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Mok CC. The Dawn of a New Era of Therapies in Systemic Lupus Erythematosus. RHEUMATOLOGY AND IMMUNOLOGY RESEARCH 2020; 1:31-37. [PMID: 36465076 PMCID: PMC9524766 DOI: 10.2478/rir-2020-0005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Accepted: 07/02/2020] [Indexed: 06/17/2023]
Abstract
Systemic lupus erythematosus (SLE) is a complicated multisystem autoimmune disease that is associated with significant mortality and morbidity in the younger population. The development of novel therapies of SLE lag behinds other autoimmune inflammatory rheumatic diseases because of its clinical and immunological heterogeneities, the complexity of outcome assessments in multiple systems, and difficulty in optimizing the design of clinical trials. Despite the futility of quite a number of clinical trials, we are seeing the dawn of novel therapeutics in SLE, given the promising results of the newer-generation anti-CD20, anti-CD40L biologics, and calcineurin inhibitors (CNIs), as well as anti-cytokine biologics, Jakinibs, and the mammalian target of rapamycin (mTOR) inhibitors. The initial success of the Jakinibs and combination regimens in SLE illustrates the importance of targeting multiple pathogenetic mechanisms. The results of the ongoing phase III clinical trials in SLE are eagerly awaited.
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Affiliation(s)
- Chi Chiu Mok
- Department of Medicine, Tuen Mun Hospital, Hong KongSAR, China
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Biologics in the Treatment of Lupus Erythematosus: A Critical Literature Review. BIOMED RESEARCH INTERNATIONAL 2019; 2019:8142368. [PMID: 31396534 PMCID: PMC6668536 DOI: 10.1155/2019/8142368] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 06/18/2019] [Indexed: 01/07/2023]
Abstract
Systemic lupus erythematosus (SLE) is a chronic autoimmune inflammatory disease affecting multiple organ systems that runs an unpredictable course and may present with a wide variety of clinical manifestations. Advances in treatment over the last decades, such as use of corticosteroids and conventional immunosuppressive drugs, have improved life expectancy of SLE sufferers. Unfortunately, in many cases effective management of SLE is still related to severe drug-induced toxicity and contributes to organ function deterioration and infective complications, particularly among patients with refractory disease and/or lupus nephritis. Consequently, there is an unmet need for drugs with a better efficacy and safety profile. A range of different biologic agents have been proposed and subjected to clinical trials, particularly dedicated to this subset of patients whose disease is inadequately controlled by conventional treatment regimes. Unfortunately, most of these trials have given unsatisfactory results, with belimumab being the only targeted therapy approved for the treatment of SLE so far. Despite these pitfalls, several novel biologic agents targeting B cells, T cells, or cytokines are constantly being evaluated in clinical trials. It seems that they may enhance the therapeutic efficacy when combined with standard therapies. These efforts raise the hope that novel drugs for patients with refractory SLE may be available in the near future. This article reviews the current biological therapies being tested in the treatment of SLE.
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Additional Improvements in Clinical Response From Adjuvant Biologic Response Modifiers in Adults With Moderate to Severe Systemic Lupus Erythematosus Despite Immunosuppressive Agents: A Systematic Review and Meta-analysis. Clin Ther 2017; 39:1479-1506.e45. [DOI: 10.1016/j.clinthera.2017.05.359] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Revised: 05/30/2017] [Accepted: 05/30/2017] [Indexed: 11/22/2022]
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Celhar T, Fairhurst AM. Modelling clinical systemic lupus erythematosus: similarities, differences and success stories. Rheumatology (Oxford) 2017; 56:i88-i99. [PMID: 28013204 PMCID: PMC5410990 DOI: 10.1093/rheumatology/kew400] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Indexed: 12/26/2022] Open
Abstract
Mouse models of SLE have been indispensable tools to study disease pathogenesis, to identify genetic susceptibility loci and targets for drug development, and for preclinical testing of novel therapeutics. Recent insights into immunological mechanisms of disease progression have boosted a revival in SLE drug development. Despite promising results in mouse studies, many novel drugs have failed to meet clinical end points. This is probably because of the complexity of the disease, which is driven by polygenic predisposition and diverse environmental factors, resulting in a heterogeneous clinical presentation. Each mouse model recapitulates limited aspects of lupus, especially in terms of the mechanism underlying disease progression. The main mouse models have been fairly successful for the evaluation of broad-acting immunosuppressants. However, the advent of targeted therapeutics calls for a selection of the most appropriate model(s) for testing and, ultimately, identification of patients who will be most likely to respond.
