Inhibition of IgE synthesis by anti-IgE: role in long-term inhibition of IgE synthesis by neonatally administered soluble IgE

IgE glycans promote anti-IgE IgG autoantibodies that facilitate IgE serum clearance via Fc Receptors

Background

Recent studies have shown that IgE glycosylation significantly impacts the ability of IgE to bind to its high-affinity receptor FcεRI and exert effector functions. We have recently demonstrated that immunizing mice with IgE in a complex with an allergen leads to a protective, glycan-dependent anti-IgE response. However, to what extent the glycans on IgE determine the induction of those antibodies and how they facilitate serum clearance is unclear.Therefore, we investigated the role of glycan-specific anti-IgE IgG autoantibodies in regulating serum IgE levels and preventing systemic anaphylaxis by passive immunization.

Methods

Mice were immunized using glycosylated or deglycosylated IgE-allergen-immune complexes (ICs) to induce anti-IgE IgG antibodies. The anti-IgE IgG antibodies were purified and used for passive immunization.

Results

Glycosylated IgE-ICs induced a significantly higher anti-IgE IgG response and more IgG-secreting plasma cells than deglycosylated IgE-ICs. Passive immunization of IgE-sensitized mice with purified anti-IgE IgG increased the clearance of IgE and prevented systemic anaphylaxis upon allergen challenge. Anti-IgE IgG purified from the serum of mice immunized with deglycosylated IgE-ICs, led to a significantly reduced elimination and protection, confirming that the IgE glycans themselves are the primary drivers of the protectivity induced by the IgE-immune complexes.

Conclusion

IgE glycosylation is essential for a robust anti-IgE IgG response and might be an important regulator of serum IgE levels.

Evidence that FcRn mediates the transplacental passage of maternal IgE in the form of IgG anti-IgE/IgE immune complexes

BACKGROUND

The mechanism(s) responsible for acquisition of maternal antibody isotypes other than IgG are not fully understood. This uncertainty is a major reason underlying the continued controversy regarding whether cord blood (CB) IgE originates in the mother or fetus.

OBJECTIVE

To investigate the capacity of maternal IgE to be transported across the placenta in the form of IgG anti-IgE/IgE immune complexes (ICs) and to determine the role of the neonatal Fc receptor (FcRn) in mediating this process.

METHODS

Maternal and CB serum concentrations of IgE, IgG anti-IgE, and IgG anti-IgE/IgE ICs were determined in a cohort of allergic and non-allergic mother/infant dyads. Madin-Darby canine kidney (MDCK) cells stably transfected with human FcRn were used to study the binding and transcytosis of IgE in the form of IgG anti-IgE/IgE ICs.

RESULTS

Maternal and CB serum concentrations of IgG anti-IgE/IgE ICs were highly correlated, regardless of maternal allergic status. IgG anti-IgE/IgE ICs generated in vitro bound strongly to FcRn-expressing MDCK cells and were transcytosed in an FcRn-dependent manner. Conversely, monomeric IgE did not bind to FcRn and was not transcytosed. IgE was detected in solutions of transcytosed IgG anti-IgE/IgE ICs, even though essentially all the IgE remained in complex form. Similarly, the majority of IgE in CB sera was found to be complexed to IgG.

CONCLUSIONS AND CLINICAL RELEVANCE

These data indicate that human FcRn facilitates the transepithelial transport of IgE in the form of IgG anti-IgE/IgE ICs. They also strongly suggest that the majority of IgE in CB sera is the result of FcRn-mediated transcytosis of maternal-derived IgG anti-IgE/IgE ICs. These findings challenge the widespread perception that maternal IgE does not cross the placenta. Measuring maternal or CB levels of IgG anti-IgE/IgE ICs may be a more accurate predictor of allergic risk.

Targeting membrane-expressed IgE B cell receptor with an antibody to the M1 prime epitope reduces IgE production

Elevated serum levels of both total and allergen-specific immunoglobulin E (IgE) correlate with atopic diseases such as allergic rhinitis and allergic asthma. Neutralization of IgE by anti-IgE antibodies can effectively treat allergic asthma. Preclinical studies indicate that targeting membrane IgE-positive cells with antibodies against M1 prime can inhibit the production of new IgE and significantly reduce the levels of serum IgE. We report results from two trials that investigated the safety, pharmacokinetics, and activity of quilizumab, a humanized monoclonal antibody targeting specifically the M1 prime epitope of membrane IgE, in subjects with allergic rhinitis (NCT01160861) or mild allergic asthma (NCT01196039). In both studies, quilizumab treatment was well tolerated and led to reductions in total and allergen-specific serum IgE that lasted for at least 6 months after the cessation of dosing. In subjects with allergic asthma who were subjected to an allergen challenge, quilizumab treatment blocked the generation of new IgE, reduced allergen-induced early and late asthmatic airway responses by 26 and 36%, respectively, and reduced allergen-induced increases in sputum eosinophils by ~50% compared with placebo. These studies indicate that targeting of membrane IgE-expressing cells with anti-M1 prime antibodies can prevent IgE production in humans.

