Successful treatment of lupus with fludarabine

Engineering CAR-T therapies for autoimmune disease and beyond

Chimeric antigen receptor-T cell (CAR-T) therapy has transformed the management of refractory hematological malignancies. Now that targeting pathogenic cells of interest with antigen-directed cytotoxic T lymphocytes is possible, the field is expanding the reach of CAR-T therapy beyond oncology. Recently, breakthrough progress has been made in the application of CAR-T technology to autoimmune diseases, exploiting the same validated targets that were used by pioneering CAR-T therapies in hematology. Here, we discuss recent advances and outcomes that are paving the way for extension to new therapeutic areas, including autoimmunity.

Network analysis retrieving bioactive compounds from Spirulina (Arthrospira platensis) and their targets related to systemic lupus erythematosus

Immunosuppressive drugs are essential for systemic lupus erythematosus (SLE) treatment, but there are concerns about their toxicity. In this study, Arthrospira platensis was used as a resource for screening of the SLE-related bioactive compounds. To discover the potential compounds, a total of 833 compounds of A. platensis C1 were retrieved from the Spirulina-Proteome Repository (SpirPro) database and by literature mining. We retrieved structures and bioassays of these compounds from PubChem database; and collected approved and potential drugs for SLE treatment from DrugBank and other databases. The result demonstrated that cytidine, desthiobiotin, agmatine, and anthranilic acid, from the alga, has Tanimoto matching scores of 100% with the following drugs: β-arabinosylcytosine/cytarabine, d-dethiobiotin, agmatine, and anthranilic acid, respectively. The bioassay matching and disease-gene-drug-compound network analysis, using VisANT 4.0 and Cytoscape, revealed 471 SLE-related genes. Among the SLE-related genes, MDM2, TP53, and JAK2 were identified as targets of cytarabine, while PPARG and IL1B were identified as targets of d-dethiobiotin. Binding affinity between the drug ligands and the algal bioactive compound ligands with their corresponding receptors were similarly comparable scores and stable, examined by molecular docking and molecular dynamic simulations, respectively.

Potential and pitfalls of repurposing the CAR-T cell regimen for the treatment of autoimmune disease

Chimeric antigen receptors (CARs) are synthetic proteins designed to direct an immune response toward a specific target and have been used in immunotherapeutic applications through the adoptive transfer of T cells genetically engineered to express CARs. This technology received early attention in oncology with particular success in treatment of B cell malignancies leading to the launch of numerous successful clinical trials and the US Food and Drug Administration approval of several CAR-T-based therapies. Many CAR-T constructs have been employed, but have always been administered following a lymphodepletion regimen. The success of CAR-T cell treatment in targeting malignant B cells has led many to consider the potential for using these regimens to delete pathogenic B cells in autoimmune diseases. Preliminary results have suggested efficacy, but the sample size remains small, controlled trials have not been done, the role of immunodepletion has not been established, the most effective CAR-T constructs have not been identified and the most appropriate patient subsets for treatment have not been established.

Complete Remission of Lupus Nephritis Following Chemoradiotherapy of Carcinoma Cervix: An Association

Systemic lupus erythematosus (SLE) is associated with a higher incidence of solid organ malignancies, including cervical carcinoma, creating a paradox in their management in the context of autoimmunity. We present a case of 45-year-old female presented with mucocutaneous, musculoskeletal symptoms of SLE. Renal biopsy showed class IV lupus nephritis (LN); modified NIH activity score: 8/24, chronicity score: 6/12. Post NIH regimen induction, she achieved partial remission; further developed proteinuric relapse which was re-induced with mycophenolate mofetil (MMF) to which she failed to respond. Subsequently diagnosed with carcinoma cervix stage IIB, she received four cycles of concurrent cisplatin-based chemoradiotherapy. MMF was stopped; low dose steroids continued. Following this, the patient achieved complete remission (CR) of LN and is in remission for 5 years. This is an unexpected association between chemoradiotherapy of cervical carcinoma and CR of class IV LN, allowing long-term discontinuation of immunosuppression.

Effects of fludarabine treatment on murine lupus nephritis

BXSB mice, a murine model of systemic lupus erythematosus (SLE), were treated with two different doses of fludarabine for a four-week period and examined two weeks after the final dose. Control mice were treated with saline or cyclophosphamide. Mice treated with fludarabine had a significant reduction in renal pathology compared to control mice. Fludarabine-treated mice also had an almost 10-fold increase in percentile of CD8+CD25+ T cells in the spleen and a smaller but significant increase in CD4+CD25+ cells. Mice treated with cyclophosphamide had a greater leucopenia compared to the other groups and a significant reduction in percentile of B220+ cells in peripheral blood and spleen. Serum autoantibody levels to dsDNA did not differ significantly among the groups, but were higher in 4/10 mice treated with fludarabine. Although few trials of fludarabine for human SLE have been conducted, additional studies may be warranted.

Management of lupus erythematosus: recent insights

This article reviews and cites only publications relating to the management of lupus that have appeared since 1999. The data in these publications demonstrate that preventive and proactive strategies are as important as medication in improving the quality of life and life span of the patient with lupus. The use of lasers and thalidomide represents major advances in cutaneous lupus. The first major study over 25 years using nonsteroidal anti-inflammatory drugs to manage lupus suggests benefits. Further evidence was presented showing that dehydroepiandrosterone, leflunomide, and methotrexate are effective in treating mild to moderate disease. Various iterations and modifications of traditional cyclophosphamide therapy with or without mycophenolate mofetil, cyclosporine, and azathioprine continue to be studied for treating organ-threatening disease. Intravenous gamma globulin and selective apheresis are niche therapies appropriate in a few, highly selected patients. Immunoablative doses of cyclophosphamide appear to be as effective as stem cell transplantation for serious disease resistant to conventional doses of cyclophosphamide. Twelve biologic agents have been studied in lupus since 1999, with only LJP-394 showing clear-cut, convincing efficacy.

