The need for a Paradigm shift in treatment of the Spectrum of Drug-Resistant TB

Transcription

1 The need for a Paradigm shift in treatment of the Spectrum of Drug-Resistant TB Alimuddin Zumla, UCL and Royal Free, London, UK Anton Lutskji, St Petersburg, Russia, Children s Hospital Andrey Maryandyshev, Archangelsk, Dept of Phtysiology, Russia Alena and Alexander Skrahin, Dept of Phtysiology, Belarus Gerhard Walzl, Stellenbosch, Cape Town and Marthie Ehlers, Johannesburg, SA. markus.maeurer@ki.se

2 Adjunct Immunotherapies for Tuberculosis 1. Tune it up! (I will survive Gloria Gaynor) 2. All that is good has to come to an end - Nelly Furtado

3 Cohort of newly diagnosed cases with M.tb drug sensitive / resistant St Petersburg Stronger INF-gamma production in PBMCs directed against M. tb targets, yet not against CMV or EBV M.tb targets Drug R Blue pos - Duration of infection / Exposure Drug S Red - neg - Host / pathogen relationship - Genetic, biochemical and immunological mapping of the bug

4 Lung in MDR-/ XDR-TB Lung tissue destroyed Alveoli and bronchioles fibrosed Lung immune responses poor or non-existent Lung tissue teeming with mycobacteria which continue proliferating - Lung issue is effectively destroyed and oxygenation, greatly induced collagen-synthesis, TGFbeta production

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7 Adjunct therapies: Would help to shorten the window for drug treatment(s) Damage control (collagen synthesis, anergy, control of high TNFalpha, IL-18 which represents risk for bleeding) Need to choose the right timing - May even aid to establish productive, non-damaging immune responses

8 Evidence from other diseases: - Sepsis: Different need, depending on the timing of IFN production. Initial IFN-delivery may endanger the patient, yet IFN in the contraction phase of the immune response leads to significantly increased better survival (counter-acting IL-10 and TGFbeta). - Simple measurement: Decreased HLA-DR expression on CD14 monocytes, which is usually 100%. Docke WD, Randow F, Syrbe U, et al. Monocyte deactivation in septic patients: restoration by IFN-gamma treatment. Nat Med. 1997;3(6): Influenza infection. Strong immune response is needed to protect from infection. Yet the cytokine storm may even kill the patient. Similar protocols now for patients with sepsis. - Treatment of sever Flu with cyclophosphamide (Henter JI, Palmkvist- Kaijser K, Holzgraefe B, Bryceson YT, Palmer K. Cytotoxic therapy for severe swine flu A/H1N1. Lancet. 2010;376(9758):2116.

9 Evidence in TB Treatment of TB meningitis with glucocorticosteroids, particularly in children (note: different pro-inflammatory reactions with increased Th17 responses) Modulation of the leukotriene A4 hydrolase (LTA4H) locus, which controls the balance of pro/anti- inflammatory eicosanoids (and finally TNF) reveals two mechanism. Host derived therapies (addressing excess inflammation) is associated with better survival (Tobin et al, Cell 148; 434; 2012) Leukotrienes impact on Lymphocyte differentiation Some studies showed faster clearance of M.tb in patients with pulmonary TB and glucocorticosteroid treatment (Muthuswamy 1995) Anti-TNF treatment may accelerate M.tb clearance (Wallis 2005). Recent study showed that ASS treatment leads to better M.tb treatment outcomes in patients with TB meningitis (Misra 2010) Key pathways in inflammation, tissue damage and subsequent loss of immune control are untapped. Know your enemy: mutations in M.tb targets. Comas I, Chakravartti J, Small PM, Galagan J, Niemann S, et al. (2010) Human T cell epitopes of Mycobacterium tuberculosis are evolutionarily hyperconserved. Nat Genet 42:

10 Mutant / variant TB10.4 M.tuberculosis epitopes are recognized from different CD8+ T-cells MYNYP(A/T)ML(G/D) B PAT 6088 PAT MYNYP(A/T)ML(G/D)

