Tail of two diseases: regulating immune responses in the retina

Andrew D Dick Director of UCL-Institute of Ophthalmology Duke Elder Professor of Ophthalmology, Institute of Ophthalmology, UCL Professor of Ophthalmology, Bristol Medical School, University of BristolNational Institute for Health Research (NIHR) Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, United Kingdom.

Common and Rare Eye diseases in UK

2 million adults and children suffer from sight loss

1:3 over 85 live with sight loss

£8bn/annum cost to economy through sight loss

The tail of Two Conditions

&

Costs (Adjusted)

After adjustment for baseline characteristics, total direct and indirect costs were higher for NIU cases than for controls (Figure 4)

2012

USD

US$0

US$3,000

US$6,000

US$9,000

US$12,000

Total Direct Costs Total Indirect Costs

US$1,510

US$5,090

US$3,034

US$11,424

NIU patients Controls

2.0 times*

Figure 4. Adjusted Total Direct and Indirect Costs for Patients With NIU vs. Controls

*P<0.05

Thorne et al Acta Ophthalmologica (2016)

2.2 times*

Figure 2. KM Survival Analysis for Time to Any Ocular ComplicationRi

sk o

f Any

Ocu

lar C

ompl

icat

ion

0.00

0.25

0.50

0.75

1.00

Years From Index Date0 1.001 2.002 3.003 4.004 5.005 6.006 7.007 8.008 9.009 10.01

NIU patients Controls

1-Year RiskNIU: 0.450 Controls: 0.066

5-Year RiskNIU: 0.664 Controls: 0.239

10-Year RiskNIU: 0.753 Controls: 0.369

P-value (log-rank test) <.001

Hazard Ratio (95% CI): 5.22 (4.57, 5.96)

Dick et al Ophthalmology (2015)

NIU: 783 524 361 267 194 138 88 54 24 18

Controls: 1,284 926 680 492 367 263 189 127 78 46

Immune responses and the retina

Homeostasis

Damage

Repair

Regeneration

Tonic immune activity in maintenance of retinal health and homeostasis

Normal tonic immune activity maintaining eye homeostasis

Hyperactivity

Hypo-activity

Path

olog

y

AGE

––

+

+

+

+

––

Resident macrophages:

• Suppressive retinal environment –cognate and soluble factors CD200R

• Produce immunoregulatory cytokines IL-10

• Generate neurotrophins

• Vascular modelling

C Broderick, et al Invest Ophthalmol Vis Sci 2000; 41: 2613-1622 DA Carter, AD Dick Brit J Ophthlamol 2003; 87: 481-487. DA Carter AD Dick Curr Eye Res 2004; 28: 427-436.

Microglia mediated Homeostasis

Active Immunoregulation

Fractalkine VIPalpha MSHFasL

Contributions to Healthy Immune Homeostasis: RPE

❑ Maintenance of a regulated barrier to immune cell traffic✓ Mediated by tight junctions ✓ Production of signaling molecules

❑ Maintenance of immune regulated environment in the subretinal space✓ Induction of death of infiltrating immune monocytes/microglia (FasL, CD47, Thrombospondin,

CFH)✓ Polarized secretion of immunoregulatory cytokines (Tgfb, other cytokines) into the apical and

basal directions

❑ Immune signaling to maintain normal RPE physiology✓ Intracellular complement signaling as potential mechanism✓ IL33 signaling to maintain normal RPE metabolism

Regulating to keep steady state

Common effector responses

• CD4+ Th1/Th17 cell driven disease

• Tissue destruction requires cytokine cascade and non-specific activation of macrophages

