Future Directions in therapy of Sjogren’s Syndrome Robert Fox, MD, Ph.D. Scripps Memorial Hospital Ximed Medical Group

Disclosures None relevant to this presentation Editor of WebMD and other journals I have worked with and have patent rights: Allergan (Restasis) Daichi (Evoxac) IDEC (Rituximab) Roche (Cell cept) Sanofi (Arava)

Sjogren’s Syndrome Increased mortality risk, particularly due to lympho-proliferative complications and cardiovascular Quality of life-equated with moderate angina “Disability” predominantly due to fatigue and cognitive “Limitations”: dry eyes (limits work-esp. computer) dry mouth (limits sleep and social interaction)

Sjogren’s Syndrome -- at a Glance -- An autoimmune disorder characterized by severely dry eyes and dry mouth, due to lymphocytic infiltrates. Prevalence for primary SS: 0.1% to 0.3% of adult females. Female : Male ratio is 9:1. Two peak ages of onset—in the 30’s and in the 50’s Many of older patients diagnosed with “SLE” are actually SS Also, pediatric SS may be part of spectrum of JRA

Take home lesson-1 Current controversy about diagnostic criteria are finally resolved and will be submitted to FDA Clinical trials have failed because they do not improve “benign” symptoms—symptoms of pain and fatigue

Take home lesson-2 We can induce benign symptoms in normal or exacerbate in SS patients when treat their hepatitis C with type 1 interferon In animal models, there is a role of S1P (sphingosine-1-phosphate) pathways mediate viral symptoms of fatigue and “illness behavior)

Take home lesson-3 (Extraglandular symptoms) Sjogren’s has overlap with SLE. However, the skin, lung, renal and neurologic are slightly different. SLE is more of an immune complex disorder and SS is more of a “lymphocyte” aggressive disorder

Take home lesson-4 (Role of SS-A in pathogenesis ) Pathogenesis of SS involves anti-SS A antibody binding to a particular hYRNA hYRNA also binds to viral RNA’s SS-A and hYRNA provide a model for interaction of genetics and environmental factors in pathogenesis

Goals-1 How to design a trial for improving treatment of benign symptoms such as cognitive function In addition to symptoms, must have an objective marker

Advances in neuroscience Several recent papers outlined potential markers that help explain why we feel tired when we have a virus and similar markers up in SS Both are linked to interferon production (remember the hepatitis C patients treated with interferon)

Elevated HSP 90 in SS patients with fatigue and associated with IFN-type 1 signature

Circulating Elevation of Indoleamine is correlated with fatigue

Goals-2 Why have previous trials failed? Not improve “benign” symptoms-need to address this need by understanding the role of neural circuits in symptoms Many of the previous trials have in fact improved extraglandular symptoms, but not enough SS patients in the trial had these symptoms make the entire trial look successful

Benign Symptoms-Dry Eyes Most common cause of visit to Ophthalmologists, Epidemic Increase with increased computer use (decreased blink rate) Schirmer’s test, Tear Breakup time, Corneal Abrasions Poor correlation with objective findings

the surface epithelial surface mucin layers off. Dryness results in the clinical appearance of keratoconjunctivitis sicca (KCS) characteristic of Sjogren’s syndrome The upper lid literally sticks to the surface epithelial surface and pulls surface mucin layers off. The Rose Bengal dye retention is like “rain water pooling in a street pothole” This test can be done at bedside and allows “triage” and rapid referral of patients to Ophthalmology

fMRI maps corneal pain in SS

Emotional stressors potential the role of cytokines in pain pathways Physiological Similar pattern of Fos-ir in cortical neurons in response to distinct stressors

Severe Xerostomia with dry tongue Angular cheilitis

Sjogren’s Syndrome- Cervical Dental Caries

Lymphocytic infiltrates in Sjogren’s Syndrome Foci of lymphs Sjogren’s Normal

What Causes Sjogren’s syndrome? A combination of genetic and environmental factors In identical twins, only about 20% concordance— Since identical twins have the same genes, about 80% must be due to an environmental factor d. Hormones are important since it is 90% women

Antibody to SS-A Although SS-A is a criteria for SS, only about 18% Individuals with SS-A will develop SS if followed over a 20 year interval (Scandanavian studies) SS-A is not a criteria for SLE, although it may be found in a subset of SLE patients who have often have SS like features SS-A helps us understand the pathogenesis of SS About 30% of SS patients lack antibody to SS-A and have other autoantibodies

