Intervention Trials for Type 1 Diabetes Approaches to Prevention and Cure Grand Rounds

Intervention Trials for Type 1 Diabetes: Approaches to Prevention and Cure Peter A. Gottlieb, MD Barbara Davis Center University of Colorado Health Sciences Center Denver, CO Incidence Type 1 Diabetes per 100,000 per year Children <=14 40 35 30 25 20 15 10 5 0 Karvonnen et al., Diabetes Care, 23:1516, 2000 hi na V en ez ue la Is ra e K l uw D ait en m ar k La zi o C an da U SA Sa rd in Fi ia nl an d C Type 1 DM incidence is rising 3-5% /year 1.4 million patients in the U.S. 60 50 40 30 20 10 0 1950 1960 1970 1980 1990 2000 Rewers Incidence /100,000/ yr children age 0-14 Finland Colorado Germany Finland Incidence Type 1 DM/100K 1965-1996 50 45 40 35 30 25 20 15 10 5 0 Yrs. 65-74 75-84 85-96 1-4 yrs 5-9 yrs 10-14 yrs Diabetes Care: 22:1066-1070 Main Points • Type 1 diabetes is an autoimmune disease • It is a predictable disease with different phases • Approaches to prevention and cure are possible. • Combination therapy targeting multiple pathways may hold the greatest hope for prevention and cure. Progression to Diabetes vs Number of Autoantibodies (GAD, ICA512, Insulin) Percent not Diabetic 100 80 60 40 20 0 0 2.5 5 7.5 10 12.5 15 3 Abs 2 Abs 1 Ab Years of Follow-up 3 Ab n = 41 2 Abs n = 44 1 Abs n = 93 17 27 23 8 15 14 1 4 10 2 6 1 4 Verge et al, Diabetes 45:926-933, 1996 BDC The Balance in Autoimmunity: Epitope Spreading vs. Bystander Suppression You and Chatenoud. JCI 2006 116:3108-3110. The Major Histocompatibility Complex Class II Class III Class I Human Chromosome 6 DP DQ DR B C A Antigen Processing Genes Complement Proteins Cytokines Class I-like genes and pseduogenes Mouse Chromosome 17 Class I Class II Class III Class I K I-A I-E D L HLA-Defined T1 DM Risk Groups DAISY, Denver Population, n=21,713 IDDM risk by age 20 High 1:15 Moderate 1:60-1:200 Average 1:300 HLA-DR 3/4 4/x 4/4 3/3 3/x 3/4 4/x, 4/4 2/x others DQB1 0201/0302 0302/ 0302/ 0201/0201 0201/ 0201/not 0302 /not 0302 0602 Frequency % 2.4 12.7 3.0 1.4 12.5 1.0 6.6 60.4 Lower than 1:300 Antigen Recognition by CD8+ T Cells T cell T cell receptor Vb Va class I MHC b2m b cell T. DiLorenzo IDDM2 Genotypes in U.S. Caucasians IDDM 100 Controls 80 60 % 40 20 0 I/I I/III III/III VNTR Class Pugliese et al., J. Autoimm 7: 687- 694, 1994 VNTR alleles affect INS transcription in thymus Thymus INS Transcription Predisposing Class I VNTR Protective Class III VNTR Class I VNTR Class III VNTR Pugliese et al. Nature Genetics Pancreas INS Transcription 15:293-297, 1997 Predisposing Class I VNTR Protective Class III VNTR Chromosome IDDM1 mhc IDDM2 ins PTPN22 IDDM12,7 (“CTLA-4”) λs 3.35 1.16 1.05 1.19 CTLA 1.01 O.R. “App 30” 2.2 1.7 “3” CTLA 1.1 LOD Pgenome 6p21 11p15 1p13 2q31-33 116.3 10(-4) 1.87 .37 NS 3.34 .016 3p13-p14 IDDM15 IDDM10 1.15 1.56 1.13 1.12 1.16 “3” 1.52 .649 22.4 2.2 .191 3.21 .021 1.87 .371 6q21 9q33-q34 10p14-q11 11p15 12q14-q12 16p12-q11.1 16q22-q2 19p13.3-p13.2 1.10 1.17 1.19 1.15 1.66 .528 1.88 .363 2.64 .075 1.92 .338 No Evidence: IDDM 4,6,9,11,16,17,18 (O.R. MHC, DR3/4-DQ8) Adapted from Concannon et al, Diabetes: 54:2995-3001, 2005 BDC Type 1a Diabetes: An Autoimmune Disorder • Autoantibodies to islet proteins: insulin, GAD 65, IA-2 (ICA512) • HLA association • T cell responses to islet proteins • Immunosuppressive drugs can ameliorate