Treatment Of Several Autoimmune Diseases Research Articles

Ex vivo studies for the passive transdermal delivery of low-dose naltrexone from a cream; detection of naltrexone and its active metabolite, 6β-naltrexol, using a novel LC Q-ToF MS assay

Naltrexone (NTX) is a long-acting opiate antagonist. Low-dose naltrexone (LDN) therapy has shown promising results in the treatment of several autoimmune disorders. Our aim was to formulate NTX into a cream for the delivery of LDN and develop an analytical technique for the quantification of NTX and its active metabolite 6-β-naltrexol (NTXol) during transdermal diffusion cell permeation studies. A 1% w/w NTX cream was formulated and drug permeation was examined over 24 h using static Franz diffusion cells mounted with pig skin. A Liquid Chromatography Quadrupole-Time of Flight Mass Spectrometry (LC-MS Q-ToF) method was developed for the detection of NTX and NTXol in the receptor solution, skin membrane and residual cream on the donor chamber after completion of the diffusion studies. The cream formulation exhibited steady state release of NTX over 24 h after an initial lag time of 2.74 h. The bioconversion of NTX to NTXol in the skin membrane was 1.1%. It was concluded that the cream may be an effective formulation for the sustained transdermal delivery of LDN. The novel LC Q-ToF MS method allowed the accurate measurement of NTX and NTXol levels across the diffusion cell assemblies and the quantification of NTX metabolism in the skin.

Ultra high performance liquid chromatography–tandem mass spectrometry method for cyclosporine a quantification in biological samples and lipid nanosystems

Cyclosporine A (CyA) is an immunosuppressant cyclic undecapeptide used for the prevention of organ transplant rejection and in the treatment of several autoimmune disorders. An ultra high performance liquid chromatography-tandem mass spectrometry method (UHPLC-MS/MS) to quantify CyA in lipid nanosystems and mouse biological matrices (whole blood, kidneys, lungs, spleen, liver, heart, brain, stomach and intestine) was developed and fully validated. Chromatographic separation was performed on an Acquity UPLC(®) BEH C18 column with a gradient elution consisting of methanol and 2mM ammonium acetate aqueous solution containing 0.1% formic acid at a flow rate of 0.6mL/min. Amiodarone was used as internal standard (IS). Retention times of IS and CyA were 0.69min and 1.09min, respectively. Mass spectrometer operated in electrospray ionization positive mode (ESI+) and multiple reaction monitoring (MRM) transitions were detected, m/z 1220.69→1203.7 for CyA and m/z 646→58 for IS. The extraction method from biological samples consisted of a simple protein precipitation with 10% trichloroacetic acid aqueous solution and acetonitrile and 5μL of supernatant were directly injected into the UHPLC-MS/MS system. Linearity was observed between 0.001μg/mL-2.5μg/mL (r≥0.99) in all matrices. The precision expressed in coefficient of variation (CV) was below 11.44% and accuracy in bias ranged from -12.78% to 7.99% including methanol and biological matrices. Recovery in all cases was above 70.54% and some matrix effect was observed. CyA was found to be stable in post-extraction whole blood and liver homogenate samples exposed for 6h at room temperature and 72h at 4°C. The present method was successfully applied for quality control of lipid nanocarriers as well as in vivo studies in BALB/c mice.

FTY720 preserved islet β‐cell mass by inhibiting apoptosis and increasing survival of β‐cells in db/db mice

