IMMUNOTHERAPIE DU DIABETE AUTO-IMMUN

Transcription

1 IMMUNOTHERAPIE DU DIABETE AUTO-IMMUN INSERM U1013 INSTITUT UNIVERSITAIRE DE FRANCE

2 Natural history of type 1 diabetes b cell function (%) Time

3 AN ALARMING EPIDEMIOLOGICAL TREND EURODIAB registered new cases of T1D in children before 15 years of age between The overall annual increase was 3.9%, New cases in Europe in 2005 : (24%: 0-4 years, 35%: 5-9 years, and 41%: years). In 2020, the predicted number of new cases is , with a doubling in numbers in children younger than 5 years. Prevalence under age 15 years is predicted to rise from in 2005, to in Doubling of new cases of type 1 diabetes in children younger than 5 years and prevalent cases younger than 15 years will rise by 70%. Patterson et al. Lancet 2009, 373, 1999

4 40 PLACEBO-CONTROLLED TRIAL OF CYCLOSPORIN A IN RECENTLY DIAGNOSED IDDM (CDF study) EFFECT ON REMISSION RATE Remission (%) CsA (n = 155) Placebo (n = 127) Months G. Feutren et al. Lancet 1986; 2:

5 1 year p=0,0195 RITUXIMAB IN T1D Over time p< 0,038 One course 4 doses (375 mg/m 2 ) Over time p< 0,004 M. Pescovitz et al. New Engl J Med 2009, 361:

6 TWO STRATEGIES TO INDUCE IMMUNE TOLERANCE 1. Administration of b-cell autoantigens 2. Use of monoclonal antibodies mediating T cell signaling

7 AUTOANTIGEN TRIALS Antigen Trial Reference Oral Insulin New onset T1D Chaillous L et al. The Lancet 356, 545, 2000 Oral Insulin New onset T1D Pozilli P et al. Diabetologia 43, 1000, 2000 APL insulin B chain (NBI-6,024) New onset T1D Walter M et al. Diabetes Care 32, 2036, 2009 Hsp60 p277 New onset T1D Raz I et al. The Lancet 358, 1749, 2001 i.v. + s.c. insulin DPT-1 Oral insulin DPT1 Intranasal insulin Late preclinical T1D Insulin-autoantibody positive relatives Insulin-autoantibody positive relatives Skyler J et al. New Engl J Med 346, 1685, 2002 Skyler J et al. New Engl J Med 346, 1685, 2002 Näntö-Salonen K et al. The Lancet 372, 1746, 2008 Alum formulated GAD Recent onset T1D Ludvigsson J et al. New Engl J Med 359, 1909, 2008

8 CD3 antibody therapy - Expresses the unique ability to restore selftolerance in established autoimmunity - The therapeutic effect initially demonstrated in the experimental setting was successfully transferred to the clinic - The mode of action involves ' resetting ' of active tolerance

9 ACTIVE TOLERANCE Tolerance requiring active contribution of antigen-specific activated T cells Related concepts dominant tolerance infectious tolerance immunoregulation T-cell mediated suppression

10 HETEROGENEITY OF CD4 + REGULATORY T CELLS CD8 + T cell CD4 + CD8 + CD4 + CD25 +high Foxp3 + CD4 + CD25 +high Foxp3 + CD4 + T cell Tr1 IL-10/ TGF-b CD4 + CD25 - Foxp3 - Systemic Ag Th2 IL-4/ IL-10 Th3 TGF-b Oral Ag THYMUS IN AUTOIMMUNE PRONE INDIVIDUALS Ag Stimulation tolerogenic context CD4 + CD25 +low Foxp3 + CD4 + CD25 - Foxp3 - Cell contact TGF-b, GITR, CTLA-4 Ag Stimulation Pro-inflammatory context CD4 + Th1 Effector CD25 - Foxp

11 CD25 % Diabetes Both CD4 + CD25 high and CD4+CD25 low T cells are suppressive in vivo in NOD mice 100 CD4 + CD25 high CD4 + CD25 low CD4 + CD Diab Diab/CD25 low Diab/CD25 high CD Weeks after transfer

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13 REMISSION OF ESTABLISHED DIABETES IN CD3 ANTIBODY-TREATED NOD MICE % r e m i s s i o n A n t i - C D 3 C o n t r o l s ( n = 20 ) p < ( n = 16 ) p < ( n = 1 7 ) 0 ( n = 1 6 ) W e e k s T r e a t m e n t ( d 0 - d 5 ) L. Chatenoud et al. Proc.Natl.Acad.Sci. USA 1994; 91:

