Anti Tumor Necrosis Factor Alpha And Asthma

� Approximately 5% to 10% of patients with asthma have severe disease that is refractory or poorly responsive to inhaled corticosteroid therapycorticosteroid therapy

� Tumor necrosis factor› TNF-a – cachectin, cachexin› TNF-b - lyphotoxin

� Tumor necrosis factor and asthma� Anti-tumor necrosis factor in asthma

� Pleiotropic pro-inflammatory cytokine initially produced as a 26 kDamembrane-anchored precursor proteinTNF reppresent 2 homologus protein � TNF reppresent 2 homologus protein primarily derived from mononuclear phagocytes (TNF-α) and Lymphocyte (TNF-β)

Larry Borish : Middleton 7th edition

� TNF-α is processed as a membrane-bound protein from which the soluble active factor (17 kDa free protein) is derived via cleavage using the enzyme derived via cleavage using the enzyme TNF-α converting enzyme (TACE), known as ADAM 17

� The active form is a homotrimer (51 kDa)


� Most potent inducer of TNF by monocytes is LPS acting through TLR4 and CD14γTNF-α may be produced by neutrophils, � TNF-α may be produced by neutrophils, activated lymphocytes, natural killer cells, endothelial cells, and mast cells


� Activation results in a remarkably diverse set of cellular responses, apoptosis, inflammation and inhibit tumor genesis and viral replication

C. Russo and R. Polosa:Clinical Science (2005) 109, 135–142

Binding of TNF-a to TNFR1 results in the configuration of TRADD (TNFR-associated death domain) and FADD (Fas-associated death domain). TRADD complex recruits the adapter protein TRAF-2 (TNFR-associated factor 2), whereas FADD stimulates the caspase cascade. Known downstream signalling molecules that interact with TRAF-2 are NIK (NF-?B-inducing kinase), RIP (receptor-interacting protein) and ASK1 (apoptosis signal-regulating kinase 1) and these are capable of channelling signals towards cell death and inflammation. Binding of TNF-a to TNFR2 recruits the adapter protein TRAF-2, which directly activates the inflammatory cascade via the generation of NF-?B or p38 MAPK (mitogen-activated protein kinase) and activates caspase-mediated cell death through recruitment of FADD and RIP

� TNF-α and TNF-β bind to the same two distinct cell surface receptors – TNFR I (p55 or CD120a) and TNFR II (p75 or CD120b)CD120b)

� 2 receptors are expressed on the surface of many cell types› TNFR I expressed on cells susceptible to the

cytotoxic action of TNF-α› TNFR II expressed strongly on stimulated B- and T-

cellsLarry Borish : Middleton 7th edition

Subsequent phosphorylation of NF-κB activates the p50–65 subunit, interact with DNA chromatin structure to increase the transcription of pro-inflammatory genes, such as IL-8, IL-6, and TNF-a

Summary of TNF-a biology and signaling

Christopher Brightling, Mike Berry : J Allergy Clin Immunol 2008;121:5-10

� TNF interacts with endothelial cells to induce intercellular adhesion molecule-1 (ICAM-1), vascular cell adhesion molecule-1 (VCAM-1), and E-selectin, molecule-1 (VCAM-1), and E-selectin, permitting the egress of granulocytes into inflammatory loci

� TNF is a potent activator of neutrophils, mediating adherence, chemotaxis, degranulation, and the respiratory burst


� TNF is responsible for the severe cachexia that occurs in chronic infections and cancerTNF induces vascular leakage, has � TNF induces vascular leakage, has negative inotropic effects, and is the primary endogenous mediator of toxic shock and sepsis


Role of TNF-a in the pathogenesis of asthma. TNF-a plays a centralrole in many of the features of the asthma paradigm by exerting importanteffects on both inflammatory and structural cells


� TNF-a contributes to the dysregulatedinflammatory response seen in the asthmatic airway was raised by the findings of increased TNF-a mRNA and findings of increased TNF-a mRNA and protein in the airways of patients with asthma

