What’s New in Lupus

1. MEDICINE OF THE HIGHEST ORDER What’s New in Lupus Jennifer H. Anolik, MD, PhD Associate Professor of Medicine Division of Allergy, Immunology & Rheumatology University of Rochester Medical Center 2010

2. Systemic Lupus Erythematosus • Inflammatory multisystem disease primarily seen in females (90%), but can be seen at any age in either sex • Highly variable course and prognosis, ranges from mild to life threatening • ~50% of patients can have severe internal organ involvement which can be life threatening without treatment • Characterized by flares and remissions • Associated with characteristic autoantibodies

3. Updates • What’s new in treatment • Diagnosis • Biomarkers • What causes lupus?

4. Why there is a critical need for research in SLE • A 26 yo African American female presents to the ER with new ankle swelling. Work up reveals SLE with involvement of her kidneys. Treatment with cyclophosphamide is begun. Despite improvement, 5 years later, she is unable to conceive due to ovarian failure. • A 36 yo Caucasian female with established SLE wakes up on her wedding day with a severe red facial rash, swollen joints, and high fever. • A 15 yo Hispanic female is having trouble concentrating, complains of hair loss and fatigue, and during class one day falls to the floor and begins having a grand mal seizure. SLE is diagnosed.

5. What we’re doing at the U of R • The Rochester Autoimmunity Center of Excellence • University-wide NIH-funded multidisciplinary center • One of only 9 in the country • Ongoing Lupus projects in the division under this center (Sanz, Looney, Anolik) include: • Unraveling the mechanisms that underlie the breakdown of B-cell tolerance in SLE • Defining abnormalities in B cells in SLE • Biomarkers • Delineating the role of cytokines like interferon and BAFF in SLE • Understanding the immunological consequence of B-cell depletion and other targeted therapies in the treatment of SLE • Role of T and B cells in diabetes; Mechanisms of RA • Clinical Trials: Vitamin D (ALE02)

6. What we’re doing at the U of R • Lupus Clinical Trials Consortium • 20 centers • Infrastructure grants to support clinical trials • Collaborative Longitudinal Lupus Registry • Which medications are effective for which features of lupus? • How do lupus disease manifestations change over the course of time • How does lupus differ in various racial/ethnic groups and in different geographical areas?

7. What we’re doing at the U of R • Investigation of new, targeted biological interventions in SLE • The AIR unit has an active program in clinical trials in systemic lupus erythematosus • B cell targeted therapies: rituximab, anti-BAFF • Antagonism of interferon alpha, a cytokine of key importance in the pathogenesis of SLE • Antagonism of other key B cell activating cytokines • Blockade of co-stimulatory pathways • Inhibition of plasma cells: proteasome inhibitors

8. New Treatments for Lupus • It has been over 50 years since a new drug was approved for lupus • WHY? • Lupus is hard to study: • Clinical expression is heterogeneous • Pathology is diverse • Disease activity is intermittent • Lack of agreed upon disease activity measures and endpoints • Small patient populations- rare disease • Development costs: Estimated $1 billion to take a drug from the research stage to FDA approval • Lack of a clinical trial infrastructure

9. Steps for drug approval • Pre-clinical studies – Non-Human • Phase I studies – 1st time in humans <100 people • What are the side effects and what dose should be given? • Phase II studies – 100+ people • Does the drug work and are there other side effects? • Phase III studies – 1000+ people • Does the drug work and is it safe long term?

10. There is a need for new, targeted therapies • Recent work has focused on identifying biologic molecules critical to the lupus disease process and strategies to remove or neutralize them: ‘targets’ Klippel et al. ‘Rheumatology’, 2nd edition; MMWR 2002; Dubois ‘SLE’ 1997

11. Biological Therapies • Proteins that affect cells or signals in the immune system • Usually need to be injected or infused (IV)

12. EBV? Baseline immunological abnormalities Infection Hormonal factors Abnormal (control of) immune responses SLE SLE - Etiology • The etiology of SLE remains unknown • Yet, SLE is clearly multifactorial: • Genetic factors • Immunologic factors • Hormonal factors • Environmental factors Genetic predisposition

13. New biologic therapies under study in SLE DC CD22 CTLA4 B7 • B cell elimination: • B cell depleting: anti-CD20 • B cell depleting/modulating: anti-CD22 • Specific autoreactive B cell depletion: LJP394 • Co-stimulatory blockade: • anti-CD40L, CTLA4-Ig, anti-ICOSL • Other: anti-cytokine, anti-survival factors, factors up-stream and down-stream of B cells • anti-BAFF, TACI-Ig • anti-IL-10, anti-IL-6 • anti-IFN • anti-TNF , LTaB • anti-CXCL13 • proteasome inhibition CD20 T-cell B-cell CD40 TACI BCMA BAFFR CD40L FcRIIb

14. Rituximab targets CD20 specifically expressed on the surface of B cells Mouse Human IgG1 B cells Plasma cells Pro-B Pre-B Immature Transitional Mature Immature Mature      /  CD20