Uveitis - archetypal ocular inflammatory disease

Dendritic cell Naive T cell Activated T cell

Lym

ph

No

de

Activated T cell Macrophage Activated Macrophage

Targ

et

Org

an

S-Ag, RPB-3, Phosducin, Tyrosinase

ANTIGEN-DRIVEN T CELL RESPONSE

Systemic

CYTOKINE-DRIVEN RESPONSES

Local

Duration

Chronicity and increasing tissue damage

IL-23 IL-12 lL-17

IFNγ IL-2 TNF

IFNγ TNFα IL-1 IL-6

Autoinflammatory versus Autoimmune Genetics and Infection control…

Autoimmune

SystemicOrgan-specific

BIrdshot Chorioretinopathy

Autoinflammatory

Behcets

Spondyloarthropathies

Sarcoid

Serpiginous

Intermediate Uveitis

Sympathetic Ophthalmia Vogt Koyanagi Harada

● Diagnostic Biomarkers - Clinical criteria, Serology, Cytokine levels, genetics

● Prognostic Biomarkers - Imaging, Serology, genetics

● Treatment response Biomarkers - Imaging, biologic levels, Serology

● Remission Biomarkers

What we need to know to be Precise, Predictive and Personalised

It’s a struggle to achieve greater than a 60% response

Controlling inflammation and reducing Corticosteriods to below 10mg/day

Role for Biologics

TNF alpha blockade: TNFp55R-Ig therapy

patie

nts

in %

0 6 12 18 24 30 36 time in weeks

100 80 60 40 20

0

Duration of responseClinical response

• logMAR by 0.2 (53%) • or BIO score by 1

(88 %)

• 17 patients: - M/F: 6/11; age: 25 - 59 y (29 eyes) - duration: 6 y (0.5 -12 y) - systemic disease: Behcet (n=2), TINU (n=1) • 22 treatment periods (two infusions: 3; three infusions: 1) • follow-up: 8m (4 - 16 m)

Murphy et al. Arch Ophthalmol. 2004 Jun;122(6):845-51

Adalimumab 80 mg/40 mg every other week N=101

VISUAL-1 Trial Design

Screening Double-Masked

Placebo N=102

Weeks 0 1 4 6 8 12 16 20 24 27 32 36 80

Primary A

nalysis*

* Non-infectious intermediate, posterior, and panuveitis † May be on 1 immunosuppressive therapy and/or topical steroids at pre-defined stable doses

Steroid Burst & Taper

Active disease despite oral prednisone ≥ 10 to ≤ 60 mg/day for ≥ 2 weeks†

N=203

ARVO 2015

Primary Efficacy and Safety Results

Adverse Events (AEs): 1,047 events per 100 patient-years (PY) for adalimumab-treated patients vs. 965 events per 100PY for placebo patients.

Serious Adverse Events (SAEs): 29 events per 100PY for adalimumab‑treated patients vs. 13 events per 100PY for placebo patients.

DECREASED RISK OF EXPERIENCING TREATMENT FAILURE HAZARD RATIO=0.5, P<0.001

50%

PROLONGATION OF THE MEDIAN TIME TO TREATMENT FAILURE FROM 13 TO 24 WEEKS

87%

SYCAMORE: Study design

Primary endpoint: • Time to treatment failure (based on SUN

criteria) • Statistical analysis: log rank test to compare

treatment groups with a hazard ratio (HR) and 95% confidence interval (CI)

Secondary endpoints included:• Adverse events• Quality of life variables • Disease activity measures

ADA, adalimumab; eow, every other week; MTX, methotrexate; PBO, placebo

R

0Months

R A N D OM IZA TION

ADA 20 mg SC eow if <30 kg or

40 mg SC eow if ≥30 kg

PBO

• Active JIA-associated uveitis

• Aged 2–18 years • Stable MTX ≥12 weeks • Target N=114

≤18 24

All patients received a stable dose of MTX

FOLLOW-UP

Randomization 2:1 ratio

Successful outcome on Adalimumab

The final analysis of the primary outcome showed positive treatment effect in favour of ADA: • Log rank p<0.0001 • HR 0.25 (95% CI 0.12-0.49)