� Administration of inhaled recombinant TNF-a to normal subjects led to the development ofAHR and an airway neutrophilia Thomas PS, Barnes PJ: Tumor necrosis factor-alpha increases airway responsiveness and sputum neutrophilia in normal human subjects. Am J Respir Crit Care Med 1995,

Mike Berry: Current Opinion in Pharmacology 2007

� Administration of TNF-a to patients with asthma also leads to an increase in AHR, as measured by a reduction in methacholine PC20 methacholine PC20 Thomas PS, Heywood G: Effects of inhaled tumour necrosis factor alpha in subjects with mild asthma. Thorax 2002

� It could be caused by a direct effect of TNF-a on airway smooth muscle or by the release of the cysteinyl-leukotrienes LTC4 and LTD4


� TNF-a induces histamine release from human mast cells directly van Overveld FJ, Vermeire PA: Tumour necrosis factor stimulates human skin mast cells to release histamine and tryptase. Clin Exp Allergy 1991

Participates in a positive autocrine loop � Participates in a positive autocrine loop that potentiates human mast cell cytokine secretion Coward WR, Holgate ST: NF-kappa B and TNF-alpha: a positive autocrine loop in human lung mast cells? J Immunol 2002


� Chemoattractant for neutrophils and eosinophils it increases the cytotoxiceffect of eosinophils on endothelial cells It is involved in the activation of cytokine � It is involved in the activation of cytokine release by T cells and it increases epithelial expression of adhesion molecules such as ICAM-1 and VCAM-1


� TNF-a has several properties that might be relevant to refractory asthma, including › recruitment of neutrophils› recruitment of neutrophils› induction of glucocorticoid resistance› myocyte proliferation› stimulation of fibroblast growth and

maturation into myofibroblasts by promoting TGF-a expression


Serpil C. Erzurum, N Engl J Med 2006;354:754-758

� Direct modulation of ASM contractile function by mast-cell derived TNF-a, mechanism in AHR

� Mast cell number correlated positively � Mast cell number correlated positively with the degree ofAHR Brightling CE, Holgate ST. Mastcellinfiltration of airway smooth muscle in asthma. N Engl J Med 2002

� Mast cells are the major source of TNF-a in the airways

� TNF-a induced AHR is mediated by direct effects on ASM


1. enhanced receptor-associated calcium signals as a resultof an increased expression, function, or both of the receptor G protein (Gaq or Gai)

2. altered signal transduction, such as increased phospholipaseC (PLCb) expression, activity, or both

Molecular mechanisms activated in ASM induced by TNF-a–activatedmolecular mechanisms in ASM possibly contributing to AHR inasthma


3. abnormal calcium handling by exerting effects on key enzymes that regulate inositol-1,4,5- trisphosphate(IP3) metabolism, such as 5-phosphatase I and II, effectson function, and/or the expression of Ryanodine receptors (RyR), IP3receptor (IP3R), or calcium ATPasescalled sarcoendoplasmic calciumATPases (SERCA), which regulate calcium fluxes, or calmodulin (CaM)


calcium fluxes, or calmodulin (CaM)

4. changes in calcium sensitivity mediated by effects on RhoAexpression or increases in both myosin light chain kinase (MLCK) or myosinlight chain phosphatase (Pase) content, activity, or both

� 3 TNFα antagonists licensed in USA› 2 monoclona lAb : adalimumab (ADA) and

infliximab (INF)› soluble receptor : etanercept (ETA)› soluble receptor : etanercept (ETA)

� Certolizumab pegol : Crohn ‘s disease Sandborn WJ, et al (2007). "Certolizumab pegol for the treatment of Crohn'sdisease". N. Engl. J. Med. 357 (3): 228–38

� Golimumab : human monoclonal Ab, phase III clinical trial treatmeat RA

prevention of the cleavage of the 26 kDa membrane-bound protein to the active 17 kDa molecule

Enrico Heffler, Mike Berry : Biodrugs 2007; 21

inhibition of TNFα mRNA transcription

acceleration of TNFαmRNA degradation

inhibition of TNFαprotein translation

a : Indications approved by the Food and Drug Administration (FDA) and European Union EMEA

