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

2. 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)

3. 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)

4. 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

5. 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

6. 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)

7. 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

8. 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

9. 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

10. 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)

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

12. Circulating Elevation of Indoleamine is correlated with fatigue

13. 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

14. 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

15. 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

16. fMRI maps corneal pain in SS

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

18. Severe Xerostomia with dry tongue
Angular
cheilitis

19. Sjogren’s Syndrome- Cervical Dental Caries

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

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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

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

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

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

30. Lymphocytic Interstitial Nephritis (steroids, mycophenolic acid, rituximab)

31. 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

32. 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

33. 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)

34. 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)

35. 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)

36. 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)

37. 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

38. 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

39. 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

40. 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

41. SS-A/hYRNA migrates into apoptic bleb

42. hYRNA
Ro-60
Schematic representation of hYRNA1 binding to Ro60

43. 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

44. 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

45. 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

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

47. 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

48. 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

49. 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

50. 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

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

52. 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

53. 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

54. 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

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

57. 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

58. Additional Trials

59. Trials-2

60. Trials BAFF

61. Trials- IFN 1 R

63. 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)

64. 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)

65. 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

66. 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

67. 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.

68. 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.

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

72. Heat Shock 90 is a DAMP

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

74. 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

75. 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

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

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

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

79. Molecular “Signatures” of SS

81. 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

82. 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.

83. 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