Targeting IgE production in mice and humans

Immunoglobulin E (IgE) is pathogenic in allergic diseases such as asthma, allergic rhinitis, atopic dermatitis, and food allergy. Recent studies using genetically modified IgE reporter mice indicate that the majority of serum IgE in mice is produced by short-lived IgE plasma cells, with minor contributions from long-lived IgE plasma cells, and implicate IgG1 and IgE memory B cells as potential sources of IgE memory. Clinical studies using antibodies against IL-13 or the IL-4 and IL-13 receptor subunit IL-4Rα, as well as an antibody against the M1 prime domain of human membrane IgE, indicate that, similar to mice, a proportion of IgE in humans is derived from ongoing IgE immune responses and short-lived plasma cells. Targeting IgE production may lead to new therapies for the treatment of allergic diseases.

Antibodies specific for a segment of human membrane IgE deplete IgE-producing B cells in humanized mice

IgE-mediated hypersensitivity is central to the pathogenesis of asthma and other allergic diseases. Although neutralization of serum IgE with IgE-specific antibodies is in general an efficacious treatment for allergic asthma, one limitation of this approach is its lack of effect on IgE production. Here, we have developed a strategy to disrupt IgE production by generating monoclonal antibodies that target a segment of membrane IgE on human IgE-switched B cells that is not present in serum IgE. This segment is known as the M1' domain, and using genetically modified mice that contain the human M1' domain inserted into the mouse IgE locus, we demonstrated that M1'-specific antibodies reduced serum IgE and IgE-producing plasma cells in vivo, without affecting other immunoglobulin isotypes. M1'-specific antibodies were effective when delivered prophylactically and therapeutically in mouse models of immunization, allergic asthma, and Nippostrongylus brasiliensis infection, likely by inducing apoptosis of IgE-producing B cells. In addition, we generated a humanized M1'-specific antibody that was active on primary human cells in vivo, as determined by its reduction of serum IgE levels and IgE plasma cell numbers in a human PBMC-SCID mouse model. Thus, targeting of human IgE-producing B cells with apoptosis-inducing M1'-specific antibodies may be a novel treatment for asthma and allergy.

Anti-IgE antibodies for the treatment of IgE-mediated allergic diseases

The pharmacological purposes of the anti-IgE therapy are to neutralize IgE and to inhibit its production to attenuate type I hypersensitivity reactions. The therapy is based on humanized IgG1 antibodies that bind to free IgE and to membrane-bound IgE on B cells, but not to IgE bound by the high-affinity IgE.Fc receptors on basophils and mast cells or by the low-affinity IgE.Fc receptors on B cells. After nearly 20 years since inception, therapeutic anti-IgE antibodies (anti-IgE) have been studied in about 30 Phase II and III clinical trials in many allergy indications, and a lead antibody, omalizumab, has been approved for treating patients (12 years and older) with moderate-to-severe allergic asthma. Anti-IgE has confirmed the roles of IgE in the pathogenesis of asthma and helped define the concept "allergic asthma" in clinical practice. It has been shown to be safe and efficacious in treating pediatric allergic asthma and treating allergic rhinitis and is being investigated for treating peanut allergy, atopic dermatitis, latex allergy, and others. It has potential for use to combine with specific and rush immunotherapy for increased safety and efficacy. Anti-IgE thus appears to provide a prophylactic and therapeutic option for moderate to severe cases of many allergic diseases and conditions in which IgE plays a significant role. This chapter reviews the evolution of the anti-IgE concept and the clinical studies of anti-IgE on various disease indications, and presents a comprehensive analysis on the multiple intricate immunoregulatory pharmacological effects of anti-IgE. Finally, it reviews other approaches that target IgE or IgE-expressing B cells.

