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Kuhn C, Rezende RM, da Cunha AP, Valette F, Quintana FJ, Chatenoud L, Weiner HL. Mucosal administration of CD3-specific monoclonal antibody inhibits diabetes in NOD mice and in a preclinical mouse model transgenic for the CD3 epsilon chain. J Autoimmun 2017; 76:115-122. [PMID: 27745778 PMCID: PMC9815832 DOI: 10.1016/j.jaut.2016.10.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Revised: 10/01/2016] [Accepted: 10/03/2016] [Indexed: 01/11/2023]
Abstract
CD3-specific monoclonal antibody (mAb) treats autoimmune disease in animal models and has shown promise in clinical trials of type 1 diabetes. Whereas intravenous administration of CD3-specific mAb acts primarily by transient depletion of activated effector T cells, oral CD3-specific mAb acts primarily by the induction Tregs. We investigated whether oral CD3-specific mAb inhibits disease in non obese diabetic (NOD) mice that spontaneously develop autoimmune diabetes, closely resembling human type 1 diabetes. We found that oral CD3-specific mAb treatment delayed onset and reduced incidence of diabetes in NOD mice, inducing changes in both effector and regulatory T cell compartments. The therapeutic effect was associated with decreased T cell proliferation, decreased IFNγ and IL-17 production, and increased TGF-β and IL-10 production in vitro. In vivo transfer experiments demonstrated that oral CD3-specific mAb decreased diabetogenicity of effector T cells and increased the function of regulatory T cells. Oral OKT3, a monoclonal antibody specific for human CD3 had equivalent effects in transgenic NOD mice expressing the human CD3 epsilon chain which serves as a preclinical model for testing human CD3-specific mAb. These results suggest that oral CD3-specific mAb has the potential for treating autoimmune diabetes in humans.
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Affiliation(s)
- Chantal Kuhn
- Ann Romney Center for Neurologic Diseases, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts 02115, USA
| | - Rafael M. Rezende
- Ann Romney Center for Neurologic Diseases, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts 02115, USA
| | - Andre Pires da Cunha
- Ann Romney Center for Neurologic Diseases, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts 02115, USA
| | - Fabrice Valette
- Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA,Université Paris Descartes, Sorbonne Paris Cité, F-75475, Paris, France
| | - Francisco J. Quintana
- Ann Romney Center for Neurologic Diseases, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts 02115, USA,Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA
| | - Lucienne Chatenoud
- Université Paris Descartes, Sorbonne Paris Cité, F-75475, Paris, France,INSERM U1151, CNRS UMR 8253, Hôpital Necker-Enfants Malades, Paris, France
| | - Howard L. Weiner
- Ann Romney Center for Neurologic Diseases, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts 02115, USA
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Kuhn C, Rezende RM, M'Hamdi H, da Cunha AP, Weiner HL. IL-6 Inhibits Upregulation of Membrane-Bound TGF-β 1 on CD4+ T Cells and Blocking IL-6 Enhances Oral Tolerance. J Immunol 2016; 198:1202-1209. [PMID: 28039301 DOI: 10.4049/jimmunol.1600921] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Accepted: 11/21/2016] [Indexed: 01/04/2023]
Abstract
Oral administration of Ag induces regulatory T cells that express latent membrane-bound TGF-β (latency-associated peptide [LAP]) and have been shown to play an important role in the induction of oral tolerance. We developed an in vitro model to study modulation of LAP+ on CD4+ T cells. The combination of anti-CD3 mAb, anti-CD28 mAb, and recombinant IL-2 induced expression of LAP on naive CD4+ T cells, independent of Foxp3 or exogenous TGF-β. In vitro generated CD4+LAP+Foxp3- T cells were suppressive in vitro, inhibiting proliferation of naive CD4+ T cells and IL-17A secretion by Th17 cells. Assessing the impact of different cytokines and neutralizing Abs against cytokines, we found that LAP induction was decreased in the presence of IL-6 and IL-21, and to a lesser extent by IL-4 and TNF-α. IL-6 abrogated the in vitro induction of CD4+LAP+ T cells by STAT3-dependent inhibition of Lrrc32 (glycoprotein A repetitions predominant [GARP]), the adapter protein that tethers TGF-β to the membrane. Oral tolerance induction was enhanced in mice lacking expression of IL-6R by CD4+ T cells and by treatment of wild-type mice with neutralizing anti-IL-6 mAb. These results suggest that proinflammatory cytokines interfere with oral tolerance induction and that blocking the IL-6 pathway is a potential strategy for enhancing oral tolerance in the setting of autoimmune and inflammatory diseases.
