Aca 2013 Abstract Export Plenary Session: Plenary Session 1: Novel aspect of therapeutics of autoimmune diseases

Memory T cells afford heightened protective immunity against subsequent re-infection. It was shown that excessive inflammation during chronic autoimmune diseases (eg: Rheumatoid arthritis) can have detrimental effects on the generation of functional memory T cells. However, this effect is not yet well understood.

Our aim is:

- To show the impairment of memory T cells in different groups of RA patients through identification of memory CD4+ and CD8+ T cells phenotype and function (frequencies of IFN-g, TNF-a, IL-2, IL-17 positive cells)

Methods: Upon isolation of PBMC from peripheral blood, we proceeded to intracellular staining and flow cytometry.

Results:

Furhtermore, we have demonstrated an imbalance in TEM/TCM frequencies characterized by a significant decrease in TCM in RA patients, as compared to HC. This imbalance was observed mainly in patients under Golimumab a TNF-? inhibitor and Tasocitinib a JAK inhibitor.

Conclusion: These results suggest that in a chronic inflammatory environment such as in patients with RA, the homeostasis of memory T cells can be disrupted and may influence their response to subsequent infections.

Parallel Session: Parallel Session 5: Biosimilars & related therapies
097 THE RISE OF BIOSIMILAR MABS
S.S. Hong<sup>1


1</sup>R&D, Celltrion, Incheon, Korea

Celltrion is a global biopharmaceutical company, equipped with FDA-certified GMP production facility. Celltrion aims to develop biosimilar products based on EMA regulations, and conduct global clinical trials to show comparability with reference drugs. Celltrion has eight biosimilar candidates; some of those are Infliximab, Rituximab, Etanercept, and Adalimumab. Currently, Infliximab Biosimilar has been approved by some countries including EU. Clinical trial phase I for Rituximab has just finished and phase III will be starting soon including US.

The EMA published its guidelines for biosimilars of complex biologics in early 2012 ¹, and the US FDA has also recently provided its draft guidelines for biosimilar approval.² In response, many biopharmaceutical companies have ramped up their efforts to gain marketing approval for biosimilars, especially for mAb products. A series of recent journals and articles have demonstrated pipeline for development of biosimilars in autoimmune diseases.^3-4

Monoclonal antibodies are structurally very complex, rigorous non-clinical testing has performed to confirm quality, structural and functional comparability in vitro in accordance of EMA guidance. Especially, Remsima^TM, the infliximab biosimilar is the first monoclonal antibody biosimilar got approval from EMA. In May 2013, some of the clinical data has been published along with 30 week data of phase I and III in supplementary of ARD journals.^5-6 Celltrion will supply high quality product consistently to provide better treatment option for those who need such benefits.

In the PLANETRA trial, ACR20 were 60.9% for CT-P13 and 58.6% for INX (95% CI: -6%, 10%) at Week 30 in the ITT population. At week 54, ACR20 was highly similar between groups (CT-P13, 57.0% [172/302]; INX, 52.0% [158/304]; 95% CI: -0.03*0.13). The proportion of patients with positive ADAs was comparable between CT-P13 (40.2%, 52.3%) and INX (39.9%, 49.5%) at week 30 and 54.

PLANETAS and PLANETRA trial reported that TEAEs, ADA and tuberculosis showed similar profile between CT-P13 and INX up to week 54.

Conclusions: CT-P13 demonstrated equivalent pharmacokinetics and efficacy to INX up to week 54. CT-P13 was well-tolerated, with a safety profile comparable to that of INX up to week 54.
099 RISK MANAGEMENT PLAN IN BIOLOGIC ERA: TAIWAN EXPERIENCE
H.Y. Lin¹, W.J. Su², Y.H. Huang<sup>3


1</sup>Rheumatology and Immunology, Taipei Veterans General Hospital, Taipei, Taiwan
²Chest Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
³Gastroenterology, Taipei Veterans General Hospital, Taipei, Taiwan

Biologic agents used to treat rheumatic diseases have made a significant impact on the increased risk of serious infections, especially reactivation of latent tuberculosis infection (LTBI) and hepatitis B virus (HBV).

In Taiwan, according to a multicenter, prospective, and observational study, the incidence of LTBI in RA patients is about 11.6% based on IGRA and 18.6% by TST assay, and a high rate (37.0%) of TST conversion was observed among patients who had completed 12-month adalimumab therapy. Therefore, patients taking TNFα blockers should be aware that they are more susceptible to serious TB infections.
HBV reactivation with increase in serum HBV DNA and ALT is an important issue for HBV populations. Reverse seroconversion from hepatitis B surface antigen (HBsAg)-negative to HBsAg-positive would also happen in hepatitis B core antibody (anti-HBc)-positive patients. The incidence of HBV reactivation could be as high as 40-60% in HBV carriers during anti-TNF treatment based on some retrospective studies.