FTY720, an analogue of sphingosine-1-phosphate, has shown potential in the treatment of several autoimmune diseases, such as multiple sclerosis, type 1 diabetes and systemic lupus erythematosus. It prevents development or cure of autoimmune diabetes in animal models. Recently, we reported that FTY720 also prevents development of diabetes in db/db mice by β-cell regeneration in vivo. This study investigated the effect of FTY720 on apoptosis in β-cells in db/db mice treated with FTY720 16 weeks. Six week old female db/db mice were divided into control and FTY720 groups. FTY720 (10 mg/kg) was orally administrated daily. Body weights and fasting glucose levels were measured once a week after overnight fasting. After 16 weeks of treatment, oral glucose and insulin tolerance tests were performed, serum insulin levels and insulin contents in pancreas were determined, and then all mice were subjected to physiological and histological analyses. FTY720-treated mice showed normal fasting glucose levels, improved glucose tolerance with normal insulin sensitivity and restored β-cell function to produce and secret insulin. Pancreas histology revealed that FTY720 prevented islet damage and preserved β-cell mass by inhibiting apoptosis and increasing β-cell survival in pancreatic islets. We concluded that early intervention with FTY720 in db/db mice can prevent development of diabetes through preserving β-cell mass by inhibiting apoptosis and increasing survival of islet β-cells.

Regulatory B cells control T-cell autoimmunity through IL-21-dependent cognate interactions.

SummaryB cells regulate immune responses by producing antigen-specific antibody1. However, specific B cell subsets can also negatively regulate immune responses, validating the existence of regulatory B cells2–4. Human and mouse regulatory B cells (B10 cells) with the ability to express the inhibitory cytokine IL-10 have been identified2–5. Although rare, B10 cells are potent negative regulators of antigen-specific inflammation and T cell-dependent autoimmune diseases in mice5–7. How B10 cell IL-10 production and regulation of antigen-specific immune responses are controlled in vivo without inducing systemic immunosuppression are unknown. Using a mouse model for multiple sclerosis, we show here that B10 cell maturation into functional IL-10-secreting effector cells that inhibit in vivo autoimmune disease requires IL-21 and CD40-dependent cognate interactions with T cells. Moreover, the ex vivo provision of CD40 and IL-21 receptor signals can drive B10 cell development and expansion by four-million-fold and generate B10 effector cells producing IL-10 that dramatically inhibit disease symptoms when transferred into mice with established autoimmune disease. Thereby, the ex vivo expansion and reinfusion of autologous B10 cells may provide a novel and effective in vivo treatment for severe autoimmune diseases that are resistant to current therapies.

Sweetʼs Syndrome in Crohnʼs Disease Patient after Treatment with Humira®

Introduction: Acute febrile neutrophilic dermatosis (Sweet's syndrome) is a condition characterized by the sudden onset of fever, leukocytosis and tender, erythematous, well-demarcated papules and plaques which show dense neutrophilic infiltrates on histologic examination. Two forms have been described: 1 - Classical or idiopathic Sweet's syndrome. 2 - Malignancy associated sweet's syndrome. Adalimumab (Humira®) a monoclonal immunoglobulin directed against TNF-α with documented efficacy in treatment of several autoimmune diseases. Major reported side effects are infections, secondary malignancies, autoimmune processes, neurological side effects and heart failure exacerbation. Case: 22-year-old male with history of Crohn's disease that was diagnosed two months prior to starting Humira. Five days after patient received his second dose of Humira he developed fever, sore throat and rash, he was admitted to an outside facility where his fevers and rash were thought to be caused by Humira and was given clindamycin and Levaquin®, Humira was held and he was discharged home after he felt better. Patient was seen in our gastroenterology clinic about two weeks after the onset of rash where he was noted to be febrile with temperature up to 102 °F, the sore throat and the rash were persistent but were slightly better per the patient's report. On exam, his rash was erythematous, confluent, slightly tender papules, spread all over the body including the face, trunk and extremities. This was biopsied and patient was admitted to the hospital and started on intravenous steroids. Patient was afebrile during the hospital stay, his rash and sore throat improved significantly. Histopathology report was consistent with Sweet's syndrome. Patient was discharged home on a taper of steroids and is doing well since then. Discussion: Sweet's syndrome association with IBD is rare but has been well documented in multiple case reports. However, Sweet's syndrome has never been reported as a side effect of monoclonal antibodies up to our knowledge, and in this case the temporal relationship between the administration of Humira and the onset of rash is highly suggestive of casual relationship, despite the fact that there have been several case reports of efficacy of monoclonal antibodies in the treatment of refractory sweet's syndrome. Similar paradoxical effect of monoclonal antibodies has been observed with psoriasis, since despite the fact that monoclonal antibodies are used to treat psoriasis, several cases of psoriasis have been linked to the use of monoclonal antibodies, no explanation has been found yet.