11 No need to be afraid of Adjunct therapies: Would help to shorten the window for drug treatment(s) Damage control (collagen synthesis, anergy, control of high TNFalpha, IL-18 which represents risk for bleeding Need to choose the right timing - May even aid to establish productive, non-damaging immune responses Robust markers at which stage is the process? Use old dogs to do new tricks: This list is long and targets biologically and clinically relevant pathways. New drugs which work adjunct to conventional anti-tb drugs (e.g. antineoplastic chemotherapies work via the induction of autophagy dependent effects (Michaud, Science, 2011), similar actions of some anti-malaria drugs which affect also MHC expression on macrophages. - Do not be afraid of cellular therapy! Its safe, it can be done in the field, if the paradigm works = biologicals/drugs could be developed.

12 The T-cell receptor complex TCR Binding to MHC I / peptide complex CD3 γ ε α β ε CD3 δ α β CD8 Binding to MHC I α3 invariant domain Enhancement of lipid raft TCR/CD3 localization ζ ζ Association/activation of p56lck, induction of cascade of phosphorylation, signal transduction Activation of transcription factors, T-cell effector functions

13 CD3 epsilon zeta overlay tonsil TB sarcoidosis

14 in situ Tetramer CD8 Tetramer + CD8 Tet-Ag85b Tet-19kDa Ag Tet-gp Antigen specific T-cells are present, yet are they functional?

15 IL-7 50 µm TGF-beta IL-17a Protection rbcg +++ BCG + Control - MQ IL-7 TGF-beta IL-17a E rbcg BCG contr. rbcg BCG contr. rbcg BCG BCG Control contr. IL-17 (ACIA) 10 5 ** *

16 Novel treatments for MDR-/ XDR-TB Newer approaches are to stimulate immune responses a) Immunotherapy to stimulate effective immunity (growing list) b) Mesenchymal stromal cells adjunct therapy Hypothesis: - Stem cells regenerate lung tissue - They reduce inflammation - They could aid to refocus immune responses

17 young, beautiful and brave

18 autologous MSCs Can be easily cultured and expanded from a bone marrow aspirate = immuno-modulatory Completion of a phase I trial 9 patients Followed up now with additional 20 patients Treatment for MDR, XDR and T-DR TB

