (MS), including natalizumab, fingolimod, and dimethyl fumarate, has expanded the patient population at risk for developing progressive multifocal leukoencephalopathy (PML). These MS therapies shift the profile of lymphocytes within the central nervous system (CNS) leading to increased anti-inflammatory subsets and decreased immunosurveillance. Similar to MS, PML is a demyelinating disease of the CNS, but it is caused by the JC virus. The manifestation of PML requires the presence of an active, genetically rearranged form of the JC virus within CNS glial cells, coupled with the loss of appropriate JC virus-specific immune responses. The reliability of metrics used to predict risk for PML could be improved if all three components, i.e., viral genetic strain, localization, and host immune function, were taken into account. Advances in our understanding of the critical lymphocyte subpopulation changes induced by these MS therapies and ability to detect viral mutation and reactivation will facilitate efforts to develop these metrics.
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Affiliation(s)
- Elizabeth A Mills
- Department of Neurology, University of Michigan Medical School, Ann Arbor, MI, United States
| | - Yang Mao-Draayer
- Department of Neurology, University of Michigan Medical School, Ann Arbor, MI, United States.,Graduate Program in Immunology, Program in Biomedical Sciences, University of Michigan Medical School, Ann Arbor, MI, United States
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34
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Clottu AS, Mathias A, Sailer AW, Schluep M, Seebach JD, Du Pasquier R, Pot C. EBI2 Expression and Function: Robust in Memory Lymphocytes and Increased by Natalizumab in Multiple Sclerosis. Cell Rep 2017; 18:213-224. [PMID: 28052250 DOI: 10.1016/j.celrep.2016.12.006] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Revised: 11/06/2016] [Accepted: 11/30/2016] [Indexed: 11/19/2022] Open
Abstract
The interaction between oxysterols and the G protein-coupled receptor Epstein-Barr virus-induced gene 2 (EBI2) fine-tunes immune cell migration, a mechanism efficiently targeted by several disease-modifying treatments developed to treat multiple sclerosis (MS), such as natalizumab. We previously showed that memory CD4+ T lymphocytes migrate specifically in response to 7α,25-dihydroxycholesterol (7α,25-OHC) via EBI2 in the MS murine model experimental autoimmune encephalomyelitis. However, the EBI2 expression profile in human lymphocytes in both healthy and MS donors is unknown. Here, we characterize EBI2 biology in human lymphocytes. We observed that EBI2 is functionally expressed on memory CD4+ T cells and is enhanced under natalizumab treatment. These data suggest a significant role for EBI2 in human CD4+ T cell migration, notably in patients with MS. Better knowledge of EBI2 involvement in autoimmunity may therefore lead to an improved understanding of the physiopathology of MS.
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Affiliation(s)
- Aurélie S Clottu
- Laboratories of Neuroimmunology, Neuroscience Research Center, Department of Clinical Neurosciences, Lausanne University Hospital, Chemin des Boveresses 155, 1066 Epalinges, Switzerland; Department of Pathology and Immunology, Geneva University Medical Center, Rue Michel-Servet 1, 1211 Geneva 4, Switzerland; Division of Immunology and Allergology, Department of Medical Specialties, Geneva University Hospitals, Rue Gabrielle-Perret-Gentil 4, 1211 Geneva 14, Switzerland
| | - Amandine Mathias
- Laboratories of Neuroimmunology, Neuroscience Research Center, Department of Clinical Neurosciences, Lausanne University Hospital, Chemin des Boveresses 155, 1066 Epalinges, Switzerland
| | - Andreas W Sailer
- Developmental and Molecular Pathways, Novartis Institutes for BioMedical Research, Forum 1, 4002 Basel, Switzerland
| | - Myriam Schluep
- Division of Neurology, Department of Clinical Neurosciences, Lausanne University Hospital, Rue du Bugnon 46, 1011 Lausanne, Switzerland
| | - Jörg D Seebach
- Division of Immunology and Allergology, Department of Medical Specialties, Geneva University Hospitals, Rue Gabrielle-Perret-Gentil 4, 1211 Geneva 14, Switzerland
| | - Renaud Du Pasquier
- Laboratories of Neuroimmunology, Neuroscience Research Center, Department of Clinical Neurosciences, Lausanne University Hospital, Chemin des Boveresses 155, 1066 Epalinges, Switzerland; Division of Neurology, Department of Clinical Neurosciences, Lausanne University Hospital, Rue du Bugnon 46, 1011 Lausanne, Switzerland
| | - Caroline Pot
- Laboratories of Neuroimmunology, Neuroscience Research Center, Department of Clinical Neurosciences, Lausanne University Hospital, Chemin des Boveresses 155, 1066 Epalinges, Switzerland; Department of Pathology and Immunology, Geneva University Medical Center, Rue Michel-Servet 1, 1211 Geneva 4, Switzerland; Division of Neurology, Department of Clinical Neurosciences, Lausanne University Hospital, Rue du Bugnon 46, 1011 Lausanne, Switzerland.
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35
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Bedri SK, Fink K, Manouchehrinia A, Lundström W, Kockum I, Olsson T, Hillert J, Glaser A. Multiple sclerosis treatment effects on plasma cytokine receptor levels. Clin Immunol 2017; 187:15-25. [PMID: 28941836 DOI: 10.1016/j.clim.2017.08.023] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Revised: 08/24/2017] [Accepted: 08/27/2017] [Indexed: 01/04/2023]
Abstract
Genetic variants within some cytokine receptor genes have been associated with MS susceptibility, including IL7RA and IL2RA. As these genes are expressed by cells targeted by immune-modulatory drugs, we explored the potential role of their gene products as biomarkers in monitoring MS treatment. We assessed the impact of natalizumab followed by fingolimod on the intra-individual changes of plasma protein levels of sIL-7Rα, sIL-2Rα and also sIL-6R and sgp130 in MS patients. During natalizumab treatment we observed a decline in sgp130 and sIL-7Rα levels, while subsequent fingolimod treatment lead to increased sgp130 and sIL-7Rα and decreased sIL-2Rα levels. In addition, during fingolimod treatment sIL-7Rα levels were increasing significantly more in patients homozygous for the MS risk genotype of rs6897932. We also observed an effect of the MS associated rs71624119 on sgp130 levels. These results may elucidate the pharmacodynamics of treatments and help identify biomarkers for MS outcomes.
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Affiliation(s)
- Sahl Khalid Bedri
- Department of Clinical Neuroscience and Centrum for Molecular Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Katharina Fink
- Department of Clinical Neuroscience and Centrum for Molecular Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Ali Manouchehrinia
- Department of Clinical Neuroscience and Centrum for Molecular Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Wangko Lundström
- Department of Clinical Neuroscience and Centrum for Molecular Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Ingrid Kockum
- Department of Clinical Neuroscience and Centrum for Molecular Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Tomas Olsson
- Department of Clinical Neuroscience and Centrum for Molecular Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Jan Hillert
- Department of Clinical Neuroscience and Centrum for Molecular Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Anna Glaser
- Department of Clinical Neuroscience and Centrum for Molecular Medicine, Karolinska Institutet, Stockholm, Sweden.
