Clozapine for the treatment of IgE driven B cell disorders
阅读说明：本技术 用于治疗IgE驱动的B细胞疾病的氯氮平 (Clozapine for the treatment of IgE driven B cell disorders ) 是由 S·乔利斯 H·阿什拉菲安 D·麦克黑尔 于 2019-01-31 设计创作，主要内容包括：本发明涉及化合物氯氮平及其主要代谢物去甲氯氮平和其前药以及药学上可接受的盐和溶剂化物,用于治疗或预防致病性的IgE驱动的B细胞疾病。本发明还提供了包含所述化合物的药物组合物。(The present invention relates to the compound clozapine and its major metabolite norclozapine and its prodrugs as well as pharmaceutically acceptable salts and solvates thereof for use in the treatment or prevention of pathogenic IgE driven B cell diseases. The invention also provides pharmaceutical compositions comprising said compounds.)
1. A compound selected from the group consisting of clozapine, norclozapine, and prodrugs and pharmaceutically acceptable salts and solvates thereof, for use in treating or preventing a pathogenic IgE driven B cell disorder in a subject, wherein the compound inhibits mature B cells in the subject.
2. A method of treating or preventing a pathogenic IgE driven B cell disorder in a subject by administering to said subject an effective amount of a compound selected from the group consisting of clozapine, norclozapine, and prodrugs thereof, and pharmaceutically acceptable salts and solvates thereof, wherein said compound inhibits mature B cells in said subject.
3. Use of a compound selected from the group consisting of clozapine, norclozapine, and prodrugs and pharmaceutically acceptable salts and solvates thereof, wherein the compound inhibits mature B cells in a subject, in the manufacture of a medicament for treating or preventing a pathogenic IgE driven B cell disorder in the subject.
4. A compound for use, a method or a use according to any one of claims 1-3, wherein the compound is clozapine or a pharmaceutically acceptable salt or solvate thereof.
5. The compound for use, the method or the use according to any one of claims 1 to 4, wherein mature B cells are class-switching memory B cells.
6. The compound for use, the method or the use according to any one of claims 1 to 4, wherein mature B cells are plasmablasts.
7. The compound for use, the method or the use according to any one of claims 1 to 6, wherein the pathogenic IgE driven B-cell disease is selected from the following diseases: atopic asthma, atopic dermatitis, chronic non-autoimmune urticaria, allergic granulomatous vasculitis, allergic rhinitis and allergic eye disease, preferably atopic dermatitis, atopic asthma, allergic rhinitis and eosinophilic esophagitis.
8. The compound for use, the method or the use according to any one of claims 1 to 7, wherein the compound has the effect of reducing CD19(+) B cells and/or (-) B plasma cells.
9. A pharmaceutical composition comprising a compound selected from the group consisting of clozapine, norclozapine, and prodrugs and pharmaceutically acceptable salts and solvates thereof, and a pharmaceutically acceptable diluent or carrier for use in treating or preventing a pathogenic IgE driven B cell disease in a subject, wherein said compound inhibits mature B cells in said subject.
10. The pharmaceutical composition for use according to claim 9, wherein the pharmaceutical composition is administered orally.
11. The pharmaceutical composition for use according to claim 9 or 10, wherein the pharmaceutical composition is formulated as a liquid or solid, e.g. as a syrup, suspension, emulsion, tablet, capsule or lozenge.
12. The pharmaceutical composition for use according to any one of claims 9-11, wherein the mature B cells are class-switching memory B cells.
13. The pharmaceutical composition for use according to any one of claims 9-11, wherein the mature B-cells are plasmablasts.
14. A compound selected from clozapine, norclozapine and prodrugs thereof and pharmaceutically acceptable salts and solvates thereof for use according to any of claims 1 and 4-8 in combination with a second or other therapeutic agent for the treatment or prevention of pathogenic IgE driven B cell diseases.
15. A compound selected from clozapine, norclozapine, and prodrugs thereof, and pharmaceutically acceptable salts and solvates thereof, for use according to claim 14, wherein the second or further therapeutic agent for treating or preventing a pathogenic IgE driven B-cell disease is selected from the group consisting of: anti-TNF α drugs (such as anti-TNF α antibodies such as infliximab or adalimumab (adalimumab)), calcineurin inhibitors (such as tacrolimus or cyclosporine), antiproliferative agents (such as mycophenolic acid e.g. mycophenolate mofetil or sodium, or azathioprine), anti-inflammatory drugs in general (such as hydroxychloroquine or NSAIDS such as ketoprofen and colchicine), mTOR inhibitors (such as sirolimus), steroids (such as prednisone), anti-CD 80/CD86 drugs (such as abepil), anti-CD-20 drugs (such as anti-CD-20 antibodies such as rituximab), anti-BAFF agents (such as anti-BAFF antibodies such as tabalumab or belimumab, or asecept), immunosuppressive agents (such as methotrexate or cyclophosphamide), anti-FcRn agents (such as anti-FcRn antibodies), and other antibodies (such as ARGX-113, PRN-1008, SYNT-001, or the like, Vituzumab, ocrelizumab, ofatumumab, obinutuzumab, ublituximab, ullituximab, alemtuzumab, matuzumab, epratuzumab, and blinatumomab).
Technical Field
The present invention relates to compounds and pharmaceutical compositions containing such compounds for use in the treatment or prevention of pathogenic IgE driven B cell diseases.
Background
The compounds related to the present invention are referred to as clozapine, i.e. compounds having the following structure:
clozapine has a major active metabolite, known as norclozapine (norclozapine) (Guitton et al, 1999), which has the following structure:
clozapine is known for use in the treatment of refractory schizophrenia. Schizophrenia is a major persistent mental disorder affecting approximately 1% of the population. In addition to debilitating psychiatric symptoms, it also has serious psychosocial consequences, with a rate of unemployment as high as 80-90% and a reduction in life expectancy of 10-20 years. The suicide rate among schizophrenic patients is much higher than that of the general population, with about 5% of patients diagnosed with schizophrenia suicidality.
Clozapine is an important therapeutic drug and has been listed as the basic drug list in the WHO. It is a dibenzodiazepine
Clozapine is associated with severe adverse effects,including seizures, ileus, diabetes, thromboembolism, cardiomyopathy, and sudden cardiac death. It can also cause agranulocytosis (cumulative incidence of 0.8%); there is therefore a need for an enhanced centralized registration-based monitoring system to support its safe use. In the uk, there are three electronic registries: (www.clozaril.co.uk、www.denzapine.co.ukAndwww.ztas.co.uk) One for each clozapine supplier. Mandatory blood tests must be performed every week for the first 18 weeks, then every two weeks for 19-52 weeks, and every month thereafter, with an Absolute Neutrophil Count (ANC) below 1500/μ L as the "red flag" cutoff for treatment discontinuation.
In 2015, the U.S. Food and Drug Administration (FDA) merged and replaced the U.S. 6 existing clozapine registries, merging data from over 50,000 prescribing doctors, 28,000 pharmacies, and 90,000 patient records into one shared registry of all clozapine products, namely the clozapine risk assessment and mitigation strategy (REMS) program (www.clozapinerems.com). Some changes were introduced to lower the Absolute Neutrophil Count (ANC) threshold for discontinuation of clozapine treatment to typically less than 1000/μ L, and in Benign Ethnic Neutropenia (BEN) to less than 500/μ L. For patients with moderate to severe neutropenia, the prescriber has greater flexibility to make decisions to continue or resume treatment depending on the patient's particular circumstances, thereby maximizing the patient's benefit from clozapine use.
Schizophrenia is associated with a 3.5-fold increase in the chance of premature death compared to the general population. This is often due to physical disease, particularly Chronic Obstructive Pulmonary Disease (COPD) (standard death ratio (SMR)9.9), influenza and pneumonia (SMR 7.0). Although clozapine may reduce the overall mortality of severe schizophrenia, there is increasing evidence linking clozapine to increased pneumonia-associated hospitalization and mortality. In an analysis of 33,024 schizophrenia patients, clozapine was the highest correlation between the second generation antipsychotic and the risk of pneumonia requiring hospitalization, with an adjusted risk ratio of 3.18, with a further significant increase in risk associated with dual antipsychotic use (Kuo et al, 2013). Although quetiapine, olanzapine, zotepine and risperidone were associated with slightly increased risk, there was no clear dose dependence and the risk was not significant at time points above 30 days (Leung et al, 2017; Stoecker et al, 2017).
In a 12 year study of patients administered clozapine, 104 patients had 248 hospitalizations during the study. The most predominant type of hospitalization is the treatment of pulmonary (32.2%) or gastrointestinal (19.8%) diseases. The most common pulmonary diagnosis is pneumonia (58% of lung-related hospitalizations), and these hospitalizations are not associated with black box warnings (Leung et al, 2017).
