WO2017158393A1

WO2017158393A1 - Methods of treating graft-versus-host disease

Info

Publication number: WO2017158393A1
Application number: PCT/IB2016/000440
Authority: WO
Inventors: Yngvar FLOISAND; Knut LUNDIN
Original assignee: Oslo Universitetssykehus hf
Current assignee: Oslo Universitetssykehus hf
Priority date: 2016-03-18
Filing date: 2016-03-18
Publication date: 2017-09-21
Anticipated expiration: 2018-09-18

Abstract

The present invention relates to methods for the treatment of graft-versus-host disease (GVHD). In particular, the present invention relates to methods of treating GVHD with agents that target integrin α4β7.

Description

METHODS OF TREATING GRAFT- VERSUS-HOST DISEASE

FIELD OF THE INVENTION

BACKGROUND OF THE INVENTION

Acute graft-versus-host disesase (GvHD) occurs in up to 50 % of patients after allogeneic stem cell transplantation. Grade III-IV GvHD is associated with poor outcome, 70 - 90 % mortality (1, 2). Severe intestinal involvement is particularly difficult to treat and often leads to prolonged illness before death occurs. Treatment of steroid refractory or steroid dependent acute GvHD is notoriously difficult. Second and third line treatments are not well documented and show erratic responses. Furthermore, all treatment modalities of steroid refractory acute GvHD imply intensifying systemic immunosuppression with the risk of excess mortality due to infectious complications. Because of the poor responses in steroid- refractory acute GVHD, a wide range of immunosuppressive therapies have been tried, including antithymocyte globulin (ATG), extracorporeal photopheresis, mycophenolate mofetil (MMF), daclizumab, sirolimus, infliximab, alemtuzumab, methotrexate, basiliximab, tacrolimus, pulses of cyclophosphamide, pentostatin, mesenchymal stromal cells, and etanercept, among others. There is an obvious need for new and more effective therapy with predictable efficacy.

SUMMARY OF THE INVENTION

The present invention relates to methods for the treatment of graft-versus-host disease

(GVHD). In particular, the present invention relates to methods of treating GVHD with agents that target integrin α4β7.

In some embodiments, the present invention provides the use of an agent that inhibits one or more biological activities of integrin α4β7 to treat or prevent graft-versus-host disease (GVHD) in a subject. In some embodiments, the agent is a monoclonal antibody (e.g., vedolizumab). In some embodiments, the GVHD is steroid refractory intestinal GVHD. In some embodiments, the subject received corticosteroid therapy prior to or concurrent with the agent. In some embodiments, the subject received immunosuppressive therapy prior to or concurrent with the agent. In some embodiments, the subject exhibits or does not exhibit symptoms of GVHD (e.g., steroid refractory intestinal GVHD).

Further embodiments provide a method of treating or preventing graft-versus-host disease (GVHD) in a subject, comprising: administering an agent that inhibits one or more biological activities of integrin α4β7 to the subject.

Additional embodiments will be apparent to persons skilled in the relevant art based on the teachings contained herein.

DESCRIPTION OF THE DRAWINGS FIG. 1. Colonic biopsies in patients 1 - 3 before (a, c and e) and after (b, d and f) treatment with vedolizumab. Patient 1 had substantial crypt loss and some remaining and regenerating crypts with a few apoptotic bodies, corresponding to GVHD grade III (a).

Biopsies taken after vedolizumab showed prominent regenerative changes with crypt branching and crowding, and very few apoptotic bodies. Some areas still lacked crypts and were edematous with capillary dilatation and proliferation and iron-laden macrophages (b). In patient 2, pre-treatment biopsies showed erosions and substantial crypt loss and inflammation, and marked apoptosis in the remaining crypts, corresponding to GVHD grade III(c). After vedolizumab histology showed crypt regeneration and branching with reactive epithelial changes, and no apoptosis or inflammation (d). In patient 3, pre-treatment biopsies showed large eroded areas with crypt loss, numerous apoptotic cells in remaining crypts, and edematous lamin apropria with capillary proliferation and scattered neutrophils, eosinophils, and mononuclear cells. The findings corresponded to GVHD grade III-IV (e). After treatment there was focal abscence of crypts, and regenerating and branching crypts, but still a few apoptotic cells (f). Except for one positive nucleus in patient 3 pre-treatment, all three cases were negative for cytomegalovirus (CMV) on immunohistochemical stains.