Anti-IgE monoclonal antibody, omalizumab: a new treatment for allergic asthma

Omalizumab (Xolair Genentech, USA/Tanox, Inc., USA/Novartis Pharma AG, Switzerland) - a humanised antibody to IgE that reduces circulating free IgE - has been developed for the treatment of allergic asthma. It inhibits the early- and late-phase response to allergens, suppresses eosinophilic and T cell inflammation in asthmatic airways and reduces the levels of high-affinity IgE receptors on basophils. In clinical trials of moderate-to-severe asthma, omalizumab allowed a reduction in inhaled corticosteroid dosage while improving peak flows and reducing exacerbations, particularly in patients at high-risk of serious asthma-related morbidity and improved quality of life scores. When added to existing therapies of patients with more severe asthma, omalizumab also improved asthma control. Additionally, in asthma patients with concomitant perennial allergic rhinitis, omalizumab provides improvement in these comorbid conditions. Omalizumab is well-tolerated by asthma patients and represents a new approach to the treatment of the moderate-to-severe asthmatic patient. It is likely that it will first be used at the more severe end of the asthmatic diathesis.

Molecular aspects of allergy

Atopic diseases such as asthma, rhinitis, eczema and food allergies have increased in most industrialised countries of the world during the last 20 years. The reasons for this increase are not known and different hypotheses have been assessed including increased exposure to sensitising allergens or decreased stimulation of the immune system during critical periods of development. In allergic diseases there is a polarisation of the Th2 response and an increase in the production of type 2 cytokines which are involved in the production of immunoglobulin E and the development of mast cells, basophils and eosinophils leading to inflammation and disease. The effector phase of atopy is initiated by interaction with Fc epsilon RI expressed on effector cells such as mast cells and basophils but also found on an ever increasing list of cells. Binding of a polyvalent allergen to the variable part of IgE leads to a cross-link of the receptor that triggers the cell to release histamine and pharmacological mediators of the symptomatic allergic response. Cross-linking of Fc epsilon RI by autoantibodies against the alpha-chain of the Fc epsilon RI, causing subsequent histamine release is thought to be involved in the pathogenesis of other diseases such as chronic idiopathic urticaria (CIU). To date, most therapeutic strategies are aimed at inhibiting and controlling components of the inflammatory response. Recently, new treatment strategies have emerged that focus on the development of preventive and even curative treatments. The most promising therapeutic approaches are aimed at inhibiting the IgE-Fc epsilon RI interaction with the use of non-anaphylactogenic anti-IgE or anti-Fc epsilon RIalpha autoantibodies. Clinical trials in humans using an humanised anti-IgE antibody showed that this antibody was well tolerated and reduced both symptoms and use of medication in asthma and allergic rhinitis. Thus interruption of the atopic cascade at the level of the IgE-Fc epsilon RI interaction with the use of non-anaphylactogenic antibodies is effective and represents an attractive therapy for the treatment of atopic disease.

Peptides derived from IgE heavy chain constant region induce profound IgE isotype-specific tolerance

(BALB/c x SJL)F1 mice, perinatally injected with peptide-N-glyconase F-treated, deglycosylated IgE heavy chain or recombinant IgE heavy chain (CH epsilon 2-CH epsilon 4), were profoundly inhibited in antigen-specific IgE production. There exist minimally two tolerogenic IgE peptides, residing in the CH epsilon 2 and CH epsilon 4 domains. Peptide I, generated by V8 protease, comprises 39 amino acids within CH epsilon 2, beginning at amino acid 103. Peptide E begins at amino acid 312 of the CH epsilon 4 domain and extends through the CH epsilon 4 domain. The total lack of antigen-specific IgE responses in IgE peptide-treated mice was not due to overproduction of interferon-gamma, nor lack of interleukin (IL)-4, as predicted by the Th2/IL-4 paradigm for IgE production. IgE-tolerant mice exhibited comparable levels of circulating anti-IgE antibodies to those of PBS-treated control mice. IgG obtained from sera of both sources failed to inhibit IgE responses in vitro. Moreover, IgE responses of spleen cells from IgE peptides-treated mice were restored by CD4+ T cells from PBS-treated control mice. We hypothesize that regulation of antigen-specific IgE responses is mediated by CD4+ T cells which normally recognize IgE peptides on IgE precursor B cells, and can be rendered tolerant by perinatal IgE peptide treatment.

Anti-IgE in allergic sensitization

Anti-IgE autoantibodies exist predominantly in the sera of patients with atopic disease. For some time such anti-IgE autoantibodies have been considered a phenomenon that may not be of clinical importance. The cloning of such anti-IgE autoantibodies has eliminated doubts of whether these antibodies exist, but it is still unclear whether such autoantibodies play a pathophysiological role. However, there are ongoing clinical trials that use humanized anti-IgE antibodies for passive immunization of atopic individuals. While this approach may not definitely clarify the role of anti-IgE autoantibodies, it will nevertheless clarify the role of IgE.