Time course of autoimmune response. 1 Time course of autoimmune response* 1. Environmental stress is interpreted in context of genetic factors 2. Antibodies precede disease 3. Presence of antibody does not mean disease Innate Immune system (Toll receptor) Auto- antibodies Environmental Stress (virus-such as EBV ) (apoptotic fragment) Immune complex Type I IFN Genetic Factors (including sex) (HLA-DR) Genetic Factors (including sex) (HLA-DR) Disease Manifestations Acquired Immune system (HLA-DR) T/B-cells Time period of years

What is the relationship between SLE and SS? Both SLE and SS-- very similar genetics and antibodies; Both have Type I IFN signature SLE SS 3. SS is characterized by lymphoid infiltrates salivary and lacrimal glands Lymphoma interstitial nephritis pneumonitis 4. Homing receptors and chemokines to get lymphocytes to extraglandular tissues 5. Tissue Retension factors to prevent the egress of lymphocytes 6- Increased risk Lymphoma 2. SLE is characterized by antibody-mediated process glomerulonephritis immune complex rash pleural effusion

Systemic Manifestations Multiple organs (parotid, lung, skin, kidney, CNS, hematologic) Overlap with SLE but different Only a minority of patients have systemic manifestations at a give time so not well suited to clinical trials Rituximab is most widely used, although not approved by FDA

Sjogren’s Syndrome – with Parotid Enlargement MRI not used much for diagnosis of SS itself but of value in investigating causes of persistent salivary gland swelling. However with the increasing availability of scanners, and emerging evidence from Berlin [Vogl et al]and Japan [Izumi et al], we may see this non-invasive technique being used more frequently for diagnostic purposes

SS has several types of Rashes (erythema annulare) the “old” subacute SLE which is negative for complement staining

Arthritis distinct from RA (Jaccoud’s like or erosive OA) Hydroxychloroquine, Methotrexate, Abatacept, Rituximab (less successful with azathioprine or leflunomide limited by leukopenia)

Lymphocytic Interstitial Pneumonitis (LIP) Bi-basilar on CXR Prominent Cystic on CAT Lymphocytes on biopsy

Lymphocytic Interstitial Nephritis (steroids, mycophenolic acid, rituximab)

Transverse Myelitis Neuromyelitis Optica DeVic’s Syndrome: Transverse Myelitis Neuromyelitis Optica (NMO) After rule out infection, treatments with cytoxan and or rituximab. Maintenance with azathioprine May need to treat like multiple sclerosis—new options approved

Basics of pathogenesis Both genetic and environmental SS-A is felt to play a key role Only 20% of individuals with anti-SS A will develop SS over 20 yr follow-up Gene association (GWAC) outlines targets for therapy thus far

The Functional Circuit is starting point 5. Gland cytokines, Autoantibodies metalloproteinases 1. Ocular Surface (Tear or Saliva) Unmylinated nerves Cholinergic efferents lymphocytes 4. blood vessel Chemokines CAMs iNOS Prostaglandin 2. Midbrain (Vth Cr. N) 3. Brain cortex adrenergic Hypothalamic axis (adrenaline, cortisol)

Areas that we have studied-extensively 5. Gland cytokines, Autoantibodies metalloproteinases 1. Ocular Surface (Tear or Saliva) Unmylinated nerves Cholinergic efferents lymphocytes 4. blood vessel Chemokines CAMs iNOS Prostaglandin 2. Midbrain (Vth Cr. N) 3. cortex adrenergic Hypothalamic axis (adrenaline, cortisol)

Areas that we need to understand if we are to develop novel therapies 5. Gland cytokines, Autoantibodies metalloproteinases 1. Ocular Surface (Tear or Saliva) Unmyelinated nerves Cholinergic efferents 4. blood vessel Chemokines CAMs iNOS Prostaglandin 2. Midbrain (Vth Cr. N) 3. cortex adrenergic Hypothalamic axis (adrenaline, cortisol)

Genome Wide Associations of Sjogren Slightly different than SLE, including homing receptors HLA-DR is strongest and linked to antibody SS-A B-cell hyperactivity genes Interferon related genes Another polymorphism linked to lymphoma (TNFAIP3) and plasma cell differentiation (BLIMP1)

