Diagnosing and Trea-ng Spine and Joint Related Pain: Harnessing The Body s Own Defense Mechanism. Gaetano J Scuderi, MD

Transcription

1 Diagnosing and Trea-ng Spine and Joint Related Pain: Harnessing The Body s Own Defense Mechanism Gaetano J Scuderi, MD 1

2 The MRI Enigma MRI identifies many age related abnormalities Challenging for Physician to interpret MRI as the source of a patient s pain

3 Normal Cartilage Metabolism Highly regulated balance: synthesis vs degrada-on

4 Pathophysiology of DJD Biomechanical Mediators Pro- Inflammatory Cytokines (TNFα, IL- 1β) Biochemical Mediators Fibroblasts Endothelial cells Macro- phages Other cells Chondro- cytes MMP ADAMTS ECM fragments Osteoclasts Osteoblasts Osteophyte 4

5 Overlapping Pathophysiologic Theories of OA: 1) Biomechanical (overweight, injury, etc) Biomechanical insults ac-vate the biochemical pathway (chondrocyte ac-va-on, protease release) Treated with surgery, physical therapy 2) Biochemical (car-lage degrada-on, lesions, chondrocyte ac-va-on and protease release, inflamma-on) Biochemical insults reinforce the biomechanical pathway (instability, degrada-on, pain) Treatment: Current drugs treat pain and/or inflamma-on indirectly. AYempts at biologic treatment with mixed results (e.g. an-- TNF- alpha approach). 5

6 OA known to involve in-lammatory mediators and proteases Ø Pro- Inflammatory Cytokines Degrade Car-lage(i.e. IL- 1, IL- 6, TNFα, INFγ, MIP, MCP, etc ) Ø Metalloprotease Enzymes Breakdown Car-lage (i.e. MMP s 1,3,9,13, etc ) Ø Disintegrin Proteins Cleave Car-lage (i.e. ADAMTS 4,5 etc ) 6

7 α-2-macroglobulin 1. Α-2-Macroglobulin (A2M) is a tetramer (720KDa) with monomers connected by disulfide bonds and dimers connected by hydrophobic interactions 2. A2M has a bait region, that upon cleavage, induces a conformation change trapping the protease 7 3. The bait region has a random coil structure 4. It is well known that wild-type A2M has different affinities for multiple substrates but could be optimized for a specific pathophysiologic cascade

8 α-2-macroglobulin Inhibition of Proteases 8

9 Pathophysiology of DJD Biomechanical Mediators Pro- Inflammatory Cytokines (TNFα, IL- 1β) Biochemical Mediators A2M Fibroblasts Endothelial cells Macro- phages Other cells Chondro- cytes MMP ADAMTS ECM fragments Osteoclasts Osteoblasts Osteophyte 9

10 A Model for Cartilage Degradation ADAMTS?tx? Extra Cellular Matrix (ECM) proteins, fragments Fibroblasts Bovine Cartilage Explants (BCE) MMP/ Laboratory model for tes-ng molecules that stop car-lage loss

11 Preclinical Data: Cartilage Explants Bovine Car-lage Explant (BCE) ex vivo model Car-lage pieces with live chondrocytes are cultured Addi-on of TNFα and IL- 1β induce ac-va-on of chondrocytes and produc-on of MMPs and ADAMTSs. Car-lage catabolism is followed in the culture media with a dye that binds sulfated glycosaminoglycans (sgag). TNFα / IL- 1β BCE Cytokines Purified A2M 11

12 A2M Inhibition of Protease and Cytokine Induced Cartilage Catabolism TNFα / IL BCE Cytokines Purified A2M

13 A2M Inhibition of MMP-7 and MMP-12-digestion of Cartilage MMP- 7 MMP- 12 BCE were treated with 5ug/ ml MMP-7 or MMP-12, with or without 100ug/ml Purified A2M Stain- free α- Aggrecan G3 Untreated BCE BCE +Treatment BCE +Treatment +A2M Results: BCE digestion was blocked by purified A2M. A2M Chondroi/nase G3 BCE Purified A2M MMP- 7 MMP- 12 Confiden-al, Property of Cytonics Corp MMP- 7 MMP