Is vaccination against IgE possible?

A substantial reduction in the levels of both total and antigen specific IgE will most likely result in improved symptom scores in atopic individuals. Based on this assumption we initiated a project to study the possibility of reducing levels of circulating and mast cell bound IgE, by inducing a strong autoimmune antibody response against IgE in the host. Bacterially produced fusion proteins containing constant domains two (CH2) and three (CH3) of rat IgE directly linked to the glutathione-S-transferase (GST) protein from Schistosoma japonicum or to the maltose binding protein of Esherichia coli were used as the active components of the allergy vaccine. Injection of either of these fusion proteins together with adjuvant led to the induction of a strong autoimmune anti-IgE response in several IgE low or medium responder strains of rats. Vaccination of ovalbumin sensitised Wistar rats with the GST-C2C3 fusion protein resulted in a profound decrease in serum IgE levels and later in a nearly complete block in histamine release from mast cells and basophils upon challenge with either a cross-linking polyclonal anti-IgE antiserum or a specific allergen. This shows that it is possible to reduce IgE levels in an animal to such an extent that it gives a clear clinical effect. Recent studies with an extended panel of rat strains including four IgE high responder strains, indicate that induction of the autoimmune response is dependent on the plasma concentration of IgE before vaccination. A high concentration of IgE has a negative effect on the induction of autoimmunity, most likely by inducing a B-cell tolerance in the host. Vaccinated subjects with very high IgE concentrations thereby responds poorly to the vaccine. Current studies are aimed at overcoming this potential limitation of the vaccination procedure.

Anti-IgE therapy

Controlling the IgE response at either the synthesis level or the effector phase should have a profound impact on the allergic cascade. For more than a decade, researchers have focused on ways of interfering with the binding of IgE to its high-affinity receptor on proinflammatory cells. Several approaches have also been taken to antagonize the complex interplay of cytokines and cell-associated molecules (CD40, CD23) that are implicated in IgE synthesis. Recently, anti-IgE antibodies have been developed that are potent IgE antagonists. These antibodies are currently under clinical investigation as potential therapeutics for allergic disease.

Do autoantibodies to IgE play a role in IgE-mediated events?

Elevated blood levels of IgG anti-IgE are detectable in individuals exhibiting enhanced IgE production, namely those with allergic conditions and helminthic parasite infections. The fact that there are epitope-specific subpopulations of autoanti-IgE suggests that this autoantibody could potentially have multiple effects in immunological events involving IgE.

Inhibition of human IgE synthesis by anti-IgE antibodies requires divalent recognition

We used a selection of well-characterized murine monoclonal anti-IgE antibodies to investigate their effect on human in vitro IgE synthesis. We found anti-IgE antibodies that either inhibited or enhanced interleukin-4 plus anti-CD40-induced in vitro IgE synthesis in peripheral blood mononuclear cells (PBMC). This differential activity was isotype specific as neither IgM nor IgG synthesis were affected. Interestingly, only coding IgE mRNA was down-regulated, whereas germ-line epsilon RNA expression was not influenced by anti-IgE monoclonal antibody (mAb). On purified B cells all anti-IgE mAb inhibited interleukin-4 plus anti-CD40-induced IgE synthesis, implying a role of non-B cells for the enhancing activity observed in PBMC. Using Fab and F(ab')2 of an inhibitory anti-IgE mAb we could show that divalent recognition was required for inhibition of IgE synthesis.

High anti-IgE levels at birth are associated with a reduced allergy prevalence in infants at risk: a prospective study

Development of atopic disease was prospectively studied in 148 children from birth to the age of 18 months and related to serum levels of IgG anti-IgE antibody. Children with a dual heredity of allergy, but remaining healthy, had significantly higher IgG anti-IgE levels at birth than children with a similar predisposition to allergy, who became allergic. Children with increased allergy risk, defined by elevated IgE levels at birth (> = 0.53 kU/l) and with probable allergy symptoms had also significantly higher IgG anti-IgE levels at birth than children of the same risk group, developing definite allergy. Independent of allergy risk, there was a significantly lower prevalence of atopic disease in children with cord serum levels of IgG anti-IgE above 350 AU/l than in children with lower levels. Additionally, we showed that the allergy predictive capacity of IgE levels in cord serum was slightly improved in specificity, sensitivity and efficiency by including not only the family history of allergy, but also cord serum levels of IgG anti-IgE. Our results thus raise the possibility that high levels of IgG anti-IgE protect children of increased allergy risk from early development of atopic disease and reduce the severity of symptoms.

