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Treatment of patients with recent-onset type 1 diabetes with an anti-CD3 antibody leads to the transient stabilization of C-peptide levels in responder patients. Partial efficacy may be explained by the entry of islet-reactive T-cells spared by and/or regenerated after the anti-CD3 therapy. The CXCR3/CXCL10 axis has been proposed as a key player in the infiltration of autoreactive T cells into the pancreatic islets followed by the destruction of β cells. Combining the blockade of this axis using ACT-777991, a novel small-molecule CXCR3 antagonist, with anti-CD3 treatment may prevent further infiltration and β-cell damage and thus, preserve insulin production. The effect of anti-CD3 treatment on circulating T-cell subsets, including CXCR3 expression, in mice was evaluated by flow cytometry. Anti-CD3/ACT-777991 combination treatment was assessed in the virally induced RIP-LCMV-GP and NOD diabetes mouse models. Treatments started at disease onset. The effects on remission rate, blood glucose concentrations, insulitis, and plasma C-peptide were evaluated for the combination treatment and the respective monotherapies. Anti-CD3 treatment induced transient lymphopenia but spared circulating CXCR3+ T cells. Combination therapy in both mouse models synergistically and persistently reduced blood glucose concentrations, resulting in increased disease remission rates compared to each monotherapy. At the study end, mice in disease remission demonstrated reduced insulitis and detectable plasma C-peptide levels. When treatments were initiated in non-severely hyperglycemic NOD mice at diabetes onset, the combination treatment led to persistent disease remission in all mice. These results provide preclinical validation and rationale to investigate the combination of ACT-777991 with anti-CD3 for the treatment of patients with recent-onset diabetes.
Context: Autoimmune polyglandular syndrome (APS-2: autoimmune Addison’s disease or type 1 diabetes) is conferred by predisposing HLA molecules, vitamin D deficiency, and heritable susceptibility. Organ destruction is accompanied by cytokine alterations. We addressed the monocytic cytokines of two distinct APS-2 cohorts, effects of vitamin D and HLA DQ risk.
Methods: APS-2 patients (n = 30) and healthy controls (n = 30) were genotyped for HLA DQA1/DQB1 and their CD14+ monocytes stimulated with IL1β and/or 1,25(OH)2D3 for 24 h. Immune regulatory molecules (IL-6, IL-10, IL-23A, IL-15, CCL-2, PD-L1), vitamin D pathway gene transcripts (CYP24A1, CYP27B1, VDR), and CD14 were analyzed by enzyme-linked immunosorbent assay and RTqPCR. Results: Pro-inflammatory CCL-2 was higher in APS-2 patients than in controls (p = 0.001), whereas IL-6 showed a trend – (p = 0.1). In vitro treatment with 1,25(OH)2D3 reduced proinflammatory cytokines (IL-6, CCL-2, IL-23A, IL-15) whereas anti-inflammatory cytokines (IL-10 and PD-L1) rose both in APS-type 1 diabetes and APS-Addison´s disease. Patients with adrenal autoimmunity showed a stronger response to vitamin D. Expression of IL-23A and vitamin D pathway genes VDR and CYP27B1 varied by HLA genotype and was lower in healthy individuals with high-risk HLA (p = 0.0025; p = 0.04), while healthy controls with low-risk HLA showed a stronger IL-10 and CD14 expression (p = 0.01; p = 0.03). Conclusion: 1,25(OH)2D3 regulates the monocytic response in APS-2 disorders type 1 diabetes or Addison´s disease. The monocytic cytokine profile of individuals carrying HLA high-risk alleles is proinflammatory, enhances polyglandular autoimmunity and can be targeted by vitamin D.
Type 1 Diabetes (T1D) is an autoimmune disorder in which the own immune system attacks the insulin producing _-cells in the pancreas. Therapy of T1D with anti-CD3 antibodies (aCD3) leads to a blockade of the autoimmune process in animal models and patients resulting in reduced insulin need. Unfortunately, this effect is only temporal and the insulin need increases after a few years. In the first approach, I aimed at a blockade of the cellular re-entry into the islets of Langerhans after aCD3 treatment by neutralising the key chemokine CXCL10, which is important for the T cell migration. In the second approach I tried to block the transmigration of leukocytes trough the endothelial layer into inflamed tissue with an anti-JAM-C antibody (aJAM-C) after aCD3 treatment.