FIG. 2. Endoscopic findings in patients 1, 2 and 3. Duodenal mucosa pre-treatment (a,b and c) and after three doses of vedolizumab (d, e and f). Colonic mucosa in patient 1 pre- treatment (g) and after three doses (j). Ileal mucosa in patient 2 pre- and post-treatment (h, k) and colonic mucosa in patient 3 pre- and post-treatment (i, 1)

DEFINITIONS

To facilitate an understanding of the present invention, a number of terms and phrases are defined below: As used herein, the term "subject" refers to any animal (e.g., a mammal), including, but not limited to, humans, non-human primates, rodents, and the like, which is to be the recipient of a particular treatment. Typically, the terms "subject" and "patient" are used interchangeably herein in reference to a human subject.

As used herein, the term "non-human animals" refers to all non-human animals including, but not limited to, vertebrates such as rodents, non-human primates, ovines, bovines, ruminants, lagomorphs, porcines, caprines, equines, canines, felines, aves, etc.

As used herein, the term "sample" is used in its broadest sense. In one sense, it is meant to include a specimen or culture obtained from any source, as well as biological and environmental samples. Biological samples may be obtained from animals (including humans) and encompass fluids, solids, tissues, and gases. Biological samples include blood products, such as plasma, serum and the like. Environmental samples include environmental material such as surface matter, soil, water, crystals and industrial samples. Such examples are not however to be construed as limiting the sample types applicable to the present invention.

As used herein, the term "drug" is meant to include any molecule, molecular complex or substance administered to an organism for diagnostic or therapeutic purposes, including medical imaging, monitoring, contraceptive, cosmetic, nutraceutical, pharmaceutical and prophylactic applications. The term "drug" is further meant to include any such molecule, molecular complex or substance that is chemically modified and/or operatively attached to a biologic or biocompatible structure.

As used herein, the term "purified" or "to purify" or "compositional purity" refers to the removal of components (e.g., contaminants) from a sample or the level of components (e.g. , contaminants) within a sample. For example, unreacted moieties, degradation products, excess reactants, or byproducts are removed from a sample following a synthesis reaction or preparative method.

The terms "test compound" and "candidate compound" refer to any chemical entity, pharmaceutical, drug, and the like that is a candidate for use to treat or prevent a disease, illness, sickness, or disorder of bodily function (e.g., cancer). Test compounds comprise both known and potential therapeutic compounds. A test compound can be determined to be therapeutic by screening using screening methods known in the art.

DETAILED DESCRIPTION OF THE INVENTION The present invention relates to methods for the treatment of graft-versus-host disease (GVHD). In particular, the present invention relates to methods of treating GVHD with agents that target integrin α4β7.

Vedolizumab, a monoclonal antibody targeting the homing of T-cells to the intestinal endothelium through inhibition of binding of integrin α4β7 to the mucosal addressin

MadCAM-1, has been effective in inflammatory bowel disease (IBD) (3-5). As it is selective for receptors in the gut, it has not been associated with progressive multifocal

leukencephalopathy (PML), as is the case with monoclonal antibodies also targeting T-cell migration to the CNS (4).

Acute GvHD is an immunologically mediated disease where alloreactive donor T- cells are important contributors to the pathogenesis (6). Inhibiting T-cell induced

inflammatory response could be a promising approach.

