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Seelig E, Howlett J, Porter L, Truman L, Heywood J, Kennet J, Arbon EL, Anselmiova K, Walker NM, Atkar R, Pekalski ML, Rytina E, Evans M, Wicker LS, Todd JA, Mander AP, Bond S, Waldron-Lynch F. The DILfrequency study is an adaptive trial to identify optimal IL-2 dosing in patients with type 1 diabetes. JCI Insight 2018; 3:99306. [PMID: 30282826 DOI: 10.1172/jci.insight.99306] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Accepted: 08/21/2018] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Type 1 diabetes (T1D) results from loss of immune regulation, leading to the development of autoimmunity to pancreatic β cells, involving autoreactive T effector cells (Teffs). Tregs, which prevent autoimmunity, require IL-2 for maintenance of immunosuppressive functions. Using a response-adaptive design, we aimed to determine the optimal regimen of aldesleukin (recombinant human IL-2) to physiologically enhance Tregs while limiting expansion of Teffs. METHODS DILfrequency is a nonrandomized, open-label, response-adaptive study of participants, aged 18-70 years, with T1D. The initial learning phase allocated 12 participants to 6 different predefined regimens. Then, 3 cohorts of 8 participants were sequentially allocated dose frequencies, based on repeated interim analyses of all accumulated trial data. The coprimary endpoints were percentage change in Tregs and Teffs and CD25 (α subunit of the IL-2 receptor) expression by Tregs, from baseline to steady state. RESULTS Thirty-eight participants were enrolled, with thirty-six completing treatment. The optimal regimen to maintain a steady-state increase in Tregs of 30% and CD25 expression of 25% without Teff expansion is 0.26 × 106 IU/m2 (95% CI -0.007 to 0.485) every 3 days. Tregs and CD25 were dose-frequency responsive, Teffs were not. The commonest adverse event was injection site reaction (464 of 694 events). CONCLUSIONS Using a response-adaptive design, aldesleukin treatment can be optimized. Our methodology can generally be employed to immediately access proof of mechanism, thereby leading to more efficient and safe drug development. TRIAL REGISTRATION International Standard Randomised Controlled Trial Number Register, ISRCTN40319192; ClinicalTrials.gov, NCT02265809. FUNDING Sir Jules Thorn Trust, the Swiss National Science Foundation, Wellcome, JDRF, and NIHR Cambridge Biomedical Research Centre.
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Affiliation(s)
- Eleonora Seelig
- Experimental Medicine and Immunotherapeutics, Department of Medicine.,Wellcome Trust-MRC Institute of Metabolic Science, and.,National Institute for Health Research, Cambridge Biomedical Research Centre, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom.,JDRF/Wellcome Trust Diabetes and Inflammation Laboratory and
| | - James Howlett
- National Institute for Health Research, Cambridge Biomedical Research Centre, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom.,MRC Biostatistics Unit Hub for Trials Methodology Research, Cambridge Institute of Public Health, University of Cambridge, Cambridge, United Kingdom.,National Institute for Health Research, Cambridge Clinical Trials Unit
| | - Linsey Porter
- Experimental Medicine and Immunotherapeutics, Department of Medicine.,National Institute for Health Research, Cambridge Biomedical Research Centre, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom.,JDRF/Wellcome Trust Diabetes and Inflammation Laboratory and
| | - Lucy Truman
- National Institute for Health Research, Cambridge Biomedical Research Centre, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom.,JDRF/Wellcome Trust Diabetes and Inflammation Laboratory and.,Department of Ear, Nose, and Throat Surgery
| | - James Heywood
- Experimental Medicine and Immunotherapeutics, Department of Medicine.,National Institute for Health Research, Cambridge Biomedical Research Centre, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom.,JDRF/Wellcome Trust Diabetes and Inflammation Laboratory and
| | - Jane Kennet
- Experimental Medicine and Immunotherapeutics, Department of Medicine.,Wellcome Trust-MRC Institute of Metabolic Science, and.,National Institute for Health Research, Cambridge Biomedical Research Centre, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom.,JDRF/Wellcome Trust Diabetes and Inflammation Laboratory and
