1. 1
Leukocyte Trafficking in Health and Diseases
(細胞接着・遊⾛の⽣理的意義と疾患との関連)
• Cell adhesion molecules
(細胞接着分子とは、ケモカインとは)
• Genetic defects
(細胞接着分子の遺伝的欠損症とは)
• Therapeutic inhibition
(細胞接着分子を治療標的にする)
Motomu Shimaoka, M.D., Ph.D.
Mie University Medical School
2. Quiz-1
Bacterial infections usually begin(細菌感染症は血管の
内側で始まるでしょうか、それとも血管の外側で始まる
でしょうか:
A) inside of the vasculatures(内側)
B) outside of the vasculature(外側)
6. Assignment: 2 Questions to Answer in English
(以下の問いをノートに写しなさい。授業中に英語で解答しなさい。ヒントは
授業中に言います)
1. Explain the molecular mechanisms by which leukocyte
extravasation is regulated.(白血球の血管外遊走の
分子メカニズムを英語で説明せよ)
2. Explain the genetic defect(s) causing leukocyte adhesion
deficiency (LAD)-I, II, and III.(LAD-I, II, IIIを起こす
遺伝子欠損について英語で説明せよ)
8. Leukocyte Adhesion Deficiency (LAD)
白血球接着不全症
Case(症例):15-year-old patient JT, who first presented as an infant
with severe and recurrent skin infections requiring prolonged
treatment with intra-venous antibiotics and surgery to remove necrotic
tissue. In spite of attentive oral hygiene, the patient suffered from
severe periodontitis and gingivitis. Otitis media and chest infections
had also been consistent features of this patient‘s condition.
Organisms isolated from infected sites included Staphylococcus
aureus, Pseudomonas, and Streptococcus species…….(Hogg M. JCI
1999)
• Recurrent and often fatal bacterial infections
• Defects in leukocyte adhesion and phagocytosis
9. (modified from von Andrian, NEJM, 2000)
3-Steps in the leukocyte-endothelial interactions
15. Rolling enables leukocytes(ローリングの役割は):
• Slow down (減速)
• Travel along the endothelial surface(血管内皮表面を走行)
Probe for chemokines that are displayed on the endothelial surfaces
(血管内皮表面を探索することを助ける)
28. β
Integrin
binding
factor
α
Integrin binding
factor
ICAM-1
7. Ligand binding
3. Separation
of α and β
tailpieces
2. Binding of factors
to integrin
cytoplasmic domains
1. Cellular
activation
5. Swing-out of hybrid
domain and activation of
I-like domain
4. Switchblade-like upward
movement of headpiece
6. Activation of I domain
by downward movement of
its C-terminal ”pull spring"
LFA-1のグローバルな�
コンフォメーション変化�
29. 188
an interaction with the NHL-domain protein Wech (Löer et al., adhesions they lose ICAP1α (Fournier et al., 2002) and the actin-
Journal of Cell Science 122 (2)
Table 1. Adaptor proteins that bind to β-integrin cytoplasmic tails
Adaptor protein Integrin to which adaptor binds Reference
Structural adaptors
α-actinin β1, β2, β3 (Otey et al., 1993; Pavalko and LaRoche, 1993)
BP180 β4 (Koster et al., 2003; Schaapveld et al., 1998)
Filamin β1, β2, β3, β7 (Calderwood et al., 2001; Kiema et al., 2006; Loo et al., 1998; Pfaff et al., 1998;
Sharma et al., 1995; Travis et al., 2004; Zent et al., 2000)
Myosin β1, β3, β5 (Jenkins et al., 1998; Sajid et al., 2000; Zhang et al., 2004)
Plectin β4 (Geerts et al., 1999)
Skelemin β1, β3 (Reddy et al., 1998)
Talin β1, β2, β3, β5, β7 (Calderwood et al., 2003; Calderwood et al., 1999; Patil et al., 1999; Pfaff et al., 1998;
Sampath et al., 1998)
Tensin β1, β3, β5, β7 (Calderwood et al., 2003; McCleverty et al., 2007)
Scaffolding adaptors
14-3-3 β1, β2, β3 (Fagerholm et al., 2005; Han et al., 2001)
β3 endonexin β3 (Eigenthaler et al., 1997; Shattil et al., 1995)
CD98 β1, β3 (Zent et al., 2000)