14 A2M Inhibition of ADAMTS- 5- digestion of Cartilage sgag (ug/ml) BCE ADAMTS- 5 A2M SFM Aggrecan G3 SDS-PAGE fractionation of proteins, visualized using Bio-Rad stain free system Several proteins were observed in ADAMTS-5- digested BCE BCE treated with ADAMTS- 5 produces an Aggrecan G3 fragment The G3 fragment is known to form a complex with Fibronec-n, detectable by ELISA Since A2M treatment reduces the G3 fragment, treatment with APIC may lower FAC forma-on Confiden-al, Property of Cytonics Corp

15 Autologous Protease Inhibitor Technology Large Proteins A2M Small Proteins Cytokines Chemokines Proteases Tangen-al Flow Filter technology allows selec-ve filtra-on without clogging pores 15

16 Post Traumatic OA Model: ACL- T In vivo Treatment and Control Groups Injec-ons at 1, 4, and 14 days Strong Evidence APIC Reduces PTOA Car/lage Lesion Score 16

17 510K Device synopsis Autologous Therapeu/c Novel tangen/al flow technology Concentrates A2M 17

18 Increasing Awareness 18

19 Conclusion

20 Conclusions Currently, there are few efficacious treatments that address the biochemical mediators in mild to moderate OA Injec-ng autologous wild- type A2M represents a novel therapeu-c approach to trea-ng OA Autologous Protease Inhibitor Concentrate (APIC) blocks car-lage catabolism in vitro and in vivo Recombinant A2M is poten-ally efficacious for OA/DJD due to selected target affinity 20

21 510k Device 21

22 If you like Platelets Platelet Concentra-on 0 22

23 If you hate WBC s WBC Concentra-on 23

24 A2M Concentrations of Other PRP/Stem Cell Systems A2M Concentra/on 0 24

25 APIC CF Phase I/II Clinical Study Treatment of Mild to Moderate OA 300 Pa-ents, 6 Month Follow Up 15 Trial Sites (10 presently/88 pts enrolled) Complete Pa-ent Enrollment in 6 Months Es-mated Cost: <$3M (phase I/II only) On Label Indica1on for Tx of OA Surrogate Human Safety and Efficacy Data for Recombinant A2M Product 25

26 Improving Response to Treatment for Patients with DDD With the use of the Fibronectin- aggrecan complex Gaetano J Scuderi Pasquale Montesano Jason Cuellar

27 Purpose: Determine the ability of FAC to predict response to biologic therapy with concentrated autologous A2M for pa-ents with LBP from DDD Study Design/Senng: Prospec-ve cohort Pa-ent Sample: 24 pa-ents with LBP pain and MRI posi-ve for DDD

28 Results: 24 Pa-ents with LBP 13 males and 11 females. Age range (ave 44.3) 13 pts had 1 level, 6 pts 2 level, and 5, 3 level procedures.

29 Results: 12 discs FAC + out of 40 discs tested 10 pa1ents out of 24 had Discogenic source of pain by FAC

30 VAS 8 7 FACT- Nega/ve FACT- Posi/ve 6 VAS *** 2 1 *** 0 Pre- op VAS 12w- VAS 24w- VAS Clinical follow- up 1me point

31 Oswestry Disability Index ODI FACT- Nega/ve FACT- Posi/ve *** *** 0.00 Pre- op ODI 12 wk ODI 24 wk ODI Clinical follow- up 1me point

32 Conclusions: Pa-ents who are FACT+ are more likely to demonstrate clinical improvement following autologous A2M injec-on. The results of this inves-ga-on suggest that not only is FAC is an important biomarker in iden-fying who will improve, but also that autologous A2M is an important biologic treatment in discogenic diseases, a true theranos-c.