| | - Emma L Arbon
- National Institute for Health Research, Cambridge Biomedical Research Centre, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom.,National Institute for Health Research, Cambridge Clinical Trials Unit
| | - Katerina Anselmiova
- Experimental Medicine and Immunotherapeutics, Department of Medicine.,Wellcome Trust-MRC Institute of Metabolic Science, and.,National Institute for Health Research, Cambridge Biomedical Research Centre, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom.,JDRF/Wellcome Trust Diabetes and Inflammation Laboratory and
| | - Neil M Walker
- National Institute for Health Research, Cambridge Biomedical Research Centre, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom.,JDRF/Wellcome Trust Diabetes and Inflammation Laboratory and.,Department of Clinical Informatics, and
| | - Ravinder Atkar
- National Institute for Health Research, Cambridge Biomedical Research Centre, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom.,Department of Dermatology, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - Marcin L Pekalski
- National Institute for Health Research, Cambridge Biomedical Research Centre, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom.,JDRF/Wellcome Trust Diabetes and Inflammation Laboratory and.,JDRF/Wellcome Diabetes and Inflammation Laboratory, Wellcome Trust Center for Human Genetics, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Ed Rytina
- National Institute for Health Research, Cambridge Biomedical Research Centre, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom.,Department of Pathology, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - Mark Evans
- Wellcome Trust-MRC Institute of Metabolic Science, and.,National Institute for Health Research, Cambridge Biomedical Research Centre, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Linda S Wicker
- National Institute for Health Research, Cambridge Biomedical Research Centre, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom.,JDRF/Wellcome Trust Diabetes and Inflammation Laboratory and.,JDRF/Wellcome Diabetes and Inflammation Laboratory, Wellcome Trust Center for Human Genetics, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - John A Todd
- National Institute for Health Research, Cambridge Biomedical Research Centre, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom.,JDRF/Wellcome Trust Diabetes and Inflammation Laboratory and.,JDRF/Wellcome Diabetes and Inflammation Laboratory, Wellcome Trust Center for Human Genetics, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Adrian P Mander
- National Institute for Health Research, Cambridge Biomedical Research Centre, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom.,MRC Biostatistics Unit Hub for Trials Methodology Research, Cambridge Institute of Public Health, University of Cambridge, Cambridge, United Kingdom
| | - Simon Bond
- National Institute for Health Research, Cambridge Biomedical Research Centre, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom.,MRC Biostatistics Unit Hub for Trials Methodology Research, Cambridge Institute of Public Health, University of Cambridge, Cambridge, United Kingdom.,National Institute for Health Research, Cambridge Clinical Trials Unit
| | - Frank Waldron-Lynch
- Experimental Medicine and Immunotherapeutics, Department of Medicine.,Wellcome Trust-MRC Institute of Metabolic Science, and.,National Institute for Health Research, Cambridge Biomedical Research Centre, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom.,JDRF/Wellcome Trust Diabetes and Inflammation Laboratory and.,National Institute for Health Research, Cambridge Clinical Trials Unit
