Présentation réalisée dans le cadre de l\’option "Méthodes Modernes de Découverte et de Développement de Médicaments"

1. Claire Jagodzinski
Laurent Magnies
Charles-Edouard Lebrun 1

2. TYPE 1 DIABETE =
Insulino-dependent Diabete
 Juvenile diabete
 Autoimmune disease
 5 to 10% of diabetics
 Risk to developp T1D in global population : 0.3%-0.4%
2
Expert Opin Biol Ther March 2010; 10(3): 459-465 « Teplizumab therapy for T1D »

3. TYPE 1 DIABETE =
Insulino-dependent Diabete
 Implication of LT autoreactive CD4+ and CD8+
(dendritic cells, macrophages, LB)
 Environnement activating factor
 Break of tolerance
 LT against β-cells (selective destruction)
 Unability to synthesize insulin by pancreas
3
Expert Opin Biol Ther March 2010; 10(3): 459-465 « Teplizumab therapy for T1D »

4. T1D diagnostic
 Clinical
 Polyuropolydipsic syndrom
 Breath characteristic
 Fatigue
 Weight reduction
 Biological
 Hyperglycemia
 Glucosuria
 Insulinopenia (can lead to acidocetose coma)
4

5. Progression of T1D
Genetic Autoimmune  Cell Impaired insulin Glucose Frank
risk activation destruction secretion intolerance disease
50- 90%
Actors:
destruction of islet
AutoAb Islet infiltration,
LT, LB
M, Dendritic cells…
5

6. Progression of T1D
 Asymptomatic Phase (5 years)
- Auto Ab against islets
- Loss of insulin secretion
6

7. Actual therapies
 No curative ttt
 Insulinotherapy all life long
 Grafts
 Immunosuppressors agents:
 Cyclosporin A
 Azathiopirine with Prednisone;
 Anti-Lc Ab with Prednisone
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Expert Opin Biol Ther March 2010; 10(3): 459-465 « Teplizumab therapy for T1D »

8. Immunosuppressive agents
 Inactive pathogenic LT
=> short term effectiveness
=>necessity of continuous ttt
=> short and long term toxicity
=> risk to benefit ratio unfavorable (infections)
Useful ttt = lasting effects + inducing tolerance
Herold and all; « A single course of anti-CD3 hOKT3 results in improvement in C-peptide responses and clinical parameters 8
for at last 2 years after onset T1D »

9. Teplizumab’s target
 Orphean disease (<4 pers. /10 000) because of new onset T1D
 New onset T1D
 Diagnostic of T1D only a few
weeks ago (6 to 12)
 Necessity of early diagnosis
 Because: residual capacity of
insulin secretion
9

10. Screening of new onset T1D
 Screening only for patients at risk
 Family where there are parents or sibling with T1D
 Autoantibodies= Marker of autoimmunity
 Testing for Ab positivity to:
• Proinsulin
• Glutamate Acid Decarboxylase (GAD)
=> Predicting progression to clinical diabetes
10
Clinical Diabetes; 2010; Gregory and All; « Incorporating T1D prevention into clinical practice »

11. -cell preservation
 Having some β cell function
 Lower risk of hypoglycemia
 Better glycemic control
 Lower rate of microvascular complication
11
Expert Opin Biol Ther March 2010; 10(3): 459-465 « Teplizumab therapy for T1D »

12. Prophylactic treatment
for T1D
12

13. Potential targets for -cell preservation
Targeting Activated T-cells (CD3)?
Genetic Immune  Cell Impaired insulin Glucose Frank
risk activation injury secretion intolerance disease
• Modulation of Ab of anti-
-Cell regeneration:
insulin reactivity?
• β-allogeneic islet transplants?
• Targeting B-cells (CD20)?
• Directed Stem cell differentiation?
- Rituximab
13

14. Immunologics reminds
T Cell Receptor
On surface of LT
Activation of LT with
predilaction
antigen, presented by CAP
Marqueur CD3
All LT are CD3+
Associated to TCR
=> form TCR complex
14

15. Anti-CD3 Ab
 1979: Kung & Goldstein : Dvpt of a mouse cell line
producing an IgG2a mAb against an Ag on LT
 IgG2a mAb= OKT3
 First of all, OKT3 used for prevention of transplant
rejection
 OKT3 is oligomeric and specific to ε
chain of CD3 complex
 ε is the major signal transducing
element of TCR
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Expert Opin Biol Ther March 2010; 10(3): 459-465 « Teplizumab therapy for T1D »