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Affiliation(s)
- Teja Celhar
- Singapore Immunology Network, A*STAR, Singapore, Republic of Singapore
| | - Anna-Marie Fairhurst
- Singapore Immunology Network, A*STAR, Singapore, Republic of Singapore.,Department of Immunology, UT Southwestern Medical Center, Dallas, TX, USA
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Mok CC. Biological and targeted therapies of systemic lupus erythematosus: evidence and the state of the art. Expert Rev Clin Immunol 2017; 13:677-692. [PMID: 28443384 DOI: 10.1080/1744666x.2017.1323635] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Chi Chiu Mok
- Department of Medicine, Tuen Mun Hospital, Hong Kong SAR, China
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Abstract
Renal involvement in systemic lupus erythematosus (SLE) carries substantial morbidity and mortality. Conventional immunosuppressive agents (cyclophosphamide and azathioprine) have suboptimal efficacy and substantial toxicity. Mycophenolate mofetil has emerged as an alternative agent for both induction and maintenance therapy in lupus nephritis because of its reduced gonadal toxicity, despite its failure to demonstrate superiority over cyclophosphamide in pivotal studies. The calcineurin inhibitor tacrolimus has equivalent efficacy to cyclophosphamide and mycophenolate mofetil for inducing remission of lupus nephritis. Although rituximab has shown promise in refractory lupus nephritis, combining rituximab with mycophenolate mofetil as initial therapy offers no additional benefit. Considerable interethnic variation is evident in the efficacy and tolerability of the various immunosuppressive regimens, which necessitates individualized treatment and comparison of the efficacy of new regimens across different ethnic groups. For example, low-dose combinations of tacrolimus and mycophenolate mofetil seem to be more effective than pulse cyclophosphamide as induction therapy in Chinese patients. The same regimen has also been used successfully to treat refractory proliferative and membranous lupus nephritis in patients of various ethnic groups. Finally, novel serum and urinary biomarkers are being validated for diagnosis, prognostic stratification and early recognition of flares in lupus nephritis.
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Affiliation(s)
- C C Mok
- Department of Medicine, Tuen Mun Hospital, 23 Tsing Chung Koon Road, New Territories, Hong Kong SAR, China
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Pathogenesis and potential therapeutic targets in systemic lupus erythematosus: from bench to bedside. AUTOIMMUNITY HIGHLIGHTS 2014; 5:33-45. [PMID: 26000154 PMCID: PMC4389042 DOI: 10.1007/s13317-014-0058-y] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/21/2013] [Accepted: 06/12/2014] [Indexed: 12/18/2022]
Abstract
Systemic lupus erythematosus (SLE) is considered an autoimmune disease with multiorgan involvement. Many advances have been made during the last decade regarding inflammatory pathways, genetic and epigenetic alterations, adaptive and innate immune system mechanisms specifically involved in SLE pathogenesis. Apoptosis has been proposed as an important player in SLE pathogenesis more than a decade ago. However, only recently new key apoptotic pathways have been investigated and the link between apoptotic debris containing autoantigens, innate immunity and ongoing inflammation has been further elucidated. Better understanding of cellular mechanisms and involved cytokines contributed to the development of new biological drugs specifically addressed for SLE therapy.
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Abstract
INTRODUCTION Systemic lupus erythematosus (SLE) is a systemic autoimmune disease with unpredictable disease course, intermingled with periods of remission and exacerbation. Current therapies for SLE are not ideal in terms of efficacy and toxicity. Although the prognosis of the disease has improved in the past decades, further improvement is hindered by the occurrence of organ damage as a result of persistent disease activity and treatment-related complications. Novel biological therapies targeting at higher treatment efficacy and fewer adverse effects are being developed. AREAS COVERED This review summarizes recent data on novel biological therapies for SLE. The pitfalls of clinical trial design and future directions of the development of SLE therapeutics are discussed. EXPERT OPINION The variable therapeutic response observed in SLE reflects the clinical and immunological heterogeneity of the disease. The treatment plan of SLE patients should be individualized, with the target of quenching out disease activity, minimizing disease flares, and treatment related morbidities. Despite the disappointment of recent clinical trials, avenues are being opened for novel agents that intervene at different levels of the pathophysiological cascade of SLE. With the availability of a new treatment armamentarium, it is hoped that the survival rate and quality of life of SLE patients can continue to improve.
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Affiliation(s)
- Chi Chiu Mok
- Tuen Mun Hospital, Department of Medicine , Tsing Chung Koon Road, New Territories, Hong Kong, SAR , China +852 2468 5386 ; +852 2456 9100 ;
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Gatto M, Kiss E, Naparstek Y, Doria A. In-/off-label use of biologic therapy in systemic lupus erythematosus. BMC Med 2014; 12:30. [PMID: 24528782 PMCID: PMC3925951 DOI: 10.1186/1741-7015-12-30] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2014] [Accepted: 01/27/2014] [Indexed: 12/17/2022] Open
Abstract
Current therapies for systemic lupus erythematosus (SLE) include corticosteroids as a persistent mainstay and traditional immunosuppressants which are given according to disease severity, organ involvement and patient status. No treatment entails certain efficacy devoid of mild-to-moderate adverse effects. Nowadays, novel therapies are being developed aiming to target specific molecules involved in SLE development and progression which show variable effectiveness and safety. Biologic agents considered for SLE comprise monoclonal antibodies (chimeric, humanized or fully human) as well as fusion molecules or antibody fragments mostly consisting of B cell-targeted therapies beside anti-cytokines as well as T cell-targeted therapies. Encouraging evidence on biologics is mostly provided by case series or uncontrolled studies; conversely, larger randomized controlled clinical trials have frequently missed their primary endpoints with the exception of BLISS-52 and BLISS-76 trials. Actually, apart from belimumab, biologics are employed in clinical practice as off-label treatments for lupus and results are often promising, depending on specific SLE features, dose regimens and individual responsiveness.