In a further nested case-control study, clozapine was found to be the only antipsychotic drug with a well-defined dose-dependent risk for recurrent pneumonia, which increased upon re-exposure to clozapine (Hung et al, 2016).
While these studies emphasize that more people are admitted to hospital or die due to pneumonia and sepsis than other antipsychotics in patients administered clozapine, concerns over extreme fatalities (death and pneumonia) may underestimate the burden of less severe but more frequent infections such as sinusitis, infections of the skin, eyes, ears, or throat, and community-acquired and treated pneumonia. Infection may be a significant additional factor leading to schizophrenia control and unstable levels of clozapine.
Various mechanisms of increased pneumonia have been proposed, including impaired aspiration, salivation, and swallowing functions with esophageal dilatation, hypomotility, and agranulocytosis. In addition, smoking is very common throughout the schizophrenic patient population and is an independent risk factor for the incidence and severity of pneumonia (Bello et al, 2014).
A small number of studies have been performed on the immunomodulatory properties of clozapine:
Hinze-Selch et al (Hinze-Selch et al, 1998) describe clozapine as an atypical antipsychotic with immunomodulatory properties. This article reports that patients receiving clozapine for 6 weeks had a significant increase in serum IgG concentrations, but no significant effect on IgA, IgM concentrations and autoantibody pattern was found.
Jolles et al (Jolles et al, 2014) reported a study of the "Calculated Globulin (CG)" parameter as a screening test for antibody deficiency. Patients with many different backgrounds were selected from 13 laboratories of wales. Of the patients with significant antibody deficiency (IgG <4g/L, reference range 6-16g/L) identified in CG screening for primary care, 13% of the samples were referred to as clozapine on the application note. However, antibody deficiency is not a side effect of clozapine as listed in the british national drug set (BNF), nor does the antibody test form part of the current clozapine monitoring regimen.
Another study by Lozano et al (Lozano et al, 2016) reported an overall decrease in mean plasma IgM levels in the study group (consisting of psychiatric outpatient with clozapine for at least 5 years) compared to the control group, and no differences in IgA, IgG, absolute neutrophil count and leukocyte count between the two groups were reported.
Thus, in view of these reported consequences of the anxious half of the world, the immunomodulatory properties of clozapine and its effects on immunoglobulin levels, particularly IgE, are neither clear nor understood in the art.
Pathogenic IgE immunoglobulin-driven diseases are caused by autoantibodies (including IgE) secreted by antibody secreting cells ("ASCs", plasmablasts and plasma cells collectively, these are types of mature B cells). These antibodies target a variety of exogenous antigens that have been identified in many of these diseases to elicit an overstimulatory response. Since the pathological process is driven by the secretion of specific immunoglobulins, which represent only a small fraction of the total immunoglobulins, an increase in total immunoglobulins rarely occurs. Secretion of IgE antibodies comes from ASC, the production of which is secondary to differentiation of class-switched and non-switched memory B cells (these are further types of mature B cells). Various lines of evidence suggest that this is a highly dynamic process, with differentiation occurring almost constantly.
Class-switching memory B cells refer to mature B cells that respond to repeated antigen recognition by replacing their original coding membrane receptor [ IgM ] with IgG, IgA, or IgE. This class switching process is an important feature of normal humoral immune memory, both "constitutive" (which is achieved by secretion of pre-existing protective antibodies by long-lived plasma cells) and "reactive", reflecting re-exposure to antigen and reactivation of memory B cells, which either differentiate into plasma cells to produce antibodies or into germinal center B cells, further diversifying the antibody response and affinity maturation. In the early stages of the immune response, plasma cells derive from unconverted activated B cells and secrete IgM. In the later stages of the immune response, plasma cells are derived from activated B cells involved in germinal centers (the region formed in secondary lymphoid follicular tissue in response to antigen challenge), which undergo class switching (retaining antigen specificity but switching immunoglobulin subtypes) and B Cell Receptor (BCR) diversification via immunoglobulin somatic hypermutation. This maturation process allows the production of BCRs with high affinity for antigens and the production of different immunoglobulin subtypes (i.e., the conversion of originally expressed IgM and IgD to IgG, IgA or IgE subtypes) (Budeus et al 2015; Kracker and Durandy 2011).
Class Switch Recombination (CSR) following a germinal center reaction in secondary lymphoid organs provides antigen primed/contacted autoreactive memory B cells, and a central pathway for the development and/or maintenance of autoimmunity. Post-emergent central B cells, class-switched to IgG or IgA, can enter other anatomical compartments at the periphery, such as the central nervous system, to undergo further affinity maturation (e.g., in the tertiary lymphoid structures of multiple sclerosis) and contribute to immunopathology (Palanichamy et al, 2014). CSR can occur locally within pathological tissues, such as ectopic lymphoid structures in chronic inflammatory tissues, e.g., synovium of rheumatoid arthritis (Alsaleh et al, 2011; Humby et al, 2009).
It is noteworthy that plasma cells (plus plasmablasts) are increasingly understood to play important effector immune functions in addition to immunoglobulin production, including the production of cytokines (Shen and fillatrea, 2015) and immune modulators such as tumor necrosis factor- α (TNF- α), Inducible Nitric Oxide Synthase (iNOS) (Fritz et al, 2011), IL-10(Matsumoto et al, 2014; Rojas et al, 2019), IL-35(Shen et al, 2014), IL-17a (Bermejo et al, 2013) and ISG15(Care et al, 2016).
Plasmablasts are short-lived, rapidly circulating antibody-secreting cells in migratory B-cell lines, and are also precursors to long-lived (post-mitotic) plasma cells, including those that home to the bone marrow microenvironment (Nutt et al, 2015). In addition to being precursors to autoreactive long-lived plasma cells, plasmablasts are themselves an important potential therapeutic target because of their ability to produce pathogenic immunoglobulin/autoantibodies (Hoyer et al, 2004). In addition to the function of direct antibody secretion, circulating plasmablasts also exert activity to enhance the immune response derived from the germinal center and thereby promote antibody production via an Il-6-induced feed-forward mechanism associated with promoting T follicular helper cell (Tfh) differentiation and expansion (Chavele et al, 2015).
The microenvironment in which long-lived plasma cells predominantly colonize the bone marrow (Benner et al, 1981), is considered to be the main source of stable autoantibody production in (physiological and) pathogenic states, and is resistant to glucocorticoids, conventional immunosuppression and B-cell depletion therapies (Hiepe et al, 2011). In non-human primates, to demonstrate the critical importance of this B cell population for long-term antibody production, the survival of bone marrow-derived plasma cells in specific regions with a durable (up to 10 years post-immunization) antibody response to previous antigens has been demonstrated despite the continued depletion of memory B cells (Hammarlund et al, 2017). In view of the critical role of autoreactive long-lived plasma cells in maintaining autoimmunity (Mumtaz et al, 2012) and the substantial resistance of autoreactive memory formed by these cells to conventional immunosuppressive agents such as anti-TNF or B cell depleting biologics (Hiepe et al, 2011).
CD19(+) B cells and CD19(-) B plasma cells are drivers of pathogenic IgE-driven B cell disease. Pathogenic IgE-driven B cell disease accounts for a significant proportion of all autoimmune and inflammatory diseases. The most prominent, but not exclusive, mechanism by which pathogenic immunoglobulin-driven B cells cause disease is through the production of autoantibodies.
Pathogenic IgE-driven B cell diseases are difficult to treat and therefore have a considerable mortality and morbidity rate even for "benign" diseases. Some advanced therapies are currently directed against mature B cells. For example, belimumab (belimumab) is a human monoclonal antibody that inhibits B cell activating factor. Asecept (Atacicept) is a recombinant fusion protein that also inhibits B-cell activating factors. However, memory B cells may be resistant to therapies that target survival signals such as B cell activating factors, e.g., belimumab or asecept (Stohl et al, 2012). The importance of memory B cells in the pathogenesis of autoimmune disorders is also evidenced by the low efficacy of asecept in the treatment of rheumatoid arthritis and multiple sclerosis (Kappos et al, 2014; Richez et al, 2014). Plasmapheresis and immunoadsorption therapies involve the removal of disease-causing autoantibodies from the patient's blood. However, these treatments have limited efficacy or are complicated and expensive to use. The CAR-T approach to CD19(+) B cells resulted in CD19(-) B plasma cells remaining intact and therefore not as effective. Rituximab had little effect on IgE levels and no sustained clinical benefit was observed (van von willoven et al, 2013).
Omalizumab (anti-IgE antibody) is currently used to treat asthma. However, this is an expensive drug.
Thus, there is a significant unmet medical need for new methods of treating pathogenic IgE-driven B cell diseases.
Summary of The Invention
Effect on class-switching memory B cells and antibody production
The inventors have found that clozapine has a potentially important therapeutic effect, as it significantly reduces class switching memory B cells ("CSMB"), which is one type of mature B cells.