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36
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Plavina T, Muralidharan KK, Kuesters G, Mikol D, Evans K, Subramanyam M, Nestorov I, Chen Y, Dong Q, Ho PR, Amarante D, Adams A, De Sèze J, Fox R, Gold R, Jeffery D, Kappos L, Montalban X, Weinstock-Guttman B, Hartung HP, Cree BAC. Reversibility of the effects of natalizumab on peripheral immune cell dynamics in MS patients. Neurology 2017; 89:1584-1593. [PMID: 28916537 PMCID: PMC5634662 DOI: 10.1212/wnl.0000000000004485] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Accepted: 07/17/2017] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVE To characterize the reversibility of natalizumab-mediated changes in pharmacokinetics/pharmacodynamics in patients with multiple sclerosis (MS) following therapy interruption. METHODS Pharmacokinetic/pharmacodynamic data were collected in the Safety and Efficacy of Natalizumab in the Treatment of Multiple Sclerosis (AFFIRM) (every 12 weeks for 116 weeks) and Randomized Treatment Interruption of Natalizumab (RESTORE) (every 4 weeks for 28 weeks) studies. Serum natalizumab and soluble vascular cell adhesion molecule-1 (sVCAM-1) were measured using immunoassays. Lymphocyte subsets, α4-integrin expression/saturation, and vascular cell adhesion molecule-1 (VCAM-1) binding were assessed using flow cytometry. RESULTS Blood lymphocyte counts (cells/L) in natalizumab-treated patients increased from 2.1 × 109 to 3.5 × 109. Starting 8 weeks post last natalizumab dose, lymphocyte counts became significantly lower in patients interrupting treatment than in those continuing treatment (3.1 × 109 vs 3.5 × 109; p = 0.031), plateauing at prenatalizumab levels from week 16 onward. All measured cell subpopulation, α4-integrin expression/saturation, and sVCAM changes demonstrated similar reversibility. Lymphocyte counts remained within the normal range. Ex vivo VCAM-1 binding to lymphocytes increased until ≈16 weeks after the last natalizumab dose, then plateaued, suggesting reversibility of immune cell functionality. The temporal appearance of gadolinium-enhancing lesions was consistent with pharmacodynamic marker reversal. CONCLUSIONS Natalizumab's effects on peripheral immune cells and pharmacodynamic markers were reversible, with changes starting 8 weeks post last natalizumab dose; levels returned to those observed/expected in untreated patients ≈16 weeks post last dose. This reversibility differentiates natalizumab from MS treatments that require longer reconstitution times. Characterization of the time course of natalizumab's biological effects may help clinicians make treatment sequencing decisions. CLASSIFICATION OF EVIDENCE This study provides Class III evidence that the pharmacodynamic markers of natalizumab are reversed ≈16 weeks after stopping natalizumab.
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Affiliation(s)
- Tatiana Plavina
- From Biogen (T.P., K.K.M., G.K., D.M., K.E., M.S., I.N., Y.C., Q.D., P.-R.H., D.A.), Cambridge, MA; Ashfield Healthcare Communications (A.A.), Middletown, CT; Hôpital Civil (J.D.S.), Strasbourg, France; Mellen Center for Multiple Sclerosis (R.F.), Cleveland Clinic, OH; St. Josef Hospital (R.G.), Ruhr University, Bochum, Germany; Piedmont HealthCare (D.J.), Mooresville, NC; Neurologic Clinic and Policlinic (L.K.), Departments of Medicine, Clinical Research, Biomedicine, and Biomedical Engineering, University Hospital and University of Basel, Switzerland; Vall d'Hebron University Hospital (X.M.), Barcelona, Spain; Jacobs MS Center and Pediatric MS Center of Excellence (B.W.-G.), Jacobs Neurological Institute, Buffalo, NY; Department of Neurology (H.-P.H.), Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany; and University of California San Francisco Multiple Sclerosis Center (B.A.C.C.).
| | - Kumar Kandadi Muralidharan
- From Biogen (T.P., K.K.M., G.K., D.M., K.E., M.S., I.N., Y.C., Q.D., P.-R.H., D.A.), Cambridge, MA; Ashfield Healthcare Communications (A.A.), Middletown, CT; Hôpital Civil (J.D.S.), Strasbourg, France; Mellen Center for Multiple Sclerosis (R.F.), Cleveland Clinic, OH; St. Josef Hospital (R.G.), Ruhr University, Bochum, Germany; Piedmont HealthCare (D.J.), Mooresville, NC; Neurologic Clinic and Policlinic (L.K.), Departments of Medicine, Clinical Research, Biomedicine, and Biomedical Engineering, University Hospital and University of Basel, Switzerland; Vall d'Hebron University Hospital (X.M.), Barcelona, Spain; Jacobs MS Center and Pediatric MS Center of Excellence (B.W.-G.), Jacobs Neurological Institute, Buffalo, NY; Department of Neurology (H.-P.H.), Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany; and University of California San Francisco Multiple Sclerosis Center (B.A.C.C.)
| | - Geoffrey Kuesters
- From Biogen (T.P., K.K.M., G.K., D.M., K.E., M.S., I.N., Y.C., Q.D., P.-R.H., D.A.), Cambridge, MA; Ashfield Healthcare Communications (A.A.), Middletown, CT; Hôpital Civil (J.D.S.), Strasbourg, France; Mellen Center for Multiple Sclerosis (R.F.), Cleveland Clinic, OH; St. Josef Hospital (R.G.), Ruhr University, Bochum, Germany; Piedmont HealthCare (D.J.), Mooresville, NC; Neurologic Clinic and Policlinic (L.K.), Departments of Medicine, Clinical Research, Biomedicine, and Biomedical Engineering, University Hospital and University of Basel, Switzerland; Vall d'Hebron University Hospital (X.M.), Barcelona, Spain; Jacobs MS Center and Pediatric MS Center of Excellence (B.W.-G.), Jacobs Neurological Institute, Buffalo, NY; Department of Neurology (H.-P.H.), Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany; and University of California San Francisco Multiple Sclerosis Center (B.A.C.C.)
| | - Daniel Mikol
- From Biogen (T.P., K.K.M., G.K., D.M., K.E., M.S., I.N., Y.C., Q.D., P.-R.H., D.A.), Cambridge, MA; Ashfield Healthcare Communications (A.A.), Middletown, CT; Hôpital Civil (J.D.S.), Strasbourg, France; Mellen Center for Multiple Sclerosis (R.F.), Cleveland Clinic, OH; St. Josef Hospital (R.G.), Ruhr University, Bochum, Germany; Piedmont HealthCare (D.J.), Mooresville, NC; Neurologic Clinic and Policlinic (L.K.), Departments of Medicine, Clinical Research, Biomedicine, and Biomedical Engineering, University Hospital and University of Basel, Switzerland; Vall d'Hebron University Hospital (X.M.), Barcelona, Spain; Jacobs MS Center and Pediatric MS Center of Excellence (B.W.-G.), Jacobs Neurological Institute, Buffalo, NY; Department of Neurology (H.-P.H.), Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany; and University of California San Francisco Multiple Sclerosis Center (B.A.C.C.)
| | - Karleyton Evans
- From Biogen (T.P., K.K.M., G.K., D.M., K.E., M.S., I.N., Y.C., Q.D., P.-R.H., D.A.), Cambridge, MA; Ashfield Healthcare Communications (A.A.), Middletown, CT; Hôpital Civil (J.D.S.), Strasbourg, France; Mellen Center for Multiple Sclerosis (R.F.), Cleveland Clinic, OH; St. Josef Hospital (R.G.), Ruhr University, Bochum, Germany; Piedmont HealthCare (D.J.), Mooresville, NC; Neurologic Clinic and Policlinic (L.K.), Departments of Medicine, Clinical Research, Biomedicine, and Biomedical Engineering, University Hospital and University of Basel, Switzerland; Vall d'Hebron University Hospital (X.M.), Barcelona, Spain; Jacobs MS Center and Pediatric MS Center of Excellence (B.W.-G.), Jacobs Neurological Institute, Buffalo, NY; Department of Neurology (H.-P.H.), Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany; and University of California San Francisco Multiple Sclerosis Center (B.A.C.C.)
| | - Meena Subramanyam
- From Biogen (T.P., K.K.M., G.K., D.M., K.E., M.S., I.N., Y.C., Q.D., P.-R.H., D.A.), Cambridge, MA; Ashfield Healthcare Communications (A.A.), Middletown, CT; Hôpital Civil (J.D.S.), Strasbourg, France; Mellen Center for Multiple Sclerosis (R.F.), Cleveland Clinic, OH; St. Josef Hospital (R.G.), Ruhr University, Bochum, Germany; Piedmont HealthCare (D.J.), Mooresville, NC; Neurologic Clinic and Policlinic (L.K.), Departments of Medicine, Clinical Research, Biomedicine, and Biomedical Engineering, University Hospital and University of Basel, Switzerland; Vall d'Hebron University Hospital (X.M.), Barcelona, Spain; Jacobs MS Center and Pediatric MS Center of Excellence (B.W.-G.), Jacobs Neurological Institute, Buffalo, NY; Department of Neurology (H.-P.H.), Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany; and University of California San Francisco Multiple Sclerosis Center (B.A.C.C.)