Haematopoietic stem cell transplantation (HSCT) in severe autoimmune diseases: analysis of UK outcomes from the British Society of Blood and Marrow Transplantation (BSBMT) data registry 1997–2009

The British Society of Blood and Marrow Transplantation Data Registry was used to analyse outcomes of haematopoietic stem cell transplantation (HSCT) in severe autoimmune diseases (SADs) from 1997 to 2009. 55 autologous and 15 allogeneic HSCT were registered (0·22% of overall UK HSCT activity). Sustained responses were observed following HSCT, although toxicity was significant. This is the first reported national analysis of long-term outcomes of HSCT in SADs, and should be viewed in the context of translational and developmental phases of HSCT in poor prognosis and refractory SADs. Treatment of poor-risk but reversible SADs with adequate fitness for HSCT in accordance with current guidelines is warranted.

Klippel‐Feil syndrome in a boy exposed inadvertently to cyclophosphamide during pregnancy: A case report

Cyclophosphamide (CPA) is an alkylating agent widely used as an immunosuppressive agent in the treatment of several autoimmune diseases, including systemic lupus erythematosus. Its teratogenic effect has been well studied in different experimental mammalian and non-mammalian animal models. In humans, 11 cases of CPA teratogenesis have been documented. We present a case of a patient with Klippel-Feil syndrome inadvertently exposed to CPA and prednisone in utero during the first trimester. CONCLUSIONS This case of possible cyclophosphamide embryopathy provides evidence of teratogenesis as an etiologic agent in developmental field defects such as Klippel-Feil syndrome.

163 Inflammatory demyelinating neuropathy complicating anti-TNF-α therapy

Tumour necrosis factor-α (TNF-α) inhibition represents a significant advancement in the treatment of severe autoimmune disease and now widely used. Adverse effects of TNF-α inhibition include induction of a variety...

KIR Molecules: Recent Patents of Interest for the Diagnosis and Treatment of Several Autoimmune Diseases, Chronic Inflammation, and B-cell Malignancies

There has been rapidly increasing interest in innate immunity in recent years. Natural killer (NK) cells are cytotoxic lymphocytes that constitute a major component of the innate immune system. NK cells are mainly modulated through different receptors and cytokines. The killer immunoglobulin-like receptors (KIRs) represent the largest category of NK cell receptors. KIR function is mainly regulated by binding both classical MHC I (human leukocyte antigen, HLA A, B and C) and also non-classical MHC. Some KIRs are specific to certain HLA subtypes. Questions about how the NK cells sense self-antigen, infection, and altered cells, and how a protective immune response can be induced are being answered at the molecular level. Research has revealed the central role of innate immunity in the pathogenesis of many autoimmune and inflammatory diseases, as well as B-cell malignancies, with the emergence of recent developments for KIR characterization, disease monitoring, and treatment. In this paper, we report three recent patents focused on KIR applications: the first one is targeted at the determination of the complex KIR haplotypes by using next generation sequencing; the second patent represents a practical approach for genotyping and treatment of the main KIR-related autoimmune and chronic inflammatory diseases; and the last patent describes the possible contributions of KIR to promising combination immunotherapies.

