ACOS and treatable traits: -omics approach to refine taxonomy of

obstructive airways disease

Professor Kian Fan Chung MD DSc

Experimental Studies, National Heart & Lung Institute, Imperial College London;

Biomedical Research Unit, Royal Brompton Hospital, London, UK

AIRWAY VISTA 2017Seoul, Korea

Conflict of interest

• Participation in Advisory Board meetings regarding asthma and COPD for GSK, AstraZeneca, Novartis, Johnson & Johnson, Boehringer Ingelheim and Actavis

• Research grant funding from Pfizer, GSK and Merck

• Speaking engagements: AstraZeneca, Merck, Novartis

• Investigator of IMI EU/EFPIA funded UBIOPRED Consortium on Severe Asthma

• No funding from tobacco industry

What is ACOS?

3

COPD ASTHMA

COPD ACOS ASTHMA

COPDCOPD

ACOS/D

ASTHMA

ACOS/DASTHMA

COPD ASTHMA Dutch hypothesis

British hypothesis

After John Riley, GSK

Asthma-COPD overlap (ACOS)

1. Prevalence: ACOS has a prevalence of 20% of patients with obstructive airways disease (asthma or COPD) and 2% in general population.

2. Increased illness burden: ACOS leads to significant health status impairment, increased exacerbations and increased hospitalisation

3. Treatment implications:(i) Non-recognition of asthma: potential for increased adverse events from LABA use

(ii) In COPD patients with asthma, increased response to ICS + LABA(iii) No recommendations for ACOS because not included in RCTs

4. Childhood onset: Prevention to the development of ACOS by studying early-life origins

From: Gibson & McDonald Thorax 2015; 70: 683

Severe asthma:

non-smoking

(308)

Severe asthma:

smoking & ex-

smoking (110)

Mild/Moderate

Asthma (98)

Non-asthma

(101)P-value

Age (yr) 50.9 54.5* 42.4 38.9 <0.001

Age at diagnosis 20 38* 14 NA <0.001

Female (%) 65.9 50.9* 50.00 38.61 <0.001

BMI (kg/m2) 29.08 29.56 25.88 25.31 <0.001

Exacerbations in past yr 2.48 2.55 0.37 0 <0.001

IgE (IU/ml) 119.5 126 89.4 23.45 <0.001

Atopy (%) 69 58 80 38 <0.001

Nasal polyps (%) 34.7 33.7 8.3 8.8 <0.001

Allergic rhinitis (%) 59.2 43.6* 60 16.7 <0.001

GERD (%) 47 63* 21 11 <0.001

FEV1 (% pred) 67.42 67.25 88.37 101.76 <0.001

Oral corticosteroids (%) 45.8 44.7 0 0 <0.001

Sputum eosinophils (%) 2.75 4.13 1.05 0.00 <0.001

Exhaled NO 27 23.5 25.50 19.00 <0.01

Demographics of UBIOPRED cohorts

Shaw et al: Clinical and inflammatory characteristics of the European U-BIOPRED adult severe asthma cohort.

European Respiratory Journal 46: 1308 (2015) * significant cf to non-smoking

(n)

UBIOPRED asthma clusters based on unsupervised clustering of 8 clinical features

• Cluster 1: Moderate-to-severe asthma;

well-controlled; medium to high dose ICS

• Cluster 2: Severe asthma; Late onset asthma; smoker or ex-smoker; airflow obstruction

• Cluster 3: Severe asthma; Oral corticosteroid-dependent; airflow obstruction

• Cluster 4: Severe asthma; Female; Obese;

frequent exacerbations

PARAMETERS USED

-Age of asthma onset

- Pack-years of smoking

- Body Mass Index (BMI)

- FEV1 % predicted

- FEV1/FVC

- Asthma Control Questionnaire:

ACQ-5

- Exacerbations in past year

-Medication Oral Corticosteroid

(OCS) daily dose

Lefaudeux et al 2016

Variables T1 (n = 69) – moderate– well-controlled

T2 (n = 56) – late onset – smoking – obstructive

T3 (n = 68) – severe--non-smoking – obstructive

T4 (n = 73) – female – obese – exacerbations

P-Value

Age (yrs) 43 ± 15 57 ± 10 53 ± 15 48 ± 14 < 0.001 1

Gender (female) 55% 57% 47% 84% < 0.001 3

On OCS (%)† 5.8% 48.2% 51.5% 41.1% < 0.001 2

Asthma onset (years)† 17 (5 – 30) 43 (31 – 52) 18 (5.8 – 37) 20 (7 – 37) < 0.001 2

