Equine Regenerative Medicine. Regenerative Medicine IRAP and PRP in the Equine Athlete. Stem Cells. Stem Cells. Veterinary Medical Devices

Transcription

1 Equine Regenerative Medicine Regenerative Medicine IRAP and PRP in the Equine Athlete Victoria Maxwell, DVM, MBA 2018 Potomac Regional Veterinary Conference Hyatt Regency Inner Harbor Baltimore, Maryland provide a scaffold for repair provide cells for the healing process provide growth factors to stimulate the healing process Some regenerative therapies currently used in horses: Stem Cells Platelet-Rich Plasma (PRP) Autologous Conditioned Serum (irap) Contributor: Dr.med.vet. J.Troillet; St. Petersburg Stem Cells Cells that have the ability to divide and develop into many different cell types in the body during early life and growth. May also help repair the body by dividing to replenish cells that are damaged by disease, injury, or normal wear. When a stem cell divides, each new cell has the potential to either: remain a stem cell become another type of cell with a more specialized function, such as a nerve cell, a skin cell, or a red blood cell. Stem Cells 3 types of stem cells identified in human and veterinary research: Adult stem cells Two of the most common sources of equine adult stem cells are bone marrow and adipose (fat)-derived mesesenchymal stem cells (MCS) Human embryonic stem cells (hesc) Come from embryos that develop from eggs that have been fertilized in vitro (in a test tube or another artificial environment). Induced pluripotent stem cells (ips) Generated by reprogramming adult cells that have already differentiated into a specific cell, such as a skin cell. FDA has not approved any stem cell-based products for use, except cord blood-derived hematopoietic progenitor cells (blood forming stem cells) for certain human indications including certain blood cancers and some inherited metabolic and immune system disorders. Veterinary Medical Devices Further, a device "does not achieve any of its principal intended purposes through chemical action within or on the body of man or other animals, and is not dependent upon being metabolized for the achievement of any of its principal intended purposes." Examples of devices include such things as needles, syringes, surgical instruments, prosthetic devices, X-ray equipment, certain diagnostic test kits, and dental appliances. Pre-market Approval is Not Required: The FDA does not require submission of a 510(k) or formal pre-market approval for devices used in veterinary 1

2 Medical Device for Preparation of Autologous Conditioned Serum What is irap? Orthokine vet irap 60 Orthokine vet irap 10 Interleukin-1 Receptor Antagonist Protein (irap) irap therapy utilizes the patient s own blood and natural healing mechanisms The patented irap syringe produces Autologous Conditioned Serum (ACS), which contains beneficial anti-inflammatory and regenerative cytokines. Cytokine = immunoregulatory proteins (as interleukin or interferon) secreted by cells especially of the immune system Autologous Conditioned Serum How does irap work? Autologous: 100% body s own components Conditioned: Achieved through physical processes Serum: Cell-free supernatant of coagulated whole blood Glass Beads The conditioning of the blood is achieved through exposure of the whole blood to a specific surface of borosilicate glass spheres the irap syringe contains medical grade glass beads stimulate the white blood cells to produce the anti-inflammatory and regenerative cytokines whole blood is incubated and then centrifuged to collect serum the serum, (ACS), is then re-injected into the patient. Autologous Protein Production in Whole Blood Model: Monocyte Adherence to surfaces active molecules Certain cells accumulate around these surfaces and begin to produce cytokines that are beneficial for regenerative process binding e.g. glass spheres Medical Grade A Glass Beads They are NOT coated with anything 2

3 How does ACS work? Monocyte Biomechanical Factors Activation of cytokine network cascade Macrophage Leukocytes(WBCs) Lymphocyte IL-1Ra Destruction of hyaline cartilage and it s matrix Pro-inflammatory and destructive cytokines Neutrophil granulocyte? Immunologic cell Imbalance in matrix metabolism ACS can help to inhbit the destruction of cartilage and break this vicious cycle! Dr.med.vet. J.Troillet; St. Petersburg Inflammatory Mediators One Responsible Cytokine Interleukin-1 Pro-Inflammatory cytokine Stimulation of collagenase and metallo-proteinase Destruction of hyaline cartilage and its matrix Interleukin-1 Receptor antagonist Type I and II IL-1 receptors Anti-inflammatory and chondroprotective IL- 1 ACS Mode of Action Pro-inflammatory Syngergy with TNF-α Promotes destruction of chondrocytes abd cartilage matrix IL-1 TNF α IL-1RA IL-10 IL-RA Competitive inhibition of IL-1 receptors Anti-inflammatory and chondroprotective Joint homeostasis Anabolism and Catabolism are in balance 3