Reduction of CSMB by clozapine will thereby reduce the number of ASCs and thus reduce the secretion of specific immunoglobulins including pathogenic immunoglobulins. Clozapine was also observed to cause a decrease in the level of another mature B cell, plasmablasts. This functional effect on long-lasting and long-lived adaptive B-cells and plasma cells may ameliorate diseases driven by the sustained production of pathogenic immunoglobulins, which drives the pathology of pathogenic IgE-driven B-cell diseases. This will thereby reduce the number of ASCs and thus the secretion of specific immunoglobulins, including pathogenic immunoglobulins. Clozapine was also observed to cause a decrease in the level of another mature B cell, plasmablasts. This functional effect on long-lasting and long-lived adaptive B-cells and plasma cells may ameliorate diseases driven by the sustained production of pathogenic immunoglobulins, which drives the pathology of pathogenic IgE-driven B-cell diseases. Furthermore, the inventors' new data show that there is a very significant effect on the number of circulating class-switching memory B cells, with a substantial effect on the number of plasmablasts, and importantly, by lacking a memory response to the common vaccine, there is an effect on the function of class-switching memory B cells and plasmablasts, resulting in a specific reduction of antibodies against previously exposed antigens. The inventors' new data also demonstrate the effect of the drug in reducing total immunoglobulin levels after administration. This observation strongly supports the functional effects on CSMB and plasmablasts, which are central factors for long-term production of pathogenic antibodies in pathogenic IgE-driven B cell disease, as there is no effect on other B cells, manifested by no depletion of other subtypes and total B cell numbers, but CSMB and plasmablasts are particularly reduced.
The inventors found that there was a significant reduction in class switch memory B cells in patients treated with clozapine, suggesting a stabilizing effect on the immunoglobulin class switch process. This is of particular therapeutic relevance in pathogenic immunoglobulin driven B cell diseases, where Class Switch Recombination (CSR) following a germinal center reaction in secondary lymphoid organs provides antigen primed/contacted autoreactive memory B cells, and a central pathway for development and/or maintenance of autoimmunity. Clozapine has particular therapeutic potential for CSR and reduction of the impact of immunoglobulins in situations where the impact of pathogenic immunoglobulin-driven B cell disease requires both the autoimmune memory pool and pathogenic immunoglobulins.
The inventors have identified a significant impact of clozapine on plasma cell populations, suggesting a clear potential for modulating a variety of antibody-independent effector functions of B-cells associated with (auto-) immune-mediated diseases.
Effect on plasmablast antibody-secreting cells
The inventors have found that clozapine shows a significant effect on reducing circulating plasmablast levels in a patient. Thus, the significant impact of clozapine usage on the number of circulating plasmablasts observed by the inventors demonstrates the potential of clozapine to modulate pathogenic immunoglobulin-driven B cell disease through both effects on circulating plasmablasts secreting immunoglobulins and interfering with the potent effects of plasmablasts to promote Tfh (T follicular helper cell) function.
Influence on Long-lived plasma cells
The inventors have found, using a wild-type mouse model, that regular administration of clozapine to mice significantly reduces the proportion of long-lived plasma cells in the bone marrow, which is not seen with the comparative antipsychotic drug (haloperidol). Notably, resident long-lived PCs in human bone marrow have long been recognized as a major source of circulating human Ig, thus providing the inventors with clear support for the observed reduction of Ig in patients treated with clozapine. Clozapine observed by the inventors has a specific role in depleting bone marrow long-lived plasma cells, with great therapeutic potential in eliminating inflammation and achieving remission in pathogenic immunoglobulin-driven B-cell diseases through effects on long-lived plasma cell (autoreactive) memory.
The inventors have discovered a significant impact of clozapine on plasma cell populations and have also demonstrated a clear potential to modulate a variety of antibody-independent effector functions of B cells associated with (auto-) immune-mediated diseases.
Effect on B cell precursors in bone marrow and immature/transitional cells of spleen
The inventors have found that clozapine has a significant effect on bone marrow B cell precursors after administration to wild type mice. Specifically, the proportion of pre-progenitor B cells in the bone marrow is increased, while pre-B cells, proliferating pre-B cells and immature B cells are decreased. Together, these findings indicate that clozapine has a specific effect on early B-cell development, with partial arrest between pre-pro and pre-B-cell stages in the absence of specific immunological challenges. The inventors have found that clozapine has the effect of reducing the proportion of spleen T1 cells in wild type mice. In response to the results of the murine study, the interim results of the ongoing observation study of patients with clozapine by the inventors revealed a significant reduction in circulating transitional B cells. The transitional B cell subset in the human circulation exhibits the most similar phenotype to murine T1B cells and is expanded in autoimmune diseases.
Thus, the inventors observed the effect of clozapine on reducing the ratio of bone marrow B cell progenitors to immature (T1) spleen B cells, which provides them with a source of additional anatomical compartments beyond the germinal center for finding a reduction in circulating class-switch memory B cells and immunoglobulins in patients treated with clozapine. Given that most antibodies expressed by early immature B cells are autoreactive, this further underscores their therapeutic potential (Wardemann et al, 2003).
No direct B cell toxicity in vitro
The new data for the inventors to evaluate the specific impact of clozapine, its metabolite (N-desmethylclozapine) and the control antipsychotic drug (haloperidol) using the in vitro B-cell differentiation system further demonstrates that: in the context of established in vitro assays, clozapine or its metabolites have no direct toxic effect on differentiated B cells, no consistent effect on the ability of differentiated ASCs to secrete antibodies, and no consistent inhibitory effect on the functional or phenotypic maturation of activated B cells to early PC states.
Limited in the context of these in vitro experiments, these data indicate that clozapine is unlikely to act on plasma cells or their precursors in a directly toxic manner (e.g. through intracellular effects) to induce the effects observed on immunoglobulin levels. Observations indicate that clozapine's effects on B cells are more subtle than existing B cell targeted therapies for autoimmune diseases that result in a large depletion of various B cell subsets (e.g., rituximab and other anti-CD 20 biosimilars), whose therapeutic effects are mediated via direct effects on B cells such as signaling pathway-induced apoptosis, complement-mediated cytotoxicity, or antibody-dependent cytotoxicity.
This lack of significant, substantial direct toxicity of clozapine has many potential therapeutic advantages for clozapine, including the potential to reduce the risk of widespread immunosuppression associated with indiscriminate B cell depletion, including the elimination of protective B cells, and to avoid the undesirable changes observed with conventional B cell depletion therapies.
Efficacy in a mouse model of collagen-induced arthritis (CIA), and the relevance of CIA as a B-cell driven disease model involving pathogenic immunoglobulins.
CIA is a well established experimental model of autoimmune disease, which results from immunization in genetically susceptible lines of rodents and non-human primates with type II Collagen (CII), the major protein component of cartilage, emulsified with complete freund's adjuvant (brain et al, 2004). This results in an autoimmune response with severe polyarthritis, usually 18-28 days after immunization and monophasic, resolved in mice after about 60 days (Bessis et al, 2017; Brand et al, 2007). The pathology of the CIA model resembles rheumatoid arthritis, including synovitis, synovial hyperplasia/pannus formation, cartilage degradation, bone erosion, and joint stiffness (Williams, 2012).
The immunopathogenesis of CIA relies on B-cell specific responses, producing pathogenic autoantibodies to CII, and in addition involves T-cell specific responses to CII, Fc γ R (i.e. Fc receptor for IgG) and complement. The key role of B cells in CIA genesis was demonstrated by complete avoidance of CIA genesis by B cell deficient (IgM deficient) mice, despite the presence of an intact T cell response against CII (Svensson et al, 1998). Furthermore, the occurrence of CIA has been shown to be absolutely dependent on the germinal center formation of B cells, and the anti-CII immunoglobulin response itself is largely dependent on normal germinal center formation (Dahdah et al, 2018; Endo et al, 2015). B cells are also involved in other aspects of CIA pathology, including bone erosion by inhibition of osteoblasts (Sun et al, 2018). As a corollary, depletion of B cells with anti-CD 20 monoclonal antibodies prior to CII immunization delayed the development and severity of CIA, while delaying the production of autoantibodies (Yanaba et al, 2007). In this model, the recovery of B cells is sufficient to lead to the production of pathogenic immunoglobulins and associated disease progression following collagen immunization.
Passive transfer of anti-CII serum or polyclonal IgG immunoglobulins to non-immunized animals resulted in arthritis (Stuart and Dixon,1983), while the lack of Fc γ R chains almost completely prevented the development of mouse CIA (Kleinau et al, 2000), underscoring the fundamental role played by collagen-specific autoantibodies in the pathogenesis of CIA. Furthermore, the introduction of pathogenic antibodies (i.e. collagen antibody-induced arthritis, CAIA) into germinal center-deficient mice causes arthritis, suggesting that pathogenic antibodies largely bypass the ability to require germinal center reactions (Dahdah et al, 2018). In addition, CIA is readily induced even in mice lacking adaptive immunity (i.e., B and T cells) (Nandakumar et al, 2004).