| | - Ivan Nestorov
- From Biogen (T.P., K.K.M., G.K., D.M., K.E., M.S., I.N., Y.C., Q.D., P.-R.H., D.A.), Cambridge, MA; Ashfield Healthcare Communications (A.A.), Middletown, CT; Hôpital Civil (J.D.S.), Strasbourg, France; Mellen Center for Multiple Sclerosis (R.F.), Cleveland Clinic, OH; St. Josef Hospital (R.G.), Ruhr University, Bochum, Germany; Piedmont HealthCare (D.J.), Mooresville, NC; Neurologic Clinic and Policlinic (L.K.), Departments of Medicine, Clinical Research, Biomedicine, and Biomedical Engineering, University Hospital and University of Basel, Switzerland; Vall d'Hebron University Hospital (X.M.), Barcelona, Spain; Jacobs MS Center and Pediatric MS Center of Excellence (B.W.-G.), Jacobs Neurological Institute, Buffalo, NY; Department of Neurology (H.-P.H.), Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany; and University of California San Francisco Multiple Sclerosis Center (B.A.C.C.)
| | - Yi Chen
- From Biogen (T.P., K.K.M., G.K., D.M., K.E., M.S., I.N., Y.C., Q.D., P.-R.H., D.A.), Cambridge, MA; Ashfield Healthcare Communications (A.A.), Middletown, CT; Hôpital Civil (J.D.S.), Strasbourg, France; Mellen Center for Multiple Sclerosis (R.F.), Cleveland Clinic, OH; St. Josef Hospital (R.G.), Ruhr University, Bochum, Germany; Piedmont HealthCare (D.J.), Mooresville, NC; Neurologic Clinic and Policlinic (L.K.), Departments of Medicine, Clinical Research, Biomedicine, and Biomedical Engineering, University Hospital and University of Basel, Switzerland; Vall d'Hebron University Hospital (X.M.), Barcelona, Spain; Jacobs MS Center and Pediatric MS Center of Excellence (B.W.-G.), Jacobs Neurological Institute, Buffalo, NY; Department of Neurology (H.-P.H.), Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany; and University of California San Francisco Multiple Sclerosis Center (B.A.C.C.)
| | - Qunming Dong
- From Biogen (T.P., K.K.M., G.K., D.M., K.E., M.S., I.N., Y.C., Q.D., P.-R.H., D.A.), Cambridge, MA; Ashfield Healthcare Communications (A.A.), Middletown, CT; Hôpital Civil (J.D.S.), Strasbourg, France; Mellen Center for Multiple Sclerosis (R.F.), Cleveland Clinic, OH; St. Josef Hospital (R.G.), Ruhr University, Bochum, Germany; Piedmont HealthCare (D.J.), Mooresville, NC; Neurologic Clinic and Policlinic (L.K.), Departments of Medicine, Clinical Research, Biomedicine, and Biomedical Engineering, University Hospital and University of Basel, Switzerland; Vall d'Hebron University Hospital (X.M.), Barcelona, Spain; Jacobs MS Center and Pediatric MS Center of Excellence (B.W.-G.), Jacobs Neurological Institute, Buffalo, NY; Department of Neurology (H.-P.H.), Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany; and University of California San Francisco Multiple Sclerosis Center (B.A.C.C.)
| | - Pei-Ran Ho
- From Biogen (T.P., K.K.M., G.K., D.M., K.E., M.S., I.N., Y.C., Q.D., P.-R.H., D.A.), Cambridge, MA; Ashfield Healthcare Communications (A.A.), Middletown, CT; Hôpital Civil (J.D.S.), Strasbourg, France; Mellen Center for Multiple Sclerosis (R.F.), Cleveland Clinic, OH; St. Josef Hospital (R.G.), Ruhr University, Bochum, Germany; Piedmont HealthCare (D.J.), Mooresville, NC; Neurologic Clinic and Policlinic (L.K.), Departments of Medicine, Clinical Research, Biomedicine, and Biomedical Engineering, University Hospital and University of Basel, Switzerland; Vall d'Hebron University Hospital (X.M.), Barcelona, Spain; Jacobs MS Center and Pediatric MS Center of Excellence (B.W.-G.), Jacobs Neurological Institute, Buffalo, NY; Department of Neurology (H.-P.H.), Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany; and University of California San Francisco Multiple Sclerosis Center (B.A.C.C.)
| | - Diogo Amarante
- From Biogen (T.P., K.K.M., G.K., D.M., K.E., M.S., I.N., Y.C., Q.D., P.-R.H., D.A.), Cambridge, MA; Ashfield Healthcare Communications (A.A.), Middletown, CT; Hôpital Civil (J.D.S.), Strasbourg, France; Mellen Center for Multiple Sclerosis (R.F.), Cleveland Clinic, OH; St. Josef Hospital (R.G.), Ruhr University, Bochum, Germany; Piedmont HealthCare (D.J.), Mooresville, NC; Neurologic Clinic and Policlinic (L.K.), Departments of Medicine, Clinical Research, Biomedicine, and Biomedical Engineering, University Hospital and University of Basel, Switzerland; Vall d'Hebron University Hospital (X.M.), Barcelona, Spain; Jacobs MS Center and Pediatric MS Center of Excellence (B.W.-G.), Jacobs Neurological Institute, Buffalo, NY; Department of Neurology (H.-P.H.), Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany; and University of California San Francisco Multiple Sclerosis Center (B.A.C.C.)
| | - Alison Adams
- From Biogen (T.P., K.K.M., G.K., D.M., K.E., M.S., I.N., Y.C., Q.D., P.-R.H., D.A.), Cambridge, MA; Ashfield Healthcare Communications (A.A.), Middletown, CT; Hôpital Civil (J.D.S.), Strasbourg, France; Mellen Center for Multiple Sclerosis (R.F.), Cleveland Clinic, OH; St. Josef Hospital (R.G.), Ruhr University, Bochum, Germany; Piedmont HealthCare (D.J.), Mooresville, NC; Neurologic Clinic and Policlinic (L.K.), Departments of Medicine, Clinical Research, Biomedicine, and Biomedical Engineering, University Hospital and University of Basel, Switzerland; Vall d'Hebron University Hospital (X.M.), Barcelona, Spain; Jacobs MS Center and Pediatric MS Center of Excellence (B.W.-G.), Jacobs Neurological Institute, Buffalo, NY; Department of Neurology (H.-P.H.), Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany; and University of California San Francisco Multiple Sclerosis Center (B.A.C.C.)
| | - Jerome De Sèze
- From Biogen (T.P., K.K.M., G.K., D.M., K.E., M.S., I.N., Y.C., Q.D., P.-R.H., D.A.), Cambridge, MA; Ashfield Healthcare Communications (A.A.), Middletown, CT; Hôpital Civil (J.D.S.), Strasbourg, France; Mellen Center for Multiple Sclerosis (R.F.), Cleveland Clinic, OH; St. Josef Hospital (R.G.), Ruhr University, Bochum, Germany; Piedmont HealthCare (D.J.), Mooresville, NC; Neurologic Clinic and Policlinic (L.K.), Departments of Medicine, Clinical Research, Biomedicine, and Biomedical Engineering, University Hospital and University of Basel, Switzerland; Vall d'Hebron University Hospital (X.M.), Barcelona, Spain; Jacobs MS Center and Pediatric MS Center of Excellence (B.W.-G.), Jacobs Neurological Institute, Buffalo, NY; Department of Neurology (H.-P.H.), Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany; and University of California San Francisco Multiple Sclerosis Center (B.A.C.C.)
