Clozapine for the treatment of immunoglobulin-driven B cell disorders
阅读说明：本技术 用于治疗免疫球蛋白驱动的b细胞疾病的氯氮平 (Clozapine for the treatment of immunoglobulin-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,用于治疗或预防具有T细胞组分的致病性免疫球蛋白驱动的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 and pharmaceutically acceptable salts and solvates thereof for use in the treatment or prevention of pathogenic immunoglobulin driven B cell diseases having a T cell component. 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 immunoglobulin driven B cell disease having a T cell component in a subject, wherein said compound inhibits mature B cells in said subject.
2. A method of treating or preventing a pathogenic immunoglobulin driven B cell disease having a T cell component in a subject by administering to the 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 the compound inhibits mature B cells in the 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 immunoglobulin driven B cell disease having a T cell component in a 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 immunoglobulin driven B cell disease with T cell components is selected from the group consisting of: vitiligo, psoriasis, celiac disease, dermatitis herpetiformis, discoid lupus erythematosus, dermatomyositis, polymyositis, type 1 diabetes, autoimmune Addison's disease, multiple sclerosis, interstitial lung disease, Crohn's disease, ulcerative colitis, thyroid autoimmune disease, autoimmune uveitis, primary biliary cirrhosis. Primary sclerosing cholangitis, undifferentiated connective tissue disease, autoimmune thrombocytopenic purpura, mixed connective tissue disease, immune-mediated inflammatory disease (IMID) such as scleroderma, rheumatoid arthritis, sjogren's disease, and autoimmune connective tissue disease such as systemic lupus erythematosus.
8. The compound for use, the method or the use according to claim 7, wherein the pathogenic immunoglobulin driven B cell disease with T cell components is psoriasis, connective tissue diseases such as systemic lupus erythematosus, or Immune Mediated Inflammatory Diseases (IMID) such as scleroderma, rheumatoid arthritis or sjogren's disease.
9. The compound for use, the method or the use according to any one of claims 1 to 6, wherein the pathogenic immunoglobulin driven B cell disease with a T cell component is graft versus host disease.
10. The compound for use, the method or the use according to any one of claims 1 to 9, wherein the compound has the effect of reducing CD19(+) B cells and/or (-) B-plasma cells.
11. 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 immunoglobulin driven B cell disease with a T cell component in a subject, wherein the compound causes the inhibition of mature B cells in the subject.
12. The pharmaceutical composition for use according to claim 11, wherein the pharmaceutical composition is administered orally.
13. The pharmaceutical composition for use according to claim 11 or 12, wherein the pharmaceutical composition is formulated as a liquid or solid, e.g. as a syrup, suspension, emulsion, tablet, capsule or lozenge.
14. The pharmaceutical composition for use according to any one of claims 11-14, wherein mature B cells are class-switching memory B cells.
15. The pharmaceutical composition for use according to any one of claims 11-14, wherein mature B cells are plasmablasts.
16. 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 6-10 in combination with a second or other therapeutic agent for the treatment or prevention of pathogenic immunoglobulin driven B cell diseases having a T cell component.
17. A compound selected from clozapine, norclozapine, and prodrugs thereof, and pharmaceutically acceptable salts and solvates thereof, for use according to claim 16, wherein the second or further therapeutic agent for treating or preventing a pathogenic immunoglobulin driven B cell disease having a T cell component is selected from the group consisting of: anti-TNF α drugs (such as anti-TNF α antibodies, e.g. infliximab or adalimumab), calcineurin inhibitors (such as tacrolimus or cyclosporine), antiproliferative agents (such as mycophenolic acid, e.g. mycophenolate mofetil or sodium, or azathioprine), anti-inflammatory agents 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 abepilin), anti-CD-20 drugs (such as anti-CD-20 antibodies, e.g. rituximab), anti-BAFF agents (such as anti-BAFF antibodies, e.g. tabalumab 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, vet-001, vitamumab, ocrelizumab, ofatumumab, obinutuzumab, ublituximab, alemtuzumab, milatuzumab, epratuzumab, and blinatumumab).
Technical Field
The present invention relates to compounds and pharmaceutical compositions containing such compounds for the treatment or prevention of pathogenic immunoglobulin driven B cell diseases having a T cell component.
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 serious 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.
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-way, the immunomodulatory properties of clozapine and its effect on immunoglobulin levels are neither clear nor understood in the art.
Pathogenic immunoglobulins with a T cell component (including IgG, IgA, and IgM) driven B cell diseases are caused by autoantibodies (mainly IgG and/or IgA) secreted by antibody secreting cells ("ASC", plasmablasts and plasma cell populations, which are types of mature B cells). These antibodies target various autoantigens characterized in many of these diseases (in the case of IgG and IgA driven diseases). 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. The secretion of IgG and IgA antibodies comes from ASC, the production of which is secondary to the 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. The T cell component, which contributes to the pathology of the disease, appears because B cells act as professional antigen-presenting cells for T cells (the importance of which is also increased by their large number). B cells secrete a number of cytokines that affect T cells, and the interaction of B and T cells is also involved in responses to T-dependent protein antigens and class switching. Thus, T cells will help the activity and maturation of B cells in a variety of ways.
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 also enter other anatomical compartments peripherally, 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 also 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).
A large proportion of the plasma cells of the bone marrow are IgA+(-40%) and IgA+Plasma cells further constitute the majority (about 80%) of the serum (Mei et al, 2009), which is in turn associated with IgA+Plasma cells contribute much of the same mass of the bone marrow population of long-lived cells. Intestinal mucosa is IgA+The major induction sites of plasma cells, mainly through gut-associated lymphoid tissue (GALT, including colleting lymph nodules and isolated lymphoid follicles) (Craig and Cebra,1971), as well as the mesenteric lymph nodes and underlying gut lamina propria themselves, achieve class-switch recombination to IgA through both T-cell independent (preneogenic center formation) (Bergqvist et al, 2010; Casola et al, 2004) and T-cell dependent (Pabst,2012) mechanisms. Notably, IgA +Plasma cells and other 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-alpha (TNF-alpha), 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 themselves are an important potential therapeutic target because of their ability to produce pathogenic immunoglobulins/autoantibodies (Hoyer et al, 2004), in particular IgG, but also IgM, which are described in several disease contexts, such as neuromyelitis optica (Chihara et al, 2013; Chihara et al, 2011), idiopathic pulmonary hypertension, IgG 4-related diseases (Wallace et al, 2015), multiple sclerosis (Rivas et al, 2017) and transverse myelitis (Ligocki et al, 2013), rheumatoid arthritis (owczarkyk et al, 2011) and Systemic Lupus Erythematosus (SLE) (Banchereau et al, 2016). 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 immunoglobulin-driven B cell diseases. In particular, pathogenic immunoglobulin-driven B cell diseases account 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 immunoglobulin-driven B cell diseases with T cell components 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 is a drug currently used to treat some pathogenic IgG-driven B cell diseases. It targets B
Thus, there is a significant unmet medical need for new methods of treating pathogenic immunoglobulin driven B cell diseases with T cell components.
Summary of The Invention
The inventors have found that treatment with clozapine in humans is associated with a significant reduction in immunoglobulin levels and an impaired response to vaccination with T-independent unconjugated pneumococcal polysaccharide antigen and T-dependent protein antigen (e.g. Hib), confirming both quantitative and qualitative effects on B cell antibody production. There is also a significant reduction in class switched memory B Cell (CSMB) levels and the observed reduction in plasmablast levels, which are two forms of mature B cells. CSMB is an antigen-activated mature B cell that no longer expresses IgM and IgD, but rather immunoglobulin IgG, IgA, or IgE. They are important antibody producers. Plasmablasts are also mature B cells, which are important antibody producers, in a more advanced stage of maturation than CSMB. A decrease in CSMB levels indicates that clozapine has an effect on pathways involved in the maturation of B cells into mature plasma cells. B cells are also professional antigen-presenting cells and cytokine producers, and play a role in CD 4T cell priming. The inventors' new data also demonstrate the effect of the drug in reducing total IgG, IgA, and IgM levels after administration. This observation strongly supports the functional effect on CSMB and plasmablasts, which are critically important for long-term production of pathogenic antibodies in pathogenic immunoglobulin-driven B cell diseases with a T cell component, since there is no effect on other B cells, manifested by an absence of other subtypes and total B cell numbers, but CSMB and plasmablasts are particularly reduced.
Effect on class-switching memory B cells and antibody production
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 immunoglobulin-driven B-cell diseases. The inventors' new data show that there is a very significant effect on the number of circulating class-switching memory B cells, a substantial effect on the number of plasmablasts and, importantly, the function of class-switching memory B cells and plasmablasts is affected by the lack of a memory response to the common vaccine, 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 IgG, IgA, and IgM 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 immunoglobulin (especially IgG and IgA) driven B cell diseases, as there is no effect on other B cells, manifested as 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. In addition, it is of particular therapeutic interest because the B lymphoid kinase haplotypes associated with B cell driven autoimmune disease exhibit expansion of class switch memory B cells, and the inherent B cell over-reactive disease model is associated with spontaneous CSR because it is associated with high titers of IgG autoantibodies. Clozapine has particular therapeutic potential for the impact of CSR and IgG reduction in situations where the impact on both the autoimmune memory pool and pathogenic immunoglobulin is required for pathogenic immunoglobulin driven B cell disease.
Effect on IgA
The inventors have identified a significant reduction in circulating total IgA (left shift in immunoglobulin distribution) in patients treated with clozapine, which significantly shows a disproportionate reduction compared to that found in IgG and IgM. The inventors also confirmed that the functional impact of this is demonstrated by a very significant reduction in pneumococcal specific IgA in patients receiving clozapine treatment compared to clozapine naive patients administered other antipsychotic drugs. To recapitulate this in a mammalian model system, the inventors demonstrated that administration of clozapine to wild type mice resulted in a significant reduction in circulating IgA compared to control or haloperidol treatment. Although IgA is present in plasma at relatively low concentrations compared to other immunoglobulin subtypes, IgA forms a significant proportion of all mammalian immunoglobulins and produces about 3 grams per day in humans.
The inventors found that in response to clozapine treatment, total IgA decreased significantly, reflecting clozapine versus IgA+The important effects of plasma cell function. Such cells are produced in both bone marrow and intestinal mucosa.
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 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 PC in human bone marrow has long been recognized as a major source of human circulating IgG, thus providing clear support for the inventors' observation of IgG reduction in clozapine-treated patients. Clozapine observed by the inventors has a specific role in depleting bone marrow long-lived plasma cells, suggesting that it has 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.
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 exhibited the most similar phenotype to murine T1B cells and was expanded in SLE patients.