FEV1% predicted† 89 ± 17 59 ± 16 49 ± 14 79 ± 15 < 0.001 1

FEV1/FVC† 0.74 ± 0.084 0.56 ± 0.098 0.51 ± 0.079 0.74 ± 0.083 < 0.001 1

ACQ_5† 0.8 (0.25 – 1.6) 2 (1.2 – 2.8) 2.4 (1.6 – 3.6) 2.6 (1.8 – 3.2) < 0.001 2

Excacerbations† 0 (0 – 1) 1 (0.75 – 3) 2 (1 – 3.25) 3 (2 – 4) < 0.001 2

BMI† 25 (22 – 28) 29 (26 – 33) 25 (23 – 29) 32 (27 – 36) < 0.001 2

Pack Years† 0 (0 – 0) 16 (4.9 – 26) 0 (0 – 0) 0 (0 – 0) < 0.001 2

ICS dose range (high) 37% 98% 97% 96% < 0.001 3

Blood eosinophils (103/µl) 0.20 (0.1 – 0.3) 0.30 (0.12 – 0.56) 0.22 (0.1 – 0.49) 0.2 (0.10 – 0.38) 0.0273 2

Blood neutrophils (103/µl) 4.0 (3.1 – 4.9) 5.1 (4.0 – 7.2) 5.1 (3.7 – 7.6) 4.7 (3.6 – 6.7) < 0.001 2

Sputum eosinophils (%) 0.78 (0.25 – 5.9) 4.9 (1.4 – 20) 3.7 (1.0 – 30) 2.4 (0.29 – 7.1) 0.0147 2

Sputum neutrophils (%) 54 (27 – 64) 60 (44. – 71) 63 (40 – 86) 49 (32 – 70) 0.268 2

1 Anova2 Kruskal – Wallis3 χ2

† included in the clustering

Characteristics of 4 clinical clusters

Mean ± SDMedian (IQR)

Lefaudeux et al 2017 JACI

UBIOPRED : smoking (cluster 2) vs non-smoking (cluster 3) of airflow obstruction

●Pathway analysis of sputum cell

transcriptomics

Regulation of actin cytoskeleton (ITGB1, FN1,ACTN2)Fibronectin matrix formation (ITGB1, FN1)

●Differentially-expressed proteins in sputumsupernatantsLYN: src non-receptor lyn tyrosine kinaseFUT5: Fucosyltransferase 5

Lefaudeux et al 2017 JACI

Japanese smoking clusters of severe asthma

Konno et al Ann ATS 2015; 123: 1771

Asthma-COPD Overlap syndrome:Phenotypes/endotypes

From: Bateman et al Lancet 2015:3;719

ACOSPhenotypes/endotypes

ACOSEosinophilic

ACOSAsthma in

smokers

Chronic airflowlimitation

Bronchodilatorresponse

Asthma COPD

Treatable traits of chronic airways disease

• Airflow limitation

• Eosinophilic airway inflammation

• Chronic bronchitis

• Airway bacterial colonisation

• Bronchiectasis

• Cough reflex hypersensitivity

• Pre-capillary pulmonary hypertension

• Chronic respiratory failure

● Deconditioning● Obesity● Cachexia● OSA● CVS disease● GORD● Upper airways diseaseRhinosinusitisVocal cord dysfunction● Psychiatric: DepressionAnxiety● Breathing pattern disorders● Persistent systemic inflammmation

Pulmonary Extrapulmonary

Agusti et al ERJ 2016: 47: 410

Severe Asthma: distribution of 3 ACOS features

311 NON-SMOKERS22 (7.1%) had none

of 3 traits

(11.6%)

(9.0%) (15.8%)

(18.3%)

(8.4%) (8.7%)(20.6%)

(56.3%) (63.3%)

110 SMOKERS6 (5.5%) with none of 3

traits

(36.4%)

(6.4%)

(14.5%)(4.5%)

(5.5%)

(11.8%)

67.3%70.9%

(63.6%)(54.7%)

P. Hekking

(14.0%)

Airflow limitation Airflow limitationEosinophilic inflamEosinophilic inflam

Bronchodilator respBronchodilator resp

Airflow obstruction No airflow obstruction

Non-smoker (n=175)

Smoker (n=74)

P value Non-smoker (n=131)

Smoker (n=235)