| | - Robert Fox
- From Biogen (T.P., K.K.M., G.K., D.M., K.E., M.S., I.N., Y.C., Q.D., P.-R.H., D.A.), Cambridge, MA; Ashfield Healthcare Communications (A.A.), Middletown, CT; Hôpital Civil (J.D.S.), Strasbourg, France; Mellen Center for Multiple Sclerosis (R.F.), Cleveland Clinic, OH; St. Josef Hospital (R.G.), Ruhr University, Bochum, Germany; Piedmont HealthCare (D.J.), Mooresville, NC; Neurologic Clinic and Policlinic (L.K.), Departments of Medicine, Clinical Research, Biomedicine, and Biomedical Engineering, University Hospital and University of Basel, Switzerland; Vall d'Hebron University Hospital (X.M.), Barcelona, Spain; Jacobs MS Center and Pediatric MS Center of Excellence (B.W.-G.), Jacobs Neurological Institute, Buffalo, NY; Department of Neurology (H.-P.H.), Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany; and University of California San Francisco Multiple Sclerosis Center (B.A.C.C.)
| | - Ralf Gold
- From Biogen (T.P., K.K.M., G.K., D.M., K.E., M.S., I.N., Y.C., Q.D., P.-R.H., D.A.), Cambridge, MA; Ashfield Healthcare Communications (A.A.), Middletown, CT; Hôpital Civil (J.D.S.), Strasbourg, France; Mellen Center for Multiple Sclerosis (R.F.), Cleveland Clinic, OH; St. Josef Hospital (R.G.), Ruhr University, Bochum, Germany; Piedmont HealthCare (D.J.), Mooresville, NC; Neurologic Clinic and Policlinic (L.K.), Departments of Medicine, Clinical Research, Biomedicine, and Biomedical Engineering, University Hospital and University of Basel, Switzerland; Vall d'Hebron University Hospital (X.M.), Barcelona, Spain; Jacobs MS Center and Pediatric MS Center of Excellence (B.W.-G.), Jacobs Neurological Institute, Buffalo, NY; Department of Neurology (H.-P.H.), Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany; and University of California San Francisco Multiple Sclerosis Center (B.A.C.C.)
| | - Douglas Jeffery
- From Biogen (T.P., K.K.M., G.K., D.M., K.E., M.S., I.N., Y.C., Q.D., P.-R.H., D.A.), Cambridge, MA; Ashfield Healthcare Communications (A.A.), Middletown, CT; Hôpital Civil (J.D.S.), Strasbourg, France; Mellen Center for Multiple Sclerosis (R.F.), Cleveland Clinic, OH; St. Josef Hospital (R.G.), Ruhr University, Bochum, Germany; Piedmont HealthCare (D.J.), Mooresville, NC; Neurologic Clinic and Policlinic (L.K.), Departments of Medicine, Clinical Research, Biomedicine, and Biomedical Engineering, University Hospital and University of Basel, Switzerland; Vall d'Hebron University Hospital (X.M.), Barcelona, Spain; Jacobs MS Center and Pediatric MS Center of Excellence (B.W.-G.), Jacobs Neurological Institute, Buffalo, NY; Department of Neurology (H.-P.H.), Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany; and University of California San Francisco Multiple Sclerosis Center (B.A.C.C.)
| | - Ludwig Kappos
- From Biogen (T.P., K.K.M., G.K., D.M., K.E., M.S., I.N., Y.C., Q.D., P.-R.H., D.A.), Cambridge, MA; Ashfield Healthcare Communications (A.A.), Middletown, CT; Hôpital Civil (J.D.S.), Strasbourg, France; Mellen Center for Multiple Sclerosis (R.F.), Cleveland Clinic, OH; St. Josef Hospital (R.G.), Ruhr University, Bochum, Germany; Piedmont HealthCare (D.J.), Mooresville, NC; Neurologic Clinic and Policlinic (L.K.), Departments of Medicine, Clinical Research, Biomedicine, and Biomedical Engineering, University Hospital and University of Basel, Switzerland; Vall d'Hebron University Hospital (X.M.), Barcelona, Spain; Jacobs MS Center and Pediatric MS Center of Excellence (B.W.-G.), Jacobs Neurological Institute, Buffalo, NY; Department of Neurology (H.-P.H.), Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany; and University of California San Francisco Multiple Sclerosis Center (B.A.C.C.)
| | - Xavier Montalban
- From Biogen (T.P., K.K.M., G.K., D.M., K.E., M.S., I.N., Y.C., Q.D., P.-R.H., D.A.), Cambridge, MA; Ashfield Healthcare Communications (A.A.), Middletown, CT; Hôpital Civil (J.D.S.), Strasbourg, France; Mellen Center for Multiple Sclerosis (R.F.), Cleveland Clinic, OH; St. Josef Hospital (R.G.), Ruhr University, Bochum, Germany; Piedmont HealthCare (D.J.), Mooresville, NC; Neurologic Clinic and Policlinic (L.K.), Departments of Medicine, Clinical Research, Biomedicine, and Biomedical Engineering, University Hospital and University of Basel, Switzerland; Vall d'Hebron University Hospital (X.M.), Barcelona, Spain; Jacobs MS Center and Pediatric MS Center of Excellence (B.W.-G.), Jacobs Neurological Institute, Buffalo, NY; Department of Neurology (H.-P.H.), Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany; and University of California San Francisco Multiple Sclerosis Center (B.A.C.C.)
| | - Bianca Weinstock-Guttman
- From Biogen (T.P., K.K.M., G.K., D.M., K.E., M.S., I.N., Y.C., Q.D., P.-R.H., D.A.), Cambridge, MA; Ashfield Healthcare Communications (A.A.), Middletown, CT; Hôpital Civil (J.D.S.), Strasbourg, France; Mellen Center for Multiple Sclerosis (R.F.), Cleveland Clinic, OH; St. Josef Hospital (R.G.), Ruhr University, Bochum, Germany; Piedmont HealthCare (D.J.), Mooresville, NC; Neurologic Clinic and Policlinic (L.K.), Departments of Medicine, Clinical Research, Biomedicine, and Biomedical Engineering, University Hospital and University of Basel, Switzerland; Vall d'Hebron University Hospital (X.M.), Barcelona, Spain; Jacobs MS Center and Pediatric MS Center of Excellence (B.W.-G.), Jacobs Neurological Institute, Buffalo, NY; Department of Neurology (H.-P.H.), Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany; and University of California San Francisco Multiple Sclerosis Center (B.A.C.C.)
| | - Hans-Peter Hartung
- From Biogen (T.P., K.K.M., G.K., D.M., K.E., M.S., I.N., Y.C., Q.D., P.-R.H., D.A.), Cambridge, MA; Ashfield Healthcare Communications (A.A.), Middletown, CT; Hôpital Civil (J.D.S.), Strasbourg, France; Mellen Center for Multiple Sclerosis (R.F.), Cleveland Clinic, OH; St. Josef Hospital (R.G.), Ruhr University, Bochum, Germany; Piedmont HealthCare (D.J.), Mooresville, NC; Neurologic Clinic and Policlinic (L.K.), Departments of Medicine, Clinical Research, Biomedicine, and Biomedical Engineering, University Hospital and University of Basel, Switzerland; Vall d'Hebron University Hospital (X.M.), Barcelona, Spain; Jacobs MS Center and Pediatric MS Center of Excellence (B.W.-G.), Jacobs Neurological Institute, Buffalo, NY; Department of Neurology (H.-P.H.), Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany; and University of California San Francisco Multiple Sclerosis Center (B.A.C.C.)
| | - Bruce A C Cree
- From Biogen (T.P., K.K.M., G.K., D.M., K.E., M.S., I.N., Y.C., Q.D., P.-R.H., D.A.), Cambridge, MA; Ashfield Healthcare Communications (A.A.), Middletown, CT; Hôpital Civil (J.D.S.), Strasbourg, France; Mellen Center for Multiple Sclerosis (R.F.), Cleveland Clinic, OH; St. Josef Hospital (R.G.), Ruhr University, Bochum, Germany; Piedmont HealthCare (D.J.), Mooresville, NC; Neurologic Clinic and Policlinic (L.K.), Departments of Medicine, Clinical Research, Biomedicine, and Biomedical Engineering, University Hospital and University of Basel, Switzerland; Vall d'Hebron University Hospital (X.M.), Barcelona, Spain; Jacobs MS Center and Pediatric MS Center of Excellence (B.W.-G.), Jacobs Neurological Institute, Buffalo, NY; Department of Neurology (H.-P.H.), Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany; and University of California San Francisco Multiple Sclerosis Center (B.A.C.C.)