Jan Lin : Clin Immunol. 2008 January ; 126(1): 13–30

Infliximab is a chimaeric mouse/human monoclonal anti-TNF-α antibody etanercept is a soluble fusion protein combining two p75 TNFRs with an Fcfragment ofhuman IgG1adalimumab is a fully human monoclonal anti-TNF-α antibody

C. Russo and R. Polosa:Clinical Science (2005) 109, 135–142

� This was the first description of the use of anti-TNFa in asthma and, although an open study, it generated considerable excitement in the field

� Method› TNFa BAL fluid of 26 healthy controls, 42 subjects with

mild asthma and 20 with severe asthma› TNFa BAL fluid of 26 healthy controls, 42 subjects with

mild asthma and 20 with severe asthma› TNFa gene expression was determined in

endobronchial biopsy specimens from 14 patients with mild asthma and 14 with severe asthma

› open label uncontrolled clinical study in 17 subjects with severe asthma to evaluate the effect of 12 weeks of treatment with the soluble TNFa receptor-IgG1Fc fusion protein, etanercept

P H Howarth, S T Holgate : Thorax 2005;60:1012–1018

A : TNFa concentrations in bronchoalveolar lavageB : TNFa gene expression in endobronchial biopsyC : Immunoreactive TNFa positive cell counts in endobronchial biopsy specimenD : Immunohistochemical staining and localisation of TNFa in submucosal cells


� TNFa levels in BAL fluid, TNFa gene expression and TNFa immunoreative cells were increased in subjects with severe corticosteroid dependent asthmacorticosteroid dependent asthma

� Etanercept treatment was associated with improvement in asthma symptoms, lung function, and bronchial hyperresponsiveness


� This was the first double-blind placebo-controlled study of anti-TNFa in asthma

� Method› measured markers of TNF-α activity on › measured markers of TNF-α activity on

peripheral-blood monocytes (CD14)› 10 refractory asthma, 10 mild-moderate

asthma and 10 placebo› Investigated the effects of treatment with

the soluble TNF-α receptor etanercept (25 mg twice weekly), refractory asthma

Mike A. Berry, N Engl J Med 2006;354:697-708

Treatment periods lasted 10 weeks and were separated by a 4-week washout period. The washout phase was chosen because the half-life of etanercept is 70 hours and, according to information provided by the manufacturer, clinical experience in patients with rheumatoid arthritis suggested that symptoms return within one month after treatment is stopped.


Open symbols in Panels A and B represent patients who received etanercept first in the crossover trial, and closed symbols those who received placebo first


� Compare patients with mild-to-moderate asthma and controls, patients with refractory asthma had increased expression of membrane-bound TNF-α, expression of membrane-bound TNF-α, TNF-α receptor 1, and TNF-α–converting enzyme by peripheral-blood monocytes


� Clinical trial, as compared with placebo, 10 weeks of treatment with etanerceptwas associated with a significant increase in the concentration PC20, increase in the concentration PC20, improvement in the asthma-related quality-of-life score and 0.32-liter increase in postbronchodilator FEV1


� Method› Double-blind, placebo controlled, 38

moderate asthma with ICS but symptomatic during a run-in phasesymptomatic during a run-in phase› Infliximab (5 mg/kg) or placebo by IV

infusion at Weeks 0, 2, and 6› clinical response by monitoring lung

function, symptoms, and inhaledβ2 agonist usage using hand held electronic device

Edward M, Peter J. Barnes : Am J Respir Crit Care Med Vol 174. pp 753–762, 2006

ITT intention to treat; PEP primary endpoint group with sufficient PEF rate in the last 7 d before the penultimate clinic visit (approximately 8 wk); PP per protocol (patients meet inclusion criteria and complete clinic visits).