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. This further underscores the therapeutic potential of most antibodies expressed by early immature B cells, given that they are autoreactive.
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), relevance of CIA as a model of pathogenic immunoglobulin-driven B cell disease with T cell components, and importance of B cell-T cell interactions in autoimmunity
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, 2018B). 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 IgG 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).
Dynamic interactions between B cells and T cells are key to the adaptive immune response and contribute to the production of pathogenic immunoglobulins in disease. One example is the germinal center cell response by which high affinity long-lived memory B cells and plasma cells are generated. Differentiation of B cells into these distal mature cell types requires B cell activation and a multi-phase selection/survival signal that is provided by mature T follicular helper cells to germinal center B cells by immune synapse-directed delivery to them, thereby achieving kinetic, temporal and spatial separation of multiple (bi-directional) signal/co-stimulatory molecules and cytokines (Allen et al, 2007), including persistent B cells, CD40L-CD40(Foy et al, 1994) required for T cell adhesion, IL-21 (the most potent cytokine that promotes plasma cell differentiation) (tinger et al, 2005; Kuchen et al, 2007; Zotos et al, 2010), PD-1/PD-L1(Dorfman et al, 2006; Good-Jacobson et al, 2010), ICOS-ICOSL (Choi et al, 2011; Liu et al, Xu et al, 2013), SLAM family signaling molecule receptors (Cannos), 2010) and the like. This "entanglement" process is directed to selectively transmitting helper cell signals to high affinity, non-self It is important that reactive B cell clones select for differentiating plasma cells. Emphasizes the T follicular helper cell (T)FH) Of importance in generating B cell memory is TFHCells and their PI3K activity are the major limiting factor in the development of germinal centers (Rolf et al, 2010). T isFHThe cells also secrete class switch factors (Crotty,2011) required to direct class switch recombination in B cells, including IL-4 for IgG1(Reinhardt et al, 2009) and IgE, and IL-21 for IgG3, IgA, and IgE (Avery et al, 2008; Pen et al, 2004). Notably, the process of B cell-T cell interaction in lymphoid tissues is not limited to germinal center TFHInteraction with germinal center B cells, also including (Tangye et al, 2015): plasmablasts assisted by extrafollicular T cells via IL-21 and Bcl-6(Lee et al, 2011) with stromal cell-derived APRIL (Zhang et al, 2018), T in the follicular cuffFHInteraction with non-cognate B cells and cognate interaction at the T-B boundary. It is noteworthy that these interactions are not completely unidirectional, and therefore, plasmablasts in circulation can regulate T in reverseFHCells and promotion of T by secretion of IL-6FHDifferentiation procedure (Chavele et al, 2015). This positive feedback loop and prior observations underscore the interdependence of B-cells and T-cells in response to the development/continuation of physiological and pathological immunoglobulin production and autoimmunity.
Homologous interactions between B cells and T cells are thought to be critical for induction of CIA. Thus, blocking of CD4 using monoclonal anti-CD 40-L antibody+The interaction of CD40 ligand (gp39) expressed on the surface of T (helper) cells with CD40 on the surface of B cells was sufficient to completely prevent CIA in mice and to reduce the associated pathogenic anti-CII antibodies (Durie et al, 1993). Also, T-cell-B-cell ICOS signaling has been shown to be essential for induction and maintenance of CIA in mice (pannton et al, 2018); as a corollary, inhibition of ICOS/ICOS-L interaction reduced the severity and progression of the disease in mice (O' Dwyer et al, 2018). In addition, IL-21 knockout mice resist the development of CIA and show lower IgG anti-CII antibodies, and IL-21 signal transduction in B cells has been shown to be the cause of CIA development (Sak)ura et al, 2016).
Another T cell population that has been shown to play a role in (suppressing) humoral immunity is Foxp3+Regulatory T cells (Tregs). Underscoring the importance of Tregs, the depletion of Tregs using anti-CD 25 or diphtheria toxin resulted in a strong induction of autoantibodies, enhancing TFHCellular and germinal center responses, as well as histological evidence of autoimmunity (Leonardo et al, 2012; Sakaguchi et al, 1995). Specifically, within secondary lymphoid tissues, T follicular regulatory cells (Sayin et al, 2018), which reside at the T cell zone-B cell follicular border and at the B cell follicular border, pass through with B cells and T cells FHMultiple interactions of cells were shown to inhibit antibody production, and proposed mechanisms (Wing et al, 2018) include: direct inhibition of follicular b cells, prevention of TFHEntry of cells into germinal centers, and inhibition of B cell differentiation within germinal centers themselves. Thus, regulatory T cells regulate the differentiation of antibody-secreting cells through the germinal center by which T cells are differentiatedFHCo-selection of differentiation pathways was achieved (Chung et al, 2011; Linterman et al, 2011). Emphasizing the importance of Treg cells in the pathogenesis of CIA, inherited transfer antigen-specific Treg cells can inhibit the progression of CIA (Sun et al, 2018 a).
The inventors have found that clozapine results in a significant reduction of the proportion of B cells in the lymph nodes of mice immunized with heterologous type II collagen. Similar findings were also found in the spleen in smaller magnitudes. Similar reductions were also observed when clozapine was administered to healthy wild-type mice, but without a preference for a specific major B-cell subset, suggesting the effect of clozapine on reducing major secondary lymphoid tissue B-cell subsets.
The inventors' data also show that clozapine has a highly significant ability to reduce the proportion of germinal center B cells, and that their level of activation is also very significantly dose-dependent reduced, as judged by its expression of GL7 activating antigen/epitope. It is noteworthy that GL7 hiIn addition to exhibiting greater antigen presenting capacity, B cells also exhibit greater specificity and total antibody production. Thus, the inventors' findings indicate that clozapine is abundant in B cells in the center of development andboth of these effects have an effect which together inhibit the function and/or formation of an effective germinal center.
Furthermore, the inventors have identified another major cell type where clozapine is critical for germinal center formation and function, namely T follicular helper cells (T)FH) An additional effect of (c). They found that clozapine greatly reduced the critical TFHExpression of markers PD-1 (programmed cell death-1) and CXCR5 without perturbing T in secondary lymphoid tissuesFHThe proportion of cells. T isFHCells express PD-1 at high levels (and rapidly up-regulate expression following antigen stimulation), which serves as a key regulatory TFHPosition and function in the center of hair growth. Specifically, when peripheral follicular B cells, which constitutively express PD-1 ligand (PD-L1), are attracted, PD-1 plays a role in inhibiting T cell recruitment into the follicles, thereby enabling T cellsFHCells are concentrated in the germinal center itself. This is for TFHIt is crucial that the cell exerts its own role to support germinal center B cells. PD-1 is also T FHRequired for optimal production of IL-21 by the cells. As a corollary, PD-1 deficient mice had fewer long-lived plasma cells, partly due to more germinal center cell death. Within the germinal center, the interaction of PD-1/PD-L1 also serves to optimize B cell competition and affinity maturation.
Consistent with this, the inventors have also observed clozapine to reduce TFHThere is a highly significant effect on the expression of CXCR5 on cells. CXCR5 is believed to be TFHThe most typical marker for cells, and is required for T cell follicular homing. Notably, CXCR5 deficient T cells, while able to enter the follicular germinal center, are ineffective in supporting GC responses.
Therefore, the results of the studies of the inventors indicate that clozapine is useful for TFHThe formation of functional and germinal centers produces inhibitory effects, at least in part, by altering the expression of PD-1 and
Furthermore, the inventors have also shown that clozapine in addition to up-regulating Foxp3 +In addition to CD25 expression on tregs, Foxp3 was also increased in secondary lymphoid tissues (draining lymph nodes and spleen)+The proportion of regulatory T cells, a population of immunosuppressive T cells (tregs). Foxp3 in the context of lymphoid follicles+T follicular regulatory cells (Tfr) regulate germinal center responses, serving to restrict germinal center B cells and TFHQuantitative and inhibits antibody affinity maturation, plasma cell differentiation and secretion of antigen-specific immunoglobulins. Thus, the results of the inventors' studies suggest that clozapine may act, in part, by Treg interacting with B cells (in addition to providing T cell help to B cells), thereby alleviating the humoral immune response.
Thus, the inventors have adopted the CIA model as a clinically highly relevant experimental system, in which B-cell derived pathogenic immunoglobulins produced in response to sample-specific antigens after B-cell interaction with T-cells (including in the draining lymph node germinal center) (Dahdah et al, 2018) drive 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 IgG1 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.
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 immunoglobulin driven B cell disease with a T cell component in a subject, in particular wherein said compound causes the inhibition of 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 a)). Also shown are serum immunoglobulin profiles adapted from (Ponsford et al, 2018a) 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).
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). B cell subset as CD19+ cellsFor gating, the definition is 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), lymphPercentage of cells (% L), or absolute value (abs). Mean ± SEM (see example 2).
FIGS. 10A-C show peripheral blood memory B cells (CD 19) for patients with non-clozapine antipsychotic ('control', left) and 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).
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) tableShown in the figure. Mean ± SEM (see example 2).
Figures 15A-C show the results of metaphase data on peripheral plasmablast levels in patients with non-clozapine antipsychotic ('control', left) and clozapine (right), as total B cells (CD 19), respectively+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 (see example 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 clozapine versus control for Treg in spleen and regional lymph nodes of CIA mice (CD 4)+/CD25+/FoxP3+) The effect of the cells. Mean ± SEM (see example 4).
FIG. 39 shows the effect of clozapine on CD25 expression on Tregs in the spleen and regional lymph nodes of CIA mice compared to control. MFI, mean fluorescence intensity. Mean ± SEM (see example 4).
FIG. 40 shows the effect of clozapine on FoxP3 expression on Tregs in the spleen and regional lymph nodes of CIA mice compared to controls. MFI, mean fluorescence intensity. Mean ± SEM (see example 4).
FIG. 41 shows a schematic of the protocol for in vitro generation/differentiation of human plasma cells (see example 5).
Figure 42 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 immunoglobulin driven B cell disorder having a T cell component in a subject by administering to the subject an effective amount of a compound selected from clozapine, norclozapine and prodrugs thereof, and pharmaceutically acceptable salts and solvates thereof, in particular, wherein the compound inhibits mature B cells in the 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 immunoglobulin driven B cell disease with a T cell component in a subject, in particular wherein the compound causes mature B cells to be inhibited 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 immunoglobulin-driven B cell disease with a T cell component" includes B cell-mediated diseases, in particular autoimmune diseases, which involve pathogenic immunoglobulins (e.g. IgG, IgA and/or IgM) which target autoantigens (e.g. autoantibodies IgG, IgA and/or IgM) and have T cell-mediated inflammation as a major mechanism. The term also includes immunological rejection of allografts, for example in graft versus host disease.