19 fluorescence intensivty cell number

20 Pati ent ID Pt1 BM0 6 Pt2 BM0 3 Pt3 BM2 2 Pt4 BM1 7 Pt5 BM1 9 Gen der, Age Case Definition Previous Treatment (cycles) DST M, 31 New Case 0 XDR-TB (HRSEAmKOf x EtoCs) M, 39 Treatment Failure M, 49 Chronic Case M, 24 Chronic Case F, 25 Chronic Case 1 MDR-TB (H, R, S) 3 MDR-TB (S,H,R,E,Km,C m,pto) 4 XDR-TB (S,H,R,E,Ofx,A m,km,pas,cs) 2 MDR-TB (H,S,R,E,Z,Ofx,Eto,Cs) Second Line individualised Regimen (IR) 1 Km,Ofx,Eto,Cs,PAS / 2 Mfx, PAS, Pto, Cs, Amx,/Clv, Lnz / 3 Mfx, PAS, Pto, Cs, Z, H /18 Mfx, PAS, Pto, Cs, Z 2 PAS, Pto, Km, Cs, Ofx / 15 Cm, Ofx, Z, Cs, Eto / 12 Ofx, Z, Cs, Eto 12 Am,Ofx,Pto,PAS,Cs/ 12 Am,Ofx,Pto,PAS,Cs Amx-Clv, Clr/ palliative care 3 Cm,Ofx,Pto,PAS,Cs / 3 Cm, Ofx, Pto, PAS, Cs, Amx-Clv /9 Mfx, Cm, Cs, Eto, PAS, Amx-Clv/11 Cm, Cs, Eto, PAS 2 Ofx,Km,Pto,PAS,Cs / 9 Ofx, Cs, Km, Amx-Clv, PAS, Pto, Clr / 3 Ofx, Cm, PAS, Cs, H, Pto /6 Mfx, Pto, Cm, Amx-Clv, Clr, PAS/palliative care Days of treatment before MSC therapy Smear and culture at IR start and BM harvest 74 Smear + / 240 Smear - / 192 Smear + / 172 Smear - / 102 Smear - / Smear and culture at the time of MSC infusion Smear - / Smear - / Smear + / Smear - / Smear - / MSC dose infused 1x10 6 (1x10 6 /kg) 55 (0,75) 17 (0,28) 94 (1,3) 74 (1,04) 65 (1,14) Months before sputum conversion (after IR initiation) 4 Smear - / Culture - 17 Smear - / Culture - no sp.con. Smear - / Culture + 12 Smear - / Culture - no sp.con. Smear + / Culture + Months before sputum conversion (after MSC infusion) no sp.con. Smear - / Culture +7 no sp.con. Smear + / outcome Cured IR stopped at 24 mo. Cured IR stopped at 29 mo. treatment failure Cured IR stopped at 26 mo Treatment failure Pt6 BM1 0 Pt7 BM2 0 F, 29 Chronic Case M, 41 Chronic Case 2 MDR-TB (HSRE) 3 XDR-TB (H,R,S,E,Am,K m,ofx,pas) 8 Km, Ofx, PAS, Eto, Cs /14 Ofx, PAS, Eto, Cs 2 Z, E, Am, Pto, Ofx, PAS / 11 Mfx, Am, E, Z, Cs, Pto / 5 Mfx, Pto, PAS, Amx-Clv, Clr, Cs, Cm / 3 Pto, PAS, Cs, Amx-Clv, Mfx, Lnz /7 Pto, PAS, Cs, amx-clv, Mfx 280 Smear - / 250 Smear + / Smear - / Culture - Smear - / 41 (0,7) 43 (0,65) 4 Smear - / Culture - 10 Smear - / Culture Cured IR stopped at 22 mo Cured Treatment completed Pt8 BM2 1 Pt9 BM0 8 M, 25 Chronic Case F, 28 Treatment Failure 4 XDR-TB (H,R,S,E,Km, Ofx,Eto) 1 MDR-TB (H,S,R,Z,E, Eto) 11 Km,Ofx,Eto,E,Cs /3 Ofx, Cm, Cs, Amx-Clv, Clr, Pto /10 Ofx, Cm, Cs, Amx-Clv, Pto/ /palliative care 1 Km, Ofx, Pto, Pas, Z / 4 PAS, Km, Ofx, Eto, Cs /14PasKmOfxEtoCs / 6PasOfxEtoCs 130 Smear + / 322 Smear - / Smear + / Smear - / 76 (0,95) 13 (0,25) no sp. conv Smear - / Culture + 4 Smear - / Culture - no sp. conv Smear - / -6 treatment failure Cured IR stopped d at 25 mo

21 Days from days MSC infusion Days to culture conversion 81 after MSC second line regimen started 73 days before MSC infusion, infusion 118 days after TB diagnosis. Improvement of pulmonary lesions. Xrays were serially taken every 2 weeks; representative example from patient 1 with improvement 53 days after MSC infusion, culture conversion was documented 81 days after MSC infusion.

22 IFNγ pg / ml days: 0 pos control Rv BCG Patients regain immune-competence neg control Rv2957 Rv patient Serie1 1 Serie2 2 Serie3 3 Serie4 4 Serie5 5 Serie6 6 Serie7 9 after MSC

23 Patient 9; Production of IL2 by CD4+ T cells 0 7d 28d 2m after MSC medium PMA TB10.4

24 Why? Patients with MDR and XDT will succumb to the disease! 30% may die within the first year worse than cancer! Drug treatment alone will not help at this point. summary of the phase I trial: 1. Bone marrow aspirate: Autologous mesenchymal stem cells 2. Culture 2-3 weeks 3. Quality control 4. Transfer into the patient Reduce unproductive inflammation Rebuild lung tissue Refocus of the anti-tb immune response This is a paradigm and calls that we employ robust, biologically and clinically sound treatment concepts. This has been done, in part in patients with cancer, and could be achieved in patients with drug resistant TB.

25 Scientifically and clinically relevant models and smartly designed phase I trials Robust markers old drugs or new bullets: important is that it works then we can tailor it and make it cheaper. Adjunct therapies have been implement in a number of different medical disciplines.

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