IRF5: TNIP1: STAT4: BLK: IL12A: CXCR5: NFkB signaling, binds TNFAIP3 IRF5: Type I IFN signaling, cytokine production (e.g. IL12, IL6, TNF) STAT4: IL12 signaling, T cell differentiation BLK: B cell proliferation and differentiation, insulin secretion? IL12A: IFNg signaling, T1/T2 differentiation GW Significant: HLA, IRF5, STAT4, IL12A, BLK, CXCR5, and TNIP1 GW Suggestive (P-value <0.05 in both datasets): TNFAIP3, PTTG1, PRDM1, DGKQ, FCGR2A, IRAK1BP1, ITSN2, and PHIP 21 additional loci surpassed suggestive thresholds after meta-analysis CXCR5: B & T cell homing STAT4, TNIP1, IRF5, and BLK: effects appear identical to SLE IRF5: 2 independent effects IL12A & CXCR5: not in top ~40 for SLE Lessard et al, Nature Genetics, 2013

Summary: key pathways established in SS through genetic studies to date Type 1 IFN Type 2 IFN NFKB signaling Antigen presentation T cell/IL12 signaling B cell signaling Lymphocyte migration Lymphocyte homeostasis

SS-A or Ro-Antigen SS-A and Ro are the same protein(s) that were identified by different investigators Actually there are two proteins (Ro-60 and Ro-52) that constitute the SS-A antigen SS-A is so common in SS that it is now a criteria for diagnosis of SS

To understand the role of SS-A When cells die (either naturally or after a viral infection), the undergo a process of cell death called apoptosis where there proteins are auto-digested This debris is then engulfed by macrophages A function of the immune system is “garbage disposal” of dead cell debris

SS-A/hYRNA migrates into apoptic bleb

hYRNA Ro-60 Schematic representation of hYRNA1 binding to Ro60

The hYRNA Normally binds SS-A In viral infection, the hYRNA binds and “chaperones” viral proteins Thus, the hYRNA runs in “bad” company and can fool the immune system into making antibodies against SS-A

SS-A and Sjogren’s SS-A is just the best known antigen Other antigens and perhaps other hYRNA like molecules play a role but are not as common The other genetic factors identified all play a role in making the anti-SS A and response to the SS-A/hYRNA complex

For example Viruses like EBV and adenovirus, both associated with SS bind to SS-A and hYRNA Endogenous sequences (called microRNA’s) also bind to SS-A and hYRNA A starting approach to look at the environmental and genetic factors is based on this hypothesis

microRNA’s that are predicted to bind to Ro60 are found in Sjogren’s glands

Role of Autoantibody: Anti-SS A Anti-SS A antibody (associated with HLA-DR3) binds to SS-A which is complexed to hYRNA Antibody to SS-A To the innate immune system (dendritic cells), hYRNA is a double-stranded RNA and looks like a viral RNA . hYRNA (ds RNA) SS-A

The Anti-SS A Complex Can Stimulate TLR receptor Fc-receptor Lysosome TLR-7/9 Fc Antibody To SS-A hYRNA SS-A The Fc-R allows The immune complex Containing hYRNA to enter lysosome And Trigger TLR IFN-I Release Perpetuates cycle

The transition from SS-A to disease Internalization of the SS-A/hYRNA-anti SS A antibody allows internalization and access to TLR-7/9 receptors in plasmacytic DC The key signature of SS is type 1 IFN Trials of antibodies to IFN-1R have failed

The continuing cycle The release of type I IFN stimulates further T-cell and B-cell activity The continued apoptosis releases more SS-A/hYRNA complexes to further the cycle

The cause of symptoms The IFN stimulates the brain to “sickness behavior” (benign symptoms) Stimulates the immune system to extra-glandular symptoms

Summary SS has benign (glandular and “benign” manifestations) Trials of therapies in SS have failed Systemic manifestations have responded to biologic agents such as rituxan and abatacept The number of patients with extraglandular manifestations was insufficient to affect the overall study

Summary-2 Treatment of “benign” manifestations (arthralgia, myalgia, cognitive) need to explored New interactions of the Innate immune system with adrenal-hypothalmic axis and prostaglandin pathways need to be explored Models of “sickness” behavior in mice after viral infection suggest markers and approaches

Conclusion is simply the place where you got tired of thinking Old Confucius saying:  Conclusion is simply the place where you got tired of thinking

Sjogren’s Syndrome Clinical Trials Let’s not make the same mistakes we did with lupus!!!!!

