Benjamin M. Segal

Repeated subcutaneous injections of IL12/23 p40 neutralising antibody, ustekinumab, in patients with relapsing-remitting multiple sclerosis: a phase II, double-blind, placebo-controlled, randomised, dose-ranging study

BACKGROUND Repeated subcutaneous injections of a monoclonal antibody against the p40 subunit of interleukins 12 and 23, ustekinumab, were used to treat patients with relapsing-remitting multiple sclerosis (RRMS) to assess the drugs safety, efficacy, and pharmacokinetics. METHODS In this phase II, multicentre, randomised, double-blind, placebo-controlled study, 249 patients with RRMS, aged 18-65 years, were eligible to be assigned equally (by a central randomisation procedure based on study site and presence or absence of gadolinium-enhancing T1-weighted lesions at baseline) to one of five groups that received placebo or four different ustekinumab dosages at weeks 0, 1, 2, 3, 7, 11, 15, and 19. Ustekinumab doses were 27 mg, 90 mg q8w, 90 mg, or 180 mg; the 90 mg q8w dosage group received placebo substitute at weeks 7 and 15. The primary endpoint was the cumulative number of new gadolinium-enhancing T1-weighted lesions on serial cranial MRI through week 23. Patients were followed up through week 37. Analysis was by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT00207727. FINDINGS From August, 2004, to December, 2006, 249 patients underwent randomisation (49 for placebo; 50 for each ustekinumab group). Ustekinumab treatment did not show a significant reduction in the primary endpoint for any dosage groups versus placebo. At week 37, adverse events occurred in 38 (78%) placebo-treated patients and 170 (85%) ustekinumab-treated patients, with infections most commonly reported. Serious adverse events occurred in one (2%) placebo-treated patient and six (3%) ustekinumab-treated patients. Malignant diseases were reported in two patients shortly after the initiation of ustekinumab treatment; both patients were withdrawn from the trial and given appropriate treatment, which resulted in complete remission. No serious infections, cardiovascular events, or exacerbation of demyelinating events occurred. A dose-dependent increase in serum concentrations of ustekinumab was recorded. INTERPRETATION Ustekinumab is generally well tolerated but does not show efficacy in reducing the cumulative number of gadolinium-enhancing T1-weighted lesions in multiple sclerosis.

Th17 cells in autoimmune demyelinating disease

Recently published studies in multiple sclerosis (MS) and experimental autoimmune encephalomyelitis (EAE) have demonstrated an association between the development of demyelinating plaques and the accumulation of Th17 cells in the central nervous system and periphery. However, a causal relationship has been difficult to establish. In fact, in reports published thus far, interleukin (IL)-17A deficiency or neutralization in vivo attenuates, but does not completely abrogate, EAE. There is growing evidence that clinically similar forms of autoimmune demyelinating disease can be driven by myelin-specific T cells of distinct lineages with different degrees of dependence on IL-17A production to achieve their pathological effects. While such observations cast doubts about the potential therapeutic efficacy of Th17 blocking agents in MS, the collective data suggest that IL-17A expression in peripheral blood mononuclear cells could serve as a surrogate biomarker of neuroinflammation and plaque formation and be a useful outcome measure for future clinical trials.

Neutrophil-related factors as biomarkers in EAE and MS

Using a mouse model of multiple sclerosis (MS), the authors show that neutrophils expand in the bone marrow and accumulate in the circulation before clinical onset of disease. Early in disease development, neutrophils infiltrate the CNS, which is suppressed by G-CSF receptor deficiency and blockade of CXCL1 to ameliorate disease. In patients with MS, systemic expression of neutrophil-related mediators correlates with new lesion formation, lesion burden, and clinical disability.

EAE mediated by a non-IFN-Γ/non-IL-17 pathway

Previous studies have shown that EAE can be elicited by the adoptive transfer of either IFN‐γ‐producing (Th1) or IL‐17‐producing (Th17) myelin‐specific CD4+ T‐cell lines. Paradoxically, mice deficient in either IFN‐γ or IL‐17 remain susceptible to EAE following immunization with myelin antigens in CFA. These observations raise questions about the redundancy of IFN‐γ and IL‐17 in autoimmune demyelinating disease mediated by a diverse, polyclonal population of autoreactive T cells. In this study, we show that an atypical form of EAE, induced in C57BL/6 mice by the adoptive transfer of IFN‐γ‐deficient effector T cells, required IL‐17 signaling for the development of brainstem infiltrates. In contrast, classical EAE, characterized by predominant spinal cord inflammation, occurred in the combined absence of IFN‐γ and IL‐17 signaling, but was dependent on GM‐CSF and CXCR2. Our findings contribute to a growing body of data, indicating that individual cytokines vary in their importance across different models of CNS autoimmunity.