Department of Health and FDA in Taiwan propose the post-marketing risk management plan (RMP) in April, 2012. Following the policy, Taiwan Rheumatology Association provides a recommendation for LTBI screening and HBV evaluation. (1) Rheumatic patients who are candidates for biologics should receive LTBI and TB screening; (2) If patients have LTBI based on the exposure history, CXR findings, or the results of IGRA, may consider of prophylactic therapy; (3) Routine HBV markers screening, including HBsAg and anti-HBc, is mandatory prior to receiving biologic agents for all rheumatologic patients.

Lupus nephritis is a leading cause for the morbidity and mortality of systemic lupus erythematosus (SLE). Impaired T cell function, oxidative stress and renal mononuclear leukocyte infiltration are associated with the acceleration and deterioration of lupus nephritis, although the exact pathogenic pathway remains largely unclear. Establishment of a new pathogenesis-oriented therapeutic strategy for the disease is clinically warranted. Citral (3,7-dimethyl-2,6-octadienal), a major active compound in a Chinese herbal medicine of Litsea cubeba, can inhibit oxidant activity, macrophage and NF-κB activation. In the present study, we tested the renoprotective effects of Citral in a mouse accelerated and severe lupus nephritis (ASLN) model induced by the administration of lipopolysaccharide to SLE-prone NZB/W F1 mice. The results show that Citral at a daily dose of 200 mg/kg of body weight by gavage for consecutive one month significantly ameliorated hematuria, proteinuria, renal function disturbance and severe renal lesions including neutrophil infiltration and crescent in the glomerulus, and T cell/macrophage infiltration in renal interstitium. Further mechanistic analyses revealed that Citral negatively regulated T cell function, inhibited the activation of NLRP3 inflammasome and augmented Nrf2 anti-oxidative activities in the kidney. Our data support that Citral is renoprotective in the mouse model of severe lupus nephritis by its anti-inflammatory and anti-oxidative activities.

(Backgrounds)

Current treatment strategy of polymyositis/dermatomyositis is based largely on successful experiences in treatment of other systemic autoimmune disorders. To develop a new treatment that addresses specific pathology, CD226 (DNAM-1), which expressed on T cells to promote killer cell function upon interaction with its ligands, was investigated as a candidate therapeutic target.

(Methods and Results)

Immunostaining of CD226 ligands (CD112 and CD155) disclosed that C2C12 myoblasts and C2C12-derived myotubes expressed CD155 but not CD112 at the protein levels. In vitro treatment of splenic CD8 T cells with immobilized monoclonal anti-CD226 antibodies (Tx42) augmented IFN gamma secretion when the T cells were stimulated with immobilized anti-CD3 antibodies. The augmentation was more obvious when the CD3 antibody concentration was low. C-protein induced myositis (CIM) we developed as a new polymyositis model was ameliorated when immunized mice were treated with F(ab')2 of Tx42 both in preventive and therapeutic protocols. Intact Tx42 was not effective in either protocol.

(Conclusions and Discussions)

Muscles express ligands of CD226. Blockade of CD226 with F(ab')2 antibodies, but not with intact antibodies, suppressed CIM. In vitro agonistic effects of the CD226 antibodies in accelerating CD8 T cell activation suggested that abrogation of Fc mediated cross-linking by digestion to produce F(ab')2 is essential for the therapeutic effects of the antibodies. Killer cell inhibition by CD226 blockade should be a new therapeutic approach that addresses specific pathology of autoimmune myositis.
103 MULTIPOTENT STROMAL CELLS-CLINICAL APPLICATIONS IN AUTOIMMUNE DISEASES AND BEYOND - SHOULD AUTISM SPECTRUM DISORDERS BE NEXT?
B. Gesundheit¹, D. Naor², M. Melamed², J.P. Rosenzweig<sup>3


1</sup>Autism Research, Alon Shvut Darom, Alon Shvut, Israel
²Lautenberg Center for General and Tumor Immunology, Hebrew University Hadassah Medical School, Jerusalem, Israel
³Autism Research, Feuerstein, Jerusalem, Israel

New directions in Autism Spectrum Disorders (ASD) research suggest that a subgroup should be discussed in the context of autoimmunity and, as a result, even in context of potential cell therapy. Immunological aspects of ASD will be summarized, focusing on the cytokine profile of a subset of ASD, along with the rationale for cellular therapy. Potential safety concerns will be contrasted with hazards in cell therapy for other diseases. Questions for future research will be posed, highlighting areas demanding further attention.

