Perry D. Haaland

Modeling individual variation in biomarker response to combination immunosuppression with stimulated lymphocyte responses—potential clinical implications

BACKGROUND In mitogen-stimulated lymphocyte responses (sLR), cytokines and cell-surface receptors in peripheral human blood lymphocytes (PBL) are sensitive to cyclosporine (CsA), and can predict its in vivo effect with pharmacodynamic (PD) modeling. This is not known for multiple-agent combinations. METHODS Twenty-five concentration mixtures of CsA (0-1200 ng/ml) plus sirolimus (SRL, 0-30 ng/ml) were added to whole blood from five normal human subjects (NHS) for effect on a limited array of six targets. Effect-concentration relationships were analyzed with E(max) PD equations, and expressed as the range of concentration mixtures associated with one-half of maximal inhibitory effect (EC(50)) on a model biomarker target. This predicted range was examined to see whether it contained representative concentration mixtures of these two drugs, which were associated with a stable post-transplant outcome in a logistic regression model of 1039 clinical trial patients. RESULTS PD analyses suggested that in NHS samples containing CsA+SRL (n=5), (1) PMA-Ionomycin-stimulated T-cell expression of intracellular IL-2, TNF-alpha, and IFN-gamma was inhibited by CsA, and minimally by SRL, and (2) the two agents inhibited pokeweed mitogen (PWM)-stimulated B-cell expression of CD54 and CD95, but not CD86 (ICAM-1, Fas antigen, and B7.2), synergistically. With CD54 as the model biomarker, contour plots also predicted a wide range of concentration mixtures of the two agents across which an EC(50) could be predicted for CsA+SRL in a population (e.g., CsA-72 ng/ml+SRL 15 ng/ml, n=5), as well as in the individual subject (e.g., CsA-0 ng/ml+SRL-13.75 ng/ml in NHS-D310). Logistic regression analysis of clinical outcomes in 1039 patients suggested that the concentration mixture of CsA congruent with 50-150 ng/ml+SRL congruent with 10 ng/ml was associated with a stable post-transplant course. The EC(50) contour plot for CD54 suggested a nearly identical CsA concentration of 120 ng/ml in the presence of 10 ng/ml of sirolimus. CONCLUSIONS Our data suggest that pharmacodynamic evaluation of immunosuppressive agents with biomarkers may be an efficient process with which to characterize immunosuppressive effect of combination agents in individual patients and in patient populations.