16. Anti-CD3 Ab
 « Flu-like » syndrome: high
fever, chills, headache, gastrointestinal symptoms
 Cross-linking to the TCR/CD3 complex on LT
surface, which releases cytokine (TNF α, IFN γ, IL)
 Dvpt of human anti-mouse Ab, which causes rapid
clearance of this anti-CD3 and reduces efficacity
 Solution: humanizing this Ab, by Bluestone and
Colleagues
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Expert Opin Biol Ther March 2010; 10(3): 459-465 « Teplizumab therapy for T1D »

17. 2 anti-CD3 Ab humanized
 Teplizumab = hOKT3γ1 (Ala-Ala)
 Humanized version
 Same binding region of OKT3
 Variation of 2AA (234 and 235 of the human IgG1 Fc) in Ala
=> Resulting in decreased Fc binding with others cells
 Otelixizumab = ChAglyCD3
 Humanized version of a rat anti-CD3 mAb
 Lacking of a crucial glycosylation site in the Fc portion
=> Resulting in decreased Fc binding with others cells
 Decrease cytokines release potential
 Maintain their immunomodulatory effects
17
Expert Opin Biol Ther March 2010; 10(3): 459-465 « Teplizumab therapy for T1D »

18. Short term effect
• Antigenic modulation of the TCR/CD3 complex
• Grouping
• Internalization
• Reprogrammation
18
Nature; August 2007; Chatenoud and Bluestone; « CD3-specific Ab: a portal to the ttt of autoimmunity »

19. Short term effect
• CD95L of activated T cells binding with CD95 on LT surface
• Intracellular signals
=> Induction of apoptosis
19
Nature; August 2007; Chatenoud and Bluestone; « CD3-specific Ab: a portal to the ttt of autoimmunity »

20. Short term effect
• Inhibition of transduction pathways
=> Induction of anergy T cells
20
Nature; August 2007; Chatenoud and Bluestone; « CD3-specific Ab: a portal to the ttt of autoimmunity »

21. Short term effect
During Ab treatment
Presence of Anti-CD3 in the body
21
Nature; August 2007; Chatenoud and Bluestone; « CD3-specific Ab: a portal to the ttt of autoimmunity »

22. Preclinical studies
22

23. Preclinical studies
 Diabete induced by multidose of streptozotocin in
NOD mouse
 5 days after streptozotocin, ttt with hOKT3γ1 (Ala-Ala)
 Remission of 80% of the mice
 Disease did not recur when the ttt is stopped
 NOD mice in clinical T1D (no onset) receive grafts
which isn’t destroyed
 Inducing of tolerance toward pancreatic β-cell
Herold and all; « A single course of anti-CD3 hOKT3 results in improvement in C-peptide responses and clinical parameters 23
for at last 2 years after onset T1D »

24. Tolerance
-> Induction of LT apoptosis by modulating the TCR/CD3
complex
-> Conversion of LT CD4+ into LTreg due to TGF-β, secreting
by dendritics cells and macrophages
24
Medecine/sciences 2009; 25: 325-54; Sylvain Perruche et phillipe Saas; « Mort sur ordonnance »

25. Endpoints
25

26. Endpoints
 Peptide C:
 Specific marker of insulin endoproduction
 Half life longer than insulin ( 35 VS 5 min)
 Used in quantification of β-cells residuals function in new
onset T1D
 HbA1C
 Reflects glc control
 Retrospective marker of glycemia 3 months ago
 CD4+/CD8 + T cells ratio
 Immunocapacity
26

27. Clinical Trials
27

28. Phase I/II
 Study the safety and efficacy on the loss of insulin
production , over 2years
 42 patients
 New onset T1D (less 6 weeks after diagnosis)
 Auto Ab
 24 months study
 Drug treated and control group similars
(age, sex, duration of T1D, Cpeptide response…)
 Insulinotherapy
Herold and all; « A single course of anti-CD3 hOKT3 results in improvement in C-peptide responses and clinical parameters
28
for at last 2 years after onset T1D »

29. Protocol
 A single course of hOKT3γ1 (Ala-Ala)
 Intravenous administration over 15 min
• 12 patients, during 14 days • 9 patients, during 12 days
•Day 1: 1.42 µg/kg •Day 1: 460 µg/m²
•Day 2: 5.67 µg/kg •Day 2: 919 µg/m²
•Day 3: 11.3 µg/kg •Day 3-12: 1818 µg/m²
•Day 4: 22.6 µg/kg
•Day 5-14: 45.4 µg/kg => dosing change 23% increased
Herold and all; « A single course of anti-CD3 hOKT3 results in improvement in C-peptide responses and clinical parameters
29
for at last 2 years after onset T1D »