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Zhao TX, Kostapanos M, Griffiths C, Arbon EL, Hubsch A, Kaloyirou F, Helmy J, Hoole SP, Rudd JHF, Wood G, Burling K, Bond S, Cheriyan J, Mallat Z. Low-dose interleukin-2 in patients with stable ischaemic heart disease and acute coronary syndromes (LILACS): protocol and study rationale for a randomised, double-blind, placebo-controlled, phase I/II clinical trial. BMJ Open 2018; 8:e022452. [PMID: 30224390 PMCID: PMC6144322 DOI: 10.1136/bmjopen-2018-022452] [Citation(s) in RCA: 70] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION Inflammation and dysregulated immune responses play a crucial role in atherosclerosis, underlying ischaemic heart disease (IHD) and acute coronary syndromes (ACSs). Immune responses are also major determinants of the postischaemic injury in myocardial infarction. Regulatory T cells (CD4+CD25+FOXP3+; Treg) induce immune tolerance and preserve immune homeostasis. Recent in vivo studies suggested that low-dose interleukin-2 (IL-2) can increase Treg cell numbers. Aldesleukin is a human recombinant form of IL-2 that has been used therapeutically in several autoimmune diseases. However, its safety and efficacy is unknown in the setting of coronary artery disease. METHOD AND ANALYSIS Low-dose interleukin-2 in patients with stable ischaemic heart disease and acute coronary syndromes is a single-centre, first-in-class, dose-escalation, two-part clinical trial. Patients with stable IHD (part A) and ACS (part B) will be randomised to receive either IL-2 (aldesleukin; dose range 0.3-3×106 IU) or placebo once daily, given subcutaneously, for five consecutive days. Part A will have five dose levels with five patients in each group. Group 1 will receive a dose of 0.3×106 IU, while the dose for the remaining four groups will be determined on completion of the preceding group. Part B will have four dose levels with eight patients in each group. The dose of the first group will be based on part A. Doses for each of the subsequent three groups will similarly be determined after completion of the previous group. The primary endpoint is safety and tolerability of aldesleukin and to determine the dose that increases mean circulating Treg levels by at least 75%. ETHICS AND DISSEMINATION The study received a favourable opinion by the Greater Manchester Central Research Ethics Committee, UK (17/NW/0012). The results of this study will be reported through peer-reviewed journals, conference presentations and an internal organisational report. TRIAL REGISTRATION NUMBER NCT03113773; Pre-results.
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Affiliation(s)
- Tian Xiao Zhao
- Department of Medicine, Division of Cardiovascular Medicine, University of Cambridge Medicine, Cambridge, UK
- Division of Experimental Medicine and Immunotherapeutics (EMIT), Department of Medicine, University of Cambridge Medicine, Cambridge, Cambridgeshire, UK
| | - Michalis Kostapanos
- Division of Experimental Medicine and Immunotherapeutics (EMIT), Department of Medicine, University of Cambridge Medicine, Cambridge, Cambridgeshire, UK
| | - Charmaine Griffiths
- Cambridge Clinical Trials Unit, Cambridge University Hospitals, Cambridge, Cambridgeshire, UK
| | - Emma L Arbon
- Cambridge Clinical Trials Unit, Cambridge University Hospitals, Cambridge, Cambridgeshire, UK
| | - Annette Hubsch
- Division of Experimental Medicine and Immunotherapeutics (EMIT), Department of Medicine, University of Cambridge Medicine, Cambridge, Cambridgeshire, UK
| | - Fotini Kaloyirou
- Division of Experimental Medicine and Immunotherapeutics (EMIT), Department of Medicine, University of Cambridge Medicine, Cambridge, Cambridgeshire, UK
| | - Joanna Helmy
- Division of Experimental Medicine and Immunotherapeutics (EMIT), Department of Medicine, University of Cambridge Medicine, Cambridge, Cambridgeshire, UK
| | - Stephen P Hoole
- Department of Interventional Cardiology, Royal Papworth Hospital NHS Trust, Cambridge, UK
| | - James H F Rudd
- Department of Medicine, Division of Cardiovascular Medicine, University of Cambridge Medicine, Cambridge, UK
| | - Graham Wood
- Department of Immunology, Cambridge University Hospitals, Cambridge, UK
| | - Keith Burling
- Clinical Biochemistry, Cambridge University Hospitals, Cambridge, UK
| | - Simon Bond
- Cambridge Clinical Trials Unit, Cambridge University Hospitals, Cambridge, Cambridgeshire, UK
| | - Joseph Cheriyan
- Division of Experimental Medicine and Immunotherapeutics (EMIT), Department of Medicine, University of Cambridge Medicine, Cambridge, Cambridgeshire, UK
- Cambridge Clinical Trials Unit, Cambridge University Hospitals, Cambridge, Cambridgeshire, UK
| | - Ziad Mallat
- Department of Medicine, Division of Cardiovascular Medicine, University of Cambridge Medicine, Cambridge, UK