The range of autoantigens involved in autoimmune diseases includes myelin (multiple sclerosis), pancreatic beta cell protein (
Exemplary pathogenic IgG-driven B cell diseases with a T cell component may be the skin-related diseases vitiligo, psoriasis, celiac disease, dermatitis herpetiformis, or discoid lupus erythematosus. Alternatively, the disease may be a muscle-related disease dermatomyositis or polymyositis. Alternatively, the disease may be the pancreas-related
Alternatively, the disease may be graft versus host disease.
References which illustrate the role of pathogenic immunoglobulins, B and T cells in the above diseases include:
vitiligo
Vitiligo is an acquired chronic de-pigmenting disease caused by the selective destruction of melanocytes (Ezzedine et al, 2015).
Vitiligo patients often show higher autoantibodies than controls, including anti-thyroid peroxidase, anti-thyroglobulin, antinuclear, anti-parietal cell and anti-adrenal antibodies (Liu and Huang,2018), some of which are associated with vitiligo clinical activity (Colucci et al, 2014). Vitiligo is associated with elevated total IgG, IgG1 and IgG2, as well as melanocyte-reactive antibodies, compared to controls (Li et al, 2016 b). The latter are most commonly directed against pigment cell antigens (Cui et al, 1992), including melanin-concentrating hormone receptor 1(Kemp et al, 2002). It has been proposed that melanocyte death in vitiligo reflects apoptosis and is promoted in vitro by serum IgG in vitiligo patients (Ruiz-argueles et al, 2007). Notably, IgG (and C3) deposition has been observed in the basal membrane region of the diseased skin. Furthermore, the binding of IgG from vitiligo patients to cultured melanocytes increases with the extent and activity of the disease, and vitiligo activity is also associated with anti-melanocyte IgA levels (Kemp et al, 2007).
Although debate has been made as to whether the presence of autoantibodies in vitiligo reflects a major cause or consequence of disease, it is clear that vitiligo autoantibodies have the ability to cause pigmented cell damage through a variety of effector mechanisms, including antibody-dependent cellular cytotoxicity and complement-mediated cell damage in vitro (Cui et al, 1993; Norris et al, 1988).
Autoantibodies blocking MCHR function have also been identified in vitiligo patients, which are expected to interfere with normal melanocyte function (Gottumukkala et al, 2006). In addition to the role of MCHR1 as a B cell autoantigen, the importance of B cells in vitiligo was further suggested by the identification of Bcl-2 positive infiltrates in close proximity to the depigmenting region (Ruiz-argueles et al, 2007). Vitiligo has also been reported to respond to B cell depletion using monoclonal antibodies against CD20 (Ruiz-argueles et al, 2013).
Notably, T regulatory cells (tregs) are deficient in vitiligo, and the increase in PD-1 expressing tregs suggests depletion of tregs and a possible role in vitiligo pathogenesis (Tembhre et al, 2015). Loss of this inhibition and CD8+Over-activation of cytotoxic T cells is involved, which is known to play a key role in vitiligo-induced depigmentation (Lili et al, 2012).
Primary Biliary Cirrhosis (PBC)
Primary Biliary Cirrhosis (PBC), also known as primary biliary cholangitis, is a chronic cholestatic liver disease that is pathologically characterized by progressive intrahepatic small bile duct destruction with associated portal inflammation, fibrosis and risk of progression to cirrhosis, and serologically (> 95%) characterized by anti-mitochondrial antibodies (AMA) and generally elevated serum IgM (Carey et al, 2015). Notably, autoantibodies (such as anti-centromere) are strongly associated with the risk of progression to cirrhosis and portal hypertension (Nakamura, 2014).
Although T cells have been reported to constitute a large proportion of the cellular infiltrate of early PBC, B cells/plasma cells have also been identified (Tsuneyama et al, 2017). In particular, in PBC patients, follicular aggregates of IgG and IgM expressing plasma cells have been noted to form around intrahepatic ducts, which is further associated with higher AMA titers (Takahashi et al, 2012). The findings of oligoclonal B-cell proliferation and accumulation of somatic mutations in the hepatic portal region of PBC patients are consistent with antigen-driven B-cell responses (Sugimura et al, 2003). Sustained severe B cell responses in PBC were also indicated by the discovery of high levels of autoantigen-specific peripheral plasmablasts (directed against the pyruvate dehydrogenase complex autoantigen PDC-E2) consistent with sustained activation of autoreactive B cells (Zhang et al, 2014). Notably, newly diagnosed PBC patients exhibit elevated numbers of circulating T follicular helper and plasma cells, both positively correlated with each other and with serum AMA and IgM levels (Wang et al, 2015). Rituximab has been reported to reduce PBC patients serum total IgG, IgA and IgM, but also AMA IgA and IgM, and incomplete responses to ursodeoxycholic acid (Tsuda et al, 2012), and limited but distinguishable positive effects on alkaline phosphatase and pruritus (Myers et al, 2013).
Primary Sclerosing Cholangitis (PSC)
PSC is a chronic liver disorder characterized by multifocal biliary strictures and a high risk of biliary duct cancer, and is closely associated with inflammatory bowel disease (Karlsen et al, 2017). Large amounts of autoantibodies were detected in PSC patients, but generally with low specificity, including pANCA, ANA, SMA, and anti-biliary epithelial cells (Hov et al, 2008). Noteworthy and consistent with the known physiological major role of secretory IgA in bile, the presence of autoreactive IgA against biliary epithelia was associated with a faster clinical progression of PSCs (lethal/liver transplantation) (Berglin et al, 2013).
Functional IgA, IgM, and IgG antibody secreting cells have been found in PSC liver explants (Chung et al, 2016). Notably, most of these cells are plasmablasts rather than plasma cells (Chung et al, 2017). Alterations in the peripheral circulating T-follicular helper cell compartment were found in PSCs, which are key promoters of antibody responses (Adam et al, 2018). Supporting the role of the acquired immune response shared by liver and gut in PSCs associated with inflammatory bowel disease, B cells of common clonal origin were found in both tissues, with evidence that higher somatic hypermutations are consistent with (same) antigen-driven activation (Chung et al, 2018).
Like PBC, potentially pathogenic TFH cells (CCR 7)loCXCR5+PD-1+CD4+T cells) suggesting T follicular helper cells (T)FH) Contribution to disease pathogenesis (Adam et al, 2018). Notably, genetic and functional data also support compromised Foxp3+Role of regulatory T cell (Treg) function in promoting immune dysregulation of PSCs (Sebode et al, 2014).
Notably, PSCs are also considered to be part of the IgG 4-associated disease spectrum (gidway et al, 2017), and IgG 4-associated diseases are multi-organ fiber inflammatory disorders that are also associated with autoimmune pancreatitis and increased stabilization of circulating plasmablasts/plasma cells. These cells were decreased following treatment with glucocorticoids (Lin et al, 2017). This correlates with class switching memory B cells and TFHThe cells were all increased, IgG levels were associated with circulating plasma cells and TFHFrequency and apparent tissue TFHEvidence of cellular infiltrationAre all related (Kubo et al, 2018). Evidencing the role of B cells in IgG 4-related diseases, depletion of B cells with rituximab was effective in both induction and treatment of relapse (Ebbo et al, 2017).
Autoimmune thrombocytopenic purpura (immune thrombocytopenia; adult immune thrombocytopenia)
Immune Thrombocytopenia (ITP) is a disease characterized by acquired thrombocytopenia (low platelet count) driven by immune recognition of platelet autoantigens with consequent destruction of platelets.
Early studies highlighted the importance of humoral immune mechanisms, which revealed that infusion of serum from patients with ITP into healthy volunteers resulted in severe thrombocytopenia, which was dose-dependent, and humoral factors could be adsorbed by platelets, appearing in the IgG fraction (Harrington et al, 1951; Karpatkin and Siskind, 1969; Shulman et al, 1965). In addition to IgG autoantibodies against platelet Glycoprotein (GP) IIb/IIIa, IgA and IgM antiplatelet autoantibodies have been found (He et al, 1994), as well as antibodies against other platelet surface proteins such as GPIb/IX, which are highly specific for ITP (McMillan et al, 2003). These autoantibodies cause antibody-dependent platelet phagocytosis by splenic macrophages and peripheral neutrophils seen in vitro (Tsubakio et al, 1983) and in vivo (Firkin et al, 1969; Handin and Stossel, 1974). Notably, the number of platelet-associated IgG is inversely related to platelet count (Tsubakio et al, 1983).
In addition to promoting platelet destruction, autoantibodies have also been shown to directly affect the maturation of bone marrow megakaryocytes (Nugent et al, 2009). GPIIb/IIIa and GPIb/IX are both expressed on megakaryocytes, whereas autoantibodies are found to bind to them in ITP (McMillan et al, 1978). Furthermore, plasma from patients with ITP inhibits megakaryocyte production and maturation in vitro, an effect that is ameliorated by the adsorption of autoantibodies to immobilized antigens, and is also seen in patient IgG rather than control IgG (McMillan et al, 2004).
Splenectomized samples from ITP patients exhibited significant follicular hyperplasia with the formation of germinal centers and an increase in plasma cells, consistent with a consistently active B cell response in ITP (Audia et al, 2011). Notably, the frequency of splenic T-follicular helper cells was higher in ITP compared to the control group, splenic pre-germinal central B cells, germinal central B cells were also further expanded (in addition to plasma cells) and all positively correlated with the percentage of T-follicular helper cells (Audia et al, 2014). Depletion of B cells with rituximab is effective in improving platelet counts in about 60% of ITP patients, while patients with continued presence of autoantibodies are more unable to exhibit clinical response (Arnold et al, 2017; Khellaf et al, 2014). Patients resistant to B cell depletion with rituximab showed autoreactive anti-GpIIb/IIIa plasma cells expressing a long-lived gene program in the spleen (Mahevas et al, 2013), highlighting the important role of long-lived plasma cells as a basis for the sustained production of pathogenic autoantibodies mediating platelet destruction and reduced production.
T cells contribute significantly to the pathogenesis of ITP, and evidence suggests that autologous T cells prolong survival and absent Treg function (Wei and Hou, 2016).
Autoimmune Addison Disease (AAD)
AAD is a rare autoimmune endocrinopathy characterized by an abnormal immune destructive response to adrenal corticosteroidal forming cells (Mitchell and Pearce, 2012).