Role of antibody and T cells in the long-term inhibition of IgE synthesis

We have shown that the long-term inhibition of IgE synthesis associated with perinatal inoculation of syngeneic IgE is accompanied by the synthesis of autoantibodies to IgE. Synthesis of IgE can also be inhibited by passive transfer of syngeneic anti-IgE antibodies. In the present investigation we made use of adoptive transfer experiments to assess the relative roles of antibodies and T cells in the inhibitory process. It was found that spleen cells from IgE-suppressed mice (synthesizing anti-IgE antibodies) could adoptively transfer the state of inhibition to syngeneic adult mice. The inhibition occurred only under conditions in which the recipient mice synthesized anti-IgE antibodies. Separated B cells, CD4+ T cells, CD8+ T cells, or a mixture of B and CD8+ T cells were ineffective. However, strong inhibition of IgE synthesis (as indicated by serum levels and numbers of IgE-secreting cells in the spleen) was observed after transfer of a mixture of B cells and CD4+ (helper) T cells. The results indicate that in this experimental model anti-IgE antibodies are the suppressive agent and that T cells do not play a role other than that of providing help to B cells for anti-IgE synthesis.

Can anti-IgE be used to treat allergy?

A summary of the properties of CGP 51901 is shown in Table 3. On the basis of its binding to IgE and IgE-secreting cells and its activity in vitro and in vivo, CGP 51901 is expected to be able to decrease serum IgE by direct clearance of IgE and by reduction of the numbers and productivity of IgE-secreting cells. The end result of reduction of IgE in the circulation and on mast cells is expected to be the attenuation of IgE-mediated reactions and the improvement in allergy symptoms. The effective serum concentration of CGP 51901 is expected to be in the range 1-10 micrograms/ml. Because CGP 51901 is an antibody specific for IgE, it is expected to be highly selective in its activity. Because IgE does not appear to be essential and because CGP 51901 has been rigorously tested to confirm its non-anaphylactic nature, this treatment is not expected to have any adverse effects. Therefore, CGP 51901 is expected to be safe and to have a good probability of being effective when it is tested in human clinical trials.

IgE-secreting cells in the thymus: correlation with induction of tolerance to IgE

We have shown previously that normal mice become tolerant to endogenous IgE when they are approximately 2 weeks old and that this corresponds closely with the initial appearance of IgE in serum. Tolerance evidently is restricted to T cells, since B cells responsive to IgE are present in neonatal and adult mice. The present report shows that IgE-secreting cells can be detected in the thymus between days 7 and 11 after birth and that the onset of tolerance to IgE occurs at the age of 11 days. Similar results were obtained in A/J and (BALB/c x A/J)F1 mice. This suggests that tolerance is induced in the thymus, probably by cells bearing peptide fragments of IgE. The order of appearance of IgE-secreting cells is thymus, spleen, and mesenteric lymph nodes.

Mechanisms of IgE tolerance: dual regulatory T cell lesions in perinatal IgE tolerance

The mechanisms of genetic control of IgE responses are exercised at different immuno-physiological levels. This study centered upon the development of IgE lineage-specific regulatory T cells. Herein, we demonstrate the following points: (a) perinatal administration of soluble self IgE molecule or self IgE complexed with foreign antigen induces IgE tolerance as manifested by antigen-specific IgE unresponsiveness and a generalized IgE immunodeficiency, and the induction of IgE tolerance does not affect antigen-specific IgG1, IgG, and IgA responses; (b) inducibility of perinatal IgE tolerance is correlated with complete absence of endogenously secreted IgE in the neonates; and the state of persistent IgE tolerance also does not correlate with the presence of high levels of circulating anti-IgE autoantibodies; (c) The lesions induced during the ontogeny of IgE antibody system do not appear to result from an imbalance of production of interleukin 4 and interferon-gamma by T helper Th2 and Th1 cells in antigen-stimulated cultures; the dual immunoregulatory lesions in T cell subsets are demonstrated: clonal anergy/deletion of CD4+ IgE Th cells and the presence of CD8+ IgE suppressor cells induced by perinatal IgE treatment. We propose that antigen/interleukin 4 activated B cells are controlled by IgE lineage-specific regulatory T cells which recognize self IgE determinant(s) on IgE committed B cells. Life-long IgE tolerance ensues as a result of a new steady state of IgE lineage-specific CD4+ and CD8+ T cell subsets.