Therefore, the inventors have adopted the CIA model as a clinically highly relevant experimental system in which B-cell derived pathogenic immunoglobulin responding to sample antigens drives autoimmune diseases to explore the potential efficacy of clozapine and its associated cellular mechanisms. The inventors have shown that clozapine delays the onset and reduces the incidence of CIA in mice, the effect being most pronounced when given immediately after CII immunization. Furthermore, the inventors' data indicate that clozapine reduces the severity of CIA as judged by the number of affected paws and the clinical severity score. The inventors have determined that clozapine has a significant effect on key cell types involved in the pathogenesis of CIA, including a reduction in the proportion of spleen plasma cells and a very significant reduction of germinal center B cells in regional draining lymph nodes. Furthermore, the inventors' findings indicate that in CII immunized mice, functional active markers of antibody production and antigen presentation on B cells at the germinal center of lymph nodes are reduced in response to clozapine use. A significant reduction in anti-collagen antibody levels was also observed, measured at a single time point. Taken together, the inventors' findings in the CIA model indicate the specific ability of clozapine to favorably influence pathogenic immunoglobulin B-cell driven diseases and, in turn, B-cell mediated diseases, where autoantibody formation is a key component.
Importantly, IgE memory B cells and IgE plasma cells have also been shown to be produced by the germinal center pathway (Talay et al, 2012). Notably, IgE-switching memory B cells are the major source of IgE memory for cells (Talay et al, 2012). Furthermore, IgE+The process of B cell and plasma cell development follows a phenotypic phase similar to that of IgG (1), including IgE+Germinal center-like B cells, IgE+Plasmablasts and IgE+Plasma cells, which occur through a continuous process of switching of IgG (Ramadani et al, 2017). Notably, the intrinsic maturation state of B cells determines their ability to undergo type switching to IgE, and accordingly, the highest proportion of IgE+The cells were derived from germinal center B cells (Ramadani et al, 2017). Furthermore, subtype switching depends on the number of cell divisions and is greater for IgE than for IgG (Tangye et al, 2002), which is consistent with the fact that IgE responses usually require longer antigenic stimulation (Hasbold et al, 1998). Thus, the inventors' discovery of the specific effects of clozapine on type conversion, germinal center formation and long-lived plasma cells is expected to significantly impact the ability to establish and maintain IgE-mediated immunoglobulin responses in pathogenic IgE-driven B-cell diseases. In fact, a higher number of B cells divide and require germinal center B cells to efficiently produce IgE +It is suggested that these conditions may be particularly sensitive to the effects of clozapine.
Accordingly, the present invention provides a compound selected from clozapine, norclozapine and prodrugs thereof and pharmaceutically acceptable salts and solvates thereof, for use in the treatment or prevention of a pathogenic IgE driven B cell disease in a subject, in particular wherein said compound inhibits mature B cells in said subject.
Brief Description of Drawings
FIGS. 1A-C show the relative frequency of patient numbers per serum concentration value for IgG, IgA, and IgM, for patients treated with clozapine (black) and patients without clozapine (grey), respectively (see example 1).
Figure 1D shows a density plot showing the distribution of serum immunoglobulin levels in patients receiving clozapine treatment for immunological evaluation (light grey left-most curve, n-13) after removal of 4 patients (n-2 hematological malignancy patients and n-2 patients previously included in the inventors' recent case control study (Ponsford et al, 2018 b)). Also shown are serum immunoglobulin profiles adapted from (Ponsford et al, 2018b) treated with clozapine (middle curve in middle grey, n-94) and without clozapine (rightmost curve in dark grey, n-98). The dashed lines represent the 5 th and 95 th percentiles of healthy adults (see example 1). It was observed in the patients with clozapine that for each of IgG, IgA and IgM the distribution curve of total immunoglobulins shifts to the left compared to the patients without clozapine; this finding is particularly evident for referral patients using clozapine.
Figure 2 shows the effect of duration of clozapine use on serum IgG levels (see example 1).
FIG. 3A shows the number of class-switching memory B Cells (CSMB) (CD27+/IgM-/IgD-, expressed as a percentage of total CD19+ cells) in healthy controls, clinical visits and general variable immunodeficiency disease (CVID) patients administered clozapine (see example 1).
Figure 3B shows B cell subsets, expressed as a percentage of the total number of CD19+ cells, in clinical visits with a history of clozapine treatment (numbers shown), patients with common variable immunodeficiency disease (CVID, n-26) and healthy controls (n-17). The B cell subset was gated on CD19+ cells and was defined as follows: naive B cells (CD 27)-IgD+IgM+) Marginal zone like B cells (CD 27)+IgD+IgM+) Class switching memory B cells (CD 27)+IgD-IgM-) Plasmablast (CD 19)+CD27HiIgD-). Non-parametric Mann-Whitney test on non-normally distributed data<0.05,**p<0.01,***p<0.001,****p<0.0001 (see example 1).
FIG. 4A shows the number of plasmablasts (CD38+ + +/IgM-, expressed as a percentage of the total number of CD19+ cells) in healthy controls, clinical visits with clozapine and patients with Common Variable Immunodeficiency Disease (CVID) (see example 1).
Figure 4B illustrates vaccine-specific IgG response assessment (see example 1).
FIG. 5 shows a gradual recovery of serum IgG from 3.5 to 5.95g/L over three years after discontinuation of clozapine. LLN ═ lower limit of normal (see example 1).
Figures 6A-C show interim data results for circulating IgG, IgA, and IgM levels for patients using non-clozapine antipsychotic medication ('control', left) versus clozapine (right). Mean ± SEM (see example 2).
Figure 7 shows the results of metaphase data on pneumococcal specific IgG levels in peripheral blood of patients using non-clozapine's antipsychotic drug (' control ', left) compared to clozapine (right). Mean ± SEM (see example 2).
Figures 8A-B show peripheral blood B cells (CD 19) for patients with non-clozapine antipsychotic ('control', left) and clozapine (right)+) Results for metaphase data for levels, expressed as absolute levels and as a percentage of lymphocytes (%, i.e., as a percentage of T + B + NK cells). Mean ± SEM (see example 2).
Figures 9A-C show peripheral blood naive B cells (CD 19) for patients using non-clozapine antipsychotic ('control', left) with clozapine (right)+/CD27-) Results of the horizontal metaphase data, respectively, were calculated as total B cells (CD 19) +Cell,% B), percentage of lymphocytes (% L), or absolute value (abs). Mean ± SEM (see example 2).
Figures 10A-C show information regarding patients with non-clozapine antipsychotic medication ('control', left) and clozapine (right)Peripheral blood memory B cells (CD 19)+/CD27+) Results of the horizontal metaphase data, respectively, were calculated as total B cells (CD 19)+Cell,% B), percentage of lymphocytes (% L), or absolute value (abs). Mean ± SEM (see example 2).
FIGS. 11A-C show peripheral blood Class Switch (CS) memory B cells (CD 27) for patients with non-clozapine antipsychotic ('control', left) and clozapine (right)+/IgM-/IgD-) Results of the horizontal metaphase data, respectively, were calculated as total B cells (CD 19)+Cell,% B), percentage of lymphocytes (% L), or absolute value (abs). Mean ± SEM (see example 2).
FIGS. 12A-C show peripheral blood high IgM low IgD (CD 27) for patients with non-clozapine antipsychotic ('control', left) and clozapine (right)+/IgM++/IgD-) Metaphase data for memory B cell (i.e., IgM-only B cells after center of development) levels were calculated as total B cell (CD 19)+Cell,% B), percentage of lymphocytes (% L), or absolute value (abs). Mean ± SEM (see example 2).
FIGS. 13A-C show peripheral blood transitional B cells (IgM) for patients with non-clozapine antipsychotic ('control', left) and clozapine (right)++/CD38++) Results of the horizontal metaphase data, respectively, were calculated as total B cells (CD 19)+Cell,% B), percentage of lymphocytes (% L), or absolute value (abs). Mean ± SEM (see example 2).
Figures 14A-C show peripheral blood Marginal Zone (MZ) B cells (CD 27) for patients with non-clozapine antipsychotic ('control', left) and clozapine (right)+/IgD+/IgM+) Results of the horizontal metaphase data, respectively, were calculated as total B cells (CD 19)+Cell,% B), percentage of lymphocytes (% L), or absolute value (abs). Mean ± SEM (see example 2).
Figures 15A-C show the results of metaphase data for peripheral plasmablast levels in patients with non-clozapine antipsychotic ('control', left) and clozapine (right)In total B cells (CD 19)+Cell,% B), percentage of lymphocytes (% L), or absolute value (abs). Mean ± SEM (see example 2).