In recent years, multipotent stromal/stem cells (MSC) have been the subject of intense research owing to their ability to differentiate into a variety of cell types. By avoiding allorecognition these cells can be used therapeutically for a spectrum of conditions without triggering rejection by the immune system. Furthermore, in addition to tissue repair potential, MSCs can serve as regulator cells attenuating autoimmune diseases, including possibly the autoimmune subset of ASD. In order to assess which conditions can most benefit from innovative cell therapy, preclinical and clinical research will be reviewed for multiple indications, focusing on mechanism of action. Many mechanisms have been suggested for how MSCs modulate the immune system. Three main mechanisms, namely the IDO pathway, the NO pathway, and the PGE2 pathway will be elucidated. The advantages of MSC over other types of cellular therapy will be stressed along with an investigation of the benefits of allogenic versus autologous cells. The unique considerations of each indication will be considered, especially in context of ASD.

Parallel Session: Parallel Session 6: Autoantigens and autoantibodies in autoimmune diseases

107 Citrullinated antigens and new therapies for rheumatoid arthritis
R. Thomas<sup>1


1</sup>Diamantina Institute, University of Queensland, Brisbane, Australia

Disease modifying strategies are available for treatment of rheumatoid arthritis (RA), and good response rates are achieved. However, limitations include toxicity, a response rate ceiling, cost and rationing of biologic therapies, inability to cure or permanently reverse RA pathology, and inability to prevent disease. Recent evidence suggests that treatment of very early RA with immunomodulatory drugs can delay or attenuate disease onset. RA is strongly associated with the HLA-DRB1 locus that possesses the Òshared susceptibility epitope (SE)Ó, and the citrullination of self-antigens. Approximately 80% of RA patients develop autoantibodies targeted against citrullinated self peptides. These patients are more likely to have RA-associated HLA-DR risk alleles and to smoke. Using HLA-II tetramers, we demonstrated citrullinated vimentin and aggrecan-specific CD4⁺ T cells in the peripheral blood of HLA-DRB1*04:01⁺ RA patients and healthy individuals, and cytokine responses ex vivo. In RA patients, the number of autoreactive cells correlated with disease activity. We are developing antigen-specific immunotherapy to target dendritic cells (DC) in situ with liposomes encapsulating citrullinated peptide and NF-kB inhibitor. In a proof-of-concept trial, delivery of citullinated peptide and tolerogenic DC was safe and had systemic immune effects. DC represent an important target for citrullinated peptide-specific immunotherapy in RA.

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  Combination of IgG and IgA is required to achieve clinical usefulness
  
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  High specificity of the test used is crucial for valuable diagnostic support
  
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  The new fully automated EliA^TM ASCA tests demonstarte an overall suprior performace compared to 2 Elisa assays.
  
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  Carrying out ASCA testing embedded in a reasonable diagnostic workup can assure the diagnosis and support the diagnostic process for the clinician
  

Background and aims: The screening for antinuclear antibodies is the initial step for the serological analysis of patients suspected to suffer from systemic autoimmune rheumatic diseases (SARD). Recently, antibodies against DFS70 have been described as the most common cause of positive ANA screen results on HEp-2 cells without any clinical association with SARD. We present the evaluation of a new 12plex Dot blot assay with DFS70 antigen using a digital reading system.

Sera (n=140) from SARD patients were tested both using individual QUANTA Flash® or QUANTA Lite® assays for the respective autoantibodies (all INOVA Diagnostics) and by the new ANA Dot Blot assay. Interpretation was done using a digital dot recognition system, consisting of a quick load tray for the dot blot strips and a special scanning device. Agreements between QUANTA Flash/QUANTA Lite and the Dot Blot assay were calculated for the individual antigens.

High agreements of the methods were observed: Positive (PPA), negative (NPA) and total percent agreements (TPA) were close to or higher than 85%. ROC analysis against established tests resulted in high AUC values for all antigens (e.g. DFS 70: AUC=0.82, PPA=88.9%, NPA=91.7% and TPA=91.3 %)

The new ANA Profile assay in combination with the scanning system offers fast and reliable multiplex detection of 12 ANAs including anti-DFS70 antibodies. The system shows good correlation to established immunoassay systems and allows for the interpretation of often unresolved IIF results in patients without clinical evidence of SARD.