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Affiliation(s)
- Chantal Kuhn
- Ann Romney Center for Neurologic Diseases, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115
| | - Rafael Machado Rezende
- Ann Romney Center for Neurologic Diseases, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115
| | - Hanane M'Hamdi
- Ann Romney Center for Neurologic Diseases, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115
| | - Andre Pires da Cunha
- Ann Romney Center for Neurologic Diseases, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115
| | - Howard L Weiner
- Ann Romney Center for Neurologic Diseases, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115
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Liu S, da Cunha AP, Rezende RM, Cialic R, Wei Z, Bry L, Comstock LE, Gandhi R, Weiner HL. The Host Shapes the Gut Microbiota via Fecal MicroRNA. Cell Host Microbe 2016; 19:32-43. [PMID: 26764595 DOI: 10.1016/j.chom.2015.12.005] [Citation(s) in RCA: 464] [Impact Index Per Article: 58.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2015] [Revised: 11/17/2015] [Accepted: 12/21/2015] [Indexed: 12/11/2022]
Abstract
The host gut microbiota varies across species and individuals but is relatively stable over time within an individual. How the host selectively shapes the microbiota is largely unclear. Here, we show that fecal microRNA (miRNA)-mediated inter-species gene regulation facilitates host control of the gut microbiota. miRNAs are abundant in mouse and human fecal samples and present within extracellular vesicles. Cell-specific loss of the miRNA-processing enzyme, Dicer, identified intestinal epithelial cells (IEC) and Hopx-positive cells as predominant fecal miRNA sources. These miRNAs can enter bacteria, such as F. nucleatum and E. coli, specifically regulate bacterial gene transcripts, and affect bacterial growth. IEC-miRNA-deficient (Dicer1(ΔIEC)) mice exhibit uncontrolled gut microbiota and exacerbated colitis, and WT fecal miRNA transplantation restores fecal microbes and ameliorates colitis. These findings identify both a physiologic role by which fecal miRNA shapes the gut microbiota and a potential strategy for manipulating the microbiome.
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Affiliation(s)
- Shirong Liu
- Department of Neurology, Ann Romney Center for Neurologic Diseases, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Andre Pires da Cunha
- Department of Neurology, Ann Romney Center for Neurologic Diseases, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Rafael M Rezende
- Department of Neurology, Ann Romney Center for Neurologic Diseases, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Ron Cialic
- Department of Neurology, Ann Romney Center for Neurologic Diseases, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Zhiyun Wei
- Department of Neurology, Ann Romney Center for Neurologic Diseases, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Lynn Bry
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Laurie E Comstock
- Division of Infectious Diseases, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Roopali Gandhi
- Department of Neurology, Ann Romney Center for Neurologic Diseases, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Howard L Weiner
- Department of Neurology, Ann Romney Center for Neurologic Diseases, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA.
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Murugaiyan G, da Cunha AP, Ajay AK, Joller N, Garo LP, Kumaradevan S, Yosef N, Vaidya VS, Weiner HL. MicroRNA-21 promotes Th17 differentiation and mediates experimental autoimmune encephalomyelitis. J Clin Invest 2015; 125:1069-80. [PMID: 25642768 DOI: 10.1172/jci74347] [Citation(s) in RCA: 181] [Impact Index Per Article: 20.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2013] [Accepted: 12/16/2014] [Indexed: 12/18/2022] Open
Abstract
Accumulation of IL-17-producing Th17 cells is associated with the development of multiple autoimmune diseases; however, the contribution of microRNA (miRNA) pathways to the intrinsic control of Th17 development remains unclear. Here, we demonstrated that miR-21 expression is elevated in Th17 cells and that mice lacking miR-21 have a defect in Th17 differentiation and are resistant to experimental autoimmune encephalomyelitis (EAE). Furthermore, we determined that miR-21 promotes Th17 differentiation by targeting and depleting SMAD-7, a negative regulator of TGF-β signaling. Moreover, the decreases in Th17 differentiation in miR-21-deficient T cells were associated with defects in SMAD-2/3 activation and IL-2 suppression. Finally, we found that treatment of WT mice with an anti-miR-21 oligonucleotide reduced the clinical severity of EAE, which was associated with a decrease in Th17 cells. Thus, we have characterized a T cell-intrinsic miRNA pathway that enhances TGF-β signaling, limits the autocrine inhibitory effects of IL-2, and thereby promotes Th17 differentiation and autoimmunity.