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15 -Belghith M et al. Nat Med 9: , You S et al. Immunol Rev 212: , You S et al. (2007) Proc Natl Acad Sci (U S A) 104: , Chatenoud L & Bluestone JA. Nat Rev Immunol 7: , You S et al. Adv Immunol 100: 13-37, 2008

16 Mean Clinical Score Mean Clinical Score Mean Clinical Score THERAPY OF ONGOING R-EAE USING CD3 ANTIBODIES Day 0-4 Treatment Control acd3 F(ab')2 Rx Days Post Disease Induction Day 6-10 Treatment Day Treatment Control acd3 F(ab')2 Rx Days Post Disease Induction Control acd3 F(ab') Rx Days Post Disease Induction

17 Humanized YTH 12.5 (CAMPATH 3) Reshape d Rat YTH 12.5 higg1 Mutation Asn to Ala position 297 (prevents glycosylation) S. Bolt et al European J Immunol, 1993, 23, 403

18 Treatment of established Type 1 diabetes with a non-mitogenic CD3 antibody Phase II trial Multicenter Placebo Controlled Between 07/06/2000 and 07/03/ consecutive recent onset diabetic patients were screened 80 patients included years old. positive for ICA and/or GAD Abs insulin-treatment <4 weeks 8mg/day of ChAglyCD3 for 6 consecutive days EBV IgG positive. Keymeulen B. N. Engl. J. Med 2005, 352:

19 % IU/kg/day Insulin dose n=27 n=29 n=31 n=31 ChAglyCD3 0.6 n=28 Placebo n=31 n=33 n=31 n=33 n=33 n=32 n=31 n=32 n= p=0.004 p<0.001 p=0.001 p= Months 9 HbA1c p=0.761 p=0.984 p=0.990 p= Months Keymeulen B. Diabetologia 2009, 53:

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23 Insulin dose U/Kg/day 12 MONTHS AFTER TREATMENT HbA1C % NS NS NS* * 0.25 NS NS NS NS NS 0.5 NS NS NS 0.75 NS NS: non significant difference between placebo and CD3 antibody-treated patients (Chi Square) Data from European Phase II trial using otelixizumab (Keymeulen B. N. Engl. J. Med 2005, 352: )

24 Phase III Study : teplizumab Lancet. 2011; 378 :

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26 GENETIC PREDISPOSITION LOSS OF BETA CELL FUNCTION GENETIC PREDISPOSITION GENETIC PREDISPOSITION GENETIC PREDISPOSITION AUTOIMMUNE DIABETES MULTIPLE SCLEROSIS BETA CELL AUTOANTIBODIES BENIGN CD3 mab Therapeutic Window BETA CELL AUTOANTIBODIES RELAPSING REMITTING DISABILITY BETA CELL AUTOANTIBODIES SECONDARY CHRONIC PROGRESSIVE BETA CELL AUTOANTIBODIES PRIMARY CHRONIC PROGRESSIVE OVERT HYPERGLYCEMIA

27 counts counts mcd8 mcd3 Transgenic Human CD3e-NOD mice thymus spleen NOD NOD-huCD3e NOD NOD-huCD3e 17 < hucd3 82 < <1 53 < <1 13 <1 mcd mcd3 M1 NOD 38% MFI=142 NOD-huCD3e 40% MFI=72 hucd3 M1 human PBMCs 75% MFI=244 NOD-huCD3e 36% MFI=119

28 % remission % diabetes % infiltrated islets NOD NOD-huCD3e (n = 40) (n = 32) weeks of age wk 12-wk diabetic Otelixizumab islets with invasive infiltration islets with peripheral infiltration islets w/o infiltration (n = 26) 60 (n = 23) anti-cd3 NOD + F(ab ) 2-2C11 NOD-huCD3e + Otelixizumab weeks after treatment

29 6-wk 12-wk diabetic Otelixizumab merge CD3 FoxP3 Insulin merge

30 SPU / 10 6 cells SPU / 10 6 cells % diabetes CD25 - CD62L - diabetic CD25 - CD62L - Otelixizumab weeks after transfer IGRP PI B: SPLEEN 30 SPLEEN wk 16wk diab 2wk >8wk remission 0 6wk 16wk diab 2wk >8wk remission 600 BLOOD 300 BLOOD wk 16wk diab 2wk >8wk remission 0 6wk 16wk diab 2wk >8wk remission

31 BEFORE TREATMENT CD3Ab TREATMENT AFTER TREATMENT

32 CONCLUSIONS CD3 antibodies are effective at preserving b cell function and decreasing insulin needs in newly diagnosed Type 1 diabetic patients The effect is long lasting Patients are responsive to unrelated antigens CD3 antibodies induce/ expand TGF-b dependent adaptive Tregs These results are a proof of concept and pave the way for the use of CD3 antibodies as tolerance-promoting agents in various T cell-mediated autoimmune diseases, in transplantation and cell therapies

