Rationales behind novel therapies for coeliac disease Ludvig M. - PowerPoint PPT Presentation

Rationales behind novel therapies for coeliac disease Ludvig M. Sollid Director (CIR), Professor (UiO) Coeliac UK Research Conference London, March 11, 2015

CONFLICT OF INTEREST Ludvig M. Sollid Ø Regeneron Pharma – Consulting / Funding Ø ImmusanT Inc – Membership on advisory committee / Honoraria Ø Alvine Pharma – Membership on advisory committee / Honoraria Ø Glenmark Pharma – Consulting

NORMAL MUCOSA CELIAC DISEASE MUCOSA + gluten l - gluten Magliocca et al Arch Histol Cytol 1992

CELIAC DISEASE MUCOSA NORMAL MUCOSA + gluten - gluten antibodies to gluten (gliadin) transglutaminase 2 (TG2) Photo: Per Brandtzaeg

GENOME WIDE ASSOCIATION STUDIES Koblingsanalyse Mathew, Nat Rev Genet 2007

GWAS and MHC (HLA) S Slide courtesy: TH Karlsen

HLA association in celiac disease 60-90% DQ2.5 ¡ 5-30% DQ2.2 ¡ 1-5% DQ8 ¡ 1-5%

Antigen TCR MHC II T APC Antigen Presenting Cell T-cell

Plasma cell Antibodies Ag BCR B B-cell

The celiac lesion Wheat CD8 T cell Hüe et al Meresse et al Immunity 2004 TCR NKG2D cyto- lysis MIC IL-15 CD8 Enterocyte CD8 CD4 T cell TG2 CD4 IFN- γ CD4 TCR IL-21 APC HLA-DQ2 APC CD4 (or -DQ8) Deamidation CD4 APC by TG2

¡ A gluten peptide caught in the act ¡ Gluten ¡pep/de ¡ HLA-­‑DQ2.5 ¡ Stanford ¡& ¡Oslo ¡

Generation of T-cell epitopes in the gut α 2 -gliadin (AJ133612) 1 MVRV 1 MVRVPVPQLQ PQNPSQQQ QQQPQ E EQVPLV LVQQQQ QQQQ F FPGQQQ QQQPF PFPP PP QQ QQPYPQPQPF F PSQQ LQLQ QQPYL YLQLQ 61 PFPQPQLPYP QPQLPYPQPQ L 61 61 PFPQPQLPYP QPQLPYPQPQ L 61 LPYPQPQPFR LPYPQPQPF F FR PQQ QQPYPQSQP QYS YSQPQQ QQPIS IS QQQQQQQQQQ QQQQQQQQQQ 121 QQ 121 QQKQQQQQQQ QQQQQQQ QIL ILQQ QQIL ILQQQ QQQ LIPCRDVVL LIPCRDVVLQ QHSIAYGSS HSIAYGSSQ VL VLQQ QQSTY STYQLV LV QQ QQLCC LCCQQ QQLW LWQ 181 IPEQSRC 181 I SRCQAI HNVVHAIILH AI HNVVHAIILH QQQQQQQQQQ QQ QQQQQQQQQQ QQPLS LSQVSF VSFQ QPQQQ QQQYPSG YPSGQ GSF GSFQPSQQ QQNP 241 QAQGSV 241 GSVQPQQ QQ L LPQFEEIRNL ALETL FEEIRNL ALETLPAMCN VYI AMCN VYIPP PPYCTIA YCTIA PVGIFGTNYR VGIFGTNYR digestive enzymes Transglutaminase (QXP) after transglutaminase treatment LQLQ 61 PFPQP E LPYP QP E LPYPQP E L 61 LPYPQPQPF F peptide (33 amino acids) PFPQP E LPY Y 6 copies of PQP E LPYP Q PYP QP E LPY T cell epitopes Y P QP E LPYPQ PYPQP E LPY Y PQP E LPYPQ Q Shan et al, Science 2002; Arentz-Hansen et al, Gastroenterology 2002