Figure 16 shows the weight gain curves of WT mice in response to different doses of clozapine compared to haloperidol and vehicle control. Mean ± SEM (see example 3).
Figure 17 shows a comparison of WT mice body weight on
Figure 18 shows the effect of clozapine on total B cell content and pre-progenitor B cells and progenitor B cell precursors in WT mouse bone marrow compared to haloperidol and vehicle controls. Mean ± SEM (see example 3).
Figure 19 shows the effect of clozapine on pre-B cells, proliferating B cells and immature B cell precursors in WT mouse bone marrow compared to haloperidol and vehicle controls. Mean ± SEM (see example 3).
Figure 20 shows the effect of clozapine on class switching memory B cells, plasmablasts and long-lived plasma cells in the bone marrow of WT mice compared to haloperidol and vehicle controls. Mean ± SEM (see example 3).
FIG. 21 shows clozapine versus total B cells, T cells, other cell populations (TCR-. beta.) in the spleen of WT mice as compared to haloperidol and vehicle control-/B220-) And the effects of activating T cells. Mean ± SEM (see example 3).
Figure 22 shows the effect of clozapine on transitional (T1 and T2), follicular, Marginal Zone (MZ) and Germinal Center (GC) B cells in the spleen of WT mice compared to haloperidol and vehicle controls. Mean ± SEM (see example 3).
FIG. 23 shows the effect of clozapine on B cell subsets and T cells in the Mesenteric Lymph Nodes (MLN) of WT mice compared to haloperidol and vehicle controls. Mean. + -. SEM. T1 and T2 are
Figure 24 shows the effect of clozapine on circulating immunoglobulins in WT mice compared to haloperidol and vehicle control. Mean ± SEM (see example 3).
FIG. 25 shows the effect of clozapine on the clinical day of onset of CIA. Mean ± SEM (see example 4).
FIG. 26 shows the effect of clozapine on the incidence of CIA (see example 4).
Figure 27 shows the effect of clozapine on the severity of CIA, as judged by clinical score and thickness of the first affected paw, using mice dosed starting on
Figure 28 shows the effect of clozapine on the severity of CIA, as judged by the number of affected paws, as measured by the day of treatment with clozapine after immunization (
FIG. 29 shows clozapine versus control for B220 in spleen and regional lymph nodes of CIA mice +(i.e., CD45+) The effect of the cells. Mean ± SEM (see example 4).
FIG. 30 shows the effect of clozapine on Plasma Cells (PC) in the spleen and regional lymph nodes of CIA mice compared to control. Mean ± SEM (see example 4).
FIG. 31 shows clozapine versus control on Germinal Center (GC) B cells (B220) in spleen and regional lymph nodes of CIA mice+/IgD-/Fas+/GL7+) The influence of (c). Mean ± SEM (see example 4).
FIG. 32 shows clozapine versus control on Germinal Center (GC) B cells (B220) in spleen and regional lymph nodes of CIA mice+/IgD-/Fas+/GL7+) The effect of expression of GL7 on (c). MFI means mean fluorescence intensity. Mean ± SEM (see example 4).
FIG. 33 shows the effect of clozapine on the levels of anti-collagen IgG1 and IgG2a antibodies in the peripheral blood of CIA mice compared to the control group (see example 4).
FIG. 34 shows clozapine versus control, T follicular helper cells (CD 4) colonizing germinal centers in spleen and regional lymph nodes of CIA mice+PD1+) The influence of (c). Mean. + -. SEM (seeExample 4).
FIG. 35 shows clozapine versus control, T follicular helper cells (CD 4) colonizing germinal centers in spleen and regional lymph nodes of CIA mice+PD1+) (iii) the effect of PD1 expression. MFI, mean fluorescence intensity. Mean ± SEM (see example 4).
FIG. 36 shows clozapine versus control, T follicular helper cells (CD 4) colonizing germinal centers in spleen and regional lymph nodes of CIA mice+PD1+) (iii) the effect of CXCR5 expression above. MFI, mean fluorescence intensity. Mean ± SEM (see example 4).
FIG. 37 shows clozapine versus control, T follicular helper cells (CD 4) colonizing germinal centers in spleen and regional lymph nodes of CIA mice+PD1+) Influence of expression of CCR7 above. MFI, mean fluorescence intensity. Mean ± SEM (see example 4).
FIG. 38 shows a schematic of the protocol for in vitro generation/differentiation of human plasma cells (see example 5).
Figure 39 shows a schematic of the experiment illustrating a dose escalation (titration) phase of clozapine followed by injection of typhi vaccine (Typhim Vi) (arrow) followed by continuous administration of clozapine. Control cohort (vaccine only, no clozapine) and optional cohort (dose selected guided by the results of
Detailed Description
The invention also provides a method of treating or preventing a pathogenic IgE driven B cell disorder in a subject by administering to said subject an effective amount of a compound selected from the group consisting of clozapine, norclozapine and prodrugs thereof, and pharmaceutically acceptable salts and solvates thereof, in particular, wherein said compound inhibits mature B cells in said subject.
The invention also provides the use of a compound selected from the group consisting of clozapine, norclozapine, and prodrugs and pharmaceutically acceptable salts and solvates thereof, in the manufacture of a medicament for treating or preventing a pathogenic IgE driven B cell disease in a subject, in particular wherein the compound causes the inhibition of mature B cells in the subject.
Clozapine or norclozapine may optionally be used in the form of a pharmaceutically acceptable salt and/or solvate and/or prodrug. In one embodiment of the invention clozapine or norclozapine is used in the form of a pharmaceutically acceptable salt. In another embodiment of the invention, clozapine or norclozapine is used in the form of a pharmaceutically acceptable solvate. In yet another embodiment of the invention, clozapine or norclozapine is not in the form of a salt or solvate. In yet another embodiment of the invention, clozapine or desclozapine is used in the form of a prodrug. In another embodiment of the invention, clozapine or desclozapine is not used in the form of a prodrug.
The term "pathogenic IgE driven B cell disease" includes B cell mediated diseases, particularly inflammatory diseases, involving exogenous antigens that cause abnormally high and pathogenic IgE levels as the primary mechanism.
The range of exogenous antigens for pathogenic IgE driven B cell diseases includes: neutrophils (allergic granulomatous vasculitis) and pollen antigens (allergic rhinitis, allergic eye disease and atopic asthma, but may have other etiologies).
An exemplary pathogenic IgE driven B cell disease may be lung related disease atopic asthma. Alternatively, the disease may be the skin-related diseases atopic dermatitis and chronic non-autoimmune urticaria. Alternatively, the disease may be allergic granulomatous vasculitis, a neurologically related disease. Alternatively, the disease may be allergic rhinitis, a nasal related disease. Alternatively, the disease may be an ocular related disease allergic eye disease. Alternatively, the disease may be the oesophageal related disease eosinophilic esophagitis.
References that emphasize the role of B cells and pathogenic IgE antibodies in the above diseases include:
eosinophilic Esophagitis (EO)
EO is a chronic allergen-driven immune-mediated disorder, pathologically characterized by marked eosinophilic infiltration (Chen and Kao, 2017). An important role for
Esophageal biopsies of EO patients showed an increase in the mast cell density of B cells and bound IgE compared to the control group, and a positive correlation was made between CD20+ B cell density and mast cells (Vicario et al, 2010). Notably, by detecting germline transcripts of μ and
The role of IgE is further suggested by observation of IgE-bearing cells, including mast cells, in EO (Straumann et al, 2001). Notably, cells expressing the high affinity receptor FcRI for IgE are abundant in the esophageal epithelium of EO patients, suggesting that this receptor is important for IgE-mediated immune cell activation in EO (Yen et al, 2010).
EO is often associated with IgE sensitization to allergens in food in children and to allergens in plants/air in adults. Serum IgE levels in EO patients are also often significantly elevated, consistent with the presence of IgE-producing long-lived plasma cells (Aalberse et al, 2016), which, together with specific IgE antibodies, suggests IgE contribution to pathogenesis (Straumann et al, 2001). It is noteworthy that food-specific IgE antibodies are predictive of esophageal eosinophilia in children (Erwin et al, 2017). Motile esophagitis in EO is associated with elevated plasma cell levels in the esophagus (Mohammad et al, 2018).
Notably, in addition to immunoglobulins targeting exogenous antigens, recent data indicate the presence of autoantibodies in EO, particularly against NC16A, which appear to be associated with histological responses (Dellon et al, 2018).
Supporting the pathogenic role of IgE in EO, an experimental study using omalizumab for anti-IgE therapy showed that some patients were clinically improved with lower tissue IgE levels, tryptase positive cells and eosinophils (Loizou et al, 2015).
Atopic asthma (extrinsic, early-onset or allergic asthma).