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Abadie V, Abraham C, Adams DH, Agace WW, Alexander-Brett J, Alkhairy O, Ambite I, Anderson DJ, Artis D, Atmar RL, Aymeric L, Bachert C, Bakema JE, Baker K, Beagley KW, Befus A, Bemark M, Berin MC, Berings M, Berzofsky JA, Bilej M, Biswas N, Blumberg RS, Bienenstock J, Bogdanos D, Boirivant M, Boonnak K, Bracke KR, Brandtzaeg P, Braun J, Bringer MA, Broadbent AJ, Bronson R, Brusselle GG, Bulmer JN, Butler J, Cardenas PA, Cebra JJ, Cella M, Cerutti A, Challacombe SJ, Chattha K, Cheroutre H, Chiba T, Chorny A, Clements JD, Colonna M, Cookson WO, Corbeil LB, Corthésy B, Cripps AW, van Crombruggen K, Pires da Cunha A, Cunningham-Rundles S, Curtiss R, Darfeuille-Michaud A, de Jonge WJ, Deban L, Denning TL, Di Santo JP, Diefenbach A, DiRita VJ, Downey J, Du MQ, Edelblum KL, van Egmond M, Epple HJ, Fagarasan S, Fahey JV, Ferris MJ, Fichtner-Feigl S, Fidel PL, Flach M, Flavell R, Fleit HB, Franchini G, Freytag LC, Fuchs A, Fujihashi K, Fuss IJ, Gagliani N, Garcia MR, Garrett WS, Gershwin ME, Gevaert P, Gleeson M, Godaly G, Goldblum RM, Gour N, Gursel M, Hajishengallis G, Hammad H, Hammarström L, Hänninen A, Hanson LÅ, Hayday A, Herzog R, Hodgins DC, Holgate ST, Holmgren J, Holtzman MJ, Hook EW, Huber S, Hurwitz JL, Ivanyi J, Iwasaki A, Jabri B, Jackson S, Jacobs J, Jalkanen S, Janoff EN, Jerse AE, Jeyanathan M, Julian BA, Kacskovics I, Kaetzel CS, Kaushic C, Kelsall BL, Kessans S, Kesselring R, Kilian M, Kiyono H, Klinman DM, Korotkova M, Kronenberg M, Krysko O, Kurono Y, Kverka M, Lambrecht BN, Lamm ME, Lantz O, Lash GE, Lavelle E, Lefrancois L, Leung PS, Levine MM, Lim DJ, Lippolis J, Louis NA, Luster AD, Lutay N, Lycke N, Macpherson AJ, Mantis NJ, Marcotte H, Martin DH, Mason HS, Massa HM, Matoba N, Mayer L, Maynard CL, McElrath MJ, McEntee C, McGhee JR, McGuckin MA, Mestecky J, Mikhak Z, Miller RD, Moldoveanu Z, Montgomery PC, Mor T, Neurath MF, Neyt K, Nicholson LK, Novak J, Nowicki S, O’Hagan D, O’Sullivan NL, Ogra P, Orihuela C, Ouellette AJ, Owen RL, Pabst O, Parkos CA, Parreño V, Patel MV, Perez-Novo C, Perkins DJ, Prussin C, Pudney J, Raghavan S, Rainard P, Ramani S, Randall TD, Raska M, Renukaradhya GJ, Rescigno M, Rosenthal KL, Rothenberg ME, Ruemmele FM, Russell MW, Saif LJ, Salinas I, Salmi M, Salmon H, Sampson HA, Sansonetti P, Schneider T, Serafini N, Sharma D, Shen Z, Shi HN, Shirlaw PJ, Shivhare SB, Smith PD, Smith PM, Smith DJ, Smythies LE, Spencer J, Strober W, Subbarao K, Svanborg C, Svennerholm AM, Taubman MA, Telemo E, Thornhill MH, Thornton DJ, Thuenemann E, Tlaskalova-Hogenova H, Tristram D, Trivedi P, Tuomanen E, Turanek J, Turner JR, Underdown BJ, van Helden MJ, Veazey RS, Verdu EF, Vlasova A, Vliagoftis H, Vogel SN, Walker WA, Wang X, Watanabe T, Weaver CT, Weiner HL, Wells JM, Wen T, Whittum-Hudson J, Whitsett JA, Williams IR, Wills-Karp M, Wira CR, Woof JM, Wotherspoon AC, Xing Z, Xu H, Zaph C, Zeissig S, Zeitz M. Contributors. Mucosal Immunol 2015. [DOI: 10.1016/b978-0-12-415847-4.01002-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Chen L, Chen Z, Baker K, Halvorsen EM, da Cunha AP, Flak MB, Gerber G, Huang YH, Hosomi S, Arthur JC, Dery KJ, Nagaishi T, Beauchemin N, Holmes KV, Ho JWK, Shively JE, Jobin C, Onderdonk AB, Bry L, Weiner HL, Higgins DE, Blumberg RS. The short isoform of the CEACAM1 receptor in intestinal T cells regulates mucosal immunity and homeostasis via Tfh cell induction. Immunity 2012; 37:930-46. [PMID: 23123061 DOI: 10.1016/j.immuni.2012.07.016] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2011] [Accepted: 07/30/2012] [Indexed: 12/11/2022]
