Modifying atherosclerosis in cardiometabolic disease: targeting inflammation!

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1 Modifying atherosclerosis in cardiometabolic disease: targeting inflammation Peter Libby Brigham & Women s Hospital Harvard Medical School Primary Care Congress for Cardiometabolic Health Boston April 24,, 2013 Obesity is An Inflammatory Stimulus Visceral Adipose Tissue (cm 2 ) ,3 1,3 (1) (2) (3) (4) (5) C-Reactive Protein Quintiles Lemieux I. et al. Arterioscler Thromb Vasc Biol (2001) 21: Waist girth (cm) ,2 1,2,3 (1) (2) (3) (4) (5) C-Reactive Protein Quintiles ATP III Metabolic Syndrome Criteria Inflammation in the Metabolic Syndrome C-reactive protein (mg/l) Women s Health Study: n=14, Number of Components of the Metabolic Syndrome Ridker Circulation 1003; Inflammation Drives Diabetes Elevated Levels of CRP Predict Development of Type 2 Diabetes in the Women s Health Study Adjusted Relative Risk for Diabetes* P= Quartile of C-reactive protein (CRP) *Adjusted for BMI, family history of diabetes, smoking, physical activity, alcohol consumption, hormone therapy. Pradhan et al. JAMA. 2001;286: Page 1

2 Monocyte/ Macrophage Heterogeneity in Atherosclerosis P. Libby Inflammation in atherosclerosis Nature 2002;420: Mononuclear Phagocyte Heterogeneity in Atherosclerosis Hyperlipidemia markedly expands circulating inflammatory monocytes in mice Siamon Gordon, J. Clin. Invest. 2007;117:89-93 Swirski, F et al. J Clin Invest 2007;117: Myeloid cells accumulate in the splenic red pulp in hypercholesterolemic mice wt spleen apoe / spleen red pulp red pulp white pulp white pulp Swirski 2011 CD11b (myeloid cells) Page 2

3 Hematopoietic stem cell differentiation in the spleen shapes the evolution of atheromata Robbins et al. Circulation 2012;125: Do new insights into plaque inflammation have clinical implications? Hypothesis: An echo in the arterial wall of the inflammation due to acute myocardial infarction aggravates atherosclerosis Interleukin-1 gene expression in rabbit vascular tissue in vivo Induction of IL-1α and β mrna in aortic tissue 2 hours after intravenous injection of 10 pg/kg of E. coli endotoxin in rabbits fed control and atherogenic diets for 10 weeks. Three centimeters of thoracic aorta from rabbits provided RNA for Northern analysis for rabbit IL-1α and IL-1β. The data presented represent one rabbit per treatment group. Similar results were observed for three additional rabbits per treatment. Clinton SK, et al. Am. J. Pathol. 1991;138: Page 3

4 Atherogenic diets enhance endotoxin-stimulated interleukin-1 and tumor necrosis factor gene expression in rabbit aortae Fleet JC, Clinton SK, Salomon RN, Loppnow H, Libby P. J Nutr 1992;122: The echo phenomenon: A systemic inflammatory stimulus, Intravenous endotoxin, evokes a local cytokine response in arteries dependent on the amount of pre-existing atherosclerosis J Nutr 1992;122: Infectious agents by systemic and local effects can activate artery wall cells Libby P et al. Circulation 1997;96: JULY 2012 VOL 487 NATURE 325 Molecular Biology of the High-Risk Plaque MI enhances protease activity in plaque Week 0 Week 3 Week 3 Synthesis Lipid core IFN-γ CD-40L + After Libby P. Circulation Breakdown Collagen-degrading Proteinases + IL-1" TNF-α" MCP-1" M-CSF Fibrous" cap Tissue Factor Procoagulant MI No MI Increase in protease activity (pmol) 30 * 15 0 No MI MI No MI MI Dutta et al. Nature 487:325; 2012 Ex vivo TBR FRI * Page 4

5 MI enhances pro-inflammatory monocytes in plaque Ly-6C high monocytes (10 3 ) / aorta Age (in weeks) MI No MI Post MI plaque necrotic cores enlarge and fibrous caps thin No MI MI Fibrous cap thickness (µm) No MI Necrotic core area (mm 2 ) * MI * Increased progenitor numbers in spleen after MI Long-term Short-term Granulocyte Macrophage hematopoietic hematopoietic Macrophage dendritic cell stem cell stem cell progenitor progenitor No MI MI Increased splenic progenitor proliferation in patients after MI c-kit DAPI Ki-67 c-kit DAPI Ki-67 MDPs Lineage+IL7R LSKs (10 6 )/ spleen c-kit SSC-A * * * Week after MI Sca-1 GMPs (10 6 )/ spleen LSKs CD115 c-kit ** *** ** * Week after MI MDPs (10 6 )/ spleen CD16/32 CD34 ** * * * Week after MI GMPs No MI MI c-kit+ cells / 5 HPF * Human splenic red pulp No MI (n=29) MI (n=13) MI enhances atherosclerosis Nature. 2012;487:325-9 Page 5