Atopic asthma I is associated with atopy (allergic rhinitis and atopic eczema) and is thought to be essentially composed of
Of note is
Importantly, class switch recombination from IgM/IgG/IgA to IgE can occur locally in bronchial tissue of asthma, leading to clonal selection and affinity maturation of IgE-producing B cells to local release of IgE (Takhar et al, 2007). Allergic asthma patients showed highly elevated IgE in the airways compared to healthy and "allergic" controls+CD19+B cell levels, and increased IgE+Memory B cells and IgE+Plasma cells (Oliveria et al, 2017). Notably, IgE+The frequency of B cells was positively correlated with the levels of eosinophils, IgE and BAFF in the airways, which were found to correlate with IgE in the airways of patients with allergic asthma+Local maturation and proliferation of B cells are consistent (Oliveria et al, 2017) in order to drive disease progression through their IgE production and potent antigen-presenting function (Wypych et al, 2018). In addition, colonisation of memory B cells in tissues has also been identified in the airways of mouse models of allergic asthma, providing a colonising B cell population that can be rapidly activated locally in response to allergen/antigen re-exposure (Turner et al, 2017).
Children with asthma and/or allergy except IgE +Memory cells and
The key role of B cells in the pathogenesis of atopic asthma was demonstrated by the depletion of B cells in HDM-sensitized mice with an anti-CD 20 antibody prior to House Dust Mite (HDM) challenge, significantly reducing allergic reactions, reducing CD4 in the lung immune infiltrate+CD44+T cells, eosinophils and neutrophils, which correlates with
The role of IgE in atopic/allergic asthma is demonstrated by the inhibition of early and late responses to inhaled allergens by administration of FcRI-targeted monoclonal antibody therapy to patients with allergic asthma (thereby inhibiting the binding of endogenous IgE to mast cells and other effector cells without stimulating mast cell activation), which is associated with the reduction of serum IgE, desensitization of the sensitivity to inhaled allergens, and alleviation of the respiratory decline associated with inhaled allergens (Fahy et al, 1997). Further evidence demonstrating the key pathogenic role of IgE in persistent asthma comes from the testing of omalizumab, a humanized monoclonal anti-IgE antibody, in children and young adults within cities. It shows that despite a lower demand for inhaled glucocorticoid and β -receptor agonist therapy, the burden, frequency of exacerbations, and especially the seasonal peak of asthma symptoms is significantly reduced (Busse et al, 2011). Specific in vitro immunoadsorption of IgE has also demonstrated efficacy in reducing allergen-specific basophil sensitivity and clinical symptoms in allergic asthma patients during the pollen season (Lupinek et al, 2017). Unlike administration of omalizumab, this method, although invasive, is not limited by threshold levels of IgE (Lupinek et al, 2017).
Atopic dermatitis (AD; atopic eczema)
AD is a chronic inflammatory skin disorder characterized by pruritic eczematous lesions. It is associated with other atopic diseases (asthma and allergic rhinitis) and has common pathophysiological aspects, in particular a propensity to form IgE antibodies and sensitivity to exogenous triggers (Zheng et al, 2011). AD is considered to be a biphasic T-cell mediated condition, with T being an important disease component driven by B-cell derived
Notably, serum IgE is elevated in about 80-90% of AD patients, and elevated levels are associated with IgE autoreactivity to various antigens (Furue et al, 2017). Enhanced IgE levels are thought to reflect primarily the larger number of IgE antibody producing cells (Thomas et al, 1995).
AD patients exhibit IgE autoantibodies to keratinocyte proteins, particularly in severe cases (Altrichter et al, 2008). The correlation of auto-reactive IgE in AD with clinical severity, as well as the absence in other skin conditions, supports the role of IgE-mediated auto-reactivity in disease pathogenesis (Navarrete-Dechent et al, 2016). Notably, AD also occurs in association with other autoimmune diseases, such as vitiligo (Mohan and Silverberg,2015), and a proportion of patients with severe facial skin rash show ANA positive (Higashi et al, 2009), suggesting a more general humoral immune dysregulation in AD. The autoantibodies described include those targeting SART-1, cytokeratin type II, hMnSOD and BCL7B, etc. (Navarete-Decent et al, 2016). Clinical severity scores are highly correlated with some of these specific IgE autoantibodies (Schmid-Grendelmeier et al, 2005). The allergenicity of this antigen is further supported by its ability to induce T cell proliferation and a positive immediate response to skin challenge (Schmid-Grendelmeier et al, 2005).
Further supporting the role of B cells in AD, analysis of subpopulations of peripheral lymphocytes showed a positive correlation between B cell activation and memory T cell levels, particularly in children with AD (Czarnowicki et al, 2017). In addition, peripheral blood analysis indicated that early AD was characterized by abnormal B cell maturation and revealed memory B cells and T in
In adults, AD is associated with an increase in circulating transitional B cells, long-term activated memory B cells, plasmablasts, and IgE memory B cells (Czarnowicki et al, 2016). Notably, in AD, circulating cells express CD23 (a low affinity receptor for the Fc region (FcRII) of IgE) which is increased and is associated with the clinical severity of AD (Czarnowicki et al, 2016); this observation is noteworthy in view of the role of CD23 in promoting IgE synthesis/response (pen, 1989).
Supporting the major role of B cells in the pathogenesis of AD, depletion of B cells with rituximab results in substantial clinical improvement (severity/involvement area), as well as improvement in histology (reduced B cell and T cell infiltration), some reduction in IL-5/IL-13 and total IgE (Simon et al, 2008). It is noteworthy that although circulating B cells were almost completely depleted, there was not as much reduction in B cells in the skin (-50%) and plasma cells were evident in both skin samples before and after treatment (Simon et al, 2008). Furthermore, the sequential treatment of severe refractory AD with anti-IgE (omalizumab) and B-cell depletion (rituximab) is reported to have a significant clinical response as well as to reduce serum IgE and peripheral blood B-cell levels (Sanchez-Ramon et al, 2013). Further supporting the role of pathogenic IgE immunoglobulins in driving AD is the repeated IgE immunoadsorption by AD patients with elevated serum IgE, leading to significant clinical improvement, as well as a reduction in IgE (Daeschlein et al, 2015).
Allergic granulomatous vasculitis (Hill-Shi's vasculitis; eosinophilic granulomatous disease with polyangiitis; CSS/EGPA)
Allergic granulomatous vasculitis, also known as eosinophilic granulomatosis with polyangiitis (EGPA), is a necrotizing vasculitis of the medium and small vasculature, is part of the clinical lineage of ANCA-associated vasculitis (ANCA, approximately-40 positive for anti-neutrophil cytoplasmic antibodies), and is associated with severe adult-onset asthma, sinusitis, and blood/tissue eosinophilia (Groh et al, 2015).
The pathogenesis of CSS involves T cells (in particular excessive T)H2 response, but also
Supporting the role of IgE in the pathogenesis of CSS, mice experience a reverse passive argus reaction of the skin (using IgE) to provide an IgE-immune complex challenge, with cutaneous eosinophilic vasculitis reminiscent of CSS occurring (Ishii et al, 2009). Notably, eosinophil infiltration in this model is surprisingly specific for IgE-mediated immune complex challenge, with little observation in IgG antibody injection (Ishii et al, 2009). There is also evidence to support the pathogenesis of IgE in CSS through immune complex formation and complement activation (Manger et al, 1985).
CSS patients presenting with active disease and frequent relapses show elevated levels of activated B cells and reduced levels of circulating T regulatory cells (Tsurikisawa et al, 2013). CSS patients also exhibit a cellular environment that favors plasma cell differentiation and antibody-mediated responses by increasing IL-21 secreting T helper cells, particularly in ANCA positive patients (abdula had et al, 2013).
Supporting the key role of B cells and their autoantibodies in the pathogenesis of CCS, depletion of B cells with rituximab can clinically effectively induce remission or partial responses and reduce the need for corticosteroid therapy; notably, baseline ANCA levels were associated with higher levels of remission (Mohammad et al, 2016). These findings were confirmed in another clinical study on refractory CSS patients that rituximab reduced the levels of IgE, CRP, and eosinophils, and induced remission (Thiel et al, 2017). There is also evidence that targeting IgE using omalizumab in refractory/relapsing CCS has a corticosteroid sparing effect (Jachiet et al, 2016).
Allergic Rhinitis (AR)
AR is a common chronic IgE-mediated inflammatory nasal disorder, often combined with other atopic features (asthma and atopic dermatitis). Exposure to specific allergens promotes the production of allergen-specific IgE, which then binds to target cells (e.g. mast cells and basophils) via the high affinity receptor FcRI (Wise et al, 2018). In turn, nasal mast cells of AR patients exhibit an increase in FcRI expression and cell-bound IgE associated with serum IgE levels; these cells also induce IgE production by B cells, suggesting that the feed forward IgE-FcRI-mast cell axis is critically dependent on pathogenic IGE, which perpetuates AR (Pawankar and Ra, 1998).