Dab1 β1, β2, β3, β5, β7 (Calderwood et al., 2003)
Dab2 β3, β5 (Calderwood et al., 2003)
Dok1 β2, β3, β5, β7 (Calderwood et al., 2003)
Fhl2 β1, β2, β3, β6 (Wixler et al., 2000)
Fhl3 β1 (Samson et al., 2004)
Grb2 β3 (Blystone et al., 1996; Law et al., 1996)
IAP β3 (Brown et al., 1990)
JAB1 β2 (Bianchi et al., 2000)
Kindlin 2 β1, β3 (Ma et al., 2008; Montanez et al., 2008)
Kindlin 3 β1, β3 (Moser et al., 2008)
Melusin β1 (Brancaccio et al., 1999)
Numb β3, β5 (Calderwood et al., 2003)
Paxillin β1, β3 (Chen et al., 2000; Schaller et al., 1995)
Rack1 β1, β2, β5 (Liliental and Chang, 1998)
Shc β3, β4 (Dans et al., 2001; Law et al., 1996)
TAP20 β5 (Tang et al., 1999)
WAIT1 β7 (Rietzler et al., 1998)
Catalytic adaptors
Src β3 (Arias-Salgado et al., 2003; Arias-Salgado et al., 2005)
Yes β1, β2, β3 (Arias-Salgado et al., 2005)
Cytohesin 1 β2 (Kolanus et al., 1996)
Eps8 β1, β3, β5 (Calderwood et al., 2003)
ERK2 β6 (Ahmed et al., 2002)
FAK β1, β2, β3, β5 (Chen et al., 2000; Eliceiri et al., 2002; Schaller et al., 1995)
Fyn β3 (Arias-Salgado et al., 2005)
ILK β1, β3 (Hannigan et al., 1996; Pasquet et al., 2002)
Lyn β1, β2, β3 (Arias-Salgado et al., 2005)
PKD1 β1, β3 (Medeiros et al., 2005; Woods et al., 2004)
PP2A β1 (Kim et al., 2004)
Shp2 β4 (Bertotti et al., 2006)
Other adaptors
ICAP1α β1 (Chang et al., 1997; Zhang and Hemler, 1999)
MIBP β1 (Li et al., 1999)
JournalofCellScience
Cytoplasmic proteins interacting with β integrin tails
Legate KR, J Cell Sci 2009
30. signaling). Integrins
low-affinity confor-
“inside-out” signal-
ins is regulated by
uced intracellularly
rect binding of reg-
ytoplasmic domains
w- to a high-affinity
vation” (1, 2).
with which integrins
for various cellular
uring development
vated integrins at
h newly protruded
face on which they
egrins at their rear.
brinogen receptors
are swiftly activated
and aggregation in
ause aIIbb3 integ-
to fibrinogen, it is
so as to prevent
tion and thrombus
nflammation leuko-
ion in order to ad-
he endothelium on
Abnormal function
ins or mutations in
quired for integrin
ant development or
sorders, leukocyte-
n blistering. In this
structural and bio-
om genetic manip-
new light on how
and b subunits. In mammals, 18 a and 8 b sub-
units combine in a restricted manner to form 24
specific dimers, which exhibit different ligand-
binding properties. Integrin subunits have large
dependent adhesion site (MIDAS), which binds
divalent cations required for ligand binding by
integrins. The b subunit is composed of a hybrid
domain that connects to the bI domain, which is
A Inactive
low affinity integrin
Active
high affinity integrin
B C D
βA
βα
βTD
β propeller
Hybrid
Thigh
Genu
Calf 1
MD NxxY
MP NPxY
Calf 2
PSI
Transmembrane
Cytoplasmic
Head
EGF
Rod
F1
F1
F2
F2F3
F3
F0
PH
N-term
Kindlin
Talin
Fig. 1. (A) Integrin architecture and schematic representation of integrin activation. Specific contacts
between the ectodomains, the TM, and cytoplasmic domains keep the integrin in its bent conformation.
onJwww.sciencemag.orgDownloadedfrom
タリンとキンドリンがインテグリンを活性化する
Talin and Kindlin activate integrin
Moser M, Science 2009
31. egrins without an I domain, ligands bind to
crevice between the ab subunit interface,
here they interact with a metal ion–occupied
IDAS within the b subunit and the propeller
main of the a subunit.