Abstract
Carcinoembryonic antigen cell adhesion molecule like I (CEACAM1) is expressed on activated T cells and signals through either a long (L) cytoplasmic tail containing immune receptor tyrosine based inhibitory motifs, which provide inhibitory function, or a short (S) cytoplasmic tail with an unknown role. Previous studies on peripheral T cells show that CEACAM1-L isoforms predominate with little to no detectable CEACAM1-S isoforms in mouse and human. We show here that this was not the case in tissue resident T cells of intestines and gut associated lymphoid tissues, which demonstrated predominant expression of CEACAM1-S isoforms relative to CEACAM1-L isoforms in human and mouse. This tissue resident predominance of CEACAM1-S expression was determined by the intestinal environment where it served a stimulatory function leading to the regulation of T cell subsets associated with the generation of secretory IgA immunity, the regulation of mucosal commensalism, and defense of the barrier against enteropathogens.
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Affiliation(s)
- Lanfen Chen
- Gastroenterology Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
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Wu HY, Quintana FJ, da Cunha AP, Dake BT, Koeglsperger T, Starossom SC, Weiner HL. In vivo induction of Tr1 cells via mucosal dendritic cells and AHR signaling. PLoS One 2011; 6:e23618. [PMID: 21886804 PMCID: PMC3160310 DOI: 10.1371/journal.pone.0023618] [Citation(s) in RCA: 80] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2011] [Accepted: 07/21/2011] [Indexed: 12/14/2022] Open
Abstract
Background Type 1 regulatory T (Tr1) cells, characterized by the secretion of high levels of the anti-inflammatory cytokine interleukin-10 (IL-10), play an important role in the regulation of autoimmune diseases and transplantation. However, effective strategies that specifically induce Tr1 cells in vivo are limited. Furthermore, the pathways controlling the induction of these cells in vivo are not well understood. Methodology/Principal Findings Here we report that nasal administration of anti-CD3 antibody induces suppressive Tr1 cells in mice. The in vivo induction of Tr1 cells by nasal anti-CD3 is dependent on IL-27 produced by upper airway resident dendritic cells (DCs), and is controlled by the transcription factors aryl hydrocarbon receptor (AHR) and c-Maf. Subsequently, IL-21 acts in an autocrine fashion to expand and maintain the Tr1 cells induced in vivo by nasally administered anti-CD3. Conclusions/Significance Our findings identify a unique approach to generate Tr1 cells in vivo and provide insights into the mechanisms by which these cells are induced.