The major autoantigen for AAD is steroid 21-hydroxylase, and most (> 80%) patients exhibit autoantibodies against this antigen (Dalin et al, 2017), and serum from AAD patients reacts with the globular band of the adrenal cortex (Winqvist et al, 1992). Anti-adrenal antibodies are predictive of the progression to dominant disease or subclinical adrenal insufficiency in other autoimmune patients (Betterle et al, 1997). Notably, the level of adrenal autoantibodies correlates with the severity of adrenal dysfunction, suggesting a correlation with the destructive stage of autoimmune adrenalitis. In contrast, patients who exhibit biochemical remission of adrenal dysfunction, including biochemical remission in response to corticosteroid therapy, also exhibit loss of adrenal cortex autoantibodies and 21-hydroxylase autoantibodies (De Bellis et al, 2001; Laureti et al, 1998). While it is not clear whether these autoantibodies are directly pathogenic (especially in view of their intracellular targets), organ-specific reactive antibodies have been demonstrated from AAD serum (Khoury et al, 1981).
Histologically, AAD is characterized by a diffuse inflammatory infiltrate, including plasma cells (Bratland and rosebye, 2011).
Genetic support for the important role played by B cells in AAD susceptibility comes from the identification of BACH2 as a major risk site (Eriksson et al, 2016; Pazderska et al, 2016). BACH2 encodes a transcriptional repressor that is required for class switch recombination and somatic hypermutation in B cells by regulating the B cell gene regulatory network (Muto et al, 2010; Muto et al, 2004). Administration of rituximab induced B cell depletion in AAD, which has been reported to be effective in one new case, with evidence of a sustained improvement in cortisol and aldosterone (Pearce et al, 2012).
Supporting the T cell component in the pathogenesis of AAD, a high frequency of 21-hydroxylase-specific T cells, CD8, is recognized in patients+T cells are able to lyse 21-hydroxylase positive target cells (Dawoodji et al, 2014).
Multiple Sclerosis (MS)
MS is an inflammatory demyelinating disease of the Central Nervous System (CNS).
Although MS is generally conceptualized as a CD4 Th1/Th 17T cell-mediated disease, based primarily on findings using an Experimental Autoimmune Encephalomyelitis (EAE) model, T cell-specific therapy did not show significant efficacy in relapsing-remitting MS (Baker et al, 2017). In contrast, many effective MS immunomodulation and disease-modifying therapies are identified that affect the B cell compartment and/or deplete memory B cells, whether physiologically or functionally (Baker et al, 2017; Longbrake and Cross, 2016).
The most recognized and persistent immunodiagnostic abnormality in MS (i.e., the presence of oligoclonal bands, usually of the IgG subtype (but also IgM), in cerebrospinal fluid (CSF)) is the product of B-lineage cells (Krumbholz et al, 2012). Notably, the cloned IgG in CSF is time-stable, consistent with local production of antibody secreting cells from either resident long-lived plasma cells or matured from memory B cells (Eggers et al, 2017). anti-CD 20 treatment reduced CSF B cells but had no apparent effect on the oligoclonal band, indicating that long-lived plasma cells play a fundamental role in the generation of oligoclonal bands (Cross et al, 2006). The correlation of the immunoglobulin group in CSF samples showed strong overlap with the transcriptome of CSF B cells, highlighting the latter as a source (Obermeier et al, 2008). Most of the B cells in the CSF of MS patients are memory B cells and short-lived plasmablasts, the latter being the major source of intrathecal IgG synthesis, and MRI revealed that they are associated with parenchymal inflammation (Cepok et al, 2005), with evidence suggesting that they are more involved in acute inflammation associated with relapsing-remitting MS (Kuenz et al, 2008).
Pathologically, there are organized ectopic tertiary lymph node-like structures with germinal centers in the meninges of MS (Serafini et al, 2004). As with parenchymal lesions, IgG (about 90%, remainder IgM) is predominantly used for B cell cloning in meningeal aggregates (Lovato et al, 2011). In addition, antigen-contacted B cell clones were shared between these meningeal aggregates and the corresponding parenchymal lesions (Lovato et al, 2011). In addition, flow cytometry and deep immune pool sequencing of peripheral blood and CSF B cells indicated that peripheral class switch B cells, including memory B cells, are linked to CNS compartments (palanicomy et al, 2014). Notably, memory B cells have recently been shown to promote autoreactive CD4 of Th1 brain homing in MS +Autoimmune proliferation of T cells (Jelcic et al, 2018).
The most characteristic autoantigen in MS is Myelin Oligodendrocyte Glycoprotein (MOG), which is the target of autoantibodies in EAE, against which antibodies are found in about 20% of children with demyelinating disease, but relatively few adults (Krumbholz et al, 2012; Mayer and Meinl, 2012). Evidence supporting the role of pathogenic autoantibodies in MS includes the therapeutic efficacy of plasma exchange in some patients (Keegan et al, 2005), and the presence of complement-dependent demyelinating/axonogenic autoantibodies in a subset of MS patients (Elliott et al, 2012). Other autoantibodies have been identified to be directed against axonal glial proteins surrounding the nodes of langerhans, including autoantibodies directed against contactin-2 and fascin, and there is evidence that use of in vivo models can result in significant axonal damage after transfer with MOG-specific encephalitogenic T cells, and inhibition of axonal conduction when used with hippocampal slices in vitro (Mathey et al, 2007).
Demonstrating the key role of B cells in relapsing-remitting MS, rituximab depletion of B cells using the chimeric anti-CD 20 antibody reduced brain inflammatory lesions and clinical relapse (Hauser et al, 2008). Similar clear positive effects were also observed in relapsed MS (Hauser et al, 2017) and primary progressive MS (Montalban et al, 2017) using other CD20 depleting agents such as ocrilizumab (humanized monoclonal anti-CD 20 antibody).
Illustrating the cross-talk between B-cells and T-cells in MS, circulating TFH cells are expanded in MS and associated with disease progression, and they are also present in lesions where they can promote inflammatory B-cell functions, including antibody secretion (Morita et al, 2011; Romme Christensen et al, 2013; Tzartos et al, 2011).
T1DM is an autoimmune disease characterized by immune-mediated destruction of islet beta cells. Although the major cellular effector of islet beta cell destruction is generally thought of as islet antigen-reactive T cells, there is a substantial body of evidence that B cells are also involved in the pathogenesis of this process and disease (Smith et al, 2017).
A non-obese diabetic (NOD) mouse model of autoimmune diabetes shows autoimmune insulitis. B-cell deficient NOD mice exhibit inhibition of insulitis, preservation of islet beta cell function, and protection from diabetes, as compared to NOD mice, suggesting that B cells are critical for the development of diabetes in this model (Akashi et al, 1997; Noorchashm et al, 1997). Similar findings were also observed by using anti-CD 20-mediated B cell depletion, including reversal of established hyperglycemia in a significant proportion of mice (Hu et al, 2007). Demonstrating an important role of B cells in the pathogenesis of human T1DM, depletion of B cells with rituximab in newly diagnosed T1DM patients may result in partial preservation of islet β cell function after 1 year (Pescovitz et al, 2009).
Studies in NOD mice have shown that the presentation of islet autoantigens by B cells to T cells is an important component of their pathogenic role (Marino et al, 2012; Serreze et al, 1998). Alterations in peripheral blood B cell subsets, including a decrease in transitional B cells and an increase in plasmablast numbers, have been identified in T1DM patients (parkacova et al, 2017). Furthermore, activated T follicular helper cells in the circulation are increased in newly diagnosed T1DM children and in high-risk children who are autoantibody positive (weisanen et al, 2017).
The preclinical stage of T1DM is characterized by the presence or absence of islet autoantibodies in the circulation, such as autoantibodies to glutamate decarboxylase 65(GAD65) and insulinoma antigen 2(IA 2). Most children with multiple islet autoantibody seroconversion positive at genetic risk for T1DM subsequently developed clinical diabetes (Ziegler et al, 2013). Although these autoantibodies predict the development of T1DM, their precise pathogenic role is controversial. Supportive evidence for its pathogenicity comes from studies in NOD mice, where blocking maternal-fetal transmission of autoantibodies from pre-diabetic NOD mice protects progeny from developing diabetes (greeney et al, 2002). Notably, NOD mice lacking the IgG activating Fc receptor (Fc γ R) were protected from spontaneous pathogenesis of T1DM (Inoue et al, 2007).
Celiac disease and dermatitis herpetiformis
Celiac disease is a chronic immune-mediated enteropathy directed against dietary gluten in genetically predisposed individuals (Lindfors et al, 2019). The acquired immune response plays a key role in the pathogenesis of celiac disease, characterized by the production of two antibodies against gliadin (IgA and IgG) and
Celiac autoantibodies bring about a number of potential pathogenic effects (Caja et al, 2011), including antibodies of the IgA subclass, such as: interfering with intestinal epithelial cell differentiation (Halttunen and Maki, 1999); promote the reverse transcytosis of prolamins, which enter the intestinal mucosa to cause inflammation (Matysiak-Budnik et al, 2008); increase intestinal permeability and induce monocyte activation (Zanoni et al, 2006); and inhibition of angiogenesis by targeting vascular TG2 in the lamina propria (Myrsky et al, 2008).
The specificity of gluten and TG 2B cells has been thought to act as gluten-specific CD4+Antigen presenting cells of T cells, HLA-deamidated gluten peptide-T cell receptor interaction leads to activation of both T and B cells, which differentiate into plasma cells, with consequent production of antibodies against prolamin and endogenous TG2 (du Pre and Sollid, 2015; Sollid, 2017).
Although genetic association studies have emphasized CD4+The key role of T cells in the pathogenesis of celiac disease, but the integrated multisystem biological approach emphasizes a significant role of B cell responses in celiac disease (disease SNPs are significantly enriched in B cell specific enhancers) (Kumar et al, 2015).
Patients with active celiac disease showed a clear expansion of TG 2-specific plasma cells in the duodenal mucosa. Further increases in extracellular IgM and IgA are evident in lamina propria and epithelial cells in response to gluten, consistent with an active immunoglobulin response within the small intestine mucosa (Lancaster-Smith et al, 1977). Notably, TG 2-specific IgM plasma cells have been described in celiac disease, which may play a pathogenic role through their ability to activate complement to promote inflammation. Indeed, in untreated and partially treated (but unsuccessfully treated) celiac patients, subepithelial deposition of the terminal complement complex has been observed, correlating with gluten-specific IgM and IgG levels in serum (Halstensen et al, 1992).