Sleep-disordered breathing in multiple sclerosis

Background: The objectives of this cross-sectional study were to assess the prevalence and severity of sleep apnea in patients with multiple sclerosis (MS) referred for overnight polysomnography (PSG) and to explore the radiographic and clinical features that might signal risk for undiagnosed sleep apnea. Methods: Apnea-hypopnea (AHI) and central apnea indices (CAI) from laboratory-based PSG among 48 patients with MS were compared with those of group A, 84 sleep laboratory−referred patients without MS matched for age, gender, and body mass index; and group B, a separate group of 48 randomly selected, referred patients. Results: Mean AHI was higher among patients with MS than among control groups A or B (2-way analysis of variance and multiple linear regression, p = 0.0011 and 0.0118, respectively). Median and mean CAI were also increased among patients with MS in comparison to control groups (Wilcoxon signed rank and multiple linear regression, p = 0.0064 and 0.0027, respectively). Among MS patients with available data, those with evidence of brainstem involvement, compared with groups A and B, showed particularly robust differences in AHI (p = 0.0060 and 0.0016) and CAI (p = 0.0215 and <0.0001). In contrast, MS patients without brainstem involvement, compared with groups A and B, showed diminished differences in AHI, and CAI did not significantly differ among groups. Conclusions: These data suggest a predisposition for obstructive sleep apnea and accompanying central apneas among patients with MS, particularly among those with brainstem involvement.

Lymphoid chemokines in the CNS

Lymphoid chemokines, including CCL19, CCL21 and CXCL13, are critical in the development and organization of secondary lymphoid tissues and in the generation of adaptive immune responses. These molecules have also been implicated in the development of ectopic lymphoid structures in the setting of chronic inflammation. Here we review current knowledge on the production of lymphoid chemokines in the central nervous system during both homeostatic conditions and in disease states. Accumulating evidence suggests that constitutive expression of CCL19 plays a critical immunosurveillance role in healthy individuals. In contrast, aberrant induction of CCL19, CCL21 and CXCL13 may support the establishment of chronic autoimmunity and hematopoietic tumors within the CNS.

The lymphoid chemokine, CXCL13, is dispensable for the initial recruitment of B cells to the acutely inflamed central nervous system

Abstract Cases of progressive multifocal leukoencephalopathy can occur in patients treated with the B cell depleting anti-CD20 antibody, rituximab, highlighting the importance of B cell surveillance of the central nervous system (CNS). The lymphoid chemokine, CXCL13, is critical for B cell recruitment and functional organization of peripheral lymphoid tissues, and CXCL13 levels are often elevated in the inflamed CNS. To more directly investigate the role of CXCL13 in CNS B cell migration, its role in animal models of infectious and inflammatory demyelinating disease was examined. During acute alphavirus encephalitis where viral clearance depends on the local actions of anti-viral antibodies, CXCL13 levels and B cell numbers increased in brain tissue over time. Surprisingly, however, CXCL13-deficient animals showed normal CNS B cell recruitment, unaltered CNS virus replication and clearance, and intact peripheral anti-viral antibody responses. During experimental autoimmune encephalomyelitis (EAE), CNS levels of CXCL13 increased as symptoms emerged and equivalent numbers of B cells were identified among the CNS infiltrates of CXCL13-deficient mice compared to control animals. However, CXCL13-deficient mice did not sustain pathogenic anti-myelin T cell responses, consistent with their known propensity to develop more self-limited EAE. These data show that CXCL13 is dispensable for CNS B cell recruitment in both models. The disease course is unaffected by CXCL13 in a CNS infection paradigm that depends on a pathogen-specific B cell response, while it is heightened and prolonged by CXCL13 when myelin-specific CD4+ T cells drive CNS pathology. Thus, CXCL13 could be a therapeutic target in certain neuroinflammatory diseases, but not by blocking B cell recruitment to the CNS.