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Villani S, Zanotta N, Ambrogi F, Comar M, Franciotta D, Dolci M, Cason C, Ticozzi R, Ferrante P, Delbue S. Multiplex array analysis of circulating cytokines and chemokines in natalizumab-treated patients with multiple sclerosis. J Neuroimmunol 2017; 310:91-96. [DOI: 10.1016/j.jneuroim.2017.06.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Revised: 06/28/2017] [Accepted: 06/29/2017] [Indexed: 01/22/2023]
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Recognition of viral and self-antigens by T H 1 and T H 1/T H 17 central memory cells in patients with multiple sclerosis reveals distinct roles in immune surveillance and relapses. J Allergy Clin Immunol 2017; 140:797-808. [DOI: 10.1016/j.jaci.2016.11.045] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Revised: 10/18/2016] [Accepted: 11/10/2016] [Indexed: 11/18/2022]
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Gahlen A, Trampe AK, Haupeltshofer S, Ringelstein M, Aktas O, Berthele A, Wildemann B, Gold R, Jarius S, Kleiter I. Aquaporin-4 antibodies in patients treated with natalizumab for suspected MS. NEUROLOGY-NEUROIMMUNOLOGY & NEUROINFLAMMATION 2017. [PMID: 28642888 PMCID: PMC5473957 DOI: 10.1212/nxi.0000000000000363] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Objective: To evaluate (1) the frequency of aquaporin-4 antibody (AQP4-ab)-seropositive cases among patients treated with natalizumab (NAT) and previously diagnosed with MS (MSNAT) in a nationwide cohort, (2) the clinical course of NAT-treated AQP4-ab–seropositive neuromyelitis optica spectrum disorder (NMOSD) patients (NMONAT), (3) AQP4-ab titers in NMONAT and AQP4-ab–seropositive NMOSD treated with other immunotherapies (NMOIT), and (4) immune mechanisms influencing disease activity in NMONAT. Methods: MSNAT serum samples were retrospectively screened with a cell-based assay for AQP4-IgG and titers determined by ELISA. The annualized relapse rate (ARR) and disability progression were assessed. Serum levels of proinflammatory cytokines (interleukin [IL]-1β, IL-4, IL-6, IL-8, IL-10, IL-17, IL-21, and interferon [IFN]-γ) and the chemokine CXCL-10 of NMONAT patients identified in this (n = 4) and a previous study (n = 5) were measured by cytometric bead array and ELISA. Results: Of the 1,183 MSNAT patients (851 female, median 9 NAT infusions), only 4 (0.33%; 3 female, 1 male) had AQP4-IgG. Of these, 2 fulfilled the 2006 NMO criteria and all met the 2015 NMOSD criteria. The ARR was higher in NMONAT vs MSNAT (p = 0.0182). All 4 NMONAT patients had relapses and 2 had an increase of disability. AQP4-ab titers were higher in NMONAT (n = 9) vs NMOIT (n = 13; p = 0.0059). IL-8, IL-1β, and IFN-γ serum levels were significantly higher, and CXCL-10 was significantly lower in NMONAT vs NMOIT. Conclusions: Misdiagnosis of NMOSD with MS is rare. NAT was not able to control disease activity in NMONAT patients, who had higher serum levels of AQP4-IgG and proinflammatory cytokines than patients with NMOSD treated with other immunotherapies.
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Affiliation(s)
- Anna Gahlen
- Department of Neurology (A.G., A.-K.T., S.H., R.G., I.K.), St. Josef-Hospital, Ruhr-University Bochum; Department of Neurology (M.R., O.A.), Medical Faculty, Heinrich-Heine-University Düsseldorf; Department of Neurology (A.B.), Klinikum Rechts der Isar, Technische Universität München; and Molecular Neuroimmunology Group (B.W., S.J.), Department of Neurology, University of Heidelberg, Germany
| | - Anne-Kathrin Trampe
- Department of Neurology (A.G., A.-K.T., S.H., R.G., I.K.), St. Josef-Hospital, Ruhr-University Bochum; Department of Neurology (M.R., O.A.), Medical Faculty, Heinrich-Heine-University Düsseldorf; Department of Neurology (A.B.), Klinikum Rechts der Isar, Technische Universität München; and Molecular Neuroimmunology Group (B.W., S.J.), Department of Neurology, University of Heidelberg, Germany
| | - Steffen Haupeltshofer
- Department of Neurology (A.G., A.-K.T., S.H., R.G., I.K.), St. Josef-Hospital, Ruhr-University Bochum; Department of Neurology (M.R., O.A.), Medical Faculty, Heinrich-Heine-University Düsseldorf; Department of Neurology (A.B.), Klinikum Rechts der Isar, Technische Universität München; and Molecular Neuroimmunology Group (B.W., S.J.), Department of Neurology, University of Heidelberg, Germany
| | - Marius Ringelstein
- Department of Neurology (A.G., A.-K.T., S.H., R.G., I.K.), St. Josef-Hospital, Ruhr-University Bochum; Department of Neurology (M.R., O.A.), Medical Faculty, Heinrich-Heine-University Düsseldorf; Department of Neurology (A.B.), Klinikum Rechts der Isar, Technische Universität München; and Molecular Neuroimmunology Group (B.W., S.J.), Department of Neurology, University of Heidelberg, Germany
| | - Orhan Aktas
- Department of Neurology (A.G., A.-K.T., S.H., R.G., I.K.), St. Josef-Hospital, Ruhr-University Bochum; Department of Neurology (M.R., O.A.), Medical Faculty, Heinrich-Heine-University Düsseldorf; Department of Neurology (A.B.), Klinikum Rechts der Isar, Technische Universität München; and Molecular Neuroimmunology Group (B.W., S.J.), Department of Neurology, University of Heidelberg, Germany
| | - Achim Berthele
- Department of Neurology (A.G., A.-K.T., S.H., R.G., I.K.), St. Josef-Hospital, Ruhr-University Bochum; Department of Neurology (M.R., O.A.), Medical Faculty, Heinrich-Heine-University Düsseldorf; Department of Neurology (A.B.), Klinikum Rechts der Isar, Technische Universität München; and Molecular Neuroimmunology Group (B.W., S.J.), Department of Neurology, University of Heidelberg, Germany
| | - Brigitte Wildemann
- Department of Neurology (A.G., A.-K.T., S.H., R.G., I.K.), St. Josef-Hospital, Ruhr-University Bochum; Department of Neurology (M.R., O.A.), Medical Faculty, Heinrich-Heine-University Düsseldorf; Department of Neurology (A.B.), Klinikum Rechts der Isar, Technische Universität München; and Molecular Neuroimmunology Group (B.W., S.J.), Department of Neurology, University of Heidelberg, Germany
| | - Ralf Gold
- Department of Neurology (A.G., A.-K.T., S.H., R.G., I.K.), St. Josef-Hospital, Ruhr-University Bochum; Department of Neurology (M.R., O.A.), Medical Faculty, Heinrich-Heine-University Düsseldorf; Department of Neurology (A.B.), Klinikum Rechts der Isar, Technische Universität München; and Molecular Neuroimmunology Group (B.W., S.J.), Department of Neurology, University of Heidelberg, Germany
| | - Sven Jarius
- Department of Neurology (A.G., A.-K.T., S.H., R.G., I.K.), St. Josef-Hospital, Ruhr-University Bochum; Department of Neurology (M.R., O.A.), Medical Faculty, Heinrich-Heine-University Düsseldorf; Department of Neurology (A.B.), Klinikum Rechts der Isar, Technische Universität München; and Molecular Neuroimmunology Group (B.W., S.J.), Department of Neurology, University of Heidelberg, Germany
| | - Ingo Kleiter
- Department of Neurology (A.G., A.-K.T., S.H., R.G., I.K.), St. Josef-Hospital, Ruhr-University Bochum; Department of Neurology (M.R., O.A.), Medical Faculty, Heinrich-Heine-University Düsseldorf; Department of Neurology (A.B.), Klinikum Rechts der Isar, Technische Universität München; and Molecular Neuroimmunology Group (B.W., S.J.), Department of Neurology, University of Heidelberg, Germany
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Paužuolis M, Eich T, Burman J. Quantification of γδ T cells and HLA-DR+ NK cells does not predict emergence of new contrast enhancing lesions in MS patients suspending natalizumab treatment. PLoS One 2017; 12:e0179095. [PMID: 28586378 PMCID: PMC5460885 DOI: 10.1371/journal.pone.0179095] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Accepted: 05/23/2017] [Indexed: 11/19/2022] Open
Abstract
Background Natalizumab (NTZ) is a drug that has been widely used in the treatment of multiple sclerosis (MS). NTZ is very effective in suppressing inflammation, but if treatment is suspended many patients will experience relapses. Objective To investigate if quantification of γδ T cells and HLA-DR+ NK cells could predict early disease reactivation after NTZ suspension. Methods Absolute counts of γδ T cells and HLA-DR+ NK cells in whole blood were determined with flow cytometry in fifteen patients treated with NTZ. NTZ treatment was then withdrawn and patients were followed with clinical visits and MR investigations. Results Patients with recurrent disease had higher absolute counts of γδ T cells 129 (±156) cells/μl in comparison to patients with stable disease 50.0 (±51.0) cells/μl but the difference was not statistically significant and largely driven by outliers. Patients with recurrent and stable disease had similar absolute counts of HLA-DR+ NK cells. Conclusion Quantification of γδ T cells and HLA-DR+ NK cells could not predict active disease after NTZ suspension.