Dermatitis herpetiformis is a pruritic, vesicular skin disorder believed to be a cutaneous manifestation of celiac disease (Collin et al, 2017). It is characterized by a granular IgA deposition within the dermal papilla of the uninvolved skin (Caja et al, 2011). Dermatitis herpetiformis patients show autoantibodies against epidermal TG3, which are gluten-dependent, responding slowly to a gluten-free diet (Hull et al, 2008). Its pathogenesis is thought to involve active celiac disease in the gut, leading to the formation of
Notably, in one example of refractory dermatitis herpetiformis, depletion of B cells with rituximab resulted in complete clinical and serological remission (Albers et al, 2017). Similarly, rituximab resulted in significant clinical improvement in one mixed case of symptomatic celiac disease and sjogren's syndrome (Nikiphorou and Hall, 2014).
Psoriasis disease
Psoriasis is a chronic immune-driven disease that affects primarily the skin and joints (Greb et al, 2016). Pathophysiologically, psoriasis involves components of innate and acquired immunity, particularly T cells (particularly T)H17 cells), dendritic cells, and keratinocytes (Greb et al, 2016).
Analysis of psoriatic arthritis synovium revealed frequent ectopic lymphogenesis, which can drive local antigen-driven B cell development, with marked decline after treatment (Canete et al, 2007). Critically, these tertiary lymphoid structures triggered by persistent inflammation comprise highly organized follicles, partitioned B-and T-cell regions, and follicular dendritic cell networks, providing a substrate for a generation-centric response to support local (aberrant) acquired immune responses to locally presented antigens, including autoreactive lymphocyte clonal cell survival and pathogenic immunoglobulin production (Canete et al, 2007; Pipi et al, 2018).
Psoriasis has recently been found to be associated with several serum autoantibodies, including IgG directed to LL37(Cathelicidin) and ADAMTSL5 (disintegrin and metalloprotease domain-
Analysis of peripheral blood lymphocyte subpopulations showed that psoriasis patients circulate activated B cells and T cells compared to healthy donorsFHCytosis and serum IL-21 elevation; notably, the level of each of these factors is positively correlated with psoriasis severity (Niu et al, 2015). Of functional importance, circulation T from psoriatic patientsFHThe cells show signs of activation and produce higher levels of cytokines, which are significantly reduced after treatment. In addition, psoriatic lesions exhibit a broad TFHInfiltration (Wang et al, 2016 b). Patients with psoriasis have been found to produce fewer IL-10-producing regulatory B cells (i.e., B10 cells), exhibit impaired activity, and are negatively associated with IL-17 and IFN- γ producing T cells (Mavropoulos et al, 2017).
Depletion of B cells using rituximab has been reported to induce newly formed psoriatic lesions (das et al, 2007), although this is controversial (Thomas et al, 2012), but improves arthritis (Jimenez-Boj et al, 2012), highlighting the complex role of B cells in the pathogenesis of the disease and the importance of nonstandard B cell function (i.e., in addition to autoantibody production), including but not limited to cytokine production and antigen presentation to affect autoreactive T cells (Hayashi et al, 2016; Yoshizaki et al, 2012).
Idiopathic Inflammatory Myopathy (IIM) including Dermatomyositis (DM) and Polymyositis (PM)
DM and PM are inflammatory myopathies, usually resulting in symmetric proximal myopathies, differing in clinical characteristics, pathology and clinical response/prognosis (Findlay et al, 2015). DM is characterized by skin damage and (usually except in the case of sarcopenia) inflammation of skeletal muscle. PM traditionally refers to a term attributed to idiopathic inflammatory myopathy when neither DM nor sporadic inclusion body myositis (Findlay et al, 2015). Other recognized IIM subtypes include necrotizing autoimmune myositis and overlap syndrome (Dalakas, 2015).
Supporting the role of B cells, IIM is associated with myositis-specific and myositis-associated autoantibody production (clinically useful in diagnosis), including for DM (anti-MDA-5, anti-Mi-2, anti-TIF-1, anti-NXP-2), PM (anti-synthetase antibody), necrotizing autoimmune myositis (anti-HMGCR, anti-SRP) and inclusion body myositis (anti-cN 1A) (Dalakas, 2015). Notably, autoantibody levels in myositis patients have been shown to decrease with B cell depletion and to correlate with changes in disease activity (Aggarwal et al, 2016).
DM is believed to be essentially humoral, complement activation mediated by pathogenic antibodies against endothelial cells, leading to necrosis, ischemia, and myofiber destruction (Kissel et al, 1986), a complement-mediated microvascular pathology. Indeed, ectopic lymphoid structures have been found in skeletal muscle of DM patients, including evidence of germinal centers with dark/light zone tissue and molecular evidence of in situ B cell differentiation (Radke et al, 2018). PM and inclusion body myositis have traditionally been thought to be predominantly CD8 +Cytotoxic T cell-mediated diseases, however, a large enrichment of plasma cells was found in muscle biopsies of patients with these diseases, with high expression of immunoglobulin transcripts (Greenberg et al, 2005). Further supporting the local B cell antigen specific response in PM and inclusion body myositis, affinity maturation was found within IgH chain gene transcripts of local B cells and plasma cells in patients (including somatic mutations, class switching and oligoclonal expansion), but not in control muscle tissue (Bradshaw et al, 2007). Similar B cell clonal diversification was also noted in DM, consistent with antigen-driven chronic B cell responses in inflammatory muscles (McIntyre et al, 2014).
BAFF (B cell activating factor, belonging to the tumor necrosis factor family) is a key factor in B cell survival and maturation, with serum levels significantly elevated in DM, associated with increased expression of BAFF over normal controls in the peri-musculoskeletal region of patients (Baek et al, 2012). Notably, in myositis patients, BAFF receptor expression has been co-localized with or near plasma cells and B cells, and there is a correlation between the number of cells expressing BAFF receptors and plasma cell frequency, particularly those expressing anti-Jo-1 or anti-Ro 52/Ro60 autoantibodies, consistent with local BAFF driven differentiation of plasma cells in myositis (Krystufkova et al, 2014). Supporting these altered functional roles, expression of the BAFF pathway is positively correlated with disease activity in idiopathic inflammatory myopathy (Lopez De Padilla et al, 2013).
Supporting the key pathogenic role of B cells in idiopathic inflammatory myopathy, refractory rashes have been shown to improve in response to B cell depletion using rituximab (Aggarwal et al, 2017), evidence suggesting some clinical response in DM or PM patients (Mok et al, 2007; Oddis et al, 2013; Sultan et al, 2008).
Showing T-B cell interaction and CD4 in DM+A specific role of T cells in assisting B cell responses is that circulating T cellsFHAlterations in cell subpopulations have been observed to favor subtypes that are B-cell assisted, thereby promoting immunoglobulin production by IL-21 (Morita et al, 2011). Notably, such a cycle TFHThe cells promote the differentiation of primary B cells into plasmablasts (Morita et al, 2011).
Interstitial Lung Disease (ILD)
ILD encompasses a complex and heterogeneous series of diseases including Idiopathic Pulmonary Fibrosis (IPF), hypersensitivity pneumonitis, drug-related ILDs, sarcoidosis, and ILDs associated with connective tissue disease and familial/other syndromes (Wallis and spines, 2015).
Supporting the role of B cells in driving ILD progression, rituximab was used in severe, progressive non-IPF ILD patients who were ineffective against conventional immunosuppression, showing evidence of improved lung capacity and stable carbon monoxide dispersion (Keir et al, 2012; Keir et al, 2014). Rituximab was reported to bring a striking clinical improvement in one patient with severe refractory hypersensitivity pneumonitis (Lota et al, 2013), a condition associated with germinal cell formation in bronchial-related lymphoid tissues (Suda et al, 1999). Favorable responses to B cell depletion in severe ILD cases associated with anti-synthetase (Sem et al, 2009) and systemic sclerosis (Sari et al, 2017) were also reported.
IPF is associated with circulating IgG autoantibodies (Feghali-Bostwick et al, 2007), and morphological evidence of microvascular damage is associated with deposition of IgG, IgM and IgA within the septal microvasculature, suggesting antibody-mediated microvascular damage (Magro et al, 2006). Established autoantigens include
Histology of the lungs of IPF patients also identified abnormal B cell aggregates, including germinal center formation, particularly near fibroproliferative regions (Campbell et al, 1985; Marchal-Somme et al, 2006). In addition, IPF is associated with elevated circulating and local CXCR13 (a source from CD 4)+Chemokines of T cells, promoting pathological B cell trafficking and the formation of ectopic lymphoid structures, and elevated in some autoantibody-mediated disorders), which is associated with exacerbation and poor outcome, suggesting a pathogenic role for CXCR13 and B cells in IPF (Vuga et al, 2014; yoshitomi et al, 2018). Furthermore, the circulating plasmablast pool in IPF is expanded and there is evidence for higher antigenic differentiation of circulating B cells and a significant increase in plasma levels of BLyS (B lymphocyte stimulating factor), a key contributor to B cell survival and differentiation, and patients showing the highest levels of BLyS are also the lowest survival patients for one year (Xue et al, 2013).
In the context of IPF, there is evidence to support the use of therapeutic plasmapheresis and rituximab to target the effects of pathogenic autoantibodies to mitigate acute respiratory exacerbations in critically ill patients with IPF, which might otherwise be fatal within a few days (Donahoe et al, 2015). Notably, plasmapheresis is associated with a reduction in anti-Hep-2 autoantibodies in patients who respond to treatment (Donahoe et al, 2015).
Inflammatory Bowel Disease (IBD) -Ulcerative Colitis (UC) and Crohn's Disease (CD)
UC is an idiopathic IBD characterized by colonic and rectal inflammation.
UC is associated with the expansion of a subpopulation of circulating plasma cells of B cells and an increase in serum IgG (Wang et al, 2016 a). Notably, inflammatory markers (CRP and ESR) are positively correlated with plasmablast levels and serum IgG levels. In contrast, treatment with mesalazine decreased plasmablast levels in UC (Wang et al, 2016 a).
UC is associated with the formation of autoantibodies, mainly anti-neutrophil cytoplasmic antibodies (ANCA) and anti-goblet cell antibodies, the latter being considered as potentially specific antibodies, and both contributing to differentiation in early CD cases (Conrad et al, 2014). Emphasizing the pathogenic role of autoantibodies in UC, complement activation was found to be associated with epithelial-bound IgG (Brandtzaeg et al, 2006). The massive infiltration of colon by B cells and plasma cells known in UC, like CD, provides them with a local source (Cupi et al, 2014).
Shows altered T follicular regulation and TFHSubgroup (which is a critical T cell subgroup for the balanced regulation of B cell responses) effect that UC patients exhibit circulating TFHIncreased cells, but lower levels of T-follicular regulatory cells, as well as increased IL-21 and decreased IL-10 (Wang et al, 2017). Of note, serum IL-21 levels and circulating TFHCellular levels were positively correlated with clinical severity scores and systemic inflammatory markers, while circulating T-follicular regulatory cells (T)FR) And IL-10 levels remained reversed (Wang et al, 2017). Such a TFR/TFHAn imbalance in ratios is also observed in other typical B-cell driven pathogenic immunoglobulin mediated diseases such as myasthenia gravis.