the disorder – ex. Cyclosporine • Recurrence of autoimmunity in pancreas transplants between monozygotic twins Autoreactivity: CD4 and CD8 T cell responses Prediabetic T cell responses to CD4 epitopes from IA-2b Keleman, Gottlieb et al. 2004. Journal of Immunology.15;172(6):3955-62. Cytotoxic T-cells from HLA-A*0201 patients with T1D recognize preproIAPP 5-13 ELISPOT analysis of peripheral blood mononuclear responses to preproIAPP5-13 in patients with the correct HLA to recognize the peptide. Diabetes 2003 52:2649 T cell reactivity to CD8 Epitopes from T1D subjects 550 patients (n=19) controls (n=6) IFN-gamma producing spots/2x05PBMCs 300 50 50 40 30 20 10 0 2 V/A HC MIX P5 IAP P9 IAP P IGR 215 P IGR 152 PH A Ouyang, et al, submitted Natural History of Type 1 Diabetes PUTATIVE ENVIRONMENTAL TRIGGER CELLULAR (T CELL) AUTOIMMUNITY HUMORAL AUTOANTIBODIES BETA CELL MASS (ICA, IAA, Anti-GAD65, IA2Ab, etc.) LOSS OF FIRST PHASE INSULIN RESPONSE (IVGTT) GLUCOSE INTOLERANCE GENETIC PREDISPOSITION INSULITIS BETA CELL INJURY “PRE”DIABETES (OGTT) CLINICAL ONSET DIABETES TIME Stochastic Model Antigen Specific Tx Non Specific Tx PREVENTION Primary Prevention autoantibodies or diabetes as the endpoint avoidance of environmental agents ? induction of autoantigen tolerance ? Rewers-BDC Early childhood diet and T1 DM ? Infant diet and beta-cell autoimmunity Norris et al. DAISY 2000 Hazard Ratio 10 Prospective cohort study 27 cases and 1,022 controls 1 breast milk cow's milk meat fruits/veg. cereal gluten 0.1 Adjusted for HLA-DR,DQ and relationship to type 1 diabetic person TRIGR 3-yr Follow-up Results Seroconversion to 1+ Autoantibody 20% 15% 10% 5% 0% 0 p=0.043 Cows Milk Formula Casein Hydrolysate n=173 6 12 24 Nutritional Intervention to Prevent Type 1 Diabetes (NIP – Diabetes) Plan: Use of an omega 3 fatty acid (Docosahexanoic acid or DHA) to prevent the initial autoimmune process. DHA supplementation will begin in: • the last trimester of pregnancy • the first 6 months after birth It will be continued in medium or high risk infants for 3 years. Dietary Intake – Western Diets The Ratio of n-6 to n-3 Fatty Acids in our diet: 1800’s = 1 or 2 (n-6) to 1 (n-3) Present = 20 or 30 (n-6) to 1 (n-3) High n-3: anti-inflammatory anti-thrombotic hypolipidemic vasodilatory (High n-6 has the opposite effect) (Am J. Clin Nutr. 70, 560-569, 1999) III) Mechanisms of Action of Omega 3 Fatty Acids  Decrease AA in cell membranes  alters PGE 1 and 2 production (inflammatory prostaglandins)  Decrease pro-inflammatory cytokines TNFa, IL-1 and IL6 ( efficacy of IL4 and IL10)  Decrease ICAM-1 on monocyte surfaces in humans fed 3g fish oil/dx 21 days ( chronic inflammation)  DHA and /or vit D may have important immune modulating effects in babies at risk for developing T1DM Antigen Specific Therapy • • • • • • Magic bullet Approach Targets autoreactive cells Generates protective cells Spares rest of immune system Minimal Toxicity Timing may be critical to efficacy Insulin/Proinsulin • Beta Cell Specific • Predominant T-cell reactivity islets NOD • Insulin expressed lymphoid tissue by dendritic and macrophage-like cells • Thymic messenger RNA for insulin related to “protective” insulin allele • Proinsulin expression in thymus prevents NOD diabetes Effect of Insulin Injections on Diabetes & Insulitis Female NOD Mice 100 90 80 