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Affiliation(s)
- Henry Yim Wu
- Center for Neurologic Diseases, Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Francisco J. Quintana
- Center for Neurologic Diseases, Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Andre Pires da Cunha
- Center for Neurologic Diseases, Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Benjamin T. Dake
- Center for Neurologic Diseases, Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Thomas Koeglsperger
- Center for Neurologic Diseases, Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Sarah C. Starossom
- Center for Neurologic Diseases, Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Howard L. Weiner
- Center for Neurologic Diseases, Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
- * E-mail:
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Abstract
The gut-associated lymphoid tissue is the largest immune organ in the body and is the primary route by which we are exposed to antigens. Tolerance induction is the default immune pathway in the gut, and the type of tolerance induced relates to the dose of antigen fed: anergy/deletion (high dose) or regulatory T-cell (Treg) induction (low dose). Conditioning of gut dendritic cells (DCs) by gut epithelial cells and the gut flora, which itself has a major influence on gut immunity, induces CD103(+) retinoic acid-dependent DC that induces Tregs. A number of Tregs are induced at mucosal surfaces. Th3 type Tregs are transforming growth factor-β dependent and express latency-associated peptide (LAP) on their surface and were discovered in the context of oral tolerance. Tr1 type Tregs (interleukin-10 dependent) are induced by nasal antigen and forkhead box protein 3(+) iTregs are induced by oral antigen and by oral administration of aryl hydrocarbon receptor ligands. Oral or nasal antigen ameliorates autoimmune and inflammatory diseases in animal models by inducing Tregs. Furthermore, anti-CD3 monoclonal antibody is active at mucosal surfaces and oral or nasal anti-CD3 monoclonal antibody induces LAP(+) Tregs that suppresses animal models (experimental autoimmune encephalitis, type 1 and type 2 diabetes, lupus, arthritis, atherosclerosis) and is being tested in humans. Although there is a large literature on treatment of animal models by mucosal tolerance and some positive results in humans, this approach has yet to be translated to the clinic. The successful translation will require defining responsive patient populations, validating biomarkers to measure immunologic effects, and using combination therapy and immune adjuvants to enhance Treg induction. A major avenue being investigated for the treatment of autoimmunity is the induction of Tregs and mucosal tolerance represents a non-toxic, physiologic approach to reach this goal.
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Affiliation(s)
- Howard L Weiner
- Center for Neurologic Diseases, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
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Abstract
Multiple mechanisms of tolerance are induced by oral antigen. Low doses favor active suppression, whereas higher doses favor clonal anergy/deletion. Oral antigen induces T-helper 2 [interleukin (IL)-4/IL-10] and Th3 [transforming growth factor (TGF)-beta] T cells plus CD4+CD25+ regulatory cells and latency-associated peptide+ T cells. Induction of oral tolerance is enhanced by IL-4, IL-10, anti-IL-12, TGF-beta, cholera toxin B subunit, Flt-3 ligand, and anti-CD40 ligand. Oral (and nasal) antigen administration suppresses animal models of autoimmune diseases including experimental autoimmune encephalitis, uveitis, thyroiditis, myasthenia, arthritis, and diabetes in the non-obese diabetic (NOD) mouse, plus non-autoimmune diseases such as asthma, atherosclerosis, graft rejection, allergy, colitis, stroke, and models of Alzheimer's disease. Oral tolerance has been tested in human autoimmune diseases including multiple sclerosis (MS), arthritis, uveitis, and diabetes and in allergy, contact sensitivity to dinitrochlorobenzene (DNCB), and nickel allergy. Although positive results have been observed in phase II trials, no effect was observed in phase III trials of CII in rheumatoid arthritis or oral myelin and glatiramer acetate (GA) in MS. Large placebo effects were observed, and new trials of oral GA are underway. Oral insulin has recently been shown to delay onset of diabetes in at-risk populations, and confirmatory trials of oral insulin are being planned. Mucosal tolerance is an attractive approach for treatment of autoimmune and inflammatory diseases because of lack of toxicity, ease of administration over time, and antigen-specific mechanisms of action. The successful application of oral tolerance for the treatment of human diseases will depend on dose, developing immune markers to assess immunologic effects, route (nasal versus oral), formulation, mucosal adjuvants, combination therapy, and early therapy.
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Affiliation(s)
- Howard L. Weiner
- Center for Neurologic Diseases, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Andre Pires da Cunha
- Center for Neurologic Diseases, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Francisco Quintana
- Center for Neurologic Diseases, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Henry Wu
- Center for Neurologic Diseases, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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