Albeit atDepletion of B cells with rituximab in a clinical trial setting has not proven effective in steroid-unresponsive, moderate UC (Leiper et al, 2011), but colonic-colonized plasma cells have been shown to be unaffected by this therapy, suggesting that failure to target this B cell/anatomical compartment may contribute to the observed lack of efficacy (Uzzan et al, 2018). Notably, the pathogenic effects of plasma cells may not be limited to the production of pathogenic autoantibodies, both UC and CD being characterised by IgA expressing granzyme B +Mucosal accumulation of plasma cells, granzyme B is a serine protease induced by B-cell IL-21 and is involved in the induction of apoptosis following cytotoxic cellular challenge (Cupi et al, 2014; Hagn et al, 2010).
CD is characterized by transmural inflammation of the gastrointestinal tract and any effect on any part of it, and like UC, exhibits a significant increase in plasma cells of the intestinal lamina propria, a common source of IgG and monomeric IgA (Uzzan et al, 2018). Notably, IgG plasma cells are associated with the severity of intestinal inflammation (Buckner et al, 2014). In addition, B cells are thought to localize around a key pathological hallmark of CD, intestinal granulomas (Timmermans et al, 2016). Analysis of circulating class-switching memory B cells in CD showed an increase in the level of somatic hypermutation consistent with chronic stimulation (Timmermans et al, 2016). Notably, the alteration of the peripheral B cell compartment is improved upon effective treatment of inflammation by targeting TNF- α (Timmermans et al, 2016).
Like UC, CD patients exhibit an abnormal B cell response, in the form of detectable (IgG/IgA) autoantibodies or antimicrobial antibodies, including antibodies Against Saccharomyces Cerevisiae (ASCA) and antibodies Against Neutrophils (ANCA), and serological markers predictive of disease prior to diagnosis (Quinton et al, 1998; van Schaik et al, 2013), and risk of relapse after surgical resection (Hamilton et al, 2017). Emphasizing their pathogenic potential, autoantibodies directed against the cytokine granulocyte macrophage colony-stimulating factor (GM-CSF) are produced by lamina propria cells and are associated with stenotic behavior (which may reflect their ability to attenuate neutrophil function) and increased intestinal permeability (Jurickova et al, 2013).
Showing the effect of T cells in promoting the CD observed B cell phenotype, circulating T patients compared to controlsFHCells were increased (Wang et al, 2014 b).
Autoimmune thyroid disease (AITD) including Graves 'disease and Hashimoto's thyroiditis
AITD is an organ-specific autoimmune disorder characterized by a disruption of the self-tolerance to thyroid antigens. Genome-wide association studies revealed a role of genetic variation of B cell signaling molecules in the development of AITD (Burton et al, 2007), including FCRL3(Chu et al, 2011B) and BACH2(Muto et al, 2004), which are involved in B cell tolerance, maturation and class switching.
Pathologically, AITD is manifested by massive accumulation of lymphocytes within the thyroid gland, including B cells at the time of diagnosis (particularly hashimoto's thyroiditis) and production of anti-thyroid antibodies (Zha et al, 2014). Patients with recently-developed AITD show thyroid-antigen-reactive B cells in peripheral blood, which are no longer anergic, but express the activation marker CD86, consistent with the activation of these cells to drive autoantibody production (Smith et al, 2018).
Graves' disease is characterized by the production of pathologically specific agonistic IgG autoantibodies directed against the thyrotropin receptor (found in 80-100% of untreated patients) which mimic TSH, stimulating thyroid hormone overproduction and goiter (Singh and Hershman, 2016). Transient and pre-primary mature B cell elevation in peripheral blood of Graves' patients, levels positively correlated with levels of free thyroxine (Van der Weerd et al, 2013). The increased levels of BAFF (B lymphocyte activator), a key factor that promotes the production of autoantibodies by B cells by increasing B cell survival and proliferation, in the serum of graves' disease patients and decreased responsiveness to methylprednisolone treatment, are consistent with B cell-driven pathophysiological processes and potentially contribute to the expansion of these B cell populations (vannuchi et al, 2012). Hyperthyroidism itself may promote plasmacytosis to increase plasma cells in the bone marrow (Bloise et al, 2014). In a mouse immunization model of the graves' disease model, B-cell depletion using an anti-mouse monoclonal CD20 antibody administered before or 2 weeks after immunization effectively inhibited the production of anti-TSHR antibodies and hyperthyroidism (Ueki et al, 2011). Reflecting this situation, rituximab also has been shown to be clinically effective against graves' ophthalmopathy (salivi et al, 2013).
In hashimoto thyroiditis, B cells produce autoantibodies to thyroglobulin (> 90% of patients) and thyroid peroxidase, which leads to thyroid follicular apoptosis via antibody-dependent cell-mediated cytotoxicity. Plasma cell accumulation associated with foci of thyroid follicular destruction has been noted in thyroidectomy specimens from hashimoto thyroiditis patients (Ben-Skowronek et al, 2013).
TFHCytoregulated B cells produce (auto) antibodies, which are found to be amplified in circulation in AITD patients, in positive correlation with autoantibody titers and free thyroid hormone levels in graves' disease; furthermore, these cells were reduced as treatment progressed and were found to be enriched in thyroid tissue in hashimoto thyroiditis patients (Zhu et al, 2012).
Autoimmune uveitis and autoimmune retinopathy
Uveitis refers to inflammation of the eye tissue, ranging from the anterior chamber, including the iris and ciliary body, to the vitreous, to the posterior structures (retina or choroid) (Smith et al, 2016). Notably, uveitis has been observed to be associated with systemic autoimmune and inflammatory diseases, such as seronegative spondyloarthritis, IBD, psoriatic arthropathy, behcet's disease, rheumatoid arthritis, juvenile idiopathic arthritis, as well as infectious diseases and other etiologies (Selmi, 2014). Thus, autoimmune uveitis is a group of diseases of the eye that are deprived of immune privilege, which may be associated with diseases affecting other tissues.
Autoimmune retinopathy is associated with progressive loss of vision associated with anti-retinal antibodies (Grange et al, 2014). Autoantibodies to a variety of retinal proteins have been found, including retinal-specific proteins such as recoverin (recoverin) which localizes in photoreceptors and alpha-enolase (Ren and Adamus,2004), the former also being described in cancer-related retinopathies. Anti-restin antibodies are able to penetrate the retinal layer and promote apoptotic photoreceptor cell death (Adamus, 2003). Notably, autoimmune retinopathy patients exhibit alterations in peripheral mature B cell memory subpopulations, including evidence of activation of primary memory B cells and alterations in subtype profiles (Stansky et al, 2017).
Mouse models of autoimmune uveitis indicate T helper cells, particularly
Evidence for the involvement of B cells in autoimmune uveitis includes: b-cell and vitreous immunoglobulins are present in intraocular inflammatory infiltrates (Godfrey et al, 1981; Nguyen et al, 2001), and relief of ocular disease is associated with the development of a Combined Variable Immunodeficiency (CVID), a primary immunodeficiency syndrome associated with impaired B-cell differentiation and hypogammaglobulinemia (Amer et al, 2007), elevation of serum BAFF in autoimmune diseases with uveitis (Gheita et al, 2012), and a response to rituximab (described below).
Highlighting the role of B-cell mediated homeostatic regulation of T-cell function (perturbed in experimental models of uveitis) is the tension-inhibiting effect on T-cell trafficking by B-cell derived peptide release (PEPIITEM)Loss, promoting T cell recruitment to promote chronic tissue damage (Chimen et al, 2015). In addition, IL-35-promoted induction of regulatory B cells has a protective role in experimental autoimmune uveitis, in part by suppressing pathogenic TH17 and
Notably, rituximab-depleted B cells showed therapeutic efficacy in stabilizing and/or improving vision in patients with autoimmune retinopathy (Maleki et al, 2017) and autoimmune uveitis and scleritis (Hardy et al, 2017; Pelegrin et al, 2014).
Mixed Connective Tissue Disease (MCTD) and Undifferentiated Connective Tissue Disease (UCTD).
MCTD is a systemic autoimmune disease characterized by the presence of antibodies to U1-RNP (U1-ribonucleoprotein).
In addition to being a serological marker for MCTD diagnosis, anti-U1-RNP autoantibodies are thought to play a central pathogenic role (Tani et al, 2014), including binding to pulmonary arterial endothelial cells (which can contribute to pulmonary arterial hypertension via triggering endothelial cell inflammation) (Okawa-Takatsuji et al, 2001). Further evidence strongly suggests that this antibody plays a role in the pathogenesis of MCTD, which results from studies involving immunization of mice with antigenic peptides of the U1-70-kd subunit of U1 snRNP, in which anti-RNP antibodies and MCTD-like autoimmunity were induced, including the development of interstitial lung disease (Greidinger et al, 2006). Autoantibodies are also thought to promote tissue damage in MCTD via immune complex formation and complement activation (Szodoray et al, 2012).
In addition to U1-RNP, other findings that show altered humoral acquired immunity to MCTD are the frequent presence of other autoantibodies (such as ANA), hypercholesterolaemia, and polyclonal B-cell hyperreactivity and activation (Hajas et al, 2013).
Consistent with the change in B cell homeostasis in MCTD, analysis of peripheral B cell subsets showed changes in the number of transitional, primary and memory B cells, as well as an increase in the number of plasma cells associated with anti-U1-RNP levels (Hajas et al, 2013). Furthermore, as with other connective tissue disorders, abnormalities in bone marrow have also been reported, including an increase in the number of plasma cells associated with lymphoid aggregates (Rosenthal and Farhi, 1989).
Supporting an important role of B cells in MCTD pathology, depletion of B cells using rituximab has been shown to stabilize lung function in patients with interstitial lung disease of interest (Lepri et al, 2016). Further supporting the role of pathogenic immunoglobulins and/or immune complexes in MCTD are plasmapheresis (Seguchi et al, 2000), immunoadsorption (Rummler et al, 2008), including those combined with anti-CD 20 therapy (Rech et al, 2006), the therapeutic effects of which are reported.
Emphasizing that the T cell component may contribute to the pathogenesis of MCTD, the level of circulating tregs is reduced, even lower in active disease patients.