4 DZ Disease Mode of Action IL-1 TNF α IL-1RA IL-10 Chronic Degeneration Suppression and synthesis Proteoglycans Type II Collagen Fibers Increased De Novo MMP s and Aggrecanase IL-1 on chondrocytes Joint Disease Anabolism and Catabolism are in out of balance Inside a Pathologic Joint Irap is used to treat a variety of inflammatory conditions in horses: Joint lameness Tendon and ligament injuries Muscle injuries Dr.med.vet. J.Troillet; St. Petersburg Controlled study with OA model in horses at CSU showed positive effects IL-1Ra is good IL-1 is bad Results*: IL-1Ra (140 fold) IL-4 (2.1 fold) Anti-inflammatory IL-10 (2.2 fold) No change IL-1 beta No change TNF alpha Pro-inflammatory *Frisbee D, Kawcak C, Werpy N, Park R, McIlwraith W, Clinical, biochemical and histological effects of intra-articular administration of autologous conditioned serum in horses with experimentally induced osteoarthritis. Amer Jour Vet Research, Vol. 68, No. 3, Equine Has irap been tested? The patented irap therapy has been used in thousands of horses around the world.* Controlled study at Colorado State University* results indicated that there was significant clinical and histological improvement in osteoarthritis-affected joints of horses following treatment with ACS, compared with placebo treatment. Horses treated with ACS had significant clinical improvement in lameness, unlike the placebo group. * Per Orthogen Veterinary, Duesseldorf, Germany **Frisbee D, Kawcak C, Werpy N, Park R, McIlwraith W, Clinical, biochemical and histological effects of intra-articular administration of autologous conditioned serum in horses with experimentally induced osteoarthritis. Amer Jour Vet Research, Vol. 68, No. 3,

5 -Equine -Equine Clinical, biochemical, and histologic effects of intra-articular administration of Autologous Conditioned Serum in horses with experimentally induced osteoarthritis (Frisbie et al. 2007) Clinical, biochemical, and histologic effects of intra-articular administration of Autologous Conditioned Serum in horses with experimentally induced osteoarthritis (Frisbie et al. 2007) 16 horses with experimentally induced OA 8 horses treated w/ 6ml of ACS on 14, 21, 28 & 35 8 horses treated w/ saline Clinical examinations Synovial fluid analysis Gross examination Histology Biochemical & biomarker No adverse reaction Improved lameness Decreased synovial membrane hyperplasia Less gross cartilage fibrillation Less synovial membrane hemorrhage Osteokine PRP What is PRP? Platelet Rich Plasma PRP is a preparation of autologous concentrated platelets (thrombocytes) PRP produced by Osteokine contains therapeutically significant concentrations of platelets How does it work? Whole blood is taken from the horse and placed into the red-capped Osteokine bag After processing in a special centrifuge a pellet of PRP is generated which can be re-suspended to treat the horse from which it was taken What can PRP be used for? Thrombocytes / Platelets PRP has been shown to accelerate healing in injuries involving fibrous tissues (tendons, ligaments, skin) and has also been used in bone healing. Platelets Platelets do more than coagulation α-granules contain GF indispensable for normal wound healing 1st phase: upon injury tissue thromboplastin induces platelet coagulation and reduces bleeding 2nd phase: plasma fibrinogen breaks to fibrin, further coagulation stops bleeding. Aggregation of platelets starts off GF secretion. GF induce cell proliferation, stem cell differentiation and migration. Macrophages migrate to the site and take over the place of platelets as source of cytokines. 5

6 Osteokine Concentrated platelets are a rich source of (autologous) growth factors. If platelets are fresh and fully functional -> optimal sequential growth factor output Total operating time to retrieve PRP is about 40 min Characteristics of the Osteokine PRP system Average platelet count in native blood: 275,000 / µl Average platelet count in 8 ml of PRP yielded by Osteokine: 1,300,000 / µl Average platelet concentration of 1,300,000 µl ± 250,000 / µl from 50 ml in a final volume of 5-10 ml Concentration factor of platelets routinely 3-6 fold Factors present in Osteokine PRP PDGF IGF FGF TGF HGF VEGF EGF Plus cytokines such as IL-1Ra, IL-6 Benefits of Osteokine PRP Accelerated wound healing in multiple tissues including skin, tendon, ligament Higher collagen content in healing injuries resulting in lower scar formation Reduced perioperative traumatic pain Lower infection rates Inject immediately into core lesions / superficial lesion Improved tissue formation (e.g. more collagen) improved bone maturation Two options to Lameness Osteokine (PRP) irap Use in soft tissue (fibrous) injuries Tendons Ligaments Skin, muscle & bone Easily produced in-clinic within minutes Treat injured horse 1 time High PRP potency Use intra-articular (IA) to treat osteo-arthritis Processed in-clinic for ease of use Used in thousands of horses around the world since 2004 Proven effective by CSU 3 initial treatments then maintenance (horse dictates need) High potency and yield Proven & trusted! 6

7 Conclusion Discussion irap IA works with great success against lameness caused by mild to moderate OA Osteokine is a fantastic PRP system to treat soft tissue injuries Only irap has been tested in controlled studies and in real world situations. 7