The α4β7 integrin is expressed on lymphocytes, natural killer cells, mast cells and basophilic granulocytes and mediate lymphocyte binding to MAdCAM-1 (7). This intestinal specificity makes the interaction an attractive target for treating immunologically mediated disease of the intestine, such as GvHD in allogeneic stem cell transplantation (8) . Expression of α4β7 on donor T-cells have been described to be important in the development of intestinal GvHD in mice (9, 10). Choi et al have reported that disruption of alloreactive donor T-cell trafficking to the target organs significantly reduces GvHD in both MHC fully - mismatched and minor-mismatched allo-HCT models (11). Thus, inhibition of α4β7, which is required for transendothelial migration and access to the intestinal lymphoid system, provides an attractive target for prevention or treatment of acute GvHD. The adhesion molecule MAdCAM-1 belongs to the immunoglobulin superfamily. It is constitutively expressed on high endothelial venules of both mesenteric lymph nodes and Peyers patches (PP) as well as on postcapillary venules of the lamina propria of the small and large intestine. PPs are essential in the development of anti-host cytotoxic T-cells leading to acute intestinal GvHD (12). MAdCAM-1 is the major ligand for α4β7 integrin, as well as being the ligand for L-selectin (13). The expression level of α4β7 integrin is relatively low on naive T-cells and B-cells, but increased on IgA-secreting plasma cells, memory T cells, and activated gut- homing CD4+ T-cells. Furthermore, α4β7 integrin is expressed on NK-cells, activated monocytes, macrophages, eosinophils, and dendritic cells (14).

Given the responses seen in IBD, we used vedolizumab in six patients with steroid refractory acute intestinal GvHD. Accordingly, provided herein are methods and uses of treating and preventing GVHD (e.g., steroid refractory acute GVHD) with agents that inhibit integrin α4β7 (e.g.,

vedolizumab). In some embodiments, subjects are at risk for GVHD (e.g., steroid refractory acute GVHD). For example, in some embodiments, subjects have undergone an organ transplant and have no symptoms of GVHD. In some embodiments, subjects have initial symptoms of GVHD. In some embodiments, subjects have symptoms of GVHD but not steroid refractory acute GVHD. In some embodiments, subjects have symptoms of steroid refractory acute GVHD. In some embodiments, subjects are monitored for symptoms or markers of GVHD before, during, or after treatment with vedolizumab. In some

embodiments, a treatment course of action (e.g., starting, stopping, or adjusting the dosage) of vedolizumab) based on the results of the monitoring. In some embodiments, the monitoring is repeated one or more times before, during, or after treatment with vedolizumab.

In some embodiments, subjects have previously or are currently being treated with an immunosuppressant (e.g., steroid therapy, antithymocyte globulin (ATG), extracorporeal photopheresis, mycophenolate mofetil (MMF), daclizumab, sirolimus, infliximab, alemtuzumab, methotrexate, basiliximab, tacrolimus, pulses of cyclophosphamide, pentostatin, mesenchymal stromal cells, or etanercept).

Examples

The following examples are provided in order to demonstrate and further illustrate certain preferred embodiments and aspects of the present invention and are not to be construed as limiting the scope thereof.

Example 1 Methods

Case series:

Patient characteristics are given in Table 1. All patients were categorized as having grade IV intestinal acute GvHD with few or no other manifestations of acute GvHD. Patients 1 and 2 had been through 2nd and 3rd line therapy with several modalities of treatment without improvement of symptoms. Patient 3 to 6 received vedolizumab as second line therapy after steroid failure (table 1). Previous treatments are described in table 1.

Vedolizumab was given as described for IBD with 300 mg intravenously without premedication week 0, 2 and 6, followed by infusions every 8 weeks on clinical indication and guided by serum concentration measurements.

Results:

Clinical and histological improvement after treatment with vedolizumab

All patients exhibited clinical response within 7 - 10 days with decrease in abdominal pain and watery diarrhoea. Serial endoscopies were performed and revealed gradual macroscopic and histological improvement; the stomach and the small intestine showing a more rapid improvement than the colon. In the colon, improvement was gradual, starting from the distal colon with the coecum and distal ileum exhibiting the slowest rate of repair (Figures 1 and 2).

After three doses of vedolizumab, 4 patients were off systemic corticosteroids. Five out of six patients received oral medication, including immunosuppressants. Concomitant immunosuppressive therapy was administered as oral cyclosporine or MMF. There were no or limited clinical symptoms of acute intestinal GvHD, maximum, grade I. Five out of six patients could be discharged from hospital after the third dose of vedolizumab. Patient 2 initially achieved a complete response after three doses of vedolizumab, but experienced a relapse of AML and developed grade IV intestinal GvHD after cessation of

immunosuppression. He was restarted on vedolizumab with effect and the GvHD subsided to grade 0 - 1 within two weeks. At last follow-up he is in complete remission of his AML.

