The Immunopathogenesis of Relapsing MS
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1 The Immunopathogenesis of Relapsing MS Olaf Stüve, M.D., Ph.D. Neurology Section VA North Texas Health Care System Dallas VA Medical Center Departments of Neurology and Neurotherapeutics University of Texas Southwestern Medical Center at Dallas
2 Disclosures Dr. Stüve has received speaker fees from Teva Neuroscience Dr. Stüve served as a consultant for Sanofi- Aventis, EMD Serono, Novartis, Pfizer, Teva Neuroscience, Roche, and Genzyme Dr. Stüve is supported by a Merit Award from the Department of Veterans Affairs, a research grant from the Dallas VA Research Corporation, and a career development grant from the Doris Duke Charitable Foundation
3 Learning objectives A. To understand the role of the adaptive immune system in the pathogenesis of relapsing-remitting MS B. To learn about the role of the innate immune system in relapsing-remitting MS C. To learn how FDA-approved therapies affect immune responses in relapsing-remitting MS
4 Multiple Sclerosis Stüve O, Zamvil SS. In: Lange: Medical Immunology (tenth edition)
5
6 Circulation Central Nervous System T-cell extravasation B cell B-cell T-cell cross-activation Chemoattraction T-cell adhesion T-cell rolling CNS APC T-cell reactivation Inflammatory mediators Plasma cell Memory B cell Antibodies & Complement APC T-cell activation Inflammation Hypoxia, ischemia Energy depletion K + Na + Activation of Na + channels NA + Ca 2+ Na + Reverse Na + Ca 2+ exchange Oligodendrocyte
7 MHC II CD4 + APC
8 Experimental Autoimmune Encephalomyelitis (EAE) myelin Ag./CFA s/c +myelin Ag. CD4+ Th1 Nitin Karandikar, UTSW.
9 Baxter A. Nat.Rev.Immunol
10 Baxter. Nat.Rev.Immunol
11 Patterson. J.Exp.Med Baxter. Nat.Rev.Immunol
12
13 Patterson. J.Exp.Med Waksman. J.Exp.Med Baxter. Nat.Rev.Immunol
14 Patterson. J.Exp.Med Waksman. J.Exp.Med Baxter. Nat.Rev.Immunol
15 Patterson. J.Exp.Med Zamvil. Nature T-cell clones specific for myelin basic protein induce EAE 1985 Waksman. J.Exp.Med Baxter. Nat.Rev.Immunol
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23 mg/dose
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25 41% p= % p=0.03
26 VLA-4 α 4 1 Natalizumab
27 Circulation Courtesy of Olaf Stüve, MD, PhD, UT Southwestern Medical Center at Dallas. Central Nervous System B cell adhesion Chemoattraction B cell cross-activation rolling CNS APC re-activation Inflammatory mediators Plasma cell Memory B cell Antibodies & Complement APC activation Inflammation Hypoxia, ischemia Energy depletion K + Na + Activation of Na + channels NA + Ca 2+ Na + Reverse Na + Ca 2+ exchange Oligodendendrocyte
28 Stüve et al. Ann Neurol
29 Stüve et al. Neurol
30 Fingolimod Presumed MOA/CNS impact Believed to modulate sphingosine 1-phosphate (S1P) receptors on lymphocytes and other tissues 1,2 S1P receptors are widely expressed, including in cardiac tissue, vascular endothelium, and pulmonary endothelium 2,3 Proinflammatory Th1 cells (MS-specific) Naïve s Anti-inflammatory Th2 cells (MS-specific) Prevents lymphocytes from leaving the lymph nodes and entering the bloodstream and CNS compartment 1,4,5 The mechanism by which fingolimod exerts therapeutic effects in MS is unknown 1 1. Gilenya (fingolimod) prescribing information. Novartis Pharmaceuticals Corporation. 2. Chun J, et al. Clin Neuropharm. 2010;33(2): Szczepaniak WS, et al. Am J Physiol Lung Cell Mol Physiol. 2010;299(1):L137-L Lopez-Diego RS, et al. Nat Rev Drug Discovery. 2008;7(11): Kappos L, et 30al. N Engl J Med. 2010;362(5):
31 Circulation Central Nervous System Fingolimod T-cell extravasation B cell B-cell T-cell cross-activation Chemoattraction T-cell adhesion T-cell rolling CNS APC T-cell reactivation Inflammatory mediators Plasma cell Memory B cell Antibodies & Complement APC Inflammation K + Na + Activation of Na + channels NA + Oligodendrocyte T-cell egress from lymphnode Hypoxia, ischemia Energy depletion Ca 2+ Na + Reverse Na + Ca 2+ exchange
32 Kowarik et al. Neurology
33 Circulation Central Nervous System T-cell extravasation B cell B-cell T-cell cross-activation Chemoattraction T-cell adhesion T-cell rolling CNS APC T-cell reactivation Inflammatory mediators Plasma cell Memory B cell Antibodies & Complement APC T-cell activation Inflammation Hypoxia, ischemia Energy depletion K + Na + Activation of Na + channels NA + Ca 2+ Na + Reverse Na + Ca 2+ exchange Oligodendrocyte