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Affiliation(s)
- Mariele Gatto
- Division of Rheumatology, University of Padova, Via Giustiniani, 2, Padova 35128, Italy
| | - Emese Kiss
- Department of Clinical Immunology, Adult- and Paediatric Rheumatology, National Institute of Rheumatology and Physiotherapy, Budapest, Hungary
- Rheumatology Division, 3rd Department of Internal Medicine, Semmelweis University, Budapest, Hungary
| | - Yaakov Naparstek
- Senior Deputy Director General for Research and Academic Affairs, Hadassah Medical Organization, Hadassah Hebrew University Medical Center, Jerusalem 12000, Israel
| | - Andrea Doria
- Division of Rheumatology, University of Padova, Via Giustiniani, 2, Padova 35128, Italy
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Beccastrini E, D'Elios MM, Emmi G, Silvestri E, Squatrito D, Prisco D, Emmi L. Systemic lupus erythematosus: immunopathogenesis and novel therapeutic targets. Int J Immunopathol Pharmacol 2013; 26:585-96. [PMID: 24067455 DOI: 10.1177/039463201302600302] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Systemic lupus erythematosus (SLE) is the prototype of autoimmune diseases with multiorgan involvement. SLE presents many genetic and epigenetic associations and the pathogenesis is characterized by a complex network of alterations affecting both adaptative and innate immunity. The disclosure of novel mechanisms of SLE pathogenesis suggested new therapeutic targets, based on interference with the cytokine pathways or on depletion of the immune cells.
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Affiliation(s)
- E Beccastrini
- SOD Medical Pathology, Center for Autoimmune Systemic Diseases, Behcet Center and Lupus Clinic, AOU Careggi, Florence, Italy
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Abstract
Lupus nephritis is an immune complex GN that develops as a frequent complication of SLE. The pathogenesis of lupus nephritis involves a variety of pathogenic mechanisms. The extrarenal etiology of systemic lupus is based on multiple combinations of genetic variants that compromise those mechanisms normally assuring immune tolerance to nuclear autoantigens. This loss of tolerance becomes clinically detectable by the presence of antinuclear antibodies. In addition, nucleic acids released from netting or apoptotic neutrophils activate innate and adaptive immunity via viral nucleic acid-specific Toll-like receptors. Therefore, many clinical manifestations of systemic lupus resemble those of viral infection. In lupus, endogenous nuclear particles trigger IFN-α signaling just like viral particles during viral infection. As such, dendritic cells, T helper cells, B cells, and plasma cells all contribute to the aberrant polyclonal autoimmunity. The intrarenal etiology of lupus nephritis involves antibody binding to multiple intrarenal autoantigens rather than the deposition of circulating immune complexes. Tertiary lymphoid tissue formation and local antibody production add to intrarenal complement activation as renal immunopathology progresses. Here we provide an update on the pathogenic mechanisms that lead to lupus nephritis and provide the rationale for the latest and novel treatment strategies.
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Affiliation(s)
- Maciej Lech
- Department of Nephrology, Medical Clinic and Polyclinic IV, University of Munich, Germany
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Romo-Tena J, Gómez-Martín D, Alcocer-Varela J. CTLA-4 and autoimmunity: new insights into the dual regulator of tolerance. Autoimmun Rev 2013; 12:1171-6. [PMID: 23851140 DOI: 10.1016/j.autrev.2013.07.002] [Citation(s) in RCA: 90] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2013] [Accepted: 07/07/2013] [Indexed: 12/23/2022]
Abstract
Cytotoxic T-Lymphocye Antigen 4 (CTLA-4) or CD152 is an inhibitory molecule that plays a critical role in maintenance of tolerance to self-antigens. CTLA-4 is structurally as well as functionally related to CD28, since it shares 31% of homology and binds the B7 family molecules CD80 and CD86 with higher affinity. Nevertheless, CTLA-4 has opposing effects on T cell activation and current evidence shows that its inhibitory role goes beyond the ligand-binding interaction. CTLA-4 competes with CD28 in binding to B7, interacts within the immunological synapsis elements and with clathrin adaptor proteins and tyrosine phosphatases through its cytoplasmic domain to regulate cell trafficking and to set the activation threshold within T cells. Moreover, we have learned from the knock out model that CTLA-4 plays a key role in regulatory T cells and in central tolerance. Because of its importance in maintenance of peripheral tolerance, CTLA-4 has been implicated in several autoimmune diseases, such as systemic lupus erythematosus. Multiple single-nucleotide polymorphisms have been located to human Ctla-4 gene, and their association with autoimmune disease is still a matter of controversy. Despite the promising results of abatacept or CTLA-4-Ig in rheumatoid arthritis and murine lupus nephritis, more clinical randomized trials and standardization of outcomes are needed to prove its efficacy and safety in human lupus nephritis.
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Affiliation(s)
- Jorge Romo-Tena
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, Tlalpan 14000, Mexico City, Mexico
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