70 60 50 40 30 20 10 0 Placebo Insulin 3 2.5 Insulitis Score % Diabetes 2 1.5 1 0.5 0 Placebo Insulin Atkinson, Diabetes 1991 Prevention of Diabetes with B:9-23 Peptide “Immunization” 100 Percent Not Diabetic B:9-23 peptide 80 Tetanus control 60 40 20 0 0 10 20 30 40 50 60 Age in Weeks D.Daniel ,D.Wegmann . PNAS,1996 Efficacy of NBI-6024 in animal models with „new onset‟ Type I diabetes. Figure 3. NBI-6024 Treatment of NOD mice Near Onset of Disease 100 control peptide (n = 21) % Diabetes-Free 80 6024 (n = 21) 60 p < 0.02 40 20 0 0 20 40 60 Age (weeks) Alleva, et al, Diabetes 2002 NBI-6024-specific Th2 cells adoptively transferred protection in NOD mice Figure 4. 100 80 60 40 20 0 10 18 26 32 40 46 Days Following Transfer 53 60 APL-specific Th2 cell line transfer From Alleva, et al. Diabetes. 2002 51(7):2126-34. Rationale for Oral Insulin TH1 Cell s IFN-g, IL-2 Destructive Cytokines TH2 Cells TH3 Cells IL-4, IL-5, IL-10 TGF-b Protective Cytokines Development of islet autoantibodies in 1610 offspring of mothers or fathers with T1D Cumulative Ab frequency (%) 20 DR3/4-DQ8 DR4/4-DQ8 15 10 5 0 0 2 4 6 8 Moderate DR4-DQ8 Neutral Moderate DR3 Protective Age (years) Walter et al, Diabetologia 2003 (updated 2004) PrePoint Study (JDRF) • Genetically at Risk – Offspring or Siblings of Multiplex Diabetic families • High Risk HLA genes – DR3/DR4 • Primary Prevention – Prior to development of Autoantibodies • Dose escalation safety study using oral insulin and intranasal insulin • Endpoints: Insulin Autoantibodies, T cell responses, No development of other Autoantibody responses or DM. • Ezio Bonifacio, Anette Ziegler (Munich/Milan), George Eisenbarth, Jennifer Barker (BDC/UCHSC) TrialNet Oral Insulin in Prediabetic IAA+ Individuals • Initial results appeared to suggest no effect of oral insulin • Secondary analysis suggests that for original cohort (IAA>80) there is delay in onset compared to placebo treated patients. • In fact, the higher the titer of IAA, the greater the protective effect that was observed. • A new trial to confirm these observations is being planned by TrialNet (Start Date – Feb, 2007) Ongoing Prevention Trials • TRIGR - Casein Hydrolysate - ongoing (Cow‟s Milk Elimination) • NIP - Nutritional Intervention to Prevent T1DM – Starting June, 2006 • DIPP - Nasal Insulin - ongoing • INIT - IntraNasal Insulin Trial • PrePoint – Oral or intranasal Insulin in High Risk HLA young children (July, 2007) • ENDIT - Nicotinamide - Ineffective • DPT-1 - Oral Insulin – May be effective in subgroup (Feb. 2007) - Parenteral - Ineffective • Anti-CD3 and Exanitide- proposed • GAD 65 – GAD 65 Ab + PreDM (Fall, 2007) Early stage Late stage Secondary Prevention  Goal - induction of diabetes remission and preservation of C-peptide  non-antigen-specific interventions  antigen specific interventions EDIC: Long Term Benefit of Intensive Treatment -The Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications Research Group. N Engl J Med 2000;342:381-9. EDIC: Long Term Benefit of Intensive Treatment -The Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications Research Group. N Engl J Med 2000;342:381-9. b-Cell Function and Hypoglycemia in the Diabetes Control and Complications Trial - Steffes MW, et al. Diabetes Care 26:832–836, 2003 b-Cell Function and Complications in the Diabetes Control and Complications Trial - Steffes MW, et al. Diabetes Care 26:832–836, 2003 63% of Patients With Diabetes are Not At A1C Goal <7% 100 80 12.4% 7.8% % of Subjects n = 404 60 40 20 0 63% 7% 17.0% 37.2% >8% A1C >10% >9% >8% 7-8% 25.8% 37.0% <7% National Health Examination Survey (NHANES), 1999-2000. Saydah SH et al. JAMA. 2004;291:335-342. 