Two of the patients developed complications leading to death. Patient 3 developed acute GvHD of the skin after discharge from hospital and high dose corticosteroids were reinstitued, subsequently complicated by staphylococcal sepsis and acute respiratory distress syndrome leading to death. Patient 4 already had multi-organ failure with hemodialysis and liver failure prior to start of vedolizumab treatment. She succumbed to complications. An autopsy was declined.

Patients 1 and 2 are receiving continuous treatment with vedolizumab 12 months after start of treatment and display no or limited symptoms of intestinal GvHD. Patients 5 and 6 did not require additional treatment after the 2. and 3. dose.

Four patients are alive and attend follow-up in the out-patient clinic with a median follow-up of 10 months.

Discussion:

Acute GvHD remains the major cause of non-relapse mortality after allogeneic stem cell transplantation This case series provides proof that targeting integrin α4β7 is feasible and may provide clinical meaningful responses in steroid refractory intestinal GvHD. The mechanism is probably a direct inhibition of homing of allo-reactive T-cells to the intestinal endothelium.

The kinetics of the responses seen in this case series may be explaineed by the distribution of PP. In the small intestine, PPs are irregularly distributed along the

antimesenteric side of the intestine. However, in the distal ileum, they are numerous and form a lymphoid tract. At least 46 % of PPs are located in the distal 25 cm of the ileum in humans (15, 16). MAdCAM-1 is not only an organ- and stimulus-specific adhesive determinant, but is also density dependent, suggesting that its highly restricted expression is decisively related to particular phases in inflammation (17).

It is a common notion that induction of MAdCAM-1 is involved in chronic gut inflammation. MadCAM-1 is constitutively expressed on high endothelial venules of both mesenteric lymph nodes and PPs. Inhibition of α4β7 integrin may not only affect T-cell homing to the intestine, but also homing of other cells that are important for initiating and propagating an allo-response, such as dendritic cells and NK-cells.

In our case series the patients who received vedolizumab as second line treatment seem to do better than patients receiving vedolizumab as third or fourth line therapy, indicating that early treatment may be beneficial.

It is likely that vedolizumab will primarily be effective in intestinal GvHD, and should probably not be used as a single agent in the treatment of acute GvHD involving other tissues.

The findings presented in this case series provide a new approach to steroid refractory intestinal GvHD. An positive effect is typically seen after 7 - 10 days. These observations need to be confirmed in a larger prospective trial.

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2. Deeg HJ. How I treat refractory acute GVHD. Blood. 2007 May

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4. Milch C, Wyant T, Xu J, et al. Vedolizumab, a monoclonal antibody to the gut homing alpha4beta7 integrin, does not affect cerebrospinal fluid T-lymphocyte

immunophenotype. J Neuroimmunol. Nov 15;264(l-2): 123-6.

5. Soler D, Chapman T, Yang LL, et al. The binding specificity and selective antagonism of vedolizumab, an anti-alpha4beta7 integrin therapeutic antibody in

development for inflammatory bowel diseases. J Pharmacol Exp Ther. 2009 Sep;330(3):864- 75.

6. Korngold R, Sprent J. Lethal graft-versus-host disease after bone marrow transplantation across minor histocompatibility barriers in mice. Prevention by removing mature T cells from marrow. J Exp Med. 1978 Dec l;148(6): 1687-98.

7. Berlin C, Berg EL, Briskin MJ, et al. Alpha 4 beta 7 integrin mediates lymphocyte binding to the mucosal vascular addressin MAdCAM-1. Cell. 1993 Jul

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8. Chen YB, McDonough S, Chen H, et al. Expression of alpha4beta7 integrin on memory CD8(+) T cells at the presentation of acute intestinal GVHD. Bone Marrow

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9. Dutt S, Ermann J, Tseng D, et al. L-selectin and beta7 integrin on donor CD4 T cells are required for the early migration to host mesenteric lymph nodes and acute colitis of graft-versus-host disease. Blood. 2005 Dec 1;106(12):4009-15.