A Supratherapeutic Dose of the Janus Kinase Inhibitor Tasocitinib (CP-690,550) Does Not Prolong QTc Interval in Healthy Participants

Tasocitinib (CP-690,550), a selective inhibitor of the Janus kinase (JAK) family, is being developed for the treatment of several autoimmune diseases and prevention of allograft rejection. The aim of this study was to characterize the effect of tasocitinib on QT interval. Sixty male and female healthy adults were enrolled in a single-dose, randomized, 3-period, crossover study of a supratherapeutic dose of tasocitinib (100 mg), placebo, and moxifloxacin 400 mg. Triplicate electrocardiograms were performed at predose baseline and serially over 24 hours postdose in each treatment period. The upper limits of the 2-sided 90% confidence intervals (CIs) for the difference in QTc interval, corrected using Fridericia correction (QTcF), between tasocitinib and placebo were less than 5 ms at all time points. Concentration-QTcF analysis showed that the predicted mean change (90% CI) in QTcF at the observed mean C(max) was -0.12 (-1.18, 0.94) ms. For moxifloxacin, mean (90% CI) estimates of the change in QTcF from placebo were 11.3 (9.4, 13.1) and 12.5 (10.7, 14.4) ms at 2 and 4 hours, respectively, thereby establishing study sensitivity. A single supratherapeutic dose of tasocitinib 100 mg was well tolerated and not associated with QTc prolongation.

Therapeutic potential of human umbilical cord mesenchymal stem cells in the treatment of rheumatoid arthritis

IntroductionRheumatoid arthritis (RA) is a T-cell-mediated systemic autoimmune disease, characterized by synovium inflammation and articular destruction. Bone marrow mesenchymal stem cells (MSCs) could be effective in the treatment of several autoimmune diseases. However, there has been thus far no report on umbilical cord (UC)-MSCs in the treatment of RA. Here, potential immunosuppressive effects of human UC-MSCs in RA were evaluated.MethodsThe effects of UC-MSCs on the responses of fibroblast-like synoviocytes (FLSs) and T cells in RA patients were explored. The possible molecular mechanism mediating this immunosuppressive effect of UC-MSCs was explored by addition of inhibitors to indoleamine 2,3-dioxygenase (IDO), Nitric oxide (NO), prostaglandin E2 (PGE2), transforming growth factor β1 (TGF-β1) and interleukin 10 (IL-10). The therapeutic effects of systemic infusion of human UC-MSCs on collagen-induced arthritis (CIA) in a mouse model were explored.ResultsIn vitro, UC-MSCs were capable of inhibiting proliferation of FLSs from RA patients, via IL-10, IDO and TGF-β1. Furthermore, the invasive behavior and IL-6 secretion of FLSs were also significantly suppressed. On the other hand, UC-MSCs induced hyporesponsiveness of T cells mediated by PGE2, TGF-β1 and NO and UC-MSCs could promote the expansion of CD4+ Foxp3+ regulatory T cells from RA patients. More importantly, systemic infusion of human UC-MSCs reduced the severity of CIA in a mouse model. Consistently, there were reduced levels of proinflammatory cytokines and chemokines (TNF-α, IL-6 and monocyte chemoattractant protein-1) and increased levels of the anti-inflammatory/regulatory cytokine (IL-10) in sera of UC-MSCs treated mice. Moreover, such treatment shifted Th1/Th2 type responses and induced Tregs in CIA.ConclusionsIn conclusion, human UC-MSCs suppressed the various inflammatory effects of FLSs and T cells of RA in vitro, and attenuated the development of CIA in vivo, strongly suggesting that UC-MSCs might be a therapeutic strategy in RA. In addition, the immunosuppressive activitiy of UC-MSCs could be prolonged by the participation of Tregs.