8 Clinical Scenario • New Onset T1D subject at 6 months post diagnosis • HbA1c 5.8, Lantus dose 1-2 units qHS, Novolog 1 unit per meal, <0.1 unit/kg/BW, avg. BS – 110, no hypoglycemia • Question: Which answer best describes this patient? • A) MMF/DZB treated 21 year old subject • B) Anti-CD3 treated 23 year old subject • C) Control subject 12 years old – no treatment Honeymoon Period (flat) Elapsed Time Profile 400 350 300 GlucoWatch BG cal pt BG (mg/dL) 24 yr. M, IDDM for 1 yr, HbA1c 5.3%, no DR or DN 250 200 150 100 50 0 0:00 2:00 4:00 6:00 8:00 10:00 12:00 14:00 Elapsed Time (h:mm) Subject 51149, 2/13/99 Source: Extended Wear Study Cellular Mechanics of Autoimmune Type 1 Diabetes Cellular Therapy NK CD4CD25 Regenerative Therapies Cellular Target Therapy b b b b b b MO Tc1 MMF DZB Anti-CD3 ATG Effector Cells b B Rituximab Th1 Th2 Tr1 Th3 NKT Regulatory Cells Insulin GAD IGRP HSP60 Lack of Effect of BCG Vaccination in New Onset T1D subjects Age 0.8 0.6 Fasting C-Peptide 1.4 1.2 1 0.8 0.6 0.4 0.2 0 0 Stimulated C-Peptide < 12 0.4 0.2 0 0 5 10 15 20 25 30 5 10 15 20 25 30 >=12 1.4 1.2 1 0.8 0.6 0.4 0.2 0 0 5 10 15 20 25 30 3 2.5 2 1.5 1 0.5 0 0 5 10 15 20 25 30 Adapted from Allen, et al, Diabetes Care 1999, 22:1703-07 Ongoing and Proposed Immunotherapy Trials in New Onset Type 1 DM Completed Enrollment • • • • • Enrolling Patients and Proposed • • • • MMF and DZB - Peter Gottlieb, TrialNet HSP 65 p277 s.c. - (Peptor) – Jerry Palmer, Seattle Multi-dose DZB - Henry Rodriguez, Indiana Exanitide and DZB – David Harlan, NIH Oral hIFN-alpha - Kristina Rother, NIH Anti-CD20 – Mark Peskovitz, Indiana, TrialNet ATG (Sandostat) – Steve Gitelman, UCSF, ITN, TrialNet Rapamycin and IL-2, Alex Rabinovitch, Canada Anti-CD3 – Dose finding TolRx (>3 months) • Anti-CD3 – Macrogenics Anti-CD3 and Exanitide – K Herold, TrialNet GAD 65 in Alum – Diamyd Proinsulin DNA Vaccine – BayHill Therapeutics, Peter Gottlieb, BDC Gastrin and EGF – Phase I Trial On Clinical Hold • Multidose anti-CD3 hOKT3 - Kevan Herold, NY – • • • • TrialNet Sites TrialNet International Sites • Australia • United Kingdom • Finland • Italy & Germany Sponsors NIDDK NIAID NICHD NCRR ADA JDRF MMF/DZB TN-02 Participating Centers Existing Centers New Centers • Joslin Diabetes Center • Columbia University • UCSF • Children‟s Hospital of Los Angeles • Kansas City, Kansas • Toronto, Canada • Milan, Italy and Munich, Germany • The Barbara Davis Center • Indiana University • Stanford University • University of Florida • University of Minnesota • Virginia Mason (Washington) MMF/DZB TN-02 study (Mycophenolate Mofetil and Daclizumab) • MMF protects BB rats from developing DM; MMF/DZB protect PolyIC:Treg depleted DR BB rats from DM • MMF is effective in islet allograft transplantation in mice, but not in NOD mice as a single agent • MMF effective in a number of human autoimmune conditions including psoraisis, uveitis, autoimmune hepatitis and lupus nephritis. • MMF has been an effective addition to multi-drug transplantation