Severe Chronic Upper Respiratory Disease: Phenotyping Inflammation Claus Bachert DGAKI Germany GA2LEN Ghent Upper Airways Research Laboratory Department of Otorhinolaryngology

Prevalence of SCURD in the EU Total population (2007): 490 millions Disease % CURD SCURD Allergic rhinitis 15-25 113 millions 37 m Non-allergic rhinitis 10-15 68 millions 17 m Chronic rhinosinusitis 6-18 70 millions 35 m More than 350 000 surgeries/year In Europe, 1M in the world Aspirin sensitivity 0.5-3 12 millions 10 m Consider socio-economic impact of SCURD !

One third suffered from both, CRS and asthma.

Management of Chronic Rhinosinusitis

Lack of T-regulatory cells in nasal polyps The expression of the transcription factors FOXP3, T-bet, GATA-3, the suppressive cytokines TGF-β1, IL-10 and major TH1/ TH2 cytokines (IFN-γ , IL-4, IL-5, IL13) were analyzed by means of RT-PCR in 13 CRSsNP, 16 CRSwNP and 10 control samples. Additional protein measurements were performed for TGF-β1 and IFN-γ by means of ELISA, and immunohistochemistry was performed for FOXP3 N. Van Bruaene et al, JACI 2008.

TGF-beta receptors (mRNA) * * * Van Bruaene et al, submitted

Different types of T effector cells orchestrate mucosal inflammation in chronic sinus disease Nan Zhang ; T Van Zele; C Perez- Novo; N Van Bruaene; G Holtappels; N Deruyck; C Bachert. JACI 2008

Different types of T effector cells orchestrate mucosal inflammation South Chinese controls South Chinese nasal polyps Belgian controls Belgian nasal polyps ANOVA * Fisher’s Exact test N 29 21 26 Age, yr (range) 38·6 (33·2-43·5) 36·4 (28·6-46·5) 30·3 (21·3-37·9) 46·2 (38·4-55·5) Female / Male 10/19 9/20 9/12 11/15 0.767 Asthma 0/29 2/29 2/21 14/26 <0.0001* Phadiotop positive 11/29 9/29 8/21 11/26 0.845 Aspirin intolerance 0/21 7/26 CT score (Lund & Mackay) 16 (11-20) 1 (0-2) 13 (11-20) <0.0001 Polyp score (Davos) 0 (0-0) 5 (4-6) 4 (4-6) Total symptom score 5 (3-6) 10 (7-11) 5 (3-7) 9 (7-11) Nasal congestion 2 (2-3) 3 (2-3) 2 (1-3) 0.033 Rhinorrhea 0 (0-1) 0 (0-2) 0.008 Sneezing 0.093 Loss of smell Headache 2 (1-2) 0.006 Different types of T effector cells orchestrate mucosal inflammation in chronic sinus disease Nan Zhang ; T Van Zele; Claudina Perez-Novo; N Van Bruaene; Gabriele Holtappels; Natalie DeRuyck; C Bachert. JACI 2008

Objective and study design To asses the therapeutic potential of two injections of 750 mg IV mepolizumab (28days) endoscopic score symptom scores CT scan Two-arm, randomized, double blind, placebo controlled, trial 20 Subjects 30 Subjects Severe nasal polyps MEPO 750mg IV Placebo Dosing Follow up * Primary endpoint 10 Subjects The design of this study was a two-arm, randomized, double-blind, placebo-controlled study. 30 patients with severe nasal polyposis were randomized in a double blinded way. 20 patients received 2 single IV injections with mepolizumab with a 4 week interval, and 10 patients received placebo injections. Follow up visits are scheduled 1 week after first dosing and 1, 3, 6, 9 months post last dose. Weeks 1 4 8 12 24 36 48 *

Endoscopic Nasal polyp score and improvement 13/20 12/20 10/20 intranasal steroids permitted When we look at our primary endpoint, the endoscopic NP score, we see that after two injections of mepolizumab, wet get a strong significant decrease in NP score at week 8, which was maintained until 6 months after treatment . Of importance, After w8 rescue medication was permitted. In the placebo group, none of the patients had a change in the NP score. When we then look at the number of patients that had an improvement in NP score Eventually, we could even speculate that if we could give even more than 2 injections, we could expect an even further decrease of the nasal polyp score. When we look then at the number of patients that showed an improvement on the endoscopic score, we found 10/20 patients that were better, which was significantly higher compared to placebo with 1/10 better. a significant higher number of better patients that were better in the treated group compared to placebo 1 month after the first dosing. This number increased after the second dosingThe percentage of patients that showed an improvement in endoscopic score was significantly better after treatment compared to placebo after week 4, week 8 till week 12. * *

S. aureus superantigens as disease modifiers Massive polyclonal lymphocyte activation Epithelial damage (barrier dysfunction) B T Hyper IgE  Cytokines  colonisation Multiclonal IgE Superantigens Eosinophils  ( apoptosis) Chemokines Bachert C et al. JACI 2001 Review: Bachert C et al. Clin Allergy Immunol. 2007

Tissue Serum ECP (µg/ ml) 602.5 (IQR: 309.9- 894.3)   Controls NP- SAEs (-) NP-SAEs (+) Tissue ECP (µg/ ml) 602.5 (IQR: 309.9- 894.3) 9806.9 (IQR: 1686.5 - 17673.8) 25 583.0 (IQR: 17226.0 - 29870.3) p < 0.0001 (*) IL- 5 (pg/ ml) 20.9 (IQR: 16.9- 25.0) 81.5 (IQR: 38.9- 291.9) 327.9 (IQR: 106.2- 385.5) p < 0.0005 (*) MPO (ng/ ml) 4882.8 (IQR: 3007.1- 7015.0) 8013.9 (IQR: 4912.1- 11476.0) 9705.2 (IQR: 7426.1- 17427.1) Total IgE (kU/ L) 1.93 (IQR: 1.9- 1.9) 323.9 (IQR: 67.2- 387.5) 1 564.0 (IQR: 739.1- 2039.7) Specific IgE to SAEs (kUA/ L) BDL 8.6 (IQR: 6..3- 17.0) P < 0.0005 (*) Serum 9.0 (IQR: 3.8- 14.1) 10.9 (IQR: 7.1- 32.7) 22.4 (IQR: 16.4- 36.9) p = 0.0467 (**) 11.8 (IQR: 8.3- 13.1) 7.5 (IQR: 3.7- 16.7) 10.3 (IQR: 5.9- 13.4) 21.8 (IQR: 8.9- 56.0) 37.2 (IQR: 20.8- 215.2) 211.2 (IQR: 152.5- 431.5) p = 0.0064 (**) 0.4 (IQR: 0.1- 1.3)

SCURD - Phenotyping Inflammation Unmet needs: Create valid nomenclature Improve clinical diagnostics and markers Define and validate targets per subgroup Understand link to lower airways Advantages: Easy access, SCURD may serve as „model“ Animal and human ex-vivo models available Clinical and epidemiologic studies achievable

Sinusitis cohort study GA2LEN 8 centres in Europe (2 co-operative centres in Asia) Inclusion started in March 2007 Clinical phenotyping completed by end of 2008 800 patients and 250 controls included Biobank 1050 blood samples and nasal secretions 450 tissue samples