Neuroinflammation triggered by β-glucan/dectin-1 signaling enables CNS axon regeneration

Significance Damage to neuronal networks in the central nervous system typically results in permanent functional deficits; however, the regenerative capacity of injured neurons can be dramatically augmented by local innate immune responses. Here we investigated the molecular and cellular events that participate in immune-mediated repair of severed optic nerve axons in the mouse. We show that intraocular administration of particulate β-glucan engages the immune receptor dectin-1 expressed on retina-resident microglia and infiltrating leukocytes, to trigger enhanced axonal regeneration. Delayed administration of β-glucan by two days is as effective as administration at the time of injury, suggesting a large therapeutic window. These data elucidate a new pathway of immune-mediated neural repair that may be targeted to reverse neurological disability. Innate immunity can facilitate nervous system regeneration, yet the underlying cellular and molecular mechanisms are not well understood. Here we show that intraocular injection of lipopolysaccharide (LPS), a bacterial cell wall component, or the fungal cell wall extract zymosan both lead to rapid and comparable intravitreal accumulation of blood-derived myeloid cells. However, when combined with retro-orbital optic nerve crush injury, lengthy growth of severed retinal ganglion cell (RGC) axons occurs only in zymosan-injected mice, and not in LPS-injected mice. In mice deficient for the pattern recognition receptor dectin-1 but not Toll-like receptor-2 (TLR2), zymosan-mediated RGC regeneration is greatly reduced. The combined loss of dectin-1 and TLR2 completely blocks the proregenerative effects of zymosan. In the retina, dectin-1 is expressed by microglia and dendritic cells, but not by RGCs. Dectin-1 is also present on blood-derived myeloid cells that accumulate in the vitreous. Intraocular injection of the dectin-1 ligand curdlan [a particulate form of β(1, 3)-glucan] promotes optic nerve regeneration comparable to zymosan in WT mice, but not in dectin-1−/− mice. Particulate β(1, 3)-glucan leads to increased Erk1/2 MAP-kinase signaling and cAMP response element-binding protein (CREB) activation in myeloid cells in vivo. Loss of the dectin-1 downstream effector caspase recruitment domain 9 (CARD9) blocks CREB activation and attenuates the axon-regenerative effects of β(1, 3)-glucan. Studies with dectin-1−/−/WT reciprocal bone marrow chimeric mice revealed a requirement for dectin-1 in both retina-resident immune cells and bone marrow-derived cells for β(1, 3)-glucan–elicited optic nerve regeneration. Collectively, these studies identify a molecular framework of how innate immunity enables repair of injured central nervous system neurons.

Highly polarized Th17 cells induce EAE via a T-bet independent mechanism

In the MOG35–55 induced EAE model, autoreactive Th17 cells that accumulate in the central nervous system acquire Th1 characteristics via a T‐bet dependent mechanism. It remains to be determined whether Th17 plasticity and encephalitogenicity are causally related to each other. Here, we show that IL‐23 polarized T‐bet−/− Th17 cells are unimpaired in either activation or proliferation, and induce higher quantities of the chemokines RANTES and CXCL2 than WT Th17 cells. Unlike their WT counterparts, T‐bet−/− Th17 cells retain an IL‐17hiIFN‐γneg‐lo cytokine profile following adoptive transfer into syngeneic hosts. This population of highly polarized Th17 effectors is capable of mediating EAE, albeit with a milder clinical course. It has previously been reported that the signature Th1 and Th17 effector cytokines, IFN‐γ and IL‐17, are dispensable for the development of autoimmune demyelinating disease. The current study demonstrates that the “master regulator” transcription factor, T‐bet, is also not universally required for encephalitogenicity. Our results contribute to a growing body of data showing heterogeneity of myelin‐reactive T cells and the independent mechanisms they employ to inflict damage to central nervous system tissues, complicating the search for therapeutic targets relevant across the spectrum of individuals with multiple sclerosis.

Fatigue, Tiredness, Lack of Energy, and Sleepiness in Multiple Sclerosis Patients Referred for Clinical Polysomnography

Objectives. To assess the relationship between nocturnal polysomnographic (PSG) findings and a group of key self-reported symptoms—fatigue, tiredness, lack of energy, and sleepiness—among sleep-laboratory referred patients with and without multiple sclerosis (MS). Methods. PSG and questionnaire data from n = 30 MS patients and n = 30 matched controls were analyzed retrospectively. Associations between symptoms of fatigue, tiredness, lack of energy, sleepiness, and PSG variables of interest were examined among MS patients and controls. Results. More MS patients than controls reported fatigue, tiredness, and lack of energy to occur often or almost always (Chi-square P < 0.0001 for each), but sleepiness was reported similarly by both groups (P = 0.3409). Among MS patients, tiredness correlated with sleepiness (Spearman correlation P = 0.005), and a trend emerged toward correlation between fatigue and sleepiness (Spearman correlation P = 0.076). Decreased sleep efficiency on PSGs correlated with fatigue, tiredness, and lack of energy in MS patients (Spearman correlation P = 0.002, 0.029, and 0.048, resp.), but not sleepiness or any symptom among controls. Conclusion. In comparison to controls, MS patients report more fatigue, tiredness, and lack energy, but not sleepiness. Fatigue and related symptoms may arise from MS itself or in relation to reduced sleep efficiency.