protocols in place of Azathioprine or as replacement for Calcineurin inhibitors where nephrotoxicity or islet toxicity is a concern (Polastri, et al, Acta Diabet, 2002). Effect of MMF and Vitamin D Analogues on Islet Allograft Survival Gregori, et al, JI, 2001 Mycophenolate Mofetil (MMF) • Inhibits inosine monophosphate dehydrogenase (IMPDH) • Inhibits de novo pathway of guanosine nucleotide synthesis – T and B cells need de novo pathway (other cell types use salvage pathway) APC MMF: Mode of action T cell • Blocking of activated T and B cell proliferation and antibody formation • Does not block IL-1, IL-2 production IL-2 Greenbaum, C Benaroya Research Institute Seattle, WA MMF Toxicities • • • • Leukopenia Gastrointestinal Increased rate of viral infections Lymphoproliferative disorder? No increase in multidrug regimens. No increase in single drug use (Psoriasis). • Cancer? (Psoriasis data – No). MMF/DZB study Rationale for DZB (Mycophenolate Mofetil and Daclizumab) • Anti-IL2R Ab protects BB rat, but not NOD islet grafts • IL2-Receptor + Cells increased at diagnosis of DM • IL-2R+, CD4hi population harbor autoreactive T cells (mouse and man) • DZB is effective as part of Edmonton protocol and in other transplantation regimens • DZB has been shown to be effective in autoimmune diseases such as uveitis and MS • Relative known toxicities of drugs are low DZB inhibits disease activity in multiple sclerosis patients failing to respond to interferon Bielekova et al, PNAS, 2004 DZB: Mode of action Inhibit IL-2 mediated activation of lymphocytes IL-2 IL-2 α ß γ DZB α ß γ Activated T cell Activated T cell Greenbaum, C;Benaroya Research Institute; Seattle, WA Daclizumab in Pediatric Transplantation: CD25 and 7G7 Expression on T Cells 26 24 22 20 18 16 14 12 10 8 6 4 2 0 1 14 28 42 CD25 7G7 % T cells 56 84 182 Baseline Day 0 Ettenger RB. Transplant Proc. 1998;30:1956-1958. Enrollment Demographics • Average age: 19.2 years – Range: 8 – 46 years – 52% of subjects are between 12 and 18 years • 39% of enrolled subjects are female • Vast majority (~96%) are of white, non-Hispanic background • Enrolled on average 76 days from diagnosis – Range: 29 – 130 days • Viral serologies – EBV Seronegative: 48% – CMV Seronegative: 70% – Varicella Seronegative: 15% Frequency of Adverse Events TN-02: MMF/DZB Clinical Trial (N = 302 Adverse Events) Marrow suppression, 30, 10% Other, 99, 33% Infection, Upper resp., 86, 28% Allergic reaction, 3, 1% GI toxicity, 45, 15% Infection, Other, 32, 11% Hepatotoxicity, 7, 2% Legend: Adverse Event, N, % Number O tit 10 20 30 40 50 60 0 is E xt er na O tit is M ed ia H SV Pe r io ra l H SV G U U TI Fo llic ul iti s C on ju nc t iv iti s (N = 302 Adverse Events) Bl e TN-02: MMF/DZB Clinical Trial ph a So re rit is Frequency of Infectious Adverse Event Th ro at Si n us iti s U In fe ct io n, R I ot he r Metabolic Control in MMF/DZB Trial Time 0 3 6 9 12 15 18 21 24 HbA1c 7.5 6.4 6.7 7 7 7.3 7 7.4 8 Range 5.1-10.3 4.89.6 4.9-9.9 5.011.2 5.1-11.0 5.511.6 5.38.7 5.1-9.4 N 100 76 54 38 29 18 12 5 1 Typical Distribution of HbA1c values from MMF/DZB Trial MMF/DZB TN-02 Study • 3 arm study: MMF alone, MMF and 2 doses of DZB and placebo • 40 subjects per arm, 120 total, through TrialNet centers • Type 1 diabetes (autoantibodies) within 12 weeks of diagnosis • Ages 8-45, without significant other disease • Outcomes: HbA1c, C-peptide, hypoglycemia, T cell assays • Start Date: Aug. 1, 2004. 