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Lo JC, Groeger JA, Santhi N, Arbon EL, Lazar AS, Hasan S, von Schantz M, Archer SN, Dijk DJ. Effects of partial and acute total sleep deprivation on performance across cognitive domains, individuals and circadian phase. PLoS One 2012; 7:e45987. [PMID: 23029352 PMCID: PMC3454374 DOI: 10.1371/journal.pone.0045987] [Citation(s) in RCA: 216] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2012] [Accepted: 08/23/2012] [Indexed: 01/21/2023] Open
Abstract
Background Cognitive performance deteriorates during extended wakefulness and circadian phase misalignment, and some individuals are more affected than others. Whether performance is affected similarly across cognitive domains, or whether cognitive processes involving Executive Functions are more sensitive to sleep and circadian misalignment than Alertness and Sustained Attention, is a matter of debate. Methodology/Principal Findings We conducted a 2 × 12-day laboratory protocol to characterize the interaction of repeated partial and acute total sleep deprivation and circadian phase on performance across seven cognitive domains in 36 individuals (18 males; mean ± SD of age = 27.6±4.0 years). The sample was stratified for the rs57875989 polymorphism in PER3, which confers cognitive susceptibility to total sleep deprivation. We observed a deterioration of performance during both repeated partial and acute total sleep deprivation. Furthermore, prior partial sleep deprivation led to poorer cognitive performance in a subsequent total sleep deprivation period, but its effect was modulated by circadian phase such that it was virtually absent in the evening wake maintenance zone, and most prominent during early morning hours. A significant effect of PER3 genotype was observed for Subjective Alertness during partial sleep deprivation and on n-back tasks with a high executive load when assessed in the morning hours during total sleep deprivation after partial sleep loss. Overall, however, Subjective Alertness and Sustained Attention were more affected by both partial and total sleep deprivation than other cognitive domains and tasks including n-back tasks of Working Memory, even when implemented with a high executive load. Conclusions/Significance Sleep loss has a primary effect on Sleepiness and Sustained Attention with much smaller effects on challenging Working Memory tasks. These findings have implications for understanding how sleep debt and circadian rhythmicity interact to determine waking performance across cognitive domains and individuals.
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Affiliation(s)
- June C. Lo
- Surrey Sleep Research Centre, Faculty of Health and Medical Sciences, University of Surrey, Guildford, United Kingdom
| | - John A. Groeger
- Surrey Sleep Research Centre, Faculty of Health and Medical Sciences, University of Surrey, Guildford, United Kingdom
- Department of Psychology, University of Hull, Hull, United Kingdom
| | - Nayantara Santhi
- Surrey Sleep Research Centre, Faculty of Health and Medical Sciences, University of Surrey, Guildford, United Kingdom
| | - Emma L. Arbon
- Surrey Sleep Research Centre, Faculty of Health and Medical Sciences, University of Surrey, Guildford, United Kingdom
| | - Alpar S. Lazar
- Surrey Sleep Research Centre, Faculty of Health and Medical Sciences, University of Surrey, Guildford, United Kingdom
| | - Sibah Hasan
- Surrey Sleep Research Centre, Faculty of Health and Medical Sciences, University of Surrey, Guildford, United Kingdom
| | - Malcolm von Schantz
- Surrey Sleep Research Centre, Faculty of Health and Medical Sciences, University of Surrey, Guildford, United Kingdom
- Department of Biochemistry and Physiology, Faculty of Health and Medical Sciences, University of Surrey, Guildford, United Kingdom
| | - Simon N. Archer
- Surrey Sleep Research Centre, Faculty of Health and Medical Sciences, University of Surrey, Guildford, United Kingdom
- Department of Biochemistry and Physiology, Faculty of Health and Medical Sciences, University of Surrey, Guildford, United Kingdom
| | - Derk-Jan Dijk
- Surrey Sleep Research Centre, Faculty of Health and Medical Sciences, University of Surrey, Guildford, United Kingdom
- Department of Biochemistry and Physiology, Faculty of Health and Medical Sciences, University of Surrey, Guildford, United Kingdom
- * E-mail:
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