Fludarabine pharmacokinetics after subcutaneous and intravenous administration in patients with lupus nephritis

STUDY OBJECTIVE

To compare the pharmacokinetics of subcutaneous and intravenous fludarabine in patients with lupus nephritis.

DESIGN

Open-label, randomized, crossover trial conducted with a phase I-II trial.

SETTING

Government research hospital.

PATIENTS

Five patients with lupus nephritis.

INTERVENTION

Fludarabine 30 mg/m2/day was administered either subcutaneously or as a 0.5-hour intravenous infusion for 3 consecutive days. All patients received oral cyclophosphamide 0.5 g/m2 on the first day of each cycle.

MEASUREMENTS AND MAIN RESULTS

Plasma samples were collected before and 0.5, 1, 1.5, 2, 4, 8, and 24 hours after the first dose. Urine was collected at 6-hour intervals for 24 hours. Plasma and urine were analyzed for fluoro-arabinofuranosyladenine (F-ara-A), fludarabine's main metabolite, using high-performance liquid chromatography. Compartmental techniques were used to determine the pharmacokinetics of F-ara-A; a linear two-compartment model best described them. Comparison of the pharmacokinetics between subcutaneous and intravenous administration was done by using a Wilcoxon signed rank test. No significant differences were found between subcutaneous and intravenous administration in median (interquartile range) maximum concentrations of 0.51 (0.38-0.56) and 0.75 (0.52-0.91) mg/L, respectively, or in fitted area under the concentration-time curves from 0-24 hours of 4.65 (4.17-4.98) and 4.55 (3.5-4.94) mg x hour/L, respectively. Bioavailability of F-ara-A after subcutaneous dosing was approximately 105% of the bioavailability after intravenous administration. Differences in renal clearance and percentage of dose excreted in urine for subcutaneous and intravenous administration were nonsignificant. No injection site reactions were seen with subcutaneous dosing.

CONCLUSION

Subcutaneous and intravenous administration of fludarabine appear to have similar pharmacokinetics in patients with lupus nephritis. Subcutaneous injection may offer a convenient alternative to intravenous administration.

Treatment of systemic lupus erythematosus

The treatment of systemic lupus erythematosus (SLE) is mainly based on a number of "traditional" drugs such as corticosteroids, antimalarials, azathioprine and cyclophosphamide. However, this scenario is rapidly changing due to the introduction of new compounds. Some of these new agents have been successfully used in other diseases, while others are being specifically designed to interfere with the immune abnormalities seen in SLE. As our knowledge on the mechanisms of immune response increases, new drugs that can interfere with T and B cell interaction and activation, production of anti-dsDNA autoantibodies, immune-complexes deposition and cytokine activation have been developed and some of these are now under investigation in SLE. Although initial data regarding their safety and efficacy are encouraging, caution must be taken before these drugs are considered as the treatment of choice for specific SLE manifestations. Specifically, controlled clinical trials with sufficient number of patients are necessary. If the promising results already available are confirmed, the use of these drugs might represent the keystone in the future management of SLE and other autoimmune diseases.

Systemic lupus erythematosus

This review covers major advances in clinical issues related to systemic lupus erythematosus (SLE) published between 1995 and 2000. The classification criteria for both SLE and antiphospholipid syndrome (APS) have been updated, and up to 19 different subsets of neuropsychiatric lupus have been defined. New epidemiological data show that the incidence of new cases and the survival of patients with SLE are both increasing. Several randomised controlled trials have defined the role of cyclophosphamide, methotrexate, antimalarials, and hormonal treatment in the management of SLE. New data are available for drugs such as ciclosporin and thalidomide. Finally, several new treatments for severe refractory cases, such as mycophenolate mofetil and stem-cell transplantation, are being increasingly used. New data also refer to management of thrombosis in APS and high-risk pregnancies in women with SLE or APS.

Therapy of systemic lupus erythematosus: new agents and new evidence

Systemic lupus erythematosus (SLE) is a disease of relatively low prevalence with a wide range of clinical manifestations. Due in part to these two facts, there is little new evidence on the treatment of lupus. In fact, randomised controlled studies and prospective series are few and usually involve a small number of patients. Despite this, some therapies have shown to be beneficial within the last five years, while others emerge as possibilities in the near future. Among the former, antimalarials appear to be the treatment of choice for maintaining mild to moderate disease in remission. Methotrexate may be an alternative to other corticosteroid-sparing drugs, especially in patients with active arthritis and skin disease. Cyclosporin can be of use in proteinuric nephritis, although the incidence of hypertension with this drug is high. Thalidomide is useful for refractory skin lesions, but the efficacy of lower, less toxic doses is still to be studied. Immunoglobulins should probably be limited to selected patients with manifestations such as thrombocytopoenia. Experience is more limited with cladribine, fludarabine, tacrolimus, danazol and pentoxifylline. New therapies for severe SLE include mycophenolate mofetil, a potent immunosuppressive drug with a reasonable safety profile and immunoablative therapy with or without stem cell transplantation, in highly resistant cases or those with a poor prognosis. Other recently developed molecules, including anti-CD40L monoclonal antibodies (mAbs), are still under investigation.