34
35 VLA-4 α 4 1 Natalizumab
36 Stüve et al. Ann Neurol
37 Stüve et al. Ann Neurol
38 CD20 Rituximab
39 Expression of CD20 on the B-Cell Lineage Roitt I et al. Immunology. 6th ed. Chapter 8. Mosby; Sell S et al. Immunology, Immunopathology, and Immunity. 6th ed. Chapter 4. ASM Press; Tedder TF et al. J Immunol. 1985;135:
40 Circulation Courtesy of Olaf Stüve, MD, PhD, UT Southwestern Medical Center at Dallas. Central Nervous System extravasation B cell B cell cross-activation Chemoattraction adhesion rolling CNS APC re-activation Inflammatory mediators Plasma cell Memory B cell Antibodies & Complement B cell activation Inflammation Hypoxia, ischemia Energy depletion K + Na + Activation of Na + channels NA + Ca 2+ Na + Reverse Na + Ca 2+ exchange Oligodendendrocyte
41
42 Cross et al. JNI
43 Circulation Courtesy of Olaf Stüve, MD, PhD, UT Southwestern Medical Center at Dallas. Central Nervous System extravasation B cell B cell cross-activation Chemoattraction adhesion rolling B cell re-activation Inflammatory mediators Plasma cell Memory B cell Antibodies & Complement APC activation Inflammation Hypoxia, ischemia Energy depletion K + Na + Activation of Na + channels NA + Ca 2+ Na + Reverse Na + Ca 2+ exchange Oligodendendrocyte
44 MHC II CD4 + B cell
45 Martin et al. Arch Neurol
46 Cell/uL Cell/uL Cladribine: The Clarity Study Phase III Trial: Hematological Effects CD19 B-cell Count CD4 T-cell Count Placebo (n=434) Cladribine 3.5 mg/kg (n=428) Cladribine 5.25 mg/kg (n=451) Adapted from Rieckmann P, et al. Presented at: 25th Congress of the European Committee for Treatment and Research in Multiple Sclerosis; September 9-12, 2009; Düsseldorf, Germany.
47 Are all lymphocytes bad for patients with relapsingremitting MS?
48
49 CD4 + s CD8 + s CD19 + B cells Cox et al. EJI
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55 Circulation Central Nervous System T-cell extravasation B cell B-cell T-cell cross-activation Chemoattraction T-cell adhesion T-cell rolling CNS APC T-cell reactivation Inflammatory mediators Plasma cell Memory B cell Antibodies & Complement APC T-cell activation Inflammation Hypoxia, ischemia Energy depletion K + Na + Activation of Na + channels NA + Ca 2+ Na + Reverse Na + Ca 2+ exchange Oligodendrocyte
56
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58 Conclusion During relapsing-remitting MS, clinical attacks are likely caused by lymphocytes
59 Conclusion During relapsing-remitting MS, clinical attacks are likely caused by lymphocytes Much of our knowledge on the immunology in relapsing-remitting MS stems from observations made with specific pharmacotherapies
60 Conclusion During relapsing-remitting MS, clinical attacks are likely caused by lymphocytes Much of our knowledge on the immunology in relapsing-remitting MS stems from observations made with specific pharmacotherapies There is an intricate interplay between many cellular subsets
61 Conclusion CD4 + s and B cells are thought to be key players in MS pathogenesis
62 Conclusion CD4 + s and B cells are thought to be key players in MS pathogenesis Some s and B cells also have regulatory function
63 Conclusion CD4 + s and B cells are thought to be key players in MS pathogenesis Some s and B cells also have regulatory function Regulatory cells may be used therapeutically
64 Conclusion More recently, data have been generated on cell subsets of the innate immune system, including: Myeloid cells Granulocytes
65 Conclusion More recently, data have been generated on cell subsets of the innate immune system, including: Myeloid cells Granulocytes These cells can be modulated with pharmacotherapies
66 Obtaining CME Credit If you would like to receive CME credit for this activity, please visit: This information can also be found in the Summit 2011 Program on page 8
67 The End
Disclosures. Consultant and Speaker for Biogen Idec, TEVA Neuroscience, EMD Serrono, Mallinckrodt, Novartis, Genzyme, Accorda Therapeutics
Mitzi Joi Williams, MD Neurologist MS Center of Atlanta, Atlanta, GA Disclosures Consultant and Speaker for Biogen Idec, TEVA Neuroscience, EMD Serrono, Mallinckrodt, Novartis, Genzyme, Accorda Therapeutics
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