UCTD describes a group of non-classifiable systemic autoimmune diseases that overlap with the serological and clinical features of well-defined Connective Tissue Diseases (CTDs), such as SLE, systemic sclerosis, DM, PM, MCTD, rheumatoid arthritis, and sjogren's syndrome, but do not meet the criteria for classification as a specific CTD (Mosca et al, 2014). Notably, a significant proportion of these patients continue to evolve into clear CTD (Mosca et al, 2014). Patients often appear positive for antinuclear antibodies (ANA).
UCTD patients have been shown to exhibit a significant increase in the expression of the activation marker CD86 on circulating B cells, while circulating plasma cells and T cellsFHThere was a nominally, but not statistically significant, increase in cells (Baglaenko et al, 2018). Showing the T cell component of the disease, UCTD patients showed lower levels of circulating CD4+CD25+Foxp3+Regulatory T cells (Tregs) and increased INF- γ production (Szodoray et al, 2008).
Autoimmune connective tissue diseases such as Systemic Lupus Erythematosus (SLE); discoid Lupus Erythematosus (DLE).
Systemic lupus erythematosus is a multisystemic prototype autoimmune Connective Tissue Disease (CTD), mainly affecting women, biased toward affecting kidneys, joints, central nervous system and skin, and the presence of autoantibodies to nucleic acids and nucleoproteins (Kaul et al, 2016).
Systemic lupus erythematosus is associated with autoantibodies, some of which are present years before clinical onset, such as IgG/IgM antiphospholipid antibodies, antinuclear antibodies (ANA), and the like (McClain et al, 2004). Other antibody targets and disease associations include: c1q, dsDNA and smith (sm) in lupus nephritis, Ro (SSA, sjogren's syndrome associated antigen) and la (ssb) in secondary sjogren's syndrome and cutaneous lupus, U1-RNP and Ro in interstitial lung disease, prothrombin and
In addition to autoantibody production indicating that B cell self-tolerance is disrupted, there is a number of lines of evidence that B cells are a major participant in SLE pathophysiology. Active lupus patients exhibit a deficiency in central and peripheral B cell tolerance that will promote survival and activation of autoreactive B cells (Jacobi et al, 2009; Yurasov et al, 2005). Hyperfunction of B cells and interaction of plasmacytoid dendritic cells with RNA-containing immune complexes serve to promote further expansion of B cells (Berggren et al, 2017).
A mouse model exhibiting systemic lupus erythematosus-like pathology spontaneously forms germinal centers with increased numbers of plasma cells, a decreased threshold for B cell activation, and impaired elimination of autoreactive B cells (Kil et al, 2012). Lupus-predisposed mice exhibit expansion of antigen-activated Marginal Zone (MZ) B cells, which migrate to lymphoid follicles to interact with CD4+T-cell engagement, promoting autoantibody production, is consistent with breakthrough of follicular exclusion (Duan et al, 2008; Zhou et al, 2011).
B cells and T cellsCellular interactions are a key factor in the pathogenesis of SLE, including via activation of autoreactive B cells by T cell subsets and promotion of T-derived responses FHCell-supported germinal center high affinity autoantibodies. Mouse Lupus model display TFHIs associated with autoantibody levels (Kim et al, 2015), in part by TFHCellular release/mediated elevated IL-21(Bubier et al, 2009) and ICOS-dependent (Mittereder et al, 2016) signal transduction drives. Similarly, the results of studies from SLE patients indicate that activated TFHIncreased cell levels correlate with autoantibody titers, disease-affected organ severity, and plasma cell numbers, with evidence of downregulation in response to corticosteroids (Feng et al, 2012; Simpson et al, 2010), notably these circulating T' sFHCells are phenotypically similar to those present in germinal centers, correlate with circulating plasmablast levels, and promote differentiation of B cells into IgG-secreting plasma cells in vitro (Zhang et al, 2015).
Other roles that support B-cells as disease key mediators of systemic lupus erythematosus are the clinical efficacy of B-cell depletion using rituximab in refractory patients (Iaccarino et al, 2015), including lupus nephritis (Davies et al, 2013) and neuropsychiatric lupus (Tokunaga et al, 2007) in addition to rapidly progressing crescentic cases. Notably, the more rapid recovery of memory B-cell and plasmablast populations following rituximab was associated with earlier disease recurrence (Vital et al, 2011). Notably, the use of rituximab in SLE is also associated with alterations in cytokine levels and T cell phenotype, not just with simple B cell depletion, suggesting an impact on the latter as a possible contributor to its therapeutic efficacy (Tamimoto et al, 2008). Supporting the pathogenic role of autoantibodies in lupus, the use of immunoadsorption to remove autoantibodies provides clinical benefit for refractory diseases (Kronbichler et al, 2016).
DLE is the most common form of chronic skin SLE, associated with polyclonal B cell activation (Wangel et al, 1984), and an increase in the number of B cells in the skin (hussei et al, 2008), which can promote skin fibrosis through cytokine release, and is further enhanced by BAFF (Francois et al, 2013) and T cell dominance (Andrews et al, 1986). Notably, SLE-like abnormalities have been found in circulating B cells of discoid lupus erythematosus, including association with clinical disease criteria (Kind et al, 1986; Wouters et al, 2004). Furthermore, depletion of B cells using rituximab has been shown to be effective on skin manifestations of SLE (Hofmann et al, 2013) and DLE (Quelhas da Costa et al, 2018).
Immune-mediated inflammatory diseases (IMID), such as scleroderma (SS, systemic sclerosis), rheumatoid arthritis and sjogren's disease
SS is an immune-mediated inflammatory disease characterized by fibrosis of the skin and internal organs and vasculopathy (Denton and Khanna, 2017).
SS is associated with the formation of autoantibodies, including anti-centromere, anti-Scl-70, anti-RNA polymerase III (and other ANA), and strongly associated with the manifestation/visceral involvement and fate of the disease (Nihtyanova and Denton, 2010). Evidence that autoantibodies serve as pathogenic drivers of SS complications includes documentation of functional autoantibodies targeting platelet-derived growth factor receptor (PDGFR) that promote PDGFR stimulation and expression of collagen and alpha-smooth muscle actin to support a profibrotic phenotypic shift in fibroblasts (Gunther et al, 2015). Other functional autoantibodies detected in SS include antibodies directed against those targeting angiotensin II
SS is associated with polyclonal B-cell activation and increased serum IgG (Famularo et al, 1989). Notably, circulating B cells from SS patients overexpress CD19, consistent with elevated intrinsic B cell activation, expected to promote autoantibody production (Tedder et al, 2005). An increase in activation markers, which can also be seen specifically in the memory B cell pool of SS, has an enhanced ability to produce IgG in vitro (Sato et al, 2004). Notably, diffuse cutaneous variation of SS is associated with an expanding circulating population of class-switching memory B cells (Simon et al, 2016). Further supporting the alteration of B-cell homeostasis in SS, elevated levels of key cytokines and B-cytokines involved in regulating B-cell activation, survival or homing were found in serum, including IL-6, BAFF and CXCL13(forest et al, 2018). Notably, BAFF is upregulated in the affected skin of SS patients, and an increase in serum BAFF levels is associated with new disease or exacerbation of organ involvement, whereas a decrease in serum BAFF is observed with regression of skin lesions (Matsushita et al, 2006).
Pathologically, skin lesions have been shown to include cellular infiltrates containing plasma cells (Fleischmajer et al, 1977). Furthermore, it was shown that T cells regulate the action of autoantibodies produced by B cells FHPhenotypic T cells (including ICOS-expressing) infiltrate skin lesions of SS and are associated with both skin fibrosis and clinical disease status (Taylor et al, 2018). As a corollary, administration of anti-ICOS antibodies or IL-21 neutralization to a murine model of SS-GVHD (graft versus host disease) reduced skin inflammation and/or fibrosis (Taylor et al, 2018).
Clinically, depletion of B cells using rituximab has been shown to have beneficial effects on lung function (or stabilization) and improve skin thickening in SS associated with interstitial lung disease (daousis et al, 2017; Jordan et al, 2015).
Rheumatoid Arthritis (RA)
RA is associated with a large number of autoantibodies, most described as rheumatoid factor and anti-citrullinated protein antibody (ACPA), but also includes other antibodies, such as anti-carbamoylated protein antibody and anti-acetylated protein antibody. Like SLE, the presence of these autoantibodies can precede clinical manifestations by years and also be associated with radiation disease progression (Derksen et al, 2017).
ACPA antibodies include IgG, IgA and IgM, which suggest that ACPA can bind to inflammatory RA joints in view of the presence of citrullinated proteins in synovial fluid (Derksen et al, 2017). A mouse model of collagen-induced arthritis develops antibodies to CII and cyclic citrullinated peptides early after immunization, and administration of a mouse monoclonal antibody to citrullinated fibrinogen enhances arthritis and binds to inflammatory joint synovium (Kuhn et al, 2006). Notably, the Fab-domain of ACPA shows a large number of N-linked glycans, which may alter its properties to promote specific effector functions of ACPA IgG, such as binding to immune cells (Hafkenscheid et al, 2017). Immune complexes containing ACPA and citrullinated fibrinogen can stimulate the production of TNF via binding to Fc γ receptors on macrophages (Clavel et al, 2008), including macrophages from patient synovial fluid (Laurent et al, 2011). Activation of complement by autoantibodies is also a possible pathogenic mechanism of RA, with evidence supporting the demonstration of enhanced complement activation in synovial fluid from RA patients and the ability of ACPA to activate complement via the classical and alternative pathways (Trouw et al, 2009). Pathogenic autoantibodies have also been associated with RA-related bone loss (enhanced osteoclast differentiation mediated by IL-8) (Krishnamurthy et al, 2016).
RA is associated with central and peripheral B cell tolerance defects, contributing to an overabundance of autoreactive B cells in the mature primary B cell subflush, increasing the proportion of polyreactive antibodies recognizing immunoglobulins and cyclic citrullinated peptides (Samuels et al, 2005B). Notably, despite immunosuppressive therapy in RA, the frequency of autoreactive mature naive B cell clones after treatment is still elevated, consistent with a primary early B cell tolerance deficiency and the limited ability of current therapeutic approaches to address this deficiency (Menard et al, 2011).
Early RA has high serum BAFF levels, associated with titers of IgM rheumatoid factor and anti-cyclic citrullinated peptide autoantibodies and joint involvement; furthermore, levels of BAFF improve in response to methotrexate treatment in synchrony with clinical severity and autoantibody levels (Bosello et al, 2008). Notably, elevated levels of cytokines that favor B cell activation and survival, particularly BAFF and APRIL (a proliferation-inducing ligand involved in class switch recombination and plasma cell differentiation and survival), have been found in early RA, including enrichment in synovial fluid, suggesting a major role in disease (Moura et al, 2011). Pathologically, the synovial membrane of RA joints shows infiltration of plasma cells, which is positively correlated with APRIL levels in synovial fluid (Dong et al, 2009).