Electronic diary lung function, symptoms, and β2-agonist usage


A : Incidence of exacerbations over Weeks 0–8B : freedom from exacerbation over time. Infliximab (n = 14) and placebo (n = 18)


Infliximab(n 15) and placebo (n 18). *p < 0.05 or **p <0.01 for comparison of infliximab versus placebo at giventime points,

Edward M, Peter J. Barnes : Am J Respir

Crit Care Med Vol 174. pp 753–762, 2006

� Infliximab was associated with a decrease in mean diurnal variation of PEF at Week 8

� Decrease in the number of patients with � Decrease in the number of patients with exacerbations of asthma

� Increased probability of freedom from exacerbation with time

� Infliximab decreased levels of TNF-a in sputum

� No serious adverse eventsEdward M, Peter J. Barnes : Am J Respir Crit Care Med Vol 174. pp 753–762, 2006

� Method› RDBCT, Etanacept once weekly for 12 weeks

39 severe corticosteroid refractory asthma› Efficacy was measured by change from the

pretreatment baseline in Asthma Related pretreatment baseline in Asthma Related Quality of Life (AQLQ) and Asthma Control (ACQ) Questionnaire scores (the primary endpoints), › Lung function, PEF and BHR› Sputum and serum inflammatory cells and

cytokines, serum albumin and C reactive protein as biomarkers of inflammation

J B Morjaria, S T Holgate : Thorax 2008;63:584–591

screening, baseline enrolment, during 12 weeks of etanercept treatment or placebo and subsequent follow-up


� Reduction of ACQ scores between treatment and placebo

� Improvement in systemic inflammation, as measured by serum albumin and CRPas measured by serum albumin and CRP

� Minor adverse events, including injection site pain and skin rashes, were more frequent with etanercept


� Method› 309 severe and uncontrolled asthma,

despite high-dose ICS and long-acting β2 agonists, were randomized 1:1:1:1 β2 agonists, were randomized 1:1:1:1 to monthly SC injections of placebo or golimumab (50, 100, or 200 mg) throughWeek 52› prebronchodilator percent-predicted

FEV1and the number of severe asthma exacerbations through Week 24

Sally E. Wenzel, Peter J. Barnes, Stephen T. Holgate : Am J Respir Crit Care Med Vol179. pp 549–558, 2009

Change from baseline in prebronchodilator percent-predictedFEV1 through Week 24


Number of severe asthma exacerbations from baseline through Week 24

patients who completedstudy participation throughWeek 24

Additional exacerbations calculated for patients who withdrew early


All patients all group


� Unfavorable risk–benefit profile led to early discontinuation of study-agent administration after the Week-24

� ThroughWeek 76, 20.5%of patients � ThroughWeek 76, 20.5%of patients treated with placebo and 30.3% of patients treated with golimumabexperienced serious adverse events, with serious infections

� One death and all eight malignancies occurred in the active groups


Study N Severity Design Outcome Result

HowarthEtanercept

15 GINA V Open label, uncontrolled

1: AQLQ2:FEV1, AHR

Improvement in AQLQ, FEV1,AHR

BerryEtanercept

10 7 GINA V3 GINA IV

RCT, cross over 1: AHR and AQLQ2: FEV1, eNO, sputum cell counts

Improvement in AQLQ, FEV1,AHRIncrease sputum histamine

EdwardInfliximab

38 Moderate asthma, ICS onlly

RCT 1: morning PEF2: FEV1, exacerbations,

No change morning PEFDecrease exacerbate of asthmaonlly exacerbations,

sputum markersasthmaImproved PEF variability

MorjariaEtanercept

39 21 GINA V18 GINA IV

RCT 1: AQLQ2: ACQ, FEV1, PEF, AHR, exacerbation

No benefit comparewith placeboReduction ACQ

SallyGolimumab

309 GINA V RCT 1: FEV12: exacerbation

Serious adverse effect

AHR, airway hyperresponsiveness; AQLQ, Asthma Quality of Life Questionnaire; ENO, exhaled nitric oxide; FEV1, forced expiratory volume in one second; ICS: inhaled corticosteroids; PEF, peak expiratory flow

� TNF-a elevate in severe asthma� TNF-a and asthma› Direct histamine release from mast cell› Chemoattactant› Increase adhesion molecule› AHR, ASM contraction

� Anti-TNFa, etanercept improvement AQLQ in severe athma

Anti Tumor Necrosis Factor Alpha And Asthma

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