How immunology informs the design of immunotherapeutics.

How immunology informs the design of immunotherapeutics. Stephen R Durham Allergy and Clinical Immunology, Royal Brompton Hospital and Imperial College London WAO Cancun Mon Dec 5 th 2011

How immunology informs the design of immunotherapeutics. Allergen induced early and late nasal responses Natural seasonal allergen exposure effects of corticosteroids Influence of treatment Immunotherapy anti-ige therapy

Mechanisms of allergic rhinitis Mast cell Histamine Tryptase Leukotrienes Prostaglandins Bradykinin PAF IMMEDIATE RHINITIS SYMPTOMS Itch, sneezing Watery discharge Nasal congestion IgE Allergen B cell T cell (mast cell) IL-4, IL-13 IL-3, -5 GM-CSF VCAM-1 Eosinophil CHRONIC RHINITIS SYMPTOMS Nasal blockage Nasal hyperreactivity

Inflammatory mediators during allergen-induced nasal responses Basophils? Nasal Fluid Naclerio RM. New Engl J Med 1985; 313:65-70

Leukotrienes in allergen-induced early nasal responses: RIA HPLC Positive control Nasal lavage LTs: Slow-reacting substance of anaphylaxis In vitro: Released from mast cells + basophils by Ag-IgE crosslinking Nasal lavage, post challenge: levels correlate with symptom scores LTC, LTD, LTE present Creticos PS et al. New Engl J Med 1985; 313:65-70

Time course of tryptase in allergeninduced nasal responses: nasal fluid Unpublished data

Allergen APC IL-4 IgE B-cell CD80/86 CD28 CD4 HLA CD3 T cell Th2 IL-5 Eosinophils Allergic response

Nasal biopsy

In situ hybridisation studies of nasal mucosa Anti-sense riboprobe Sense riboprobe (negative control) Durham SR J Immunol 1992; 148: 2390-4

IgE CD4 IL-4 B-cell T cell CD28 CD80/86 CD3 HLA APC Th2 CCR3 CCR4 CCR8 Eosinophils Allergic response Allergen IL-5

CCR4 mrna+ cells in nasal mucosa Banfield G, Watanabe H, Scadding G et al Allergy epub Feb 2010

CCR4 mrna+ cells in the nasal mucosa p= 0.025 p= 0.003 p= 0.2 N as a l C C R 4 m R N A+ c e lls /m m 2 1 0 0 (127) 8 0 6 0 4 0 2 0 0 D il 8 h r D il 8 h r (Atopics) (Normals) Banfield G, Watanabe H, Scadding G et al Allergy epub Feb 2010

Immunofluorescence for CCR4 and CD3 8hr after allergen challenge CD3 CCR4 Banfield G, Watanabe H, Scadding G et al Allergy epub Feb 2010

TSLP IgE CD4 IL-4 B-cell T cell CD28 CD80/86 CD3 HLA APC CCR3 CCR4 Th2 CRTH2 Eosinophils Allergic response Allergen IL-5 CCR3

CRTH2 in allergic rhinitis DP2/GPR44/CRTh2 - chemoattractant receptor-homologous molecule expressed on Th2; PGD2-CRTh2 signalling on Th2 cells, eosinophils and basophils induces chemotaxis and up-regulates expression of IL-4, IL-13 and IL-5

CRTH2 in the nasal mucosa in allergic rhinitis

TSLP in allergic rhinitis

TSLP in the nasal mucosa in allergic rhinitis Immunochemistry Quantitative RT-PCR

Topical steroid (fluticasone propionate) in hayfever Masuyama K et al, J Allergy Clin Immunol 1998;102:610-7

Immunohistology of nasal mucosa for T and B lymphocytes CD3 + T cells expressing IL-4 CD20 + B cells CD20 + B cells Expressing Ce

Topical steroids inhibit seasonal increases in IL-4 mrna+ cells Preseason Peak season Preseason Peak season Cameron L et al, J Allergy Clin Immunol 1998; 102: 330-336

Topical steroids inhibit seasonal increases in IgE mrna+ cells Preseason Peak season Preseason Peak season Cameron L et al., J Allergy Clin Immunol 1998;102:610-7

Immunohistology of nasal mucosa for IL-5+ T cells and eosinophils CD3 + T cells expressing IL-5 Eosinophils expressing MBP

Topical steroids inhibit seasonal increases in IL-5 mrna+ cells Masuyama K et al., J Allergy Clin Immunol 1998;102:610-7

Topical steroids inhibit seasonal increases in eosinophils Masuyama K et al., J Allergy Clin Immunol 1998;102:610-7