Nasal B-cells are more than 1000 times more frequent in AR than in peripheral blood and produce IgE after allergen exposure (Coker et al, 2003; Takhar et al, 2005). Evidence supports local class switch recombination in the nasal mucosa of AR patients (Cameron et al, 2000), suggesting that resident/local B cells in tissues undergo Ig subtype switch to IgE in the context of local immune responses to allergens (Cameron et al, 2003). Both IgE + B cells and IgE + plasma cells are enriched in the nasal mucosa of AR patients (klein jan et al, 2000).
Central role of IgE in AR was demonstrated, anti-IgE treatment with omalizumab was clinically effective in AR patients and also inhibited the seasonal allergen-induced tissue/blood eosinophil increase (Holgate et al, 2005; Tsabouri et al, 2014).
Allergic eye diseases
Seasonal and perennial allergic conjunctivitis is the most common form of allergic eye disease and is associated with other atopic diseases, the mechanism of which is similar to those already outlined, including the important role of B-cell derived IgE. In support of this, anti-IgE therapy with omalizumab has shown efficacy in atopic individuals with concomitant ocular disease (Kopp et al, 2009).
Chronic non-autoimmune urticaria (chronic idiopathic urticaria, CSU)
Urticaria is a common disease driven by mast cells and can be classified as acute and chronic; chronic non-autoimmune urticaria can be classified by itself into chronic idiopathic urticaria (CSU) and chronic induced urticaria (Radonjic-Hoesli et al, 2018). Although CSU has no obvious external triggers and most patients have autoimmune causes, there is also a significant proportion of patients without autoimmune disease. In these patients, IgE binding to FcRI on mast cells without cross-linking is thought to promote survival and proliferation of mast cells, lowering the threshold for mast cell mediator release (Chang et al, 2015). Consistent with this, and the pathogenic role of B cell-derived IgE in this situation, to date,
Accordingly, in one embodiment, the present invention provides (i) a compound selected from clozapine, norclozapine and prodrugs thereof and pharmaceutically acceptable salts and solvates thereof, for use in treating or preventing a pathogenic IgE driven B cell disorder in a subject, and (ii) a method of treating or preventing a pathogenic IgE driven B cell disorder in a subject by administering to said subject an effective amount of a compound selected from clozapine, norclozapine and prodrugs thereof and pharmaceutically acceptable salts and solvates thereof, wherein in the case of (i) and (ii), the pathogenic IgE driven B cell disorder is a disorder selected from the group consisting of: atopic asthma, atopic dermatitis, chronic non-autoimmune urticaria, allergic granulomatous vasculitis, allergic rhinitis and allergic eye disease, preferably atopic dermatitis, atopic asthma, allergic rhinitis and eosinophilic esophagitis.
Preferably, the disease is selected from atopic dermatitis, atopic asthma and allergic rhinitis.
Clozapine is associated with high levels of central nervous system penetration, which may prove a valuable attribute in the treatment of certain such diseases (Michel et al, 2015).
In certain diseases, such as atopic dermatitis, T cell components that contribute to disease pathology may also be present. This situation arises because B cells act as professional antigen-presenting cells for T cells (which are also of increasing importance due to their large number). B cells secrete large amounts of cytokines affecting T cells. The B-T interaction is involved in the response to T-dependent protein antigens and class switching. Thus, because of the effect of clozapine and norclozapine on reducing the number of B cells, they are expected to have an effect on T cells.
Suitably, the compound selected from clozapine, norclozapine and prodrugs thereof inhibits mature B cells, especially CSMB and plasmablasts, especially CSMB. By "inhibiting" is meant reducing the number and/or activity of the cells. Thus, clozapine or norclozapine suitably reduces the amount of CSMB and plasmablasts, in particular CSMB.
In one embodiment, a compound selected from clozapine, desclozapine, and prodrugs thereof has the effect of reducing CD19(+) B cells and/or CD19(-) B plasma cells.
The term "treatment" refers to the alleviation of a disease or the symptoms of a disease. The term "prevention" refers to the prevention of a disease or disease symptoms. Treatment includes treatment alone or in combination with other therapies. Treatment includes treatment that results in the amelioration of the disease or symptoms thereof or slowing the rate of progression of the disease or symptoms thereof. Treatment includes prevention of recurrence.
The term "effective amount" refers to an amount effective at the dosage and duration necessary to achieve the desired therapeutic effect, wherein any toxic or deleterious effects of the pharmacologically active agent are outweighed by the beneficial effects of the treatment. It will be understood that the effective dose will depend upon the age, sex, health and weight of the recipient, the nature of concurrent therapy (if any), the frequency of therapy and the nature of the effect desired. The most preferred dosage will be tailored to the individual subject, as understood and determined by those skilled in the art, without undue experimentation. Example dosages are discussed below.
As used herein, "individual" or "subject" refers to any mammal, including but not limited to humans, non-human primates, farm animals such as cows, sheep, pigs, goats, and horses; domestic animals such as cats, dogs, rabbits; laboratory animals such as mice, rats and guinea pigs, exhibit at least one symptom associated with the disease, have been diagnosed with the disease, or are at risk of developing the disease. The term does not denote a particular age or gender. Suitably, the subject is a human subject.
It will be appreciated that for pharmaceutical use, the salts of clozapine and norclozapine should be pharmaceutically acceptable. Suitable pharmaceutically acceptable salts will be apparent to those skilled in the art. Pharmaceutically acceptable salts include those described by Berge, Bighley and Monkhouse j.pharm.sci. (1977)66, pp 1-19. Such pharmaceutically acceptable salts include acid addition salts formed with inorganic acids such as hydrochloric, hydrobromic, sulfuric, nitric or phosphoric acid, and organic acids such as succinic, maleic, acetic, fumaric, citric, tartaric, benzoic, p-toluenesulfonic, methanesulfonic or naphthalenesulfonic acid. Other salts, such as oxalates or formates, may be used, for example, in the isolation of clozapine and are included within the scope of the invention.
Clozapine or norclozapine may be prepared in crystalline or amorphous form and, if in crystalline form, may optionally be solvated, for example as a hydrate. The present invention includes within its scope stoichiometric solvates (e.g., hydrates) as well as compounds containing variable amounts of solvent (e.g., water).
A "prodrug", e.g., an N-acetylated derivative (amide) (e.g., an N-acetylated derivative of norclozapine), is a compound that, when administered to a recipient, is capable of providing clozapine or an active metabolite or residue thereof (directly or indirectly). Other such examples of suitable prodrugs include alkylated derivatives of norclozapine in addition to clozapine itself.
Isotopically-labeled compounds, which are identical to clozapine or norclozapine, but for the fact that one or more atoms are replaced by an atom having an atomic mass or mass number different from the atomic mass or mass number most commonly found in nature, or in which the proportion of atoms having atomic masses or mass numbers less commonly found in nature is increased (the latter concept being referred to as "isotopic enrichment"), are also encompassed by the uses and methods of the present invention. Examples of isotopes that can be incorporated into clozapine or desclozapine include isotopes of hydrogen, carbon, nitrogen, oxygen, fluorine, iodine and chlorine such as2H (deuterium),3H、11C、13C、14C、18F、123I or125I, which may be a naturally occurring or non-naturally occurring isotope.
Containing the aforesaid isotopesClozapine or norclozapine and pharmaceutically acceptable salts of clozapine or norclozapine having isotopes of elements and/or other atoms may be used in the uses and methods of the invention. Isotopically labelled clozapine or norclozapine, e.g. having incorporated a radioactive isotope such as3H or14C, is useful in drug and/or substrate tissue distribution assays. Tritiated, i.e.3H, and carbon-14, i.e.14The C isotope is particularly preferred for its ease of preparation and detectability. 11C and18the F isotope is particularly useful in PET (positron emission tomography).
Since clozapine or norclozapine is intended for use in a pharmaceutical composition, it will be readily appreciated that it is preferably provided in substantially pure form, e.g. at least 60% pure, more suitably at least 75% pure and preferably at least 85%, especially at least 98% pure (% on a weight/weight basis). Impure preparations of the compounds can be used to prepare more pure forms for use in pharmaceutical compositions.
In general, clozapine or norclozapine can be prepared according to organic synthesis techniques known to those skilled in the art (as described, for example, in US 3539573).
The compound selected from clozapine, norclozapine and prodrugs thereof and pharmaceutically acceptable salts and solvates thereof for use in therapy is typically administered as a pharmaceutical composition. Also provided are pharmaceutical compositions comprising clozapine or norclozapine, or a pharmaceutically acceptable salt and/or solvate thereof and/or a prodrug thereof, in association with a pharmaceutically acceptable diluent or carrier. The compositions are provided for treating or preventing a pathogenic IgE driven B cell disease in an individual, wherein the compound inhibits mature B cells in the individual.