Supporting the key role of T-B interaction in activating autoreactive B cells, T cells promote extrafollicular B cell responses, amplifying autoantibody production by CD40L and IL-21 signaling as an alternative means of activating B cells via Toll-like receptors (Sweet et al, 2011). Furthermore, mice lacking CXCR5 on T cells were resistant to the development of CIA, showed impaired germinal center formation, and were unable to mount an IgG1 antibody response to CII (moskovakis et al, 2017). RA patients show peripheral circulation TFHCell expansion, which correlates with autoantibody titers; it is noteworthy that circulating plasmablast levels in RA correlate with clinical disease activity and inflammatory markers (CRP, ESR) (Nakayamada et al, 2018). In this context, plasmablasts, in addition to secreting antibodies, are responsible for presenting antigens to T cells and promoting T cell differentiation, thereby perpetuating joint inflammation (Nakayamada et al, 2018). Notably, TFHCells were also found in RA synovium with regulatory T cells (tregs) (Penatti et al, 2017) as part of the immune infiltration (Chu et al, 2014). Suggesting a potential pathogenic consequence of the latter, tregs appear to be functionally impaired in RA and have improved efficacy following anti-TNF- α therapy (Ehrenstein et al, 2004). Importantly, although CD4 +CD25+Foxp3+Tregs are enriched in inflammatory RA synovium, but they appear to be poorly functional, suggesting a weaker ability to mediate immune tolerance (Sun et al, 2017). The underlying mechanism for this observation is that inhibition of B-cell derived IFN- γ mediated Treg differentiation was shown to promote autoimmune experimental arthritis in mice (Olalekan et al, 2015).
Depletion of B cells with rituximab in RA significantly ameliorates the symptoms of RA (Edwards et al, 2004), including patients resistant to anti-TNF-alpha therapy (Cohen et al, 2006). Rituximab was more effective in RA for seropositive cases (i.e. patients exhibiting ACPA and RF); in addition, positive clinical responses were associated with a significant reduction in autoantibodies and inflammatory markers (Cambridge et al, 2003) and the extent of B cell depletion (Vancsa et al, 2013). Depletion of autoantibodies using immunoadsorption has also been shown to be effective against refractory RA (Furst et al, 2000), which may be related in part to clearance of immune complexes and potentially due to clearance of complement components (kinebaum et al, 2009).
Sjogren's syndrome (SjS; sjogren's disease)
SjS is a systemic autoimmune disease that ensures destruction of tissues primarily by inflammatory infiltrates and IgG plasma cells (especially saliva and lacrimal glands) leading to inflammation and destruction of exocrine glands, but can lead to systemic disease characterized by periepithelial infiltration of lymphocytes and immune complex deposition (Brito-Zeron et al, 2016). The latter include T cells, B cells and plasma cells (Hansen et al, 2007). Systemic involvement, such as kidney disease, is also characterized by a significant enrichment of these cells, especially plasma cells (Jasiek et al, 2017).
SjS syndrome is associated with many autoantibodies directed against autoantigens including Ra, La, Fc fragments of IgG and muscarinic M3 receptors. IgG autoantibodies targeting M3 from SjS patients have been shown to exert an anti-secretory effect in mouse and human acinar cells that is expected to impair salivary production and contribute to the dry mouth (xerostomia) observed in patients (Dawson et al, 2006).
Ectopic formation of germinal centers is found in the salivary glands of SjS, where B-cell-T-cell interactions are important for the pathogenesis of disease and B-cell dysregulation (Pontarini et al, 2018). SjS additional evidence of B cell hyperactivity includes autoantibody production, hypergammaglobulinemia and increased risk of developing B cell non-Hodgkin's lymphoma (Hansen et al, 2007).
Inflammatory salivary glands from SjS patients showed a very significant up-regulation of BAFF expression, partly produced by T cells (Lavie et al, 2004), and elevated BAFF was also found in serum, expected to promote an environment favorable for the survival of autoreactive B cells. Of importance in SjS to support this regulator of B cell survival and differentiation is that transgenic mice overexpressing BAFF, of a phenotype similar to human SjS, develop severe sialadenitis and submandibular gland destruction (Groom et al, 2002).
Peripheral circulation TFHCells expanded in SjS patients and also appeared in saliva, the latter being associated with memory B cells and plasma cells, suggesting TFHCells contribute to the pathophysiology of SjS by promoting B cell maturation (Jin et al, 2014). It is noteworthy that the increase in salivary plasma cell content was positively correlated with serum ANA levels of SjS (Jin et al, 2014). Depletion of B cells using rituximab reduces circulating TFHCellular level, reduced IL-17 producing CD4+T cells and serum IL-21 and IL-17, and circulating TFHThe reduction in cells was associated with a decrease in clinical measures of disease activity, suggesting the mechanistic importance of B-cell to T-cell cross-talk (crosstalk) to SjS (Verstappen et al, 2017).
Some evidence of clinical efficacy in SjS of B cell depletion using rituximab includes improvement of salivary gland ultrasound scores (Fisher et al, 2018). Supporting the role of enhanced B cell activation in SjS, targeting BAFF using belimumab was effective in reducing the clinical activity index (Mariette et al, 2015).
Graft Versus Host Disease (GVHD)
GVHD is the most common life-threatening complication of allogeneic hematopoietic stem cell transplantation. Although the immune pathogenesis and initiation of acute GVHD is thought to be driven by immune activation and challenge resulting from the recognition of new hosts as foreign by immunocompetent T cells in donated graft tissue (Zeiser and Blazar,2017), B cells also have a significant role in chronic GVHD in particular.
Emphasizing the deficiency in B-cell homeostasis in GVHD, B-cell derived antibodies against histocompatibility antigens (also targets for donor T cells) are evident in GVHD and associated with disease (Miklos et al, 2005). In both acute and chronic forms of GVHD, dermal-epidermal immunoglobulin deposition associated with C3 complement deposition is observed (Tsoi et al, 1978). Murine models of GVHD also demonstrate the ability of antibodies from donor B cells to damage the thymus and peripheral lymphoid organs, and the cutaneous pathogenicity of TH17 infiltration was correlated, thereby enhancing GVHD (Jin et al, 2016).
Chronic GVHD patients show a significantly increased BAFF/B cell ratio compared to patients without GVHD and healthy donors (Sarantopoulos et al, 2009). Notably, an increase in serum BAFF levels correlates with an increase in circulating pro-germinal center B cells and plasmablasts (Sarantopoulos et al, 2009). Notably, B cells from chronic GVHD patients exhibit an increased metabolic state, as well as reduced pro-apoptotic signals, enabling them to survive (Allen et al, 2012).
Studies in the mouse models of chronic GVHD and bronchiolitis obliterans revealed a stable germinal center response at the onset of disease, organ fibrosis associated with B220+ B cell and CD4+ T cell infiltration and deposition of alloantibodies (Srinivasan et al, 2012). The key role of germinal center formation was demonstrated by the associated follicular T-B cell interaction and pathogenic alloantibody formation, and blockade of germinal center formation inhibited the development of GVHD (Srinivasan et al, 2012). Similarly, donor splenocytes CD4 were depleted in the GVHD mouse model +T cells can prevent abnormal formation of germinal center and TFHAnd germinal center B cells, while B220+Depletion of allogeneic splenocytes from B cells also reduces germinal center B cells and TFHExcessive development of cells, showing interdependence between them (Shao et al, 2015).
The use of rituximab-depleted B cells as a first-line treatment of chronic GVHD has proven effective, with circulating ICOShiPD-1hiTFHThe reduction of cells was associated (Malard et al, 2017).
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 immunoglobulin driven B cell disease having a T cell component in a subject, and (ii) a method of treating or preventing a pathogenic immunoglobulin driven B cell disease having a T cell component in a subject by administering to the 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 immunoglobulin driven B cell disease having a T cell component is selected from the following diseases: vitiligo, psoriasis, celiac disease, dermatitis herpetiformis, discoid lupus erythematosus, dermatomyositis, polymyositis,
In certain diseases, specific Ig classes (e.g., IgG, IgA) are thought to play a role in the pathology of the disease. For example, in dermatitis herpetiformis and celiac disease, the production of pathogenic IgG and IgA is thought to contribute to the disease. For example, IgG is thought to contribute to multiple sclerosis, vitiligo, autoimmune addison's disease, type I diabetes, primary biliary cirrhosis, primary sclerosing cholangitis, pathogenic and autoimmune thrombocytopenic purpura. The inventors found that clozapine significantly reduced class switching memory B cells and would therefore reduce the number of ASCs and secretion of specific immunoglobulins, which means that pathogenic IgG and IgA levels should be reduced. The inventors also found that clozapine reduced total IgG and total IgA levels.
In one embodiment, the pathogenic immunoglobulin is a pathogenic IgG. In one embodiment, the pathogenic immunoglobulin is a pathogenic IgA. In one embodiment, the pathogenic immunoglobulin is a pathogenic IgM.
Preferably, the pathogenic immunoglobulin driven B cell disease having a T cell component is psoriasis, an autoimmune connective tissue disease such as systemic lupus erythematosus, an Immune Mediated Inflammatory Disease (IMID) such as scleroderma, rheumatoid arthritis or sjogren's disease.
Clozapine is associated with high levels of central nervous system penetration, which may prove valuable properties in the treatment of certain such diseases (Michel et al, 2015).
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.
A compound selected from clozapine, norclozapine and prodrugs thereof, and pharmaceutically acceptable salts and solvates thereof, 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 as 2H (deuterium),3H、11C、13C、14C、18F、123I or125I, which may be a naturally occurring or non-naturally occurring isotope.
Clozapine or norclozapine, and pharmaceutically acceptable salts of clozapine or norclozapine, containing the aforementioned isotopes and/or other isotopes of other atoms, are useful for 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. Providing the composition for treating or preventing a pathogenic immunoglobulin driven B cell disease having a T cell component 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 immunoglobulin driven B cell diseases, such as those drugs that inhibit B cell and/or T cell and/or B cell and 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), and other antibodies (such as ARGX-113, PRN-1008, SYNT-001, or the like, Veltuzumab (veltuzumab), ocrelizumab, ofatumumab (ofatumumab), obinutuzumab, ublituximab, alemtuzumab, milatuzumab, epratuzumab, and blinatumumab). Rituximab may be mentioned in particular.
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 immunoglobulin driven B cell disease having a T cell component, in combination with a second or further therapeutic agent for the treatment or prevention of a pathogenic immunoglobulin driven B cell disease having a T cell component, for example selected from the group consisting of: 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). Rituximab may be mentioned in particular.
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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