CD1a + Langerhans cells in nasal mucosa Till SJ et al., Allergy 2001;56:126-131

C D1a+ L an g e r h an s ce lls ( s u b -m u co s al) ce lls / m m 2 Topical steroids inhibit seasonal increases in dendritic cells a) p=0.005 p=0.0004 p=0.03 (60) 25 (37) 20 15 10 5 0 Peak season Preseason Preseason Peak season Till SJ et al., Allergy 2001;56:126-131 p=0.03

Allergen IgE APC Steroids IL-4 B-cell CD80/86 CD28 HLA CD3 T cell Th2 Steroids Allergic response CD4 IL-5 Eosinophils

Immunotherapy (high dose Ag) IL-4 B cell IgE Natural exposure (low dose Ag) + IgE (-) APC (-) Th2 IL-5 Allergy Th1 T r Eosinophil IFN- IL-10 TGF-β IgG IgG4 IgA Robinson DS, et al. J Clin Invest 2004;114:1389-97

Grass pollen immunotherapy for seasonal rhinitis/asthma (Alutard SQ Phleum pratense) Pollen Count/m 3 Baseline Out of season Biopsy Second year In season Biopsy 2000 120 90 60 30 0 12 26 10 24 7 21 6 20 3 17 1 15 29 12 4 18 1 15 29 13 27 3 17 MAY JUNE JULY AUGUS 1 15 29 MAY JUNE JULY AUGUST MAY JUNE JULY AUGUST IT Baseline Treatment n=44 n=37 PL Walker SM et al., J Allergy Clin immunol 2001;107:87-93

% reduction from baseline (1998/1996) Grass pollen immunotherapy for seasonal rhinitis/asthma 0 Symptoms Medication -50 P =.01 Immunotherapy Placebo -100 P =.007 Walker SM et al., J Allergy Clin immunol 2001;107:87-93

J Immunol 2004; 172: 3252-59

I L - 1 0 m R N A + c e l l s / m m 2 Grass pollen immunotherapy: IL-10 in the nasal mucosa p = 0. 0 3 1 5 ( 1 8 ) ( 2 8 ) IL-10 1 0 5 IL-10 mrna + cells 0 P r e - P o s t P r e - P o s t P o s t N o r m a l t r e a t m t er ne t a t m e tn rt e a t m t er ne t a t m e n tt r e a t m e cn n t r o l s IL-10 protein + cells P e a k s e a s o n P e a k s e a s o n O u t o f s e a s o n P l a c e b o I m m u n o t h e r a p y Nouri-Aria K et al J Immunol. 2004; 172:3252-9

S e r u m I g G 4 ( A r b i t r a r y U n i t s ) A. Allergen-specific IgG4 4 0 3 0 2 0 1 0 p=0.000 p=0.000 0 P r e I T F e b - M a r '9 6 P r e I T P o s t I T P o s t I T M a y - J u nm a y J u n O c t '9 6 '9 8 '9 8 Wachholz P et al J Allergy Clin Immunol 2003; 112, 915-922.

1. Allergen forms complexes with IgE FceRII (CD23) IgE Allergen B-Cell 2. Complexes bind FceRII on B-cell 3. Antigen Presentation and subsequent T cell activation Facilitated Antigen Presentation 4. Immunotherapy induces IgG antibodies that block IgE binding IgG T-Cell IgE

% of B cells b ou nd to IgE Inhibition of allergen-ige binding to B-cells following immunotherapy 6 0 5 0 4 0 3 0 2 0 1 0 0 IT n = 18 P l a ce b o n = 17 *** *** ou t in in out s e a s o n s e a s o n B efore IT Afte r IT Nouri-Aria KT et al. J Immunol 2004;172:3252-

Effect of omalizumab on symptoms of seasonal allergic rhinitis: a randomised controlled trial. Casale TB, Condemi J, LaForce C, Nayak A, Rowe M, Watrous M, McAlary M, Fowler-Taylor A, Racine A, Gupta N, Fick R, Della Cioppa G. JAMA 2001;286:2956-2967 536 patients (959 screened) Aged 12-75y Moderate/severe symptoms IgE 30-700 iu/ml

Nasal Symptoms in the Ragweed Season: Effects of Omalizumab Casale, T. B. et al. JAMA 2001;286:2956-2967.

Allergen Allergen immunotherapy IgE Anti-IgE therapy APC IL-4 B-cell CD80/86 CD28 CD4 HLA CD3 T cell CCR3 CCR4 Th2 Steroids IL-5 Eosinophils Allergic response

Allergy and Clinical Immunology, Imperial College and Royal Brompton Hospital, London, UK G Banfield K T Nouri-Aria M Calderon K Masuyama M R Jacobson H Gould S Rak H Watanabe S J Till G Scadding SR Durham M Shamji