10. Petrovic A, Alpdogan O, Willis LM, et al. LP AM (alpha 4 beta 7 integrin) is an important homing integrin on alloreactive T cells in the development of intestinal graft- versus-host disease. Blood. 2004 Feb 15;103(4): 1542-7.

11. Choi J, Ziga ED, Ritchey J, et al. IFNgammaR signaling mediates alloreactive

T-cell trafficking and GVHD. Blood. Nov 8;120(19):4093-103.

12. Murai M, Yoneyama H, Ezaki T, et al. Peyer's patch is the essential site in initiating murine acute and lethal graft-versus-host reaction. Nat Immunol. 2003

Feb;4(2): 154-60. 13. Clahsen T, Pabst O, Tenbrock K, et al. Localization of dendritic cells in the gut epithelium requires MAdCAM-1. Clin Immunol. Jan;156(l):74-84.

14. Erie DJ, Briskin MJ, Butcher EC, et al. Expression and function of the MAdCAM-1 receptor, integrin alpha 4 beta 7, on human leukocytes. J Immunol. 1994 Jul 15;153(2):517-28.

15. Comes JS. Number, size, and distribution of Peyer's patches in the human small intestine: Part I The development of Peyer's patches. Gut. 1965 Jun;6(3):225-9.

16. Van Kruiningen HJ, West AB, Freda BJ, et al. Distribution of Peyer's patches in the distal ileum. Inflamm Bowel Dis. 2002 May;8(3): 180-5.

17. Alexander JS, Ando T. Density-dependent control of MAdCAM-1 and chronic inflammation. Focus on "Mechanisms of MAdCAM-1 gene expression in human intestinal microvascular endothelial cells". Am J Physiol Cell Physiol. 2005 Feb;288(2):C243-4.

All publications and patents mentioned in the above specification are herein incorporated by reference. Various modifications and variations of the described method and system of the invention will be apparent to those skilled in the art without departing from the scope and spirit of the invention. Although the invention has been described in connection with specific preferred embodiments, it should be understood that the invention as claimed should not be unduly limited to such specific embodiments. Indeed, various modifications of the described modes for carrying out the invention that are obvious to those skilled in molecular biology, in vitro fertilization, development, or related fields are intended to be within the scope of the following claims.

Claims

CLAIMS We claim:

1. The use of an agent that inhibits one or more biological activities of integrin α4β7 to treat or prevent graft-versus-host disease (GVHD) in a subject.

2. The use of claim 1, wherein said agent is a monoclonal antibody.

3. The use of claim 2, wherein said monoclonal antibody is vedolizumab.

4. The use of any one of claims 1 to 3, herein said GVHD is steroid refractory intestinal GVHD.

5. The use of any one of claims 1 to 4, wherein said subject received corticosteroid therapy prior to or concurrent with said agent.

6. The use of any one of claims 1 to 5, wherein said subject received

immunosuppressive therapy prior to or concurrent with said agent.

7. The use of any one of claims 1 to 6, wherein said subject exhibits symptoms of GVHD.

8. The use of any one of claims 1 to 6, wherein said subject does not exhibit symptoms of GVHD.

9. The use of claim 7 or 8, wherein said GVHD is steroid refractory intestinal GVHD.

10. A method of treating or preventing graft-versus-host disease (GVHD) in a subject, comprising:

administering an agent that inhibits one or more biological activities of integrin α4β7 to said subject.

11. The method of claim 10, wherein said agent is a monoclonal antibody.

12. The method of claim 11, wherein said monoclonal antibody is vedolizumab.

13. The method of any one of claims 10 to 12, herein said GVHD is steroid refractory intestinal GVHD.

14. The method of any one of claims 10 to 13, wherein said subject received

corticosteroid therapy prior to or concurrent with said agent.

15. The method of any one of claims 10 to 14, wherein said subject received

immunosuppressive therapy prior to or concurrent with said agent.

16. The method of any one of claims 10 to 15, wherein said subject exhibits symptoms of GVHD.

17. The method of any one of claims 10 to 15, wherein said subject does not exhibit symptoms of GVHD.

18. The method of claim 16 or 17, wherein said GVHD is steroid refractory intestinal GVHD.