126 patients enrolled: enrollment completed on January 2nd, 2007. No major problems to date. First subjects have completed 2 years on medicine. Anti-CD3 Monoclonal Antibody in New-Onset Type 1 Diabetes Mellitus Kevan C. Herold, MD; William Hagopian, MD, PhD; Julie A. Auger, BA; Ena Poumian-Ruiz, BS; Lesley Taylor, BA, David Donaldson, MD; Stephen E. Gitelman, MD, David M. Harlan, MD; Danlin Xu, PhD; Robert A. Zivin, PhD; & Jeffrey A. Bluestone, PhD Herold K. et al., N Engl J Med 2002; 346:1692-8. hOKT3g1(Ala-Ala) Binds to CD3 hOKT3g1(Ala-Ala) is a monoclonal antibody that binds to the CD3 (T cell receptor) on human T cells. The drug is a “humanized” antibody with a mutation in the Fc chain to prevent binding to the Fc receptor. Binding to the Fc receptor and crosslinking of the CD3 molecule is thought to activate T cells, cause release of cytokines, and account for the toxicity of OKT3. Ala-Ala Changes in absolute lymphocyte count with hOKT391 (Ala-Ala) Changes in ALC with treatment 140 120 100 ALC % basal 80 60 40 20 0 10 20 30 40 50 60 70 Day Changes from Study Entry to 12 Months in the Total C-Peptide Response to Mixed-Meal Tolerance Testing Monoclonal-Antibody Group Control Group Total Area under the C-Peptide Response Curve (nmol/l/4 hr) Total Area under the C-Peptide Response Curve (nmol/l/4 hr) Herold K. et al., N Engl J Med 2002; 346:1692-8. Inversion of CD4:CD8 ratio as evidence of responder to anti-CD3 treatment effect Sustained C-peptide production in anti-CD3-tx patients Herold, et al. Diabetes 2005 54:1763-1769. Efficacy correlated to decreased CD4:CD8 ratio in responders vs. non-responders hOKT3(ala-ala) induces CD8CD25+ Treg cells • In vitro stimulation of CD8CD25+ T cells with hOKT3 cocultured with CD8-depleted responders suppress both proliferation and cytokine responses. Bisikirska, et al. 2005. JCI 115:2904-2913 Effectiveness of Combination Therapy with antiCD3 and proinsulin in diabetic mice • RIP LCMV Model Non-FC binding anti-CD3 – 20% reversal of DM; PI alone 0%; CT – 50% • NOD Model Non-FC binding anti-CD3 – 37%; PI alone – 22%; CT – 55% reversal of DM Bresson, et al. 2006. JCI116:1371-1381 • Correlated with reduction in insulitis ALS and Exendin- 4 Cures Overt Diabetes NOD Mice Ogawa et al., Diabetes 53:1700-1705; 2004 Treatment ALS(15) % Remission 40 Time to Remission Duration 55±16 (<114 days) Durable ALS + Exendin 4 (26) Exendin 4 (15) 88 37±4 (<75 days) Durable (except 1) 0 Control (15) 0 What is the rationale for Thymo? Clinical Studies • Equine ATG (ATGAM) pilot study in new onset T1DM – ATGAM group had lower HbA1C than prednisone alone or controls – 4 of 5 required < 0.2 units/kg/d of insulin for 250 days or longer – 2 did not require any exogenous insulin for > 8 mos – Responders had flip in CD4+:CD8+ ratio – Adverse events • Fever and rash in 4 of 5 • Thrombocytopenia from particular lot resulted in truncated course in 3 of 5 – Plt nadir to 25K, 47K, and 129K Eisenbarth et al, Diabetic Research 1985, 2: 271 ATG-Fresenius In New Onset T1DM (Saudek et al, 2004 RDS 1: 80-88) • • • • Randomized, placebo controlled, single blinded trial 18-35 yrs old, T1DM for < 1 month 18 mg/kg total dose – 2-4 times less potent than Thymo Interim analysis on 11 drug treated, 6 