6 Innate Immunity in Key Collaborators Atherosclerosis Initiation Progression Libby, Ridker, Maseri Circulation 2002 Complication Filip Swirski Matthias Nahrendorf Can we translate inflammation biology in atherosclerosis to the clinic? Can Targeted Anti- Inflammatory Therapy Reduce Cardiovascular Event Rates and Prolong Life? Cardiovascular Inflammation Reduction Trial (CIRT) Stable CAD (post MI) On Statin, ACE/ARB, BB, ASA Issues in the Selection of Anti-inflammatory Agents for Trials of Cardiovascular Inflammation Inhibition Statins Persistent Evidence of Inflammation How to define? TC LDL What agent to study? Anti-Inflammatory Intervention Placebo HDL TG Chylo Nonfatal MI, Nonfatal Stroke, Cardiovascular Death CRP / IL-6 Ridker, Thromb Haemost 2009 Page 6

7 Issues in the Selection of Anti-inflammatory Agents for Trials of Cardiovascular Inflammation Inhibition Statins TNF inhibition IL-6 Inhibition Issues in the Selection of Anti-inflammatory Agents for Trials of Cardiovascular Inflammation Inhibition Statins TNF inhibition IL-6 Inhibition Low dose methotrexate TC TC LDL LDL HDL HDL TG TG Chylo Chylo CRP / IL-6 CRP / IL-6 Cardiovascular Inflammation Reduction Trial (CIRT) BWH/NHLBI U01 HL (Ridker) UO1 HL (Glynn, DCC) A randomized, double-blind, placebo-controlled, event-driven trial of weekly low-dose methotrexate (LDM) in the prevention of recurrent cardiovascular events among stable post-myocardial infarction patients with type 2 diabetes or metabolic syndrome BWH/HMS - P. Ridker (PI), R. Glynn (DCC) NHLBI A. Hasan, D. Gordon Methotrexate (MTX) Inhibits Atherogenesis in Cholesterol-Fed Rabbits MTX Control Hematoxylin-eosin VSMC Macrophages MMP-9 Bulgarelli et al, J Cardiovasc Pharmacol 2012;59: MTX Inhibits Atherogenesis in Cholesterol-Fed Rabbits LDM and CVD: Observational Evidence Cohort Group HR * (95 % CI) Endpoint Exposure Wichita RA 0.4 ( ) Total Mortality LDM Choi ( ) CV Mortality LDM 0.4 ( ) CV Mortality LDM < 15 mg/wk No change TC HDLC Non-HDLC TG Netherlands RA 0.3 ( ) CVD LDM only van Helm ( ) CVD LDM + SSZ 0.2 ( ) CVD LDM + HCQ 0.2 ( ) CVD LDM + SSZ + HCQ Miami VA PsA 0.7 ( ) CVD LDM Pradanovich ( ) CVD LDM < 15 mg/wk RA 0.8 ( ) CVD LDM 0.6 ( ) CVD LDM < 15 mg/wk CORRONA RA 0.6 ( ) CVD LDM Solomon ( ) CVD TNF-inhibitor MTX Control Bulgarelli et al, J Cardiovasc Pharmacol 2012;59: QUEST-RA RA 0.85 ( ) CVD LDM Narango ( ) MI LDM 0.89 ( ) Stroke LDM UK Norfolk RA, PsA 0.6 ( ) Total Mortality LDM ( ) CV Mortality LDM Page 7