Use of Antioxidants to Prevent Cyclosporine A Toxicity

Cyclosporine A (CsA) is a potent immunosuppressor that is widely used in transplant surgery and the treatment of several autoimmune diseases. However, major side effects of CsA such as nephrotoxicity, hepatotoxicity, neurotoxicity and cardiovascular diseases have substantially limited its usage. Although molecular mechanisms underlying these adverse effects are not clearly understood, there is some evidence that suggests involvement of reactive oxygen species (ROS) . In parallel, protective effects of various antioxidants have been demonstrated by many research groups. Extensive studies of CsA-induced nephrotoxcity have confirmed that the antioxidants can restore the damaged function and structure of kidney. Subsequently, there have appeared numerous reports to demonstrate the positive antioxidant effects on liver and other organ damages by CsA. It may be timely to review the ideas to envisage the relationship between ROS and the CsA-induced toxicity. This review is comprised of a brief description of the immunosuppressive action and the secondary effects of CsA, and a synopsis of reports regarding the antioxidant treatments against the ROS-linked CsA toxicity. A plethora of recent reports suggest that antioxidants can help reduce many CsA’s adverse effects and therefore might help develop more effective CsA treatment regimens.

Immunoadsorption in nephrology and kidney transplantation

Immunoadsorption finds incremental implementation in the treatment of several autoimmune disorders as well as for kidney transplant indications (see Table 1). As opposed to plasmapheresis, immunoadsorption allows not only a more specific but also a more effective clearance of circulating immunoglobulins without the side effects associated with the substitution of fresh frozen plasma or albumin. In addition, even multiple plasma volumes may be processed, and a reduction of immunoglobulins of 80% and more is feasible [1]. However, one has to consider that plasmapheresis is not only utilized for removal of immunoglobulins but also for the substitution of different plasma components such as ADAMTS-13 in the case of thrombotic thrombocytopenic purpura [2]. Therefore, plasma infusion itself may have beneficial effects independent of the removal of circulating pathogenic substances. The use of plasmapheresis for the treatment of different kidney diseases remains controversial due to a lack of randomized controlled trials demonstrating the benefit of this procedure. This applies even more to immunoadsorption. However, for some indications especially in the field of kidney transplantation, there is now growing evidence pointing to the large potential of this treatment modality. This editorial comment will focus on the available evidence on immunoadsorption in kidney diseases and kidney transplant indications.

Rituximab for severe myasthenia gravis - experience from five patients

Rituximab (RTX), a monoclonal antibody directed against CD20+ B cells, is used in the treatment of several autoimmune disorders including severe generalized myasthenia gravis (MG). To describe the experience with RTX in five MG patients treated at our Neuromuscular Centre. Effect of RTX treatment was monitored by quantitative MG score (QMG score), forced vital capacity (FVC) and records of clinical parameters. Three patients had thymoma. Duration of MG prior to the first course of RTX was 3, 7, 26, 26 and 38 years. We found favourable response to RTX treatment in all five patients. QMG score was markedly lower after RTX and in the three patients with respiratory muscle affection the FVC was increased. A good relief of bulbar, respiratory or extremity MG weakness was thus also found in the three patients who had long-standing severe MG. Repeated RTX treatment was needed in four patients. We conclude that RTX is effective in recent onset MG as well as in long-standing cases. As thymoma is prevalent in patients with severe MG, further studies are needed to evaluate the risk of thymoma recurrence following RTX treatment.

Azathioprine in Multiple Sclerosis

Azathioprine is an immunosuppressive and steroid-sparing purine analogue, used in the treatment of several autoimmune diseases. In multiple sclerosis, available evidence suggests that oral azathioprine reduces relapse rates, provides a slight benefit on disability, and reduces new inflammatory lesions. Here, we focus on molecular mechanisms of Azathioprine and on its usefulness in multiple sclerosis.

Haematopoietic SCT in autoimmune diseases in children: rationale and new perspectives

The possible role of haematopoietic SCT (HSCT) for the treatment of severe autoimmune diseases was originally supported by animal experiments and remission of concomitant autoimmune diseases in patients undergoing transplantation for haematological disorders. Since 1996, over 100 procedures were performed in children with different severe autoimmune diseases such as juvenile idiopathic arthritis, systemic lupus erythematosus, systemic sclerosis, immune cytopaenias and Crohn's disease. This review tries to summarize the published data on efficacy and toxicity of HSCT in this group of patients.