30. Endogenous insulin production
Herold and all; « A single course of anti-CD3 hOKT3 results in improvement in C-peptide responses and clinical parameters 30
for at last 2 years after onset T1D »

31. HbA1C levels
Better glycemic
control in drug
treated group
Herold and all; « A single course of anti-CD3 hOKT3 results in improvement in C-peptide responses and clinical parameters 31
for at last 2 years after onset T1D »

32. Insulin requirement
Insulinotherapy during
the trial, using insulin
pumps or multiple
injection
Herold and all; « A single course of anti-CD3 hOKT3 results in improvement in C-peptide responses and clinical parameters 32
for at last 2 years after onset T1D »

33. Nadir of Lc
 Nadir 5 days after ttt
 Risk of infections
 Returning to normal
two weeks after
Herold and all; « A single course of anti-CD3 hOKT3 results in improvement in C-peptide responses and clinical parameters 33
for at last 2 years after onset T1D »

34. CD4+ to CD8+ T cells ratio
Herold and all; « A single course of anti-CD3 hOKT3 results in improvement in C-peptide responses and clinical parameters 34
for at last 2 years after onset T1D »

35. TRECs
● T Receptor Excision Circles
● Measuring thymopoiesis
● Detection of a marker on LT recently
leaving from thymus
● Reliable Technic

36. TCR excision circles (TREC) Assay
Recombinaison du locus  Quantification des sjTREC
par PCR en temps réel
Thymus Lymphocytes T
Dulphy; Inserm U662; Septembre 2006

37. CD4+
TRECs CD8+
● No variation of thymic production
● Recovered Lc after nadir aren’t from thymus
● Peripheric reprogrammation
Clinical Immunology; 2009; 132, 166-173; Herold and All; « Ttt of patients with new onset T1D with a single course of anti-CD3
mAb Teplizumab preserves insulin production for up to 5 years »

38. Long term effect
 AutoAg (pro-insulin, GAD) suggesting to DC
 TGF-β producted by phagocytaires cells
=> conversion LT CD4+ into LTreg
 LTreg inactive pathogenic LT
 CD4+/CD8+ ratio decreased
=> After Ab treatment
38
Nature; August 2007; Chatenoud and Bluestone; « CD3-specific Ab: a portal to the ttt of autoimmunity »

39. Results in ttt group at 1year
 Higher endogeneous insulin secretion to the MMTT
 Reduced HbA1C levels, associated with improved
insulin response
 Reduced exogen insulin requirement : prevent the loss
of insulin production
 Modification of the progression of the auto
immune process
 Long term effect
Herold and all; « A single course of anti-CD3 hOKT3 results in improvement in C-peptide responses and clinical parameters 39
for at last 2 years after onset T1D »

40. Adverse effects
 Most frequent: fever, headache, myalgia, arthralgia
 Less frequent: nausea, diarrhea, vomiting, fatigue
 A rash dvped during 3 weeks
 Controlled by AINS, antihistaminic
 No long term side effects related to drug ttt
Herold and all; « A single course of anti-CD3 hOKT3 results in improvement in C-peptide responses and clinical parameters 40
for at last 2 years after onset T1D »

41. Phase IIb
 Obj: determine wether a 2nd or 3rd course would
improve duration effects, more than 2 years
 10 subjects (diagnosis of T1D 6 weeks ago)
 Dose used 40% greater than previous trial
 Too many adverse effects => Phase stopped
 Current clinical trials use 2 courses of drug at
diagnosis and 6 months later
Clinical Immunology; 2009; 132, 166-173; Herold and All; « Ttt of patients with new onset T1D with a single course of anti-CD3 41
mAb Teplizumab preserves insulin production for up to 5 years »

42. Actual clinical study
 Phase II/III: study PROTEGE in june 2009
 530 patients
 New onset diabete
 Obj: long term innocuity and efficacity
 Phase III: study PROTEGE ENCORE
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http://www.macrogenics.com/

43. Futures objectives
 Diagnosis earlier T1D in order to treat better
 Used in others auto-immune diseases implying T cells
 Psoriatic arthritis
 Combined with other therapies in prevention of
allograft rejection (better than OKT3 because less
adverse effects)
43
Expert Opin Biol Ther March 2010; 10(3): 459-465 « Teplizumab therapy for T1D »

44. Aknowledgements
 Realised by :
 Laurent Magnies
 Claire Jagodzinski
 Charles-Edouard Lebrun
Thanks to Hélène GRAS
44