● Diagnostic Biomarkers - Clinical criteria, Serology, Cytokine levels, genetics

● Prognostic Biomarkers - Imaging, Serology, genetics

● Treatment response Biomarkers - Imaging, biologic levels, Serology

● Remission Biomarkers

What we need to know to be Precise, Predictive and Personalised

Humanising our Basic science platform

02

-2

IFNGIL17AIL17FIL22SS Th0

SS Th0

Dex

SS Th17

SS Th17

Dex

SR Th0SR Th0

Dex

SR Th17

SR Th17

Dex

Steroid resistance in inflammatory diseases

Component 2

Com

pone

nt 1 Th17C

CTh0

Principle Component Analysis 210 (out of 246) is suppressed

IL22

CD161

IL26IL17A

IL23R

Th17Th

17 C

sA

Lee et al PNAS 2015

Conjugates for Treating Inflammatory Disease and Identification of Patients

Likely to Benefit from Such Treatment

Patent application numbers US 15/106,411 and EP 14819058

Principles of an Antibody-Drug Conjugate

1. Cells + ADC

2. ADC binds to surface protein

3. ADC is internalised

4. ADC is cleaved in lysosome, releasing free drug

5. Free drug binds to target and receptor is recycled to cell surface

Develop anti-CCR6

Maximising drug release

Pre-clinical model of

humanised GvHD

Ageing - inflammation and death

Ageing reduced mitochondrial function and impaired cellular housekeeping

Senesence leading to a secretory inflammatory phenotype from tissue and systemic alteration systemic immunity

Regulation threshold set points no longer control homeostasis

Bioenergetic switch increased aerobic glucose utilisation

Factors that influence immune phenotype

Majority of high association genes are immune related

Immunotherapies for AMD

Harnessing the good face of the immune response…

Sterile Inflammation- sensing and reacting to damage

Rock et al Nat Rev Immunol. Dec 2010; 10(12): 826–837.

Evolutionarily ancient Immune Receptors-sense and react to tissue perturbation and metabolic alterations

Oxidised lipids

Extracellular ECM breakdown products

Intracellular complement

Metabolic perturbations

The Model Cell/compartment RPE Microglia Choroid

NLRP’s

IL-18, IL-33

And Growth factors

Soluble Complement

Complement Rec

Maintenance of Metabolic pathways

The role of inflammation in the road to atrophy

Tonic immune activity in maintenance of retinal health and homeostasis

Normal tonic immune activity maintaining eye homeostasis

Hyperactivity

Hypo-activity

Path

olog

y

AGE

––

+

+

+

+

––

Figure 1A B

C D

pro IL-33

cleaved IL-33

ST2L

b-actin

LPSControl Poly (I:C) LPSControl Poly (I:C)

B6RPE-07 ARPE-19

INL

ONL

ONL

OPL

INL

IPL

GCL

E F

DAPIST2c-kit ST2 Vimentin DAPI ST2 Phalloidin DAPI ST2 DAPIDAPIIL-33

IPL

INL

ONL

RPE

IPL

INL

ONL

RPE

IL-1 Family member, IL-33 is protective in AMD

Figure 3A

B

EDC

control IL-33

IL-33control

IL-33 suppresses neovascularisation

RPE

Glycolysis

glucose

Lactate

TLRST2

IL-33

Warburg effect is not just about cancer

Senescence

• IL-33 maintains RPE mitochondrial health and maintenance of TCA cycle and lactate utilisation

0 20 40 60 80 1000

5

10

15

20

25

Time (minutes)

OC

R (p

mol

/min

/µg

prot

ein) Scrambled siRNA

IL-33 siRNA

0 20 40 60 80 1000

10

20

30

40

Time (minutes)

OC

R (p

mol

/min

/µg

prot

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Control Plasmid

IL-33 Plasmid

Contro

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mid

IL-33

Plasmid

0

5

10

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(pm

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C D

Scrambled

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IL-33 si

RNA0

2

4

6

8

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OCR

(pm

ol/m

in/µ

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Pyruvate

Citrate

Succinate

Fumarate

Malate

Lactate

Oxaloacetate

Aspartate

Control Plasmid

IL-33 Plasmid

*

*

*

*

*

*

IL-33 siRNA

Control siRNA

Pyruvate

Citrate

Succinate

Fumarate

Malate

Lactate

Oxaloacetate

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*

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E F

Scram

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Scram

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siRN

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IL-33

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pPDH (Ser293)

PDH

Beta Actin

Regulation and setting of threshold of response within the tissue

CD200R

phagocytosis, activation (NO), cytokine release

IL-4

pDC/mDC

IL-33

MacrophagesIL-4 IL-33

�57

Natural History of Autoimmune Diseases

Genetic Risk • Immune • Non-Immune

Preclinical Disease

Clinically-diagnosed Disease

Environmental Exposures

Time

Environmental Exposures

�58

Genetic Risk • Immune • Non-Immune

Preclinical Disease

Clinically-diagnosed Disease

Time

Environmental Exposures

Environmental Exposures

Natural History of AMD

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