8 Cardiovascular Inflammation Reduction Trial (CIRT) Primary Aims To test directly the inflammatory hypothesis of atherothrombosis by evaluating in a randomized, double-blind, placebo-controlled trial whether LDM given at a target dose of 15 mg po weekly over a three to four year period will reduce rates of recurrent myocardial infarction, stroke, or cardiovascular death among patients with previous myocardial infarction and either type 2 diabetes or metabolic syndrome. N = 7,000 NHLBI-Sponsored Enrollment to Start March US and Canadian Sites Cardiovascular Inflammation Reduction Trial (CIRT) Primary Aims To determine in a randomized, double-blind, placebo-controlled setting whether LDM will reduce the rate of new onset type 2 diabetes among those with metabolic syndrome but not diabetes at study entry. N = 7,000 NHLBI-Sponsored Enrollment to Start March US and Canadian Sites Issues in the Selection of Anti-inflammatory Agents for Trials of Cardiovascular Inflammation Inhibition TC LDL HDL TG Chylo CRP / IL-6 Statins TNF inhibition IL-6 Inhibition LDM IL-1β$ inhibition Human endothelial cells express the interleukin-1β gene inducibly Endotoxin and tumor necrosis factor induce interleukin-1 gene expression in adult human vascular endothelial cells Libby et al. Am J Path 124: (1986) Interleukin-1 Induces Interleukin-1: an auto-amplification loop IL-1 IL-1 Interleukin-1 Induces Interleukin-1 Warner SJC, Auger KR, Libby P. Human interleukin-1 induces interleukin-1 gene expression in human vascular smooth muscle cells. J Exp Med 1987;165: Dinarello CA, Ikejima T, Warner SJC, Orencole SF, Lonnemann G, Cannon JG, Libby P. Interleukin-1 induces interleukin-1. I. Induction of circulating interleukin-1 in rabbits in vivo and in human mononuclear cells in vitro. J Immunol 1987;139: Page 8

9 Pro-inflammatory actions of IL-1 β$ IL-1 induces IL-6 production, a key mediator of the acute phase response Interleukin-1 Induces Interleukin-6: another amplification loop IL-1 IL-6 Loppnow H, Libby P. J Clin Invest 1990;85: Proliferating or interleukin-1 activated human vascular smooth muscle cells secrete copious interleukin-6. Loppnow H, Libby P. J Clin Invest 1990;85: Inflammatory Pathways in Atherogenesis ICAM-1 Selectins, HSPs, etc. Endothelium and other cells after Libby, Ridker. Circulation 1999;100: Pro-Inflammatory Risk Factors Primary Pro-Inflammatory Cytokines ( e.g., IL-1, TNF-α ) IL-6 Messenger Cytokine Circulation CRP SAA Liver Fibrinogen Plasminogen activator inhibitor-1 Interleukin-1: A Signature Cytokine of Innate Immunity IL-1 β is synthesized as inactive precursor Limited proteolysis by IL-1 β converting enzyme (caspase 1) activates IL-1 β Caspase 1 activates IL-1 β Caspase 1 (IL-1 β converting enzyme, ICE) Page 9

10 Caspase 1 in Human Atheromata Caspase 1 (IL-1β converting enzyme, ICE) in Human Plaque Geng%Y'J,%Libby%P.% Evidence%for%apoptosis%in% advanced%human% atheroma:%colocalizaaon% with%interleukin'1β' converang%enzyme.%am%j% Pathol%1995;%147(2):% 251'266.% The T-cell-Derived Cytokine CD-40L Stimulates Vascular Cells to Produce Active IL-1 β$ NLRP3 Cryopyrin Inflammasome, Caspase-1, and IL-1β Maturation Endogenous Danger Signals in Vascular Biology? IL-1 β processing by extracts of human SMC stimulated by CD40L Inactive IL-1β precursor Active, mature IL-1β 1997 by American Society for Biochemistry and Molecular Biology Drenth JPH, et al, NEJM 2006; 355: NLRP3: a Genetic Determinant of Plasma CRP Level The inflammasome activates caspase-1 and hence formation of mature IL-1β Dehgman et al, Circulation 2011;123:731-8 CR-59 Page 10

11 Duewell, P, et al, Nature 2010; 464: Human atheromata contain cholesterol crystals Rajamaki K et al, PLoS One 2010;5:e11765 Cholesterol Crystals in Atheromata Macrophages engulf cholesterol crystals Kim, S. H. et al. Circ Res 2010;106: Cholesterol%crystalliza=on%in%human%THPQ1%lipidQrich%foamy%macrophages%exposed%to%7Qketocholesterol.%Human%THPQ1%macrophages%transformed%by%phorbol%ester% (PMA)%s=mula=on%were%loaded%with%acetylated%LDL%and%then%treated%with%7Qketocholesterol.%Polarized%microscopy%was%performed%to%image%cholesterol%crystals% (arrows).%(a)%foamy%macrophages%with%cholesterol%crystals%at%37 ;%(b%and%c)%7qketocholesterolqtreated%foamy%macrophages%with%crystals;%and%(d)%floa=ng%crystals.%% Geng%YJ,%Phillips%JE,%Mason%RP,%Casscells%SW.%Cholesterol%crystalliza=on%and%macrophage%apoptosis:% % implica=on%for%atherosclero=c%plaque%instability%and%rupture.%biochem%pharmacol%2003;66(8):1485q92.% % Macrophages engulf cholesterol crystals IL-1: Potential Roles in Atherogenesis and Methods of Inhibition IL-1 type II Decoy Receptor IL-1α,β$ Anti IL-1β antibody Canakinumab IL-1r/IL-1r accessory protein IL-1 trap IL-1 Receptor Antagonist Endogenous Exogenous IL-1 type 1 Receptor inos Endothelin-1 Chemokines/cytokines Adhesion molecules Endothelial & Smooth Muscle Proliferation Macrophage Activation Endothelial Dysfunction Athero-progression Adapted from Fearon W, Fearon D. Circulation 2008;117: Page 11