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Affiliation(s)
| | - Torsten Eich
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | - Joachim Burman
- Department of Neuroscience, Uppsala University, Uppsala, Sweden
- * E-mail:
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The Enigmatic Role of Viruses in Multiple Sclerosis: Molecular Mimicry or Disturbed Immune Surveillance? Trends Immunol 2017; 38:498-512. [PMID: 28549714 PMCID: PMC7185415 DOI: 10.1016/j.it.2017.04.006] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Revised: 04/21/2017] [Accepted: 04/21/2017] [Indexed: 01/24/2023]
Abstract
Multiple sclerosis (MS) is a T cell driven autoimmune disease of the central nervous system (CNS). Despite its association with Epstein-Barr Virus (EBV), how viral infections promote MS remains unclear. However, there is increasing evidence that the CNS is continuously surveyed by virus-specific T cells, which protect against reactivating neurotropic viruses. Here, we discuss how viral infections could lead to the breakdown of self-tolerance in genetically predisposed individuals, and how the reactivations of viruses in the CNS could induce the recruitment of both autoaggressive and virus-specific T cell subsets, causing relapses and progressive disability. A disturbed immune surveillance in MS would explain several experimental findings, and has important implications for prognosis and therapy. A huge body of evidence suggests that viral infections promote MS; however, no single causal virus has been identified. Multiple viruses could promote MS via bystander effects. Molecular mimicry is an established pathogenic mechanism in selected autoimmune diseases. It is also well documented in MS, but its contribution to MS pathogenesis is still unclear. Bystander activation upon viral infection could be involved in the generation of the autoreactive and potentially encephalitogenic T helper (Th)-1/17 central memory (Th1/17CM) cells found in the circulation of patients with MS. Autoreactive Th1/17CM cells could expand at the cost of antiviral Th1CM cells in patients with MS, in particular in those undergoing natalizumab therapy, because these cells are expected to compete for the same homeostatic niche. Autoreactive Th1/17 cells and antiviral Th1 cells are recruited to the CSF of patients with MS following attacks, suggesting that viral reactivations in the CNS induce the recruitment of pathogenic Th1/17 cells. Autoreactive Th1/17 cells in the CNS might also induce de novo viral reactivations in a circuit of self-induced inflammation.
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González-Suarez I, Rodríguez de Antonio L, Orviz A, Moreno-García S, Valle-Arcos MD, Matias-Guiu JA, Valencia C, Jorquera Moya M, Oreja-Guevara C. Catastrophic outcome of patients with a rebound after Natalizumab treatment discontinuation. Brain Behav 2017; 7:e00671. [PMID: 28413713 PMCID: PMC5390845 DOI: 10.1002/brb3.671] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Accepted: 01/30/2017] [Indexed: 02/04/2023] Open
Abstract
INTRODUCTION Natalizumab (NTZ) is an effective drug for the treatment of relapsing-remitting multiple sclerosis. In some patients discontinuation is mandatory due to the risk of progressive multifocal leukoencephalopathy. However, severe clinical and radiological worsening has been described after drug cessation. Our aim was to describe the clinical and radiological features of the rebound phenomenon. MATERIAL AND METHODS Patients switched from NTZ to Fingolimod (FTY) who had presented a rebound after discontinuation were selected. Clinical and magnetic resonance imaging (MRI) data were collected. RESULTS Four JC virus positive patients were included. The mean disease duration was 9.5 years (SD: 4.12) with a mean time of 3.1 years on NTZ. All patients started FTY within 3-4 months. Neurological deterioration started in a mean time of 3.5 months (SD: 2.08) with multifocal involvement: 75% motor disturbances, 50% cognitive impairment, 25% seizures. The average worsening in Expanded Disability Status Scale [EDSS] was of 3.25 points (SD: 2.33). The MRI showed a very large increase in T2 and gadolinium-enhanced lesions (mean: 23.67, SD: 18.58). All patients received 5 days of IV methylprednisolone, one patient required plasma exchange. All the patients presented neurological deterioration with an EDSS worsening of 1.13 points (SD: 0.48). After the rebound three patients continued treatment with FTY, only one patient restarted NTZ. CONCLUSION Discontinuation of NTZ treatment may trigger a severe rebound with marked clinical and radiological worsening. A very careful evaluation of benefit-risk should be considered before NTZ withdrawal, and a close monitoring and a short washout period is recommended after drug withdrawal.
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Affiliation(s)
- Inés González-Suarez
- Neurology Department Multiple Sclerosis Center IdiSSC Hospital Clinico San Carlos Madrid Spain
| | | | - Aida Orviz
- Neurology Department Multiple Sclerosis Center IdiSSC Hospital Clinico San Carlos Madrid Spain
| | - Sara Moreno-García
- Demyelinating Disease Unit Neurology Department Hospital Universitario 12 de Octubre Madrid Spain
| | - María D Valle-Arcos
- Demyelinating Disease Unit Neurology Department Hospital Universitario 12 de Octubre Madrid Spain
| | - Jordi A Matias-Guiu
- Neurology Department Multiple Sclerosis Center IdiSSC Hospital Clinico San Carlos Madrid Spain
| | - Cristina Valencia
- Neurology Department Multiple Sclerosis Center IdiSSC Hospital Clinico San Carlos Madrid Spain
| | | | - Celia Oreja-Guevara
- Neurology Department Multiple Sclerosis Center IdiSSC Hospital Clinico San Carlos Madrid Spain
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Singh AK, Novakova L, Axelsson M, Malmeström C, Zetterberg H, Lycke J, Cardell SL. High Interferon-γ Uniquely in Vδ1 T Cells Correlates with Markers of Inflammation and Axonal Damage in Early Multiple Sclerosis. Front Immunol 2017; 8:260. [PMID: 28337205 PMCID: PMC5343019 DOI: 10.3389/fimmu.2017.00260] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Accepted: 02/21/2017] [Indexed: 11/25/2022] Open
Abstract
We have identified a population of T lymphocytes in peripheral blood, Vδ1 TCRγδ T lymphocytes, which unexpectedly was uniquely expressing high production of interferon-γ in newly diagnosed, untreated multiple sclerosis (MS) patients. IFN-γ production in this population distinctly correlated to parameters of clinical disease activity, inflammation, and neuronal damage. These Vδ1 T lymphocytes belong to a population of innate T lymphocytes that recognize antigen in the context of CD1d/CD1c and which include reactivity to the myelin glycosphingolipid sulfatide. Importantly, patients treated with natalizumab, blocking leukocyte transmigration to central nervous system, had completely normalized levels of interferon-γ-producing Vδ1 T lymphocytes. A biomarker and early sign of demyelinating disease in MS is much warranted and would help identify immunopathogenesis and prognosis of disease as well as monitor success with adequate treatment. The present study identifies the Vδ1 T lymphocytes as an early marker of MS and a possible link to understanding the disease etiology.