P value

Pb FEV1 (% pred) 63.5 69.9 0.01 91.3 90.1

Smoking (py) 2.0 20 <0.001 1.5 15 <0.001

Age (yr) 55.2 56.5 45.4 50.1

Asthma onset (yr) 24.5 39 <0.001 18 34 0.02

Gender (male %) 41.1 52.7 24.4 40

BMI 28.6 28.7 29.9 31.4

Atopy (%) 67.2 62.2 71.3 42.9 0.007

Exacerbations/yr 2.0 2.0 2.0 2.5

History of COPD (%)

4.6 14.9 <0.004 3.1 8.6 0.001

Oral steroids (%) 49.4 47.2 39.2 40

Sputum eos (%) 3.8 4.5 1.4 0.96

Sputum DE Genes 3 0

Non-smoker vs smoker with regards to airflow limitation

Eosinophilia No eosinophilia

Non-smoker (n=197)

Smoker (n=78)

P value Non-smoker (n=107)

Smoker (n=28)

P value

Sputum eos (%) 6.2 5.4 0.20 0.32

Blood eos (L) 0.36 0.30 0.1 0.1

Pb FEV1 (% pred) 73.5 77.5 78.5 72.7

Smoking (p-yr) 2 17.4 <0.001 1.5 19.4 <0.001

Age (yr) 52.9 54.9 47.5 53.4 0.062

Asthma onset (yr) 25 41.5 <0.001 16 30 0.02

Gender (male %) 37.6 43.6 28 64.3 0.001

BMI 28.8 29.4 29.4 30.4

Atopy (%) 70.8 60.3 67 46.4 0.1

Exacerbations/yr 2.0 2.0 2.0 3.0

History of COPD (%)

4.6 15.4 <0.001 2.8 7.1 0.02

Oral steroids (%) 42.8 40.5 51.5 60

Sputum DE Genes 109 0

Non-smoker to smoker with regards to eosinophilia

Gene Ontology (Biological Process) p-value

BP cell migration 2.40e-02

BP regulation of cell migration 2.89e-02

BP single-organism cellular process 1.90e-02

BP regulation of protein autophosphorylation 3.56e-02

BP regulation of response to stimulus 3.87e-02

BP single-organism metabolic process 6.43e-03

Pathway analysis of DEGs in sputum cells from smokers vs non-smokers in eosinophilic asthma

Severe Asthma Molecular Phenotypes(from U-BIOPRED sputum analysis)

Th2-like inflammation Less Th2-like inflammation

“Severe Asthma”

FEV1

Symptoms

Exacerbations

Bacterial infection

Inflammasome

Moderate airflow obstruction

More eczema

Neutrophilic/

Eosinophilic

Severe asthma

Airflow obstruction

Nasal polyps

High OCS use

Corticosteroid insensitivity

Highly Eosinophilic

Oxidative stress/Ageing

Less exacerbations

Mild Airflow obstruction

Paucigranulocytic/

eosinophilic

TAC1 TAC2 TAC3

GTPase: RASAL3Metabolism of steroid: UGT2B28

TSLP Receptor: CRLF2

T cell Receptor: TRGC2, TRGV9, TARPProtease: PRSS33

Eosinophil lysophospholipase CLC

Cytokine promoting Th17 differentiation: VSTM1

Lactose binding: LGALS12Suppressor of cytokine signaling: SOCS2

IL33 Receptor: IL1RL1Eotaxin Receptor: CCR3

Phosphatase: PTPN7

Tryptase: TPSB2Carboxypeptidase: CPA3Arachidonate 15-Lipoxygenase: ALOX15

G-protein coupled receptor: GPR42Transcriptional factor: OLIG2, SATB1

IL3 Receptor: IL3RA

B cell surface: CD24Actin: FAM101BATPase: ATP2A3Cytokine: CSF1

Multiple cytokine receptors &

Enzymes (protease, lipase)

28 genes

Receptor: TREML2, CLEC4D,IFIH1,SIGLEC5,LILRA5

Cytokine: CXCL10(IP10, ligand of CXCR3), TNFSF10(TRAIL)

GTPase: GIAMP4

Adaptor : REPS2, SPATA13

Transcriptional activator : CREB5

Ubiquitination : WDFY3, UBE2D1

Transcriptional activator : NMI

Caspase : CASP4

Chromatin replication : BAZ1A

IFN-induced protein: IFIT2, IFIT3,IFI16,MNDA

GTP cyclohydrolase : GCH1

TNF-induced protein: TNFAIP3

GTPase: RHOH

Caspase inhibitor : CARD16

Neutrophil function : S100A9

TNF and INF regulationPattern recognition receptor

27 genes

Fatty acid metabolism: ME1

Intracellular vesicle and organelle transport: MYO6, LMAN1

CAMP-Dependent Protein Kinase: PRKACBMitochondrial ribosomal proteins: MRPS15, MRPS21