I used the well-established RIP-LCMV-GP mouse model of T1D. As target autoantigen in the _-cells, such mice express the glycoprotein (GP) of the lymphocytic choriomeningitis virus (LCMV) under control of the rat insulin promoter (RIP). These mice develop T1D within 10 to 14 days only after LCMV-infection. In the combination therapy (CT) I treated diabetic RIP-LCMV-GP mice with 3 5g aCD3 per mouse (3 injections in 3 days) followed by administration of a neutralising anti-CXCL10 (CT) or aJAM-C (CT-J) monoclonal antibody (8 injections of 100 5g per mouse over 2.5 weeks).
CT reverted T1D in RIP-LCMV-GP mice significantly (CT: 67 % reversion; control: 16 % reversion) and with superior efficacy to monotherapies with aCD3 (38 % reversion) and aCXCL10 (36 % reversion).
The CD8 T cells in the spleen have fully regenerated at day 31 after infection. However, the frequency of islet antigen (GP)-specific CD8 T-cells was significantly reduced by 73 % in the spleen after CT compared to isotype control treated mice. In contrast, in aCD3 treated mice the T cells were only reduced by 56 % of the frequency of isotype control treated mice. Flow cytometry and immunohistological examinations demonstrated a marked reduction of CD8 T cells in the pancreas of CT treated mice. Importantly, the number of GP-specific CD8 T cells was reduced dramatically by 78 % in the pancreas of CT treated mice, whereas aCD3 treatment led to a less pronounced reduction of the GP-specific CD8 T cell number (23 %). This reduction of infiltration was long lasting since in the pancreas of CT treated mice the _-cells produce insulin and there were almost no infiltrating T cells present at day 182 post-infection. aCD3 treated mice also showed many insulin producing cells after 182 days post-infection. Nevertheless, their pancreas displayed also some infiltrates around the islets.
In order to confirm my data I treated non-obese diabetic (NOD) mice with CT. In contrast to RIP-LCMV-GP mice, NOD mice develop spontaneous T1D within 15 to 30 weeks after birth, due to a mutation in the CTLA-4 gene. Strikingly CT cured 55 % of diabetic NOD mice, whereas only 30 % showed T1D reversion with aCD3 alone and none reverted after isotype control administration.
The impact of CT on GP-specific T cells (Teff) was stronger in the RIP LCMV-GP than in the NOD model. In contrast, regulatory T cells (Tregs) were induced predominantly in NOD mice rather than in RIP-LCMV-GP mice. However, looking at the Treg/Teff ratio and compared to isotype control antibody treated mice, I found a significant 4-fold increase in the pancreas of CT treated RIP LCMV-GP mice and a 17-fold increase in the PDLN of CT treated NOD mice. In addition, a tendency for an increase in Treg/Teff ratio was obtained in the spleen of CT-treated RIP LCMV-GP as well as NOD mice compared to aCD3 and isotype control antibody treated mice.
In the second combination therapy with neutralising aJAM-C, CT-J (51 % reversion) slightly improved the aCD3 therapy (41 % reversion). However, there was no significant difference between CT-J and aCD3 administration in terms of total CD8 and GP-specific CD8 T cells.
JAM-C also interacts with the integrin receptor macrophage-1 antigen (MAC-1), which is among others expressed by neutrophils. Accordingly, JAM-C could be involved in neutrophil transmigration to the pancreas. Indeed, I found a significant reduction for the infiltrating neutrophils into the pancreas of mice after CT-J compared to aCD3 monotherapy.
In summary the addition of aJAM-C to aCD3 monotherapy showed a small improvement, which was associated with a reduced neutrophil migration into the pancreas. However, JAM C seemed to play only a minor role in T1D development and some other adhesion molecules might be more important. Nevertheless, the combination of aCD3 and aCXCL10 resulted in a significant and long lasting reduction of aggressive T cells in the pancreas in two independent mouse models. Furthermore a protective immune balance was obtained. Since both antibodies are available for as well as tested in humans and the therapy is only for a short period of time after disease onset, this combination therapy might kick-start a novel therapy for T1D.