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34 Incidence of prototype infectious diseases and immune disorders % 100 Hepatitis A % 300 Asthma IDDM 50 Rheumatic fever Tuberculosis 200 Crohn's disease Measles Multiple sclerosis Infectious diseases Immune disorders JF Bach, N Engl J Med, 2002

35 Incidence of IDDM (per 100,000) Incidence of multiple sclerosis (per 100,000) (56-74) 35.8 (87-99) (77-85) (66-89) 8.05 (54-86) 0.96 (mortality or incidence) (67-90) (85-88)

36 Type 1 Diabetes (incidence in children 0 14 years) Incidence per 100,000 children (0 14years) High (> 16) Intermediate (8 16) Low (0 8) No estimate Adapted from :

37 Multiple Sclerosis Prevalence per 100,000 (2007) High (> 60) Intermediate (20-60) Low (0 20) No estimate Adapted from :

38 Childhood Asthma Proportion of clinical asthma * High (> 10%) Intermediate (5.1% 10%) Low (0% 5%) No estimate Adapted from : Masoli et al. Allergy. 2004:59

39 Hepatitis A virus antibodies prevalence Risk level High Intermediate Low Adapted from : wwwn.cdc.gov

40 IDDM incidence in children of migrants from Pakistan to Yorkshire Incidence of 8 diabetes / Pakistan Migrant's children Yorkshire Staines A. (1997) and Bodansky H.J. (1992)

41 CAUSAL LINK

42 PREVENTION OF IDDM IN NOD MICE BY INFECTIOUS AGENTS Bacteria Viruses Parasites streptococci salmonella mycobacteria (CFA, BCG, ) LCMV MHV LDHV schistosoma pimworms

43 % diabetes TGF-b antibody treatment abrogates diabetes protection by OM ,,,,,, Age (weeks) OM-85 anti-tgf-b NOD controls,,,,,,,,,,,,,, NOD OM-85 + anti-tgf-b NOD OM-85

44 Immune response of dendritic cell to TLR agonists Endotoxins or LPS Mycobacterial soluble factor Proteine MMLV Mannan Fibrinogen HSP70, HSP60 Hyaluronan Beta-defensin Surfactant Protein A Lipoproteins Zymosan P. Gingivalis LPS Lipoteichoic acid Lipoarabinomannan HCMV Trypanosoma cruzi GPI KOmpA HSP70 TLR4 Flagellin TLR2 TLR5 v v lipopeptide TLR6 v MyD-88 upec TLR11 v v NF-kB AP-1 v TRIF TLR3 IRF3 v v ssarn Poly(I:C) v v TLR7 TLR8 v v IFN TLR9 Imidazoquinoline dsarn Imidazoquinoline Bacterial DNA (CpG) Herpes simplex virus 2 Lipopeptide TLR1

45 Diabetes incidence (%) TLR2, TLR3,TLR4 and TLR7 agonists delay autoimmune diabetes onset TLR2 TLR3 TLR4 TLR Non treated P40 p= Treatment Non treated Poly(I:C) p= p= Age (weeks) Non treated LPS Non treated R848 p= Similar protective results were obtained with TLR agonists : synthetic lipopetide Pam3CSK4 (TLR2 agonist) or dsrna Poly(I)Poly(C)

46 PROTECTION BY TLR AGONISTS AND IMMUNE REGULATION p <0.05 p <0.05 p <0.05 Thieblemont N et al. PLoS ONE 2010, 5(7): e11484

47 ALLERGIC ASTHMA IN NOD MICE D0 Immunization 1, 10, 100 µg OVA + Alum i.p./ s.c. D7, D8, D9 OVA challenge D10 Measurement of airway hyperreactivity to metacholine Sacrifice and collection of Sera (cytokines, IgE) BALFs (cells, cytokines) Lungs (cytokines)

48 Eosinophils in BAL 10 5 /ml p< p< OVA Araujo LM et al. Eur.J.Immunol. 2004, 34: 327

49 BALF cell count (10 5 ) Lung IL-4 level (pg/ml) Penh Lung eotaxin level (pg/ml) Prevention of allergic asthma by a TLR2 agonist Saline/Vehicle OVA/Vehicle Saline/P40 OVA/P Eosinophils Macrophages Saline OVA P40-treated Saline Neutrophils Lymphocytes OVA Vehicle 6000 p=0, OVA Saline OVA Saline P40-treated Vehicle-injected 200 p=0, OVA Saline OVA Saline P40-treated Vehicle