Hematopoietic stem cell transplantation procedures

Hematopoietic stem cell transplantation has been utilized for the treatment of severe autoimmune diseases following the results of experimental studies and of coincidental diseases. While allogeneic transplantation is still being explored, autologous transplantation is the procedure most frequently utilized worldwide. The rationale for its utilization consists in its powerful immunosoppressive effect, but immune modulation polarized towards tolerance is also postulated.The mobilization of stem and progenitor cells from the marrow and the various conditioning regimens derive from the experience with hematologic malignancies. The greatest possible reduction of trasplant-related-mortality and of the autoimmune aggression are being actively pursued. Here, the main procedural modalities will be analyzed and discussed.

Intravenous immunoglobulin suppresses experimental myasthenia gravis: Immunological mechanisms

Intravenous immunoglobulin (IVIG) administration has been beneficially used in the treatment of several autoimmune disorders including myasthenia gravis (MG), although its mechanism of action is still not clear. To study the optimal conditions of IVIG treatment and delineate its mechanism of action we established a suitable model in rat experimental autoimmune MG (EAMG). We show that IVIG has a suppressive effect on the clinical symptoms of ongoing EAMG that is associated with decreased AChR-specific cellular and humoral immune reactivity. Costimulatory factors and cytokine profile analyses suggest that IVIG immunomodulation in EAMG involves suppression of B and Th1-type T cell responses with no generation of T-regulatory cells. Our data contribute to the understanding of the immunological mechanisms underlying IVIG treatment in MG and in other autoimmune disorders.

Leukocytapheresis Is Effective in Inducing But Not in Maintaining Remission in Ulcerative Colitis

Ulcerative colitis (UC) is a chronic inflammatory bowel disease characterized by dense infiltration of lymphocytes, plasma cells, neutrophils, and monocyte-macrophages into the colonic mucosa. Leukocytapheresis is a procedure for selectively removing white blood cells from withdrawn blood. It is used for the treatment of several autoimmune diseases. This study was performed to evaluate the effectiveness of leukocytapheresis for inducing and maintaining remission in corticosteroid-resistant UC, as compared with corticosteroid-responsive UC. Forty-five patients with active UC who were treated with a dose of 1 mg/kg per day or more of prednisolone given systemically for at least 2 weeks were evaluated. Twenty patients (6 males, 14 females) in whom improvement was induced only by high doses of prednisolone were allocated as the corticosteroid-responsive group. The other 25 patients (11 males, 14 females) who did not respond to the above-mentioned dose of prednisolone therapy were allocated as the corticosteroid-resistant group and received leukocytapheresis therapy once a week for 5 weeks. Of patients who had a remission, the corticosteroid-responsive group continued to have the conventional therapy and the corticosteroid-resistant group were given leukocytapheresis once every 4 weeks for at least 2 years as maintenance therapy. Remission was induced by 5 weeks of leukocytapheresis in 23 of the 25 (92%) patients with corticosteroid-resistant active UC. The number of days required to achieve remission of UC was fewer in patients who received leukocytapheresis than in those who did not. Follow-up study of the patients who had remission showed similar relapse rates at 2 years in the patients who received leukocytapheresis and those given high doses of prednisolone alone. Leukocytapheresis is an effective treatment of acute corticosteroid-resistant UC but does not prevent the recurrence of UC.

Mycophenolate Mofetil in the Management of Alloimmune Hemolytic Anemia in ABO‐Compatible but Non‐Identical Pediatric Liver Transplantation

Mycophenolate Mofetil in the Management of Alloimmune Hemolytic Anemia in ABO‐Compatible but Non‐Identical Pediatric Liver Transplantation