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Affiliation(s)
- Avadhesh Kumar Singh
- Department of Microbiology and Immunology, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg , Gothenburg , Sweden
| | - Lenka Novakova
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg , Gothenburg , Sweden
| | - Markus Axelsson
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg , Gothenburg , Sweden
| | - Clas Malmeström
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg , Gothenburg , Sweden
| | - Henrik Zetterberg
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Mölndal, Sweden; Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden; Department of Molecular Neuroscience, UCL Institute of Neurology, London, UK
| | - Jan Lycke
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg , Gothenburg , Sweden
| | - Susanna L Cardell
- Department of Microbiology and Immunology, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg , Gothenburg , Sweden
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Fingolimod alters the transcriptome profile of circulating CD4+ cells in multiple sclerosis. Sci Rep 2017; 7:42087. [PMID: 28155899 PMCID: PMC5290459 DOI: 10.1038/srep42087] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2016] [Accepted: 01/04/2017] [Indexed: 01/09/2023] Open
Abstract
Multiple sclerosis is a demyelinating disease affecting the central nervous system. T cells are known to contribute to this immune-mediated condition. Fingolimod modulates sphingosine-1-phosphate receptors, thereby preventing the egress of lymphocytes, especially CCR7-expressing CD8+ and CD4+ T cells, from lymphoid tissues. Using Affymetrix Human Transcriptome Arrays (HTA 2.0), we performed a transcriptome profiling analysis of CD4+ cells obtained from the peripheral blood of patients with highly active relapsing-remitting multiple sclerosis. The samples were drawn before the first administration of fingolimod as well as 24 hours and 3 months after the start of therapy. Three months after treatment initiation, 890 genes were found to be differentially expressed with fold-change >2.0 and t-test p-value < 0.001, among them several microRNA precursors. A subset of 272 genes were expressed at lower levels, including CCR7 as expected, while 618 genes showed an increase in expression, e.g., CCR2, CX3CR1, CD39, CD58 as well as LYN, PAK1 and TLR2. To conclude, we studied the gene expression of CD4+ cells to evaluate the effects of fingolimod treatment, and we identified 890 genes to be altered in expression after continuous drug administration. T helper cells circulating in the blood during fingolimod therapy present a distinct gene expression signature.
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Fagius J, Feresiadou A, Larsson EM, Burman J. Discontinuation of disease modifying treatments in middle aged multiple sclerosis patients. First line drugs vs natalizumab. Mult Scler Relat Disord 2017; 12:82-87. [PMID: 28283113 DOI: 10.1016/j.msard.2017.01.009] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2016] [Revised: 11/29/2016] [Accepted: 01/13/2017] [Indexed: 11/25/2022]
Abstract
BACKGROUND Several disease-modifying drugs (DMD) are available for the treatment of MS, and most patients with relapsing-remitting disease are currently treated. Data on when and how DMD treatment can be safely discontinued are scarce. METHODS Fifteen MS patients, treated with natalizumab for >5 years without clinical and radiological signs of inflammatory disease activity, suspended treatment and were monitored with MRI examinations and clinical follow-up to determine recurrence of disease activity. This group was compared with a retrospectively analysed cohort comprising 55 MS patients treated with first-line DMDs discontinuing therapy in the time period of 1998-2015 after an analogous stable course. RESULTS Natalizumab discontinuers were followed for on average 19 months, and follow-up data for 56 months were available for first-line DMD quitters. Two-thirds of natalizumab treated patients experienced recurrent inflammatory disease activity, and one third had recurrence of rebound character. In contrast, 35% of first-line DMD quitters had mild recurrent disease activity, and no one exhibited rebound. CONCLUSIONS Withdrawal of a first-line DMD after prolonged treatment in middle-aged MS patients with stable disease appears to be relatively safe, while natalizumab withdrawal in a similar group of patients cannot be safely done without starting alternative therapy.
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Affiliation(s)
- Jan Fagius
- Department of Neuroscience, Uppsala University, Uppsala, Sweden.
| | | | - Elna-Marie Larsson
- Department of Surgical Sciences/Radiology, Uppsala University, Uppsala, Sweden
| | - Joachim Burman
- Department of Neuroscience, Uppsala University, Uppsala, Sweden
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Assessment of Serum Nitrogen Species and Inflammatory Parameters in Relapsing-Remitting Multiple Sclerosis Patients Treated with Different Therapeutic Approaches. BIOMED RESEARCH INTERNATIONAL 2016; 2016:4570351. [PMID: 28078290 PMCID: PMC5204117 DOI: 10.1155/2016/4570351] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Revised: 10/20/2016] [Accepted: 11/08/2016] [Indexed: 11/17/2022]
Abstract
The role of nitric oxide and its reactive derivatives (NO x ) is well known in the pathogenesis of multiple sclerosis, which is an inflammatory disease while NO x seems to be important in coordinating inflammatory response. The purpose of the present study was to assess serum NO x as one of the nitrogen species and inflammatory parameters in relapsing-remitting multiple sclerosis patients and to compare the effectiveness of various types of disease-modifying therapies that reduce nitric oxide and inflammatory biomarkers. Elevated NO x level was observed in patients who received the first-line disease-modifying therapy (interferons beta-1a and beta-1b) in comparison with the subjects treated with the second-line disease-modifying therapy (natalizumab; fingolimod) and healthy controls without significant differences in C-reactive protein and interleukin-1 beta. A negative correlation was observed between serum NO x level and the duration of multiple sclerosis confirmed in the whole study population and in subjects treated with the first-line agents. Only serum NO x , concentration could reveal a potential efficacy of disease-modifying therapy with a better reduction in NO x level due to the second-line agents of disease-modifying therapy.
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Natalizumab Treatment Modulates Peroxisome Proliferator-Activated Receptors Expression in Women with Multiple Sclerosis. PPAR Res 2016; 2016:5716415. [PMID: 28077943 PMCID: PMC5203914 DOI: 10.1155/2016/5716415] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Accepted: 11/24/2016] [Indexed: 11/17/2022] Open
Abstract
Peroxisome Proliferator-Activated Receptors (PPAR) are transcription factors suggested to be involved in inflammatory lesions of autoimmune encephalomyelitis and multiple sclerosis (MS). Our objective was to assess whether Natalizumab (NTZ) therapy is associated with alterations of PPAR expression in MS patients. We analyzed gene expression of PPAR in peripheral blood mononuclear cells (PBMC) as well as blood inflammatory markers in women with MS previously medicated with first-line immunomodulators (baseline) and after NTZ therapy. No differences in PPARα, PPARβ/δ, PPARγ, and CD36 mRNA expression were found in PBMC between patients under baseline and healthy controls. At three months, NTZ increased PPARβ/δ mRNA (p = 0.009) in comparison to baseline, while mRNA expression of PPARγ and CD36 (a well-known PPAR target gene) was lower in comparison to healthy controls (p = 0.026 and p = 0.028, resp.). Although these trends of alterations remain after six months of therapy, the results were not statistically significant. Osteopontin levels were elevated in patients (p = 0.002) and did not change during the follow-up period of NTZ treatment. These results suggest that PPAR-mediated processes may contribute to the mechanisms of action of NTZ therapy.