15. B cell depletion therapy (BCDT) continues to expandin the treatment of autoimmune diseases FDA-approved Others • Rheumatoid Arthritis (Anti-TNF failures) • Sjogren’s • Scleroderma • Myositis • Anti-phospholipid syndrome • ITP • TTP • Transplant rejection • Inflammatory bowel disease • Chronic Graft-versus-host disease • Blistering skin diseases • Idiopathic membranous nephropathy • Pulmonary hypertension • Hepatitis C cryoglobulinemia • IgM-associated polyneuropathy • Uveitis • Autoimmune paraneoplastic syndromes RCT completed • RR MS • Extra-renal SLE • PP MS • Renal SLE • Type 1 Diabetes • ANCA-mediated vasculitis

16. SLE Clinical Trials at the U of R B cell depletion • Targeting B cell with anti-CD20 • Initial studies • Rituximab in general lupus (Genentech; phase II/III): completed • Rituximab in proliferative lupus nephritis (LN) (Genentech; phase II/III): completed • Ocrelizumab in LN (Roche; phase III): terminated • Anti-CD22: phase IIb trial reported superior response rates compared to placebo at week 12 in recent press release

17. 100 Non-depleters (6) 10 (Lymphocytes/ul) Depleters (11) CD19+ 1 0.1 0 3 6 9 12 Months In Phase I/II open label studies B cell depletion is variable and correlates with clinical response <0.05 Anolik et al. Arthritis and Rheum 48:455, 2003 Anolik et al. Arthritis Rheum 50:3580, 2004 Anolik et al. Arthritis Rheum 56:3044, 2007

18. Multi-center randomized trial: EXPLORER African-Americans/Hispanics p=0.0408 Responders Merrill et al. Arthritis and Rheum 62:222, 2010

19. Time to First Flare Over 52 Weeks (post hoc) P = 0.0524

20. B cell depletion in SLE • Ongoing use in refractory SLE • ?Future clinical trials in subsets of disease

21. BLyS/BAFF and APRIL Functionsand Therapeutic Agents

22. BLyS/BAFF and APRIL Functionsand Therapeutic Agents

23. Belimumab (anti-BAFF) for Treatment of SLE • Acts by restoring potential for autoantibody-producing B • cells to undergo normal process of cell death. • Early trial results show significantly delayed time to SLE flare • Recent Belimumab Phase III studies: • BLISS 52: n=865; BLISS 76: n=819 • Both studies recently met primary endpoints • Belimumab (LymphoStat-B®=Benlysta) has received a FastTrack Product designation from the U.S. Food and Drug Administration

24. Other approaches to BAFF blockade • Atacicept: Phase 2/3 study • New study in general lupus to start soon Dall’Era MC et al. Arthritis and Rheumatism 56:4142, 2007

25. Other approaches to B cell modulation • Anti-CD22 • EMBLEM Phase II study • In patients with moderate to severe SLE, epratuzumab provided statistically significant improvements in disease activity • In the second half of 2010, UCB will initiate two Phase III studies of epratuzumab for the treatment of patients with moderate to severe lupus. 9th International Lupus Conference 2010

26. SLE Clinical Trials at the U of R: Costimulatory blockade • Targeting costimulation • CD28 • Abatacept plus standard of care (Bristol-Myers-Squibb; phase II/III): recently completed • ICOSL • AMG557 (Amgen; phase I, now phase II)

27. SLE Clinical Trials at the U of R • Targeting cytokines of pathogenic importance • Targeting Interferon α • Anti-interferon α (Genentech; phase I): enrollment complete, ROSE • Targeting TNF • Targeting plasma cells

28. SLE Clinical Trials: Summary • Anti-B cell • Rituximab studies completed • Ocrelizumab in nephritis on hold (Roche; phase III) • Anti-B cell growth factors • Belimumab in non-renal lupus (studies completed) • Atacicept in non-renal lupus (Serono; phase II) • Anti-interferon α • Anti-interferon α (Genentech; phase II completed) • Anti-costimulation • Anti-ICOSL (Amgen; completed) www.clinicaltrials.gov

29. Treatment of SLE: Into the 21st Century BAFF inhibitors Proteasome inhibitors pDC Anti-B cell antibodies sBAFF mBAFF BR3 IFN IFN blockade TLR inhibitors cytokines DC B TLR9 TLR inhibitors B7.1/2 B7.1/2 TLR2 TLR4 TLR6 TLR7 TLR8 IFN blockade CTLA4-Ig Abatacept CD28 CD40 IL-2, 4 IL-10 TNF IFN IL-12p40 IFN T CXCL13 CXCR4 IP-10 S1P CD40L pDC TNF blockade MØ TNF IL-1 IL-6 Cytokine inhibitors IFN- IL-12 IL-23 TNF Lymphocyte signaling inhibitors Chemokine - Lymphocyte trafficking modulators IL-6 blockade PC Anti-B cell antibodies Adapted from Martin & Chan, 2006. Annu. Rev. Immunol. 24:467-96