12 Canakinumab (Ilaris, Novartis) high-affinity human monoclonal anti-human interleukin-1β (IL-1β) antibody currently indicated for the treatment of IL-1β driven inflammatory diseases (Cryopyrin-Associated Period Syndrome [CAPS], Muckle-Wells Syndrome) designed to bind to human IL-1β and functionally neutralize the bioactivity of this pro-inflammatory cytokine long half-life (4-8 weeks) with CRP and IL-6 reduction for up to 3 months Dose Response of Canakinumab on Plasma IL-6, hscrp, and fibrinogen: Phase II data IL-6 hscrp Fibrinogen Effects of Interleukin-1β Inhibition With Canakinumab on Hemoglobin A1c, Lipids, C- Reactive Protein, Interleukin-6, and Fibrinogen: A Phase IIb Randomized, Placebo-Controlled Trial. Ridker, Howard, Walter, Everett, Libby, Hensen and Thuren Circulation. 2012;126: CANTOS: a 17,200 person phase III Trial Am Heart J 2011;162: Canakinumab Anti-inflammatory Thrombosis Outcomes Study (CANTOS) To test directly the inflammatory hypothesis of atherothrombosis To determine whether long-term inhibition of interleukin-1β with canakinumab (50 mg,150 mg or 300 mg SQ every three months) as compared to placebo will reduce rates of recurrent cardiovascular events among stable postmyocardial infarction patients who remain at elevated vascular risk due to increased levels of hscrp (> 2 mg/l) despite usual care, including statin therapy. Canakinumab Anti-inflammatory Thrombosis Outcomes Study (CANTOS) (PM Ridker PI) Randomized Canakinumab 50 mg SC q 3 months Randomized Canakinumab 150 mg SC q 3 months Stable CAD (post MI) On Statin, ACE/ARB, BB, ASA Persistent Elevation of hscrp (> 2 mg/l) Randomized Canakinumab 300 mg SC q 3 months Primary Endpoint: Nonfatal MI, Nonfatal Stroke, Cardiovascular Death N = 17,200 Novartis (>5000 currently) Secondary Endpoints: Total Mortality, New Onset Diabetes, Other Vascular Events Randomized Placebo SC q 3 months Exploratory Endpoints: DVT/PE; SVT; hospitalizations for CHF; PCI/CABG; biomarkers Page 12

13 CANTOS Trial Update 2013 Argentina Australia Austria Belgium Brazil Bulgaria Canada China Colombia Czech Republic Estonia Germany Greece Guatemala Hungary Iceland India Italy Japan Korea Latvia Lithuania Netherlands Norway Peru Poland Russia Slovakia South Africa Sweden Taiwan Turkey United Kingdom USA Venezuela Potential Strengths of IL-1β Antagonism in Atherosclerosis Selective: an important proinflammatory mediator, but not essential for host defenses Leaves IL-1α signaling intact Implicated in atherogenesis by several pre-clinical studies Potential beneficial metabolic effects IL-1 beta Antagonism CANTOS provides an exciting opportunity to Test the inflammatory hypothesis of atherosclerosis Provide a novel therapy to address residual risk in secondary prevention Inflammation, Atherothrombosis, and Cardiovascular Prevention: Three Key Translational Questions Do individuals with elevated levels of inflammatory biomarkers have high cardiovascular risk even when other risk factors are acceptable? Yes Do individuals identified at increased risk due to inflammation benefit from a therapy they otherwise would not have received? JUPITER Yes Is there evidence that reducing inflammation per se will reduce vascular events and slow progression of diabetes? CIRT, CANTOS Let s find out P. Ridker With Appreciation National Heart Lung and Blood Institute National Cancer Institute American Heart Association Doris Duke Charitable Foundation Foundation Leducq Donald W Reynolds Foundation For More Information : thecirt.org thecantos.org Dade Behring / Seimens Bristol Myers Squibb Amgen / Illumina AstraZeneca Novartis Page 13

14 Filip Swirski Matthias Nahrendorf Mikael Pittet Elena Aikawa Bill Lucinskas Farouc Jaffer Ralph Wiessleder D.W. Reynolds Foundation Thanks Eugenia Schvarz Galina Sukhova Eduardo Folco Paul M Ridker Brendan Everett Page 14