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Petersen ER, Søndergaard HB, Oturai AB, Jensen P, Sorensen PS, Sellebjerg F, Börnsen L. Soluble serum VCAM-1, whole blood mRNA expression and treatment response in natalizumab-treated multiple sclerosis. Mult Scler Relat Disord 2016; 10:66-72. [PMID: 27919501 DOI: 10.1016/j.msard.2016.09.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Revised: 07/12/2016] [Accepted: 09/05/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Natalizumab reduces disease activity in multiple sclerosis (MS). Natalizumab binds to the very late antigen-4 and inhibits vascular cell adhesion molecule-1 (VCAM-1)-mediated transmigration of immune cells across the blood-brain-barrier. This is associated with decreased serum concentrations of soluble (s)VCAM-1 and an altered composition of immune cell-subsets in the blood. OBJECTIVE We aimed to examine if sVCAM-1 serum concentrations and whole blood mRNA expression levels of immune activation biomarkers is associated with disease activity in natalizumab-treated MS-patients. METHODS sVCAM-1 serum concentrations and whole blood mRNA expression were measured in blood samples from untreated RRMS-patients and from two independent groups of natalizumab-treated patients. RESULTS sVCAM-1 serum concentrations and whole blood expression of HLX1 and IL1B mRNA were lower, whereas expression of EBI3 mRNA was higher in natalizumab-treated MS-patients. Five genes were differentially expressed in clinically unstable natalizumab-treated MS-patients in the discovery but not in the validation group. CONCLUSION Decreased serum concentrations of sVCAM-1 and altered whole blood mRNA expression levels of a panel of immunomarkers, associated with natalizumab-treatment, are not sensitive markers of MS disease activity. However, decreased expression of pro-inflammatory HLX1 and IL1B and increased expression of immunoregulatory EBI3 may indicate a less pathogenic immune activation status in natalizumab-treated MS.
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Affiliation(s)
- E R Petersen
- Danish Multiple Sclerosis Center, Department of neurology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.
| | - H B Søndergaard
- Danish Multiple Sclerosis Center, Department of neurology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - A B Oturai
- Danish Multiple Sclerosis Center, Department of neurology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Peh Jensen
- Danish Multiple Sclerosis Center, Department of neurology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - P S Sorensen
- Danish Multiple Sclerosis Center, Department of neurology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - F Sellebjerg
- Danish Multiple Sclerosis Center, Department of neurology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - L Börnsen
- Danish Multiple Sclerosis Center, Department of neurology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
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Gandoglia I, Ivaldi F, Carrega P, Armentani E, Ferlazzo G, Mancardi G, Kerlero de Rosbo N, Uccelli A, Laroni A. In vitro VLA-4 blockade results in an impaired NK cell-mediated immune surveillance against melanoma. Immunol Lett 2016; 181:109-115. [PMID: 27919749 DOI: 10.1016/j.imlet.2016.11.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Revised: 11/28/2016] [Accepted: 11/30/2016] [Indexed: 12/11/2022]
Abstract
Natalizumab (NTZ) is a monoclonal antibody targeting the α4β1 integrin (CD49d/CD29), very late antigen-4 (VLA-4), which is approved for treatment of relapsing-remitting multiple sclerosis (RR-MS). A possible association between NTZ treatment and a higher risk of melanoma is under debate. Natural Killer (NK) cells, which express VLA-4, represent an innate barrier limiting spreading of melanoma under steady state conditions. Indeed, because of their expression of activating receptors, they are very efficient in recognizing and killing melanoma cells without the need of a previous priming. For this reason, we aimed at assessing whether NK-cell functions might be impaired by sustained exposure to NTZ. To investigate this possibility we isolated NK cells from healthy donors and tested their cytotoxic and migratory functions against primary melanoma cells derived from subcutaneous and lymph node metastases. Flow cytometry analysis demonstrated expression of CD49d on both freshly isolated NK cells and activated NK cells. Moreover, VLA-4 and its receptor, vascular cell adhesion protein-1 (VCAM-1) were similarly expressed on freshly isolated NK cells. However, upon a short exposure to NTZ, expression of VLA-4 on NK cells decreased. Analysis of NK receptor expression upon exposure of NK cells from three healthy donors to NTZ indicated that DNAM-1 and NKp46 are apparently decreased, while NKG2A is increased. The degranulation of NK cells towards melanoma cells, which express both VLA-4 and VCAM-1, was not affected when NTZ was added to the co-culture or when both NK cells and melanoma cells were each pre-exposed to NTZ for over 12h. In contrast, degranulation was significantly inhibited after 48h of pre-incubation indicating that NTZ can influence NK-cell degranulation towards melanoma cells only after a prolonged exposure. Using a migration chamber assay, we observed that the migration of NK cells towards melanoma cells was dependent upon the concentration of melanoma cells in the lower chamber, and that it was significantly reduced in presence of NTZ. Our results show that upon exposure to NTZ both cytolytic activity and migration toward melanoma cells were affected, suggesting that binding of NTZ to NK cells affects pathways involved in these NK-cell functions. We analyzed the expression of CD49d on NK cells from MS patients treated with NTZ and observed that it decreases with time of treatment. These data suggest that blockade of VLA-4 on NK-cell surface alters some key functions involved in the immune surveillance toward melanoma by NK cells and may provide a mechanistic explanation for the reported occurrence of melanoma in MS patients treated with NTZ.
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Affiliation(s)
- Ilaria Gandoglia
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health Unit, University of Genoa, Genoa, Italy
| | - Federico Ivaldi
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health Unit, University of Genoa, Genoa, Italy
| | - Paolo Carrega
- Laboratory of Clinical and Experimental Immunology, Giannina Gaslini Institute, Genoa, Italy
| | - Eric Armentani
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health Unit, University of Genoa, Genoa, Italy
| | - Guido Ferlazzo
- Laboratory of Immunology and Biotherapy, Department of Human Pathology, University of Messina, Messina, Italy
| | - Gianluigi Mancardi
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health Unit, University of Genoa, Genoa, Italy; IRCCS Azienda Ospedaliera Universitaria San Martino - IST, Genoa, Italy
| | - Nicole Kerlero de Rosbo
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health Unit, University of Genoa, Genoa, Italy
| | - Antonio Uccelli
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health Unit, University of Genoa, Genoa, Italy; IRCCS Azienda Ospedaliera Universitaria San Martino - IST, Genoa, Italy.
| | - Alice Laroni
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health Unit, University of Genoa, Genoa, Italy; IRCCS Azienda Ospedaliera Universitaria San Martino - IST, Genoa, Italy
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Saraste M, Penttilä TL, Airas L. Natalizumab treatment leads to an increase in circulating CXCR3-expressing B cells. NEUROLOGY-NEUROIMMUNOLOGY & NEUROINFLAMMATION 2016; 3:e292. [PMID: 27800533 PMCID: PMC5079379 DOI: 10.1212/nxi.0000000000000292] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Accepted: 09/12/2016] [Indexed: 12/25/2022]
Abstract
OBJECTIVE To study the effects of natalizumab treatment on subgroups of circulating peripheral blood B cell populations. METHODS We studied the proportions and absolute numbers of CD19+CD20+, CD10+, and CD5+ B cell populations, and determined very late activation antigen-4 and chemokine receptor CXCR3, CCR5, and CCR6 expression on B cells in the peripheral blood of 14 natalizumab-treated patients with relapsing-remitting multiple sclerosis. Five blood samples per patient were obtained longitudinally before and during the first year of treatment. Blood samples were analyzed by 6-color flow cytometry. RESULTS Proportions of B cells and CD10+ pre-B cells were significantly increased, and very late activation antigen-4 expression on the B cell surface was significantly decreased already after 1 week of natalizumab treatment. Natalizumab-induced sustained increase in the proportion and absolute number of CXCR3-expressing B cells was statistically significant after 1 month of treatment. There were no changes in the proportions of CCR5- or CCR6-expressing B cells. CONCLUSIONS The rapid and persistent increase in circulating CXCR3-expressing B cells in response to natalizumab treatment possibly reflects the relevance of this chemokine receptor in controlling migration of B cells into the CNS in humans in vivo.
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Affiliation(s)
- Maija Saraste
- Department of Neurology (M.S), University of Turku; TYKSLAB (T.-L.P.), Laboratory of Clinical Haematology, Turku University Hospital; and Division of Clinical Neurosciences (L.A.), Turku University Hospital, and University of Turku, Finland
| | - Tarja-Leena Penttilä
- Department of Neurology (M.S), University of Turku; TYKSLAB (T.-L.P.), Laboratory of Clinical Haematology, Turku University Hospital; and Division of Clinical Neurosciences (L.A.), Turku University Hospital, and University of Turku, Finland
| | - Laura Airas
- Department of Neurology (M.S), University of Turku; TYKSLAB (T.-L.P.), Laboratory of Clinical Haematology, Turku University Hospital; and Division of Clinical Neurosciences (L.A.), Turku University Hospital, and University of Turku, Finland
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