Ubiquitination: TULP4, ZYG11B, BTBD1, RNF135

Proteinase inhibitor: CSTA

Toll-like receptor: TLR7Cell adhesion regulation: CTNND1

Anti-viral enzyme: OAS1

Pre-mRNA splicing: ZCRB1, LSM5

Lectin receptor: LMAN1, CD302

Cytochrome C oxidase: COA6

Methyltransferase: METTL5Acetyltransferase: NAA20, ACAA2Fuctosidase: FUCA1Adenosine deaminase: CECR1

Aldehyde dehydrogenase: ALDH1A1

Phospholipase: PLBD1Glycolipid metabolism: PYURF

Multiple metabolic and ubiquitination enzymes

31 genes

TAC1 TAC2 TAC3

Genes characterising each transcriptomic- associated cluster

GSE8545 (Chest 2008; 133: 1344)

Epithelial brushings from 18 normal non-smokers, 18 normal smokers and 18 smokers

with COPD (GOLD I or II).

TAC1: T2

TAC3: Mitochondrial OxPHOSTAC2: inflammasome

GSVA of TAC signatures in epithelial gene expressionfrom smokers and COPD subjects

P<0.01P<0.0005

P<0.05

Groningen & Leiden Univ study of Corticosteroids in Obstructive Lung Disease (GLUCOLD)

Irreversible airflow limitation(Post-bronch FEV1 and FEV1/IVC<90% CI of pred value)Chronic respiratory symptomsAll current or ex-smokers(≥10 pack years)

Van den Berge et al Thorax 2014; 69: 14-23

Bronchial biopsies from 162 patients with COPD before and after treatment with fluticasone.

GSE36221: van den Berge et al Thorax 2014;69(1):14-23)

Gene set variation analysis (GSVA) of TAC signatures in bronchial biopsies gene expression of COPD patients

(GLUCOLD)

0 6 30

TAC1 : T2 TAC3: mito OxPHOSTAC2: inflammasome

P<0.05P<10-4

months0 6 30

months

0 6 30

months

Corticosteroid-insensitiveCorticosteroid-sensitive

ACOSPhenotypes

ACOS-asthma smoking phenotype

Polosa & Thomson ERJ 2013;41:716.

Smoking ‘Asthma’

ACOSEosinophilic

ACOSAsthma in

smokers

Asthma/COPD

ACOSChronic airflow

limitationBronchodilator

response

Molecular phenotyping

Conclusions• Smoking asthmatics form a distinct asthma ACOS

phenotype • Smoking may impact on ACOS features including

airflow obstruction, and eosinophilic inflammation, as may non-smoking factors

• Molecular phenotyping reveals that asthma-ACOS may consist of T2 and non-T2 pathways independent of smoking

• Similar molecular phenotypes are present in COPD, perhaps with a predominance of mitochondrial OxPHOS.

• Molecular phenotyping remains the future of ACOS.

University of Amsterdam, University of

Southampton, Imperial College London, University

of Manchester, University of Nottingham, Fraunhofer

Institute Hannover, CNRS-EISBM Lyon, Université

de Méditerranee Montpellier, Karolinska Institute

Stockholm, University Hospital Umea, University Tor

Vergata Rome, Università Cattolica del Sacro Cuore

Rome, University of Catania, Hvidore Hospital

Copenhagen, University Hospital Copenhagen,

Haukeland University Bergen, Semmelweis

University Budapest, Jagiellonian University Krakow,

University Hospital Bern, University of Ghent

EFPIA Partners

Novartis

Almirall

Amgen

AstraZeneca

Boehringer Ingelheim

Chiesi

GlaxoSmithKline

Johnson & Johnson / Janssen

Merck

UCB

Roche /Genentech

SME’s

Aerocrine

BioSci Consulting

Synairgen

Philips Research

Patient organisations

Asthma UK

European Lung Foundation

EFA

Int Primary Care

Respiratory Group

Lega Italiano Anti Fumo

Netherlands Asthma

Foundation

website hosted by the ELF: www.ubiopred.eu

Funded bythe European Union