controls followed 6-12 mos – Metabolic Effects: • Rx group needed less exogenous insulin, trend to lower A1C – 2 / 11 Rx‟d group discontinued insulin – One from months 3-7; one from month 11, remains off 2 yrs later – A1C for both in normal range during remission • Glucagon-stimulated C-peptide improved from baseline to 12 months in Rx group but not in control • Flip in CD4+/CD8+ ratio, persisting at 12 months – Adverse events: (no pre-Rx offered) • • • • • 7 of 11 with transient fever > 38 oC, resolved by day 3 6 of 11 with moderate serum sickness, resolved within 4 days 2 with phlebitis of antecubital vein, resolved by day 5 No CMV reactivation No adverse events later than 1 month after ATG given What is the rationale for Thymo? Mechanistic Considerations • • • T-cell depletion, eliminates autoreactive, pathogenic T cells Alters function of remaining cells  modulation, anergy Homeostatic proliferation: – Flip in CD4+:CD8+ ratio – May induce regulatory cells, and shift balance towards Th2 • Preliminary results from Genzyme • • May affect T-cell migration – Binds to leukocyte adhesion molecules May affect APC function – Binds to B-cells and dendritic cells RITUXIMAB: AN ANTI-CD20 MONOCLONAL ANTIBODY • Genetically engineered chimeric murine/human monoclonal antibody • First monoclonal antibody to be approved by the FDA for treatment of cancer • Extensive use in over 100,000 patients worldwide in the past 10 B-Cell Antigen Presentation Step 3: • Presentation of antigen to T cell1-4 – B cell presents antigen to T-cell receptor (TCR) and also provides costimulatory signal to T cell1-3 – Activated T cell produces proinflammatory cytokines that activate macrophages1-3 References: 1. Silverman GJ et al. Arthritis Res Ther. 2003;5(suppl 4):S1-S6. 2. Dale DC et al. WebMD Scientific American Medicine. Chapter 6. WebMD Professional Publishing; 2002. 3. Klippel JH et al. Primer on the Rheumatic Diseases. 12th ed. Chapter 9. Arthritis Foundation; 2001. 4. Roitt I et al. Immunology. 6th ed. Chapter 8. Mosby; 2001. RITUXIMAB (T CELL) AUTOIMMUNE DISEASE • • • • • • • RHEUMATOID ARTHRITIS ANCA VASCULITIS LUPUS MULTIPLE SCLEROSIS DERMATOMYOSITIS ITP Transplant Rejection Rituximab in Rheumatoid Arthritis ACR Response at 24 Weeks 60 50 % of patients 55 ** 54 ** *P=0.029, **P0.001 vs placebo ** 40 30 20 13 33 34 ** 28 20 13 5 * ** 10 0 ACR20 Placebo (n=122) ACR50 Rituximab 2 x 500 mg (n=123) ACR70 Rituximab 2 x 1000 mg (n=122) N = 367 (ITT Population) Patients with insufficient data to calculate an ACR response were classified as non-responders Emery P, et al. Presented at American College of Rheumatology Annual Meeting 2005, San Diego, California. Abstract 1917. Bayhill Therapeutics  Core technology: antigen specific immune suppression  DNA plasmid platform  Two plasmid products – BHT-3009 for MS – BHT-3021 for Type 1 diabetes Ori 2989 1 333 Promoter 2657 2325 BHT-3021 3324 bp 1993 1661 1329 665 Intron Insulin 997 PolyA Antibiotic Resistance Proposed mechanism of antigen-specific tolerance Antigen Tolerance: APC (e.g. Dendritic cell) Antigen Encoding DNA proliferation T Cell IFN  Immune de-activation occurs when there is no second signal: – Antigen presented on MHC to the TCR – Lack of co-stimulation (no B7 activation)  The expectation is immune tolerance with: – Decreased proliferation of antigen-specific T cells – Reduced IFN-gamma activity of antigen-specific T cells Mouse BHT-3021 provides significant delay of diabetes onset in hyperglycemic mice at all dosing frequencies DNA dosing stopped 100 Percent Diabetic 75 50 25 0 0 5 10 15 20 25 PBS Anti-CD3 proIns II Hi QW BHT-3021 QW proIns II Hi Q2W BHT-3021 Q2W proIns II Hi Q4W BHT-3021 Q4W weeks post hyperglycaemia Treatment of hyperglycemic mice with mouse BHT3021 restores normoglycemia PBS 600 500 400 600 500 400 proIns II-DNA Hi Expression mg/dl 300 200 100 0 entry BG final BG mg/dl 300 200 100 0 entry BG final BG Regenerative Therapies: Exenatide(Byetta): Glucagon-like Peptide (GLP-1) analogues i. A GLP-1 analogue ii. Helps regulate insulin secretion and gastric emptying iii. Initial studies =  FPIR and improved OGTT iv. Animal studies =  beta cell mass v. Much experience in humans with T2D Regenerative Therapies: Exenatide(Byetta): Glucagon-like Peptide (GLP-1) analogues i. A GLP-1 analogue ii. Helps regulate insulin secretion and gastric emptying iii. Initial studies =  FPIR and improved OGTT iv. Animal studies =  beta cell mass v. Much experience in humans with T2D Cellular Therapies • CD4+CD25+ T regulatory cells – nonspecific or antigen-specific • Naïve Dendritic Cells pulsed with autoantigens to induce T Regs • Stem Cells that can restore regulatory balance – what type? Clinical Scenario • New Onset T1D subject at 6 months post diagnosis • HbA1c 5.8, Lantus dose 1-2 units qHS, Novolog 1 unit per meal, <0.1 unit/kg/BW, avg. BS – 110, no hypoglycemia • Question: Which answer best describes this patient? • A) MMF/DZB treated 21 year old subject • B) Anti-CD3 treated 23 year old subject • C) Control subject 12 years old – no treatment Answer: All 3 are correct!!! How do we correct autoreactivity? Lessons from Animal Models: Modalities of Immunotherapy of T1DM Antigens Insulin GAD65 IA-2 IGRP IAPP HSP60 Immunotherapy Cytokines Cyclosporine Anti-CD3 MMF Anti-IL2R ATG IFNa IL1-RA Anti-TNFa Anti-IL-12 IL-4, IL-10 TGFb IL-18 Growth Factors/Cellular Gastrin/EGF GLP-1 CD4CD25+ Th2 cells Tr1 cells DC cells Vitamin D Therapy of diabetes may eventually require combination therapy! Summary • Antigen specific therapy trials in new onset and prediabetic subjects are being undertaken. • Immunomodulatory trials are ongoing in new onset patients and the results with anti-CD3 are encouraging. • Multicenter trials and networks will help us find effective therapies during the next decade. • Combination therapy targeting multiple pathways may hold the greatest hope for prevention and cure. Acknowledgements Gottlieb Lab • Amy Wallace • Laurie Weiner • Kimber Westbrook • Jenni Bishop • Danielle Shimek • Amy Putnam • Becky Wagner • Jennifer Rockell • Marybeth Magilie • Avi Bram-Mostyn GWU Coordinating Center • Scott Quinlan • Kenan Zamore • Brett Loechelt BDC • Katie Keleman • John Hutton UCHSC • Dan Waid • David Wagner University of Siena • Francesco Vendrame • Francesco Dotta Neurocrine Biosciences Inc • David Alleva • Rich Maki • Roland Jimenez • Paul Conlon University of British Columbia • Qin Ouyang • Dina Panagiotopoulos • Bruce Verchere • Rusung Tan Virginia Mason Research Institute • Nathan Standifer • Jerry Nepom Funding from NIDDK and NIAID Thank you. 1-800-HALT-DM1 (1-800–425-8361) www.diabetestrialnet.org For copy of slides www.barbaradaviscenter.org