30. Your participation is important! • There are promising therapies that need to be tested • You don’t have to receive a drug to be involved in Clinical Research • Donate blood to a researcher who is studying Lupus • Companies may lose interest in developing drugs for SLE if trials cannot be completed • Recruitment is one of the biggest obstacles

31. Diagnosis

32. Early signs of lupus • Diagnosing lupus can be difficult • These researchers selected 130 patients who were diagnosed with lupus while they were in the United States military and reviewed medical records and autoantibodies years prior to diagnosis • 104/130 patients had at least one clinical feature present before the diagnosis was made. The initial feature varied widely from patient to patient, but the most common early symptom was arthritis. • 81/104 patients who had clinical symptoms before their diagnosis had detectable ANAs before the initial symptom, often years prior Clinical criteria for systemic lupus erythematosus precede diagnosis and associated autoantibodies are present before clinical symptoms Arthritis & Rheumatism, Volume 56, Issue 7, July 2007, pp. 2344-235; Arbuckle NEJM 2005

33. Biomarkers

34. Proteins on Blood Cells More Accurately Predict Lupus Disease Activity • Current measures of disease activity and prediction of flare have severe limitations • Lupus patients had higher levels of C3d and C4d bound to red blood cells than the healthy people and those with other rheumatic diseases and this correlated with disease activity Erythrocyte C3d and C4d for monitoring disease activity in systemic lupus erythematosus. Kao AH, Navratil JS, Ruffing MJ, Liu CC, Hawkins D, McKinnon KM, Danchenko N, Ahearn JM, and Manzi S. (2010). Arthritis & Rheumatism 62: 837-844

35. Urinary biomarkers • Renal biopsy is the gold standard for diagnosis of renal disease in lupus but is invasive • Cytokines and chemokines in the urine have recently been shown to be elevated in patients with nephritis • High uTWEAK levels were indicative of LN and reflected renal disease activity in longitudinal follow-up Urinary TWEAK as a biomarker of lupus nephritis: a multicenter cohort study. Schwartz N, Rubinstein T, Burkly LC, Collins CE, Blanco I, Su L, Hojaili B, Mackay M, Aranow C, Stohl W, Rovin BH, Michaelson JS, Putterman C.

36. Is there a biomarker for SLE patients who do well long term after rituximab? • In long term followup a subgroup of patients had complete remission: only anti-dsDNA vs. patients with anti-RBPs • B cell biomarkers

37. B cell Biomarkers M T T Naive M N M SLE Short-term responder SLE Long-term responder Healthy adult Neonate T M N CD24 CD38 Anolik et al. Arthritis and Rheumatism 56:3044, 2007

38. What causes lupus?

39. B cells are lymphocytes that play a large role in the humoral immune response (as opposed to the cell-mediated immune response, which is governed by T cells). The principal function of B cells is to make antibodies against soluble antigens. What are B cells and what do they do?

40. MRL-lpr/lpr JH-/- T-cell activation Tissue infiltration B-cells Serum Ab Disease - - - - B Cells are Postulated to Play Multiple Roles in SLE Pathogenesis • Production of self-reactive antibodies • Secretion of inflammatory cytokines • Antigen presentation • Augmentation of T cell activation • Generation of ectopic lymphogenesis MRL-lpr/lpr T-cell activation Tissue infiltration B-cells Serum Ab Disease + + + +

41. Peripheral blood B cell abnormalities in active SLE • We are studying B cell abnormalities as biomarkers of: • Disease activity • Prognosis • Treatment response Healthy Control SLE Anolik..Looney..Sanz et al. A and R 2004, 2007 Wei ..Anolik..Sanz et al. J Imm 2007 Anolik and Sanz ACR 2010

42. Protective B cell functions Pathogenic B cell functions Pathogenic B cell functions Protective B cell functions Disease remission Treatment failure and/or disease exacerbation A Balanced B cell Compartment

43. Genetics and Lupus • Lupus is more common in families with lupus or other immune system diseases • Some groups, such as African Americans, Hispanics, and Asians get lupus more commonly and with more severe symptoms • Twin data • Over 30 SLE associated genes Kaiser and Criswell, Curr Opin Rheum 2010

44. DNA methylation: Epigenetics • DNA methylation affects the accessibility of DNA to factors • The researchers hoped to find out if DNA methylation is different between twins when one twin has lupus and the other does not • In five pairs of identical twins where only one had lupus, there were 49 genes that had different amounts of DNA methylation between the twins with lupus and those without lupus. These 49 genes were the blueprints for proteins that are known to affect the activity of the immune system. Changes in the pattern of DNA methylation associate with twin discordance in systemic lupus erythematosus. Javierre BM, et al. (2009). Genome Research

45. Take Home Messages • Treatment in the future may be driven by the patient’s genetic makeup: personalized medicine • The pathogenesis of SLE is complex with dysregulation of multiple arms of the immune system • Despite improvement in mortality, new treatments are needed given resistant disease and the side effects of current immunosuppressives • A number of biologic molecules critical to the lupus disease process are emerging as logical targets for treatment • Information about disease pathogenesis is leading to targeted biologic therapies