The structure of the short TM domains is
orly defined because of the lack of high-
olution structures of heterodimeric TM do-
ains in their proper context, and only the
uctures of the b3 and the aIIb subunits are
lved in their entirety (3–5). The b3 TM do-
ain is a 30-residue linear a helix that is longer
an the width of a typical lipid bilayer, which
plies a pronounced helix tilt within the plas-
a membrane (5). The aIIb TM domain is a 24-
idue a helix followed by a backbone reversal
d does not exhibit a helix tilt (4). This unusual
otif is highly conserved in the 18 human
egrin a subunits and probably has an impor-
nt role in the transition from low- to high-
inity states.
A high degree of similarity is found in the
ort a and b cytoplasmic tails, especially in the
embrane proximal region where the GFFKR
d HDR(R/K)E sequences are conserved in
e a and b subunits, respectively (6). Nuclear
agnetic resonance (NMR) studies that used
egrin-derived aIIb3 polypeptides proposed
at integrins interact with each other through
drophobic and electrostatic interactions and a
t bridge between the R residue within the
FKKR motif and the D residue within the
DRRE motif (7, 8). However, these interactions
ere not seen by others, suggesting that tail
eractions are very weak at best (9). Almost
b tails have two well-defined motifs that are
rt of a canonical recognition sequence for
osphotyrosine-binding (PTB) domains (10),
nsisting of a membrane proximal NPxY (where
mains that regulates integrin subunit packing
(14). Separation of integrin TM domains has
been suggested to be a requirement for integrins
to adopt the high-affinity state. There are two
possible ways by which TM domain interactions
has been extensively examined in the rapidly
activated b2 and b3 integrins. Although muta-
tional analysis suggests that the salt bridge is
important for maintaining these integrins in a
low-affinity state (15), this might not be the case
for all integrins, especially the
b1 integrins (16). Despite the con-
troversial role of the salt bridge in
maintaining integrins in a low-
affinity state, high integrin affinity
is thought to be associated with
separation of the a and b cyto-
plasmic tails. Many proteins bind
directly to integrin tails, yet only
talin and kindlins can regulate
integrin affinity. The role of these
NxxY motifs–binding proteins in
integrin activation and function will
now be discussed in detail.
Talin Is an Essential Mediator
of Integrin Activation
Talin is a component of adhesion
plaques and interacts with integrin
cytoplasmic tails (17). Its role in
altering integrin function was orig-
inally demonstrated by its ability to
induce a shift in the affinity of a
normally inactive integrin expressed
in chinese hamster ovary (CHO)
cells (18, 19). Knockout and knock-
down experiments subsequently re-
inforced the notion that talin is a
key regulator of integrin affinity for
ligand, and many mutational and
structural studies have described
the mechanism by which it accom-
plishes this task. Talin orthologs
have been identified in all multi-
A
B
C
Autoinhibition
Binding
to the
MP NPxY
Binding
to the
MP helical
region
Integrin
PIP2 Calpain cleavage
Phosphorylation?
Talin
Activation
タリンのインテグリン細胞内ドメインへの結合が活性化をトリガーする
Talin activates integrin
Moser M, Science 2009
32. mon binding motif for PTB domain–
roteins (18, 19, 29). Mutations with-
motif of both b1 (30) and b3 (31)
well as mutations in the talin PTB
abolish talin binding and
egrin affinity. Insights
n increases integrin af-
rom NMR experiments
t the talin head effec-
mpetes the aIIb tail for
he b3 tail (7). Fluores-
y transfer (FRET) ex-
n cells confirmed that
d induces separation of
ails (in this case aLb2),
comitant with increased
n ligand binding (33).
d of talin1 by small in-
A (siRNA) cannot re-
mmon activation stimuli
rmore, genetic experi-
norhabditis elegans (34),
35), and mice (36–38)
that talin1 ablation uni-
s to integrin-adhesion
se experiments led to
at talin was both nec-
sufficient to activate
owever, the claims of
were later shown to be
ification.
question is why talin
defect (42). Expressing the talin1 head in these
cells partially restored the spreading defect, but
FAs were still absent, demonstrating that the
clustering of integrins into larger adhesion struc-
elicits a conformational change that di
autoinhibitory interaction and enhances
talin binding (45, 46). Although phosph
binding can enhance the affinity of m
domains for their substrates
does not hold true for the iso
head (46). Talin binds to PI
directs it to focal adhesions
thus, a feed-forward loop m
enhance talin recruitment
adhesion formation.
In hematopoetic cells, t
sine triphosphatase (GTPa
has been implicated in tal
ment to integrin tails. Exp
constitutively active Rap1A
increases integrin activation
the deletion of Rap1B in
decreases aIIbb3 activation
sociation of the Rap1 effec
GTP–interacting adaptor
(RIAM) resulting in a Rap
talin ternarycomplex atthein
has been shown to be requir
interaction (49, 50). A simila
mediated activation mechan
also occur in nonhematopo
because a direct interaction
talin and lamellipodin, a mem
MRL (Mig-10/RIAM/Lam
family of adaptor proteins, a
in integrin activation (51).
Integrin
PIP binding?
Phosphorylation?
Fig. 3. Hypothetical model of kindlin recruitment and binding to the b
タリンの作用機序の詳細:Talin activates integrin at the
membrane-cytoplasmic interface
Moser M, Science 2009
33. Activation
ionarily con-
oteins named
drome, a rare
hree kindlin
n-1 [Unc-112
(Mig2), and
which is pre-
s, is found in
ey; kindlin-2
st amounts in
nd kindlin-3
ematopoietic
localize to
dlin-1 and -2
3 localizes to
ent adhesion
of the integrin
ortholog of
rins in dense
ession results
t is similar to
s (66). Two
ne mutations
tive integrin
caused by the
matosis char-
esion defect
eous atrophy
mplicated in a
AD) type III
Kindlin-mediated integrin activation requires a
direct interaction between kindlin and b integrin
tails. The kindlin and talin FERM domains show
high levels of sequence similarity (73); however,
suggests that a lack of kindlin-3 binding might be
responsible for the bleeding phenotype (61).
Because kindlins and talin bind distinct re-
gions of the b integrin tail, they may cooperate to
Sequential binding
A B C
Cis co-operation Trans co-operation
Fig. 4. Putative crosstalk mechanisms between talin and kindlin during integrin activation. (A)
onJune7,2012www.sciencemag.orgdedfrom
タリンとキンドリンの協調作用
How do Talin and Kindlin act together on integrin?
Moser M, Science 2009
34. Interim summary(中間まとめ):
Cell Adhesion Cascade(細胞接着のカスケード)
Multiple Steps Happen in Sequence Leading to Extravasation
複数のステップが連続して起こる。前のステップは次のステップに必須
35. What would happen to leukocytes,
if integrins were absent?
インテグリンが欠損すると白血球に
どんな問題がおこるか?
X
37. Leukocyte Adhesion Deficiency Type-I
LAD-I
白血球接着不全症(1型)
-Primary immundeficiency(原発性免疫不全のひとつ)
-Recurrent and often fatal bacterial infection
(繰り返し、しばしば致死的な細菌感染症)
-No pus formation(膿がない)
-Leukocytosis (30,000~100,000 / µl)(血中白血球数増加)
Case: 3-year-old female presented to her dentist
“Gums are red, painful, and bleeding for 3 months”
Genetic defect of β2 integrins (CD18)
(β2インテグリンの遺伝的欠損)
38. What would happen to leukocytes,
if Sialyl LewisX (s-Lex) was absent?
糖鎖シアリルルイスXが欠損すると
白血球にどのような問題がおこるか?
X
39. -Functional defects in selectin ligand(セレクチン・リガンドの機能不全)
-Rolling interactions perturbed(ローリングが阻害される)
-Recurrent and often fatal bacterial infection
-No pus formation
-Leukocytosis
Genetic defect of the enzyme to attach sialyl lewisx (s-Lex)
糖鎖シアリルルイスXをタンパクに付加する酵素の遺伝的欠損
Leukocyte Adhesion Deficiency Type-II
LAD-II
白血球接着不全症(2型)
40. What would happen to leukocytes,
if kindlin-3 (an integrin-activating
signal) was absent?
キンドリンが欠損すると白血球にど
んな問題が起こるか?
X
41. -Functional defects in integrin activation(インテグリン活性化不全)
-Integrins are present but unresponsive to chemokines
(インテグリン発現はあるが、ケモカイン刺激に反応しない)
-Recurrent and often fatal bacterial infection
-Platelet dysfunction(白血球だけでなく、血小板凝集不全も)
-No pus formation
-Leukocytosis
Genetic defect of kindlin-3
Leukocyte Adhesion Deficiency Type-III
LAD-III
白血球接着不全症(3型)
42. Activation
ionarily con-
oteins named
drome, a rare
hree kindlin
n-1 [Unc-112
(Mig2), and
which is pre-
s, is found in
ey; kindlin-2
st amounts in
nd kindlin-3
ematopoietic
localize to
dlin-1 and -2
3 localizes to
ent adhesion
of the integrin
ortholog of
rins in dense
ession results
t is similar to
s (66). Two
ne mutations
tive integrin
caused by the
matosis char-
esion defect
eous atrophy
mplicated in a
AD) type III
Kindlin-mediated integrin activation requires a
direct interaction between kindlin and b integrin
tails. The kindlin and talin FERM domains show
high levels of sequence similarity (73); however,
suggests that a lack of kindlin-3 binding might be
responsible for the bleeding phenotype (61).
Because kindlins and talin bind distinct re-
gions of the b integrin tail, they may cooperate to
Sequential binding
A B C
Cis co-operation Trans co-operation
Fig. 4. Putative crosstalk mechanisms between talin and kindlin during integrin activation. (A)
onJune7,2012www.sciencemag.orgdedfrom
思い出そう:
How do Talin and Kindlin act together on integrin?
Moser M, Science 2009
43. ZIP code theory
Different integrins determine “lymphocyte homing”
to specific organs
Brain Gut Organ
(destination)
Integrin α4β1
+
VCAM-1
Integrin α4β7
+
MAdCAM-1
Leukocyte
+
Endothelium
46. • Chronic, often disabling disease that attacks the central nervous system
• Immune system attack against the central nervous system
• Autoimmunity to myelin.
Multiple Sclerosis(MS, 多発性硬化症)
< Pathogenesis >
47. • Paralysis or loss of vision
• Relapses leading to irreversible disability
Multiple Sclerosis
< Clinical symptoms >
49. • Integrin α4β1-VCAM-1 interaction supports immune cell
trafficking to the inflamed brain.
evaluate potential new therapies in proof-of-concept
trials.30
The effect of new gadolinium-enhancing lesions
was recognized as an appropriate outcome measure for
testing natalizumab’s efficacy, given its known mecha-
nism of action; it was investigated in a small, parallel-
group, placebo-controlled trial in which subjects re-
ceived 2 doses of placebo or natalizumab 1 month apart
and were followed up with regular MRI scans for 6
months. The trial was smaller than desirable for phase 2
evaluation of efficacy by MRI, necessitated in part by a
limited supply of drug. However, the study reached its
primary end point: the adjusted mean cumulative num-
ber of new active lesions was lower in the natalizumab-
treated group than in the placebo group (1.8 vs 3.6; P=.04,
analysis of covariance).25
Most of the new active lesions
were areas of new enhancement. In an accompanying edi-
torial,31
the trial finding was described as a “near hit.”
Had the study not reached its primary end point, one could
speculate that it would have been a near miss and that
the drug would not have been investigated further. Also,
a possible increase in relapse rate following withdrawal
of natalizumab therapy was noted in this trial; as in the
second study half, there were significantly more acute
clinical exacerbations in the natalizumab group.25
An-
other study failed to show more rapid or complete re-
lapse recovery with natalizumab treatment, although a
significant decrease in gadolinium-enhancing lesion vol-
ume was noted for both active treatment groups early in
the study. There was no evidence of increased relapses
following natalizumab withdrawal.26
27
A
B
α4 integrin
Lymphocyte
VCAM1Lumen
Endothelial cell
Parenchyma
Natalizumab
Lumen
Endothelial cell
Parenchyma
Lymphocyte
Figure 2. Schematic representations. A, Activated leukocytes expressing ␣4
integrin, which induces receptor-mediated adhesion to endothelial cells. This
interaction is required for transmigration of activated leukocytes into the
Rudick Lancet Neurol 2012
Multiple Sclerosis
< Novel therapy (anti-integrin therapy)>
50. DISCOVERY
In the 1980s, analysis of lymphocyte migration oc-
curred in many centers. At Stanford and Harvard uni-
versities, Butcher and Picker11
and Springer12
were elu-
ous antibodies applied prior to the addition of lympho-
cytes to frozen sections. Attachment was almost en-
tirely blocked by antibodies to 1 integrin. The integrin
molecule’s  chain binds to 1 of 6 unique ␣ chains. An-
tibodies specific for the ␣ chains were applied to the fro-
Phase 1
research begins
Alpha-4 integrin
discovered to be
key molecule
involved in
homing
to the brain
Biogen and Elan announce
collaboration on the
development/commercialization
of natalizumab for both MS and
Crohn disease indications
FDA approves
natalizumab for
relapsing
forms of MS
Natalizumab returns
to US market with
pharmacovigilance
plan in place; EMEA
approves natalizumab
US label lists
3 confirmed
risk factors
for PML
Phase 3 trial of
natalizumab in
RRMS begins
Drug voluntarily
suspended from US
market on the basis
of 3 PML cases
European label lists
3 confirmed risk factors
for PML
20121992 1997 2000 2001 2004 2005 2006 2011
Figure 1. Timeline of major natalizumab milestones.1-7
EMEA indicates European Medicines Agency; FDA, Food and Drug Administration; MS, multiple sclerosis;
PML, progressive multifocal leukoencephalopathy; RRMS, relapsing-remitting MS.
Rudick Lancet Neurol 2012
Multiple Sclerosis
< A model for translational medicine >
Timeline from bench to bedside
55. PML associated with anti-integrin therapies plus α
Carson KR, Lancet Oncol 2009
had AIDS. As the HIV epidemic grew in the 1980s, PML
emerged as a major complication of HIV infection (both
HIV-1 and HIV-2). The incidence of PML increased
50-fold between 1979 and 1994.12
Since then, highly active
antiretroviral therapy (HAART) has helped reduce the
progression and the severity of PML in individuals with
HIV, although HIV infection continues to account for
about 80% of all new PML diagnoses.13
However, even
with the use of HAART, the incidence of PML remains
between 3% and 5% in patients with AIDS, which is an
incidence similar to that reported in the pre-HAART
era.14
HIV-infected patients with PML who are treated
Correspondence to:
Charles L Bennett, Northwestern
University, 710 N Fairbanks Ct,
Olson Pavilion, Suite 8-250,
Chicago, IL 60611, USA
cbenne@northwestern.edu
Rituximab Natalizumab Efalizumab
Mechanism
Target Anti-CD20 Binds to the α4-integrin Anti-CD11
Lymphocytes mainly affected by the drug B lymphocytes T lymphocytes T cells
Number of confirmed cases of
drug-associated PML (mortality rate)
57 (mortality rate 89% [51 of 57])6
13 (mortality rate 23% [3 of 13]).Ten received
monotherapy (median 25 months
[range 12–25])7–9
Three (mortality rate 66·6% [2 of 3]; one
additional case clinically suspected). All had
received ≥3 years of monotherapy10
Number of PML cases identified in
epidemiology or clinical studies
One (a patient with rheumatoid arthritis
developed PML in a safety extension study)
Eight One
Epidemiological estimate for
drug-associated PML
One in 4000 estimated in rituximab-treated
patients with SLE (unapproved indication);
estimates in rituximab-treated patients with
lymphoid malignancies and rheumatoid
arthritis not available at this time
One in 1000 One in 400 in efalizumab-treated patients
who received ≥3 years of therapy
Safety actions of the FDA and the marketing authorisation holder in the USA
Dateof initial marketing approval bythe FDA November, 1997 November, 2004 October, 2003
Dates warnings on PML issued by FDA December, 2006; September, 2008 February, 2005; June, 2006; August, 2008 October, 2008; February, 2009; March, 2009
Dates manufacturer issued warning for PML September, 2008 (“Dear Healthcare
Provider” letter); February, 2007 (Black Box
warning); December, 2006 (“Dear
Healthcare Provider” letter)
June, 2006 (Black Box) October, 2008 (“Dear Healthcare Provider”
letter and Black Box warning); November, 2008
(“Dear Healthcare Provider” letter); February,
2009 (“Dear Healthcare Provider” letter)
Marketing suspension None Voluntary withdrawal (February, 2005 to June,
2006). Returned to market place as monotherapy
in conjunction with a risk management plan
Manufacturer-initiated voluntary withdrawal
(April, 2009)
Risk-management (USA) Enhanced pharmacovigilance plan for PML
implemented in 2007
Patient medication guide and revised
product label
TOUCH programme for all patients;Tysabri should
not be administered concurrently with other
immunosuppressants
Risk Evaluation and Mitigation Strategies
programme developed in March, 2009,
including Patient Medication Guide and
revised product label; manufacturer-initiated
voluntary withdrawal in April, 2009
56. Should we stop Tysabri?
Tysabri is most effective for MS
PML in 1:1000
57. If we were to continue to use Tysabri,
what should we do to prevent PML?
59. New Analysis of Risk Stratification for TYSABRI®
- Use of Biomarker has Potential to Advance
Personalized Treatment for MS Patients -
May 18, 2012
60. Art
Lancet Neu
Published O
January 6, 2
DOI:10.101
4422(11)70
See Comm
Departmen
Neuroinfla
(Prof D H M
NMR Resea
(D MacMan
Institute o
London, U
Marienkra
University
Hamburg,
(ProfTWeb
Neuroscien
Statistics,
(R Grove M
Medicine D
GlaxoSmit
(CWardell P
Research, A
Chapel Hill
(J Horrigan
Medicine D
(O Graff MD
Firategrast for relapsing remitting multiple sclerosis: a phase 2,
randomised, double-blind, placebo-controlledtrial
David H Miller, Thomas Weber, Richard Grove, Claire Wardell, Joseph Horrigan, Ole Graff, Gillian Atkinson, Pinky Dua, Tarek Yousry,
David MacManus, Xavier Montalban
Summary
Background Monoclonal antibody therapy against α4β-integrin is efficacious in patients with multiple sclerosis (MS)
with some safety concerns. We assessed the safety and efficacy of firategrast, a small oral anti-α4β-integrin molecule,
in patients with relapsing remitting MS.
Methods We did a multicentre, phase 2, randomised, double-blind, placebo-controlled, dose-ranging study in
participants with clinically definite relapsing-remitting MS. A 24-week treatment period was followed by 12 weeks of
core follow-up and 40 weeks of extended follow-up. Participants were randomly assigned, via computer-generated
block randomisation in a 1:2:2:2 ratio, to receive one of four treatments twice a day: firategrast 150 mg, firategrast
600 mg, or firategrast 900 mg (women) or 1200 mg (men), or placebo. Brain scans were obtained at 4-week intervals
to the end of core follow-up. The primary outcome was cumulative number of new gadolinium-enhancing brain
lesions during the treatment phase and was analysed using a generalised linear model with an underlying negative
binomial distribution, adjusted for sex, baseline number of new gadolinium-enhancing lesions, and country. This
study is registered with ClinicalTrials.gov, NCT00395317.
Findings Of 343 individuals enrolled, 49 received firategrast 150 mg, 95 received firategrast 600 mg, 100 received firategrast
900 mg or 1200 mg, and 99 received placebo. A 49% reduction (95% CI 21·2–67·6; p=0·0026) in the cumulative number
of new gadolinium-enhancing lesions was seen for the 900 mg or 1200 mg firategrast group (n=92, mean number of
lesions 2·69 [SE 1·18]) versus the placebo group (90, 5·31 [1·18]). In the 600 mg group (86, 4·12 [SE 1·19]), a non-
significant 22% reduction (95% CI –21·3 to 49·7; p=0·2657) occurred in mean number of new gadolinium-enhanced
lesions relative to placebo; for the 150 mg group (47, 9·51 [SE 1·24]), a 79% increase (95% CI 4·1–308·1; p=0·0353)
occurred relative to placebo. Firategrast was generally well tolerated at all doses. The frequency of all adverse events was
similar across all treatment groups except for an increased rate of urinary tract infections in the high-dose firategrast
group. No cases of progressive multifocal leukoencephalopathy or evidence of reactivation of JC virus were identified.
www.thelancet.com/neurology Vol 11 February 2012
prognosis.5–10
Orally administered disease-mo
treatments have only recently become available.11
Since 2006, natalizumab, a long-acting, hum
monoclonal antibody to α4β1 and α4β7 i
receptors, has been a treatment option for patien
highly active relapsing remitting MS. The drug
trafficking of mononuclear white blood cells acr
blood–brain barrier, and was associated with
Small-molecule inhibitor to α4 integrin alleviates MS
No PML case was seen in 149 patients receiving firategrast
61. Advanced Topics
1: More than three steps
(Vestweber, “How leukocytes cross the vascular endothelium”
Nat Rev Immunol 2015)
2: Leukocyte migration in 3D
(Weninger et al., “Leukocyte migration in the interstitial space
of non-lymphoid organs” Nat Rev Immunol 2014)
62. More than 3 steps:
the updated multistep cascade model for leukocyte extravasation