HLA-DQ2.5 and HLA-DQ8 restricted gluten T-cell epitopes DQ2.5 DQ8

HLA-DQ2.5-gluten epitope tetramers T cell B B S-PE B B

Increased frequency of gluten-specific effector- memory CD4+ T cells in celiac disease Control TCD EM UCD Christophersen et al., UEG J 2014

T cells (CD3) Plasma cells (CD138) Active celiac disease Photo: Ann-Christin Beitnes

Visualization of TG2-specific plasma cells by immunofluorescence on intestinal cryosections celiac bio$n-­‑TG2 ¡ ¡ ¡ ¡ ¡an$-­‑CD138 ¡ ¡ ¡ ¡ ¡merge ¡ Di Niro et al., Nat Med 2012

Detection of TG2-specific plasma cells by flow cytometry on intestinal cell suspensions CD patient Patient with Healthy donor on GFD active CD 0.4 0.7 3.5 8.3 0.1 0.3 biotin-TG2 Anti-IgA (gated on CD138+ plasma cells) PE TG2 b TG2 b SA b b PE TG2 TG2 Di Niro et al., Nat Med 2012

Whea t The celiac lesion CD8 IL-15 CD8 CD8 Mucosa (effector site) TG2 CD4 Deamidation APC by TG2 APC IFN- γ CD4 IL-21 APC CD4 plasmablast via lymph via blood CD4 Germinal centre CD4 B CD4 Mesenteric lymph node APC or Peyer’s patch B CD4 (priming site)

Relationship T-cell epitope and B-cell epitope T-cell epitope must be physically linked with T cell help B-cell epitope prior to Ag Ag processing TCR MHCII T B CD4 Accessory molecules Cytokines

T-cell help to TG2-specific B cells by gluten-specific T cells APC ‘Hapten-carrier like’ model Gluten peptide T-cell help HLA-DQ2 TG2 TG2-gluten peptide complex TCR T B CD4 MHCII TG2-specific B cell Gluten-specific T cell

T-cell – B-cell interaction: An amplifying loop for the T-cell reponse TG2 Gluten peptide TG2 Anti-TG2 antibodies TCR T B CD4 MHCII Activation Activation Proliferation Proliferation Clonal expansion Plasma cell differentiation

Gluten specific T cells can give help to both TG2- specific and deamidated gluten-specific B cells TG2 Gluten peptide TG2 Anti-TG2 antibodies TCR Transglutaminase (TG2) T B specific B cell CD4 MHCII Deamidated gluten peptide Anti-deamidated gluten antibodies TCR Deamidated gluten T B specific B cell CD4 MHCII

Key event in the pathogenesis of coeliac disease Clonal expansion of: - Gluten specific CD4+ T cells - TG2 specific B cells - Gluten specific B cells The point of T- and B-cell clonal expansions is when the patient is crossing the bridge.

Non-dietary therapies for coeliac disease I Prevent gluten from stimulating T cells • Grain modification • Polymers binding gluten (BioLine Rx) • Glutenases (Alvine) • Epithelial barrier (Alba) • Transglutaminase (TG2) inhibitors (Dr. Falk, Sitari) • Elafin (prevents gluten deamidation)

Non-dietary therapies for coeliac disease II Modify immune response • Cytokine therapy (anti-IL15; Celimmune, Calypso) • Peptide therapy (ImmusanT)

ACKNOWLEDGEMENTS CONTRIBUTORS Oslo Chicago Roberto Di Niro Carole Dunand Øyvind Steinsbø Patric C. Wilson Rasmus Iversen Stanford Luka Mesin Chaitan Khosla Shuo-Wang Qiao Asbjørn Christophersen Michael Bodd Elin Bergseng Siri Dørum Jorunn Stamnaes Knut E.A. Lundin Ludvig M. Sollid