NanoAthero project:A new way to fightcardiovascular diseases

www.nanoathero.eu

Nanomedicines are already on the marketand the new ones turn on cardiovascularpathologies

INSERM coordinates the EuropeanNanoAthero program.

NanoAthero FP7 NMP program with €9.8mover 5 years, is intended for the diagnosis ofatherosclerotic plaque to prevent cardiovas-cular diseases including stroke. It alsorelates to therapeutic uses for deliveringdrugs in target tissues.

NanoAthero project gathers 16 partnersfrom 10 countries including France withINSERM, AP-HP, Inserm-Transfert and CEA(Grenoble and Saclay), Austria (MedicalUniversity of Graz), Denmark (University ofSouthern Denmark), Italy with a Europeanindustrial leader Bracco, Germany with theUniversity of Erlangen, the Max PlanckInstitute and nanoPET Pharma, Hungary(Semmelweis University), England withEdinethics for ethics, Switzerland with Clinam (Association for nanomedicine),and Israel with the company Wizsoft. TheNetherlands will coordinate two clinicaltrials with Amsterdam Medical Center andthe University of Utrecht; France will beresponsible for the third clinical trial tobe conducted at Cardiology and NuclearMedicine of APHP, Bichat hospital.

Because of their size, making them compara-ble to a DNA molecule or a protein, onehundred to one thousand times smallerthan a cell, the nanoparticles have differentphysical properties from those of commonobjects. Evolving to the same scale as thebiological mechanisms of the body, theyare able to cross natural barriers and entercells. Their main therapeutic application,currently, is to ensure the transport of drugsinto the interior of the cell by wrapping intiny structures, and to protect them from

interactions with the surrounding environment.The hope is to bring more of the activeingredient to its molecular target, avoidingits degradation or distribution in healthytissues. Experiments abound in this area.Search with nanoparticle and drug as keywords gives more than 25,000 referenceson Medline search. Nearly 20 years after thearrival of the first Nanomedicine (Doxil, adoxorubicin nanoliposome, approved by theFDA in 1995) their promise in medicine arestill awaited if you take into account therelatively small number of nanomedicine onthe market. However, it is truly innovativedrugs generally providing benefit overexisting treatments. “49 health nanoproductsare currently on the market in the world,”said Laurent Lévy, Vice-President of theEuropean Technology Platform Nanomedicine(ETPN) and cofounder of Nanobiotix, on theoