RESEARCH ACCOMPLISHMENTS A. STUDIES ON THE IL-1-MEDIATED DISEASES, NOMID AND DIRA: 1. We evaluated biomarkers in the cerebrospinal fluid (CSF) that correlate with CNS inflammation and suggest a contribution on non-hematopoietic cells to the inflammatory response in the CNS. We validated these markers in patients treated with a short-acting IL-1 inhibitor anakinra and the long-acting IL-1 inhibitor canakinumab. 2. We assessed the long-acting IL-1 blocking agent rilonacept in the treatment of patients with Deficiency of IL-1 receptor antagonist (DIRA). Untreated the disease is often fatal in childhood. We determined doses needed to maintain remission, and evaluated the safety and pharmacokinetics of rilonacept in young children (<12 years). Six mutation-positive DIRA patients (children, ages 3-6 years), were treated with subcutaneous rilonacept injections of a loading dose of (4.4 mg/kg) followed by once weekly injections (2.2 or 4.4. mg/kg) for 12 months. Subjects in remission at 12 months continued rilonacept for an additional 12 months. Following optimal doses finding, all patients were in remission with stable laboratory parameters for the study period. Children are growing at normal rates and have normal heights and weights. Quality of life improved while on rilonacept and no serious adverse events were reported. B. EVALUTION OF PHARMACOKINETIC PROFILE AND CLINICAL BENEFIT OF THE JAK INHIBITOR (BARICITINIB) IN A COMPASSIONATE USE STUDY IN PATIENTS WITH INTERFERONOPATHIES. We are treating 18 patients (11 CANDLE, 4 SAVI and 4 with other AIDs) in an ongoing compassionate use study with the Janus kinase (JAK) inhibitor, baricitinib (Eli Lilly) that can inhibit interferon signaling, and assessed clinical benefit and the pharmacokinetic profile of baricitinib. All patients enrolled expressed high IP-10 (Interferon gamma-induced protein 10), MCP-1, and other chemokines and cytokines associated with interferon induced diseases and a strong interferon (IFN) response signature (IRS). Preliminary benefit and safety data are encouraging and suggest that targeting IFN signaling with a JAK1/JAK2 inhibitor may be a successful therapeutic strategy. C. COMPASSIONATE USE OF IL-18BP in NLRC4-MAS. The identification of gain-of-function mutations in the innate immune sensor, NLRC4 represents the first monogenic defect that may link high IL-18 levels and macrophage activation syndrome. Treatment of one patient with IL-18 binding protein suggests that IL-18 blockade may be a rational therapeutic target in these patients. D. ONGING STUDY OF PATIENTS WITH UNDIFFERENTIATED AUTOINFLAMMTORY DISEASES Our findings of genetic defects that cause autoinflammatory disease manifestations revealed mutations in genes that lead to the IFN-mediated conditions (SAVI and CANDLE) and suggested a role of IFN overproduction as driving autoinflammatory/autoimmune disease phenotypes. We continue to evaluate and treat patients with severe inflammatory diseases that present early in infancy particularly those with interferonopathies but yet unknown genetic mutations. In addition to a detailed immune evaluation, patients undergo genetic analyses through next generation sequencing, including whole exome sequencing (WES). All patients are undergoing screening with a test that assessed their IFN response gene signature. E. CHARACTERIZATION OF GENETIC MUTATIONS AND PATHWAYS THAT LEAD TO TYPE-I IFN PRODUCTION IN PATIENTS WITH CANDLE/PRAAS 1. CANDLE are homozygous or compound heterozygous for PSMB8 mutations or have biallelic mutations in additional proteasome genes including PSMB9, PSMB4, PSMA3 and heterozygous loss-of-function mutations in POMP (2015) that establish a digenic and autosomal dominant forms of CANDLE. The discovery of loss-of function mutations in proteasome components suggest that reduction of proteasome function below a critical level is associated with Type-I IFN production. 2. The source of IFN production varies in CANDLE and SAVI patients. While SAVI patients present with constitutive transcription of IFNB1 in peripheral blood monocytes, CANDLE and SAVI lesional skin samples show similar elevated transcription in IFNAs and IFNB1. IP-10 levels were highest in CANDLE skin samples. Understanding differences in intracellular signaling pathways activating IFN production and the IFN loop is needed to design targeted treatment approaches for the different interferonopathies. F. USE OF INVITRO MODELS TO STUDY ORGAN-SPECIFIC IMMUNE DYSREGULATION IN NOMID, DIRA, CANDLE, SAVI AND OTHER AUTOINFLAMMATORY DISEASES. 1. Tissue from skin lesions of patients with NOMID (n=4), DIRA (n=4), SAVI (n=3), CANDLE (n=5) and other interferonopathies (UIFN) (n=7) were assessed by immunohistochemistry and immunofluorescence. A distinct histologic pattern of neutrophil and macrophage infiltration characterizes SAVI, CANDLE, NOMID and DIRA skin biopsies, while Mx-1 staining and the IFN scores distinguish IFN- and IL-1-mediated AIDs suggesting that the histologic and immunologic assessment of skin biopsies may aid in identifying relevant dysregulated immune pathways. 2. The severity of interstitial lung disease varies in patients with SAVI from being absent to being severe and the cause of death. We assessed chest computed tomography (CT) and pulmonary function tests (PFTs) and lung tissue where available in 12 SAVI patients and found a genetic modifying region to be associated with the severity of lung disease. Patients with two copies of the genetic modifiers had the most severe disease that was inked to increased IFNbeta production. CONCLUSIONS AND SIGNIFICANCE Our program provides an integrative approach to the clinical, genetic and immunologic evaluation of patients with autoinflammatory diseases that continues to provide us with clues to the disease pathogenesis and to the use of targeted therapeutics to better treat patients and improve disease outcomes. Our studies have resulted in the discovery of novel autoinflammatory diseases that provided insights into the disease pathogenesis and revealed targets for treatment. 1. Two novel recently identified autoinflammatory diseases, SAVI and NLRC4-MAS shed light on basic disease mechanisms that cause autoinflammatory disease phenotypes. 2. Pathogenesis data in CANDLE, along with our findings that gain-of-function mutations in TMEM173 that cause SAVI encodes STING, a gatekeeper molecule for IFN beta transcription, suggest a causative role of IFN signaling in causing autoinflammatory disease phenotypes. 3. We have developed an IFN response gene score to screen patients with yet uncharacterized autoinflammatory diseases and assess whether a positive IFN score can aid in diagnosis and in making treatment decisions. 4. Studies in CANDLE and SAVI provide a rationale that led to an ongoifor a compassionate use study with the JAK1/2 inhibitor baricitinib that inhibits IFN signaling and allows us to assess the clinical benefit and collect safety data in patients with CANDLE and SAVI and in patients with clinical and laboratory evidence of IFN mediated disease. 5. The identification of mutations in NLRC4 causing macrophage activation led to the exploration of the role of IL-18 in macrophage activation and suggests IL-18 as a potential target for treatment. 6. Biomarker analyses aim to define markers that help us determine appropriate control of systemic and organ inflammation in NOMID and to identify potential differences in the effectiveness in controlling organ inflammation that may exist between different IL-1 blocking agents. 7. A novel DIRA mutation and a genetic test to more easily detect this mutation combined with our treatment outcomes with the long-acting IL-1 inhibitor rilonacept (Regeneron) can aid in better diagnosing and in the treatment of DIRA patients.
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