The compound selected from clozapine, norclozapine and prodrugs thereof and pharmaceutically acceptable salts and solvates thereof may be administered by any convenient method, for example by oral, parenteral, buccal, sublingual, nasal, rectal or transdermal administration, and pharmaceutical compositions adapted accordingly. Other possible routes of administration include intratympanic and intracochlear administration. Suitably, the compound selected from clozapine, norclozapine and prodrugs thereof and pharmaceutically acceptable salts and solvates thereof is administered orally.
The compound selected from clozapine, norclozapine and prodrugs thereof, and pharmaceutically acceptable salts and solvates thereof, which is active when administered orally, may be formulated as a liquid or solid, for example as a syrup, suspension, emulsion, tablet, capsule or lozenge.
Liquid preparations generally consist of a suspension or solution of the active ingredient in a suitable liquid carrier, e.g. an aqueous solvent such as water, ethanol or glycerol, or a non-aqueous solvent such as polyethylene glycol or an oil. The formulation may also contain suspending agents, preservatives, flavouring and/or colouring agents.
Compositions in tablet form may be prepared using any suitable pharmaceutical carrier conventionally used for the preparation of solid formulations, such as magnesium stearate, starch, lactose, sucrose and cellulose.
The compositions may be prepared in capsule form using conventional encapsulation procedures, for example, granules containing the active ingredient may be prepared using standard carriers and then filled into hard gelatin capsules; alternatively, a dispersion or suspension may be prepared using any suitable pharmaceutical carrier, for example an aqueous gum, cellulose, silicate or oil, and the dispersion or suspension filled into soft gelatin capsules.
Typical parenteral compositions consist of a solution or suspension of the active ingredient in a sterile aqueous carrier or a parenterally acceptable oil, for example polyethylene glycol, polyvinylpyrrolidone, lecithin, arachis oil or sesame oil. Alternatively, the solution may be lyophilized and then reconstituted with a suitable solvent prior to administration.
Compositions for nasal or pulmonary administration may conveniently be formulated as aerosols, sprays, drops, gels and powders. Aerosol formulations typically comprise a solution or fine suspension of the active ingredient in a pharmaceutically acceptable aqueous or non-aqueous solvent and are usually presented in sterile form in single or multiple doses in a sealed container, which may take the form of a cartridge or refill, for use with an atomising device. Alternatively, the sealed container may be a disposable dispensing device, such as a single dose nasal or pulmonary inhaler or an aerosol canister fitted with a metering valve. When the dosage form comprises an aerosol spray can, it will contain a propellant which may be a compressed gas, for example air, or an organic propellant such as a chlorofluorocarbon or a hydrofluorocarbon. Aerosol dosage forms may also take the form of pump atomizers.
Compositions suitable for buccal or sublingual administration include tablets, lozenges and pastilles (pastilles), wherein the active ingredient is formulated with a carrier such as sugar and acacia, tragacanth or gelatin and glycerin.
Compositions for rectal administration conveniently take the form of suppositories with conventional suppository bases such as cocoa butter.
Compositions suitable for topical application to the skin include ointments, gels, and patches.
In one embodiment, the composition is in unit dosage form, such as a tablet, capsule or ampoule.
The compositions may be prepared to have an immediate release profile after administration (i.e., after ingestion in the case of oral compositions), or a sustained or delayed release profile after administration.
For example, a composition intended to provide a constant release of clozapine over a 24 hour period is described in WO2006/059194, the content of which is incorporated herein in its entirety.
Depending on the method of administration, the compositions may contain from 0.1% to 100% by weight, for example from 10% to 60% by weight, of active substance. Depending on the method of administration, the composition may contain from 0% to 99% by weight, for example from 40% to 90% by weight, of carrier. Depending on the method of administration, the composition may contain from 0.05mg to 1000mg, for example from 1.0mg to 500mg of the active substance (i.e. clozapine or norclozapine). Depending on the method of administration, the composition may contain from 50mg to 1000mg, for example from 100mg to 400mg, of the carrier. The dosage of clozapine or norclozapine used to treat or prevent the aforementioned conditions will vary in the usual manner with the severity of the condition, the weight of the patient and other similar factors. However, as a general guide, a suitable unit dose of clozapine in free base form may be 0.05 to 1000mg, more suitably 1.0 to 500mg, and such unit doses may be administered more than once daily, e.g. two or three times daily. Such treatment may last for weeks or months.
A compound selected from the group consisting of clozapine, norclozapine, and prodrugs and pharmaceutically acceptable salts and solvates thereof may be administered in combination with another therapeutic agent for the treatment of pathogenic IgE driven B cell diseases, such as those drugs that inhibit B cell or B cell-T cell interactions. Other therapeutic agents include, for example: anti-TNF α drugs (such as anti-TNF α antibodies such as infliximab or adalimumab (adalimumab)), calcineurin inhibitors (such as tacrolimus or cyclosporine), antiproliferative agents (such as mycophenolic acid e.g. mycophenolate mofetil or sodium, or azathioprine), anti-inflammatory drugs in general (such as hydroxychloroquine or NSAIDS such as ketoprofen and colchicine), mTOR inhibitors (such as sirolimus), steroids (such as prednisone), anti-CD 80/CD86 drugs (such as abepil), anti-CD-20 drugs (such as anti-CD-20 antibodies such as rituximab), anti-BAFF agents (such as anti-BAFF antibodies such as tabalumab or belimumab, or asecept), immunosuppressive agents (such as methotrexate or cyclophosphamide), anti-FcRn agents (such as anti-FcRn antibodies), anti-IgE antibodies (such as omalizumab), and other antibodies (such as ARGX-113, ARGX-113), PRN-1008, SYNT-001, veltuzumab, ocrelizumab, ofatumumab, obinutuzumab, ublituximab, alemtuzumab, milatuzumab, epratuzumab, and blinatumumab.
Other therapies that may be used in conjunction with the present invention include non-drug therapies such as intravenous immunoglobulin therapy (IVIg), subcutaneous immunoglobulin therapy (SCIg) such as facilitated subcutaneous immunoglobulin therapy, plasmapheresis, and immunoadsorption.
Accordingly, the present invention provides a compound selected from clozapine, norclozapine and prodrugs thereof and pharmaceutically acceptable salts and solvates thereof for use in the treatment or prevention of a pathogenic IgE driven B cell disorder, in combination with a second or further therapeutic agent for the treatment or prevention of a pathogenic IgE driven B cell disorder, for example selected from: anti-TNF α drugs (such as anti-TNF α antibodies, e.g. infliximab or adalimumab), calcineurin inhibitors (such as tacrolimus or cyclosporine), antiproliferatives (such as mycophenolic acid, e.g. mycophenolate mofetil or sodium, or azathioprine), anti-inflammatory drugs in general (such as hydroxychloroquine or NSAIDS, e.g. ketoprofen and colchicine), mTOR inhibitors (such as sirolimus), steroids (such as prednisone), anti-CD 80/CD86 drugs (such as abatacept), anti-CD-20 drugs (such as anti-CD-20 antibodies, e.g. rituximab), anti-BAFF drugs (such as anti-BAFF antibodies, e.g. talalumumab or belimumab, or asecept), immunosuppressive agents (such as methotrexate or cyclophosphamide), anti-FcRn agents (e.g. anti-FcRn antibodies), and other antibodies (e.g. ARGX-113, PRN-1008, SYNT-001, or tacrolimus, or ase, Vituzumab, ocrelizumab, ofatumumab, obinutuzumab, ublituximab, ullituximab, alemtuzumab, matuzumab, epratuzumab, and blinatumomab).
When a compound selected from clozapine, norclozapine and prodrugs and pharmaceutically acceptable salts and solvates thereof is used in combination with other therapeutic agents, these compounds may be administered separately, sequentially or simultaneously by any convenient route.
The combinations described above may conveniently be presented for use in the form of a pharmaceutical formulation and thus pharmaceutical formulations comprising a combination as defined above together with a pharmaceutically acceptable carrier or excipient constitute a further aspect of the invention. The individual components of such combinations may be administered sequentially or simultaneously in separate or combined pharmaceutical formulations. The individual components of such combinations may also be used separately, by the same or different routes. For example, a compound selected from clozapine, norclozapine, and prodrugs and pharmaceutically acceptable salts and solvates thereof, and the additional therapeutic agent may both be administered orally. Alternatively, a compound selected from the group consisting of clozapine, norclozapine, and prodrugs and pharmaceutically acceptable salts and solvates thereof may be administered orally, while the other therapeutic agent may be administered intravenously or subcutaneously.
Typically, a compound selected from the group consisting of clozapine, norclozapine, and prodrugs thereof, and pharmaceutically acceptable salts and solvates thereof, is administered to a human.
Examples
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