Since 2005, 18 SLE drugs in Phase II/III trials have failed to meet their primary endpoint using FDA guidance document Abetimus Tabalumab Edratide R333 topical syk kinase Abatacept Sirukumab Rituximab Blisimibob Atacicept Laquinimod Ocrelizumab Lupuzor Sifilumumab Prasterone (DHEA) Rontiluzumab Mycophenolate Pfizer anti IL-6 Epratuzumab Many of these agents are clearly effective Positive results: belimumab and possibly anifrolumab

Additional Trials

Trials-2

Trials BAFF

Trials- IFN 1 R

Treatments-1 Topical for dryness Anti-inflammatory for topical (Restasis) Oral agents to increase moisture Agents to increase secretion (Evoxac) DMARDs (disease modifying anti-rheumatic drugs) Steroids Biologic agents Transplant rejection agents (cyclosporin, rapamycin)

Systemic Therapy Currently Used DMARDs (disease modifying anti-rheumatic drugs) such as methotrexate and cell cept Steroids-work but need to taper Biologic agents such as rituxan but not FDA approved Transplant rejection agents (cyclosporin, rapamycin)

Treatment with DMARDs that we use currently Hydroxychloroquine—remarkably little data but placebos work Methotrexate and azathioprine—generally lower than RA due to low WBC, mouth ulcers Mycophenolic Acid—less renal than cyclosporine A Rapamycin—I have found this useful

DMARD’s Hydroxychloroquine works in antigen processing and presentation MTX, Cell cept and Leflunomide work on production of de novo nucleotides needed for activation of T-cells (mostly to generate ADP for membrane glycosylation) Rapamycin works on mTOR, an interesting target but raises lipids

Initial trials in SS anti-TNF Initial reports encouraging but not repeated Controlled studies disappointing with Etanercept, Remicade and other anti-TNF’s in both systemic and benign symptoms Among RA patients with secondary SS, little improvement in their sicca symptoms.

If we want more patients with systemic manifestations Most of our “sick” SS patients are misdiagnosed as SLE or RA even in Rheumatology Clinics Most are misdiagnosed in Hematology, Pulmonary, or Nephrology Clinics Unless these patients are enrolled in studies as SS patients, we are doomed to have failures in trials.

Rasmussen et al representing excellent Rheumatology Departments (Oklahoma Medical Research Center, Cedars, University of Minnesota, Mass Eye and Ear

Heat Shock 90 is a DAMP

HS 90 Sternberg Nature Reviews Immunology 6, 318–328 (April 2006) | doi:10.1038/nri1810

Heat Shock Protein 90 Hsp90 binds both endothelial nitric oxide synthase and soluble guanylate cyclase, which in turn are involved in vascular relaxation Heat Shock Protein 90 and Heat Shock Protein 70 Are Components of Dengue Virus Receptor Complex in Human Cells

Indoleamine 2,3-dioxygenase Indoleamine 2,3-dioxygenase is the first and rate-limiting enzyme of tryptophan catabolism through kynurenine pathway, causes depletion of tryptophan which can alter T cells, astroglial cells, and neural modulation. PGE2 is able to elevate the expression of indoleamine 2,3-dioxygenase in CD11C(+) dendritic cells and promots astroglial activation

Sternberg Nature Reviews Immunology 6, 318–328 (April 2006) | doi:10 Sternberg Nature Reviews Immunology 6, 318–328 (April 2006) | doi:10.1038/nri1810

Sternberg Nature Reviews Immunology 6, 318–328 (April 2006) | doi:10 Sternberg Nature Reviews Immunology 6, 318–328 (April 2006) | doi:10.1038/nri1810

Sternberg Nature Reviews Immunology 6, 318–328 (April 2006) | doi:10 Sternberg Nature Reviews Immunology 6, 318–328 (April 2006) | doi:10.1038/nri1810

Molecular “Signatures” of SS

Improving trial design and implementation Make the trial attractive to a study center (fewer hassles, unnecessary forms, blood tests, visits) Make the trial attractive to patients: chance of getting open label drug, off steroids, appeal to altruism Adaptive trial design: Implement of more elastic data analysis and statistics during the trial (FDA Guidance Document 2012) Make the trial attractive to the community rheumatologist to refer their patients Create a “buzz” through social networking sites

Conclusions The most efficient method for advancing lupus therapy through clinical trials is to study promising agents in highly enriched populations performed by experienced, preferably academic centers involved in its design. Metrics need to be re-evaluated from scratch. Consideration should be given to prevention, induction, maintenance, flare reduction and using combinations of agents that would be disease modifying, damage preventing and cost effective. Sponsors need to be supportive and have an experienced staff.

Organ domains of the ESSDAI from 800 cases SCORING % VIGNETTES/CASES Constitutional 0-6 12 Lymphadenopathy/lymphoma 0-12 8 Glandular disease 0-4 38 Articular 50 Cutaneous 0-9 20 Pulmonary 0-15 15 Renal 7 Muscular 0-18 3 Peripheral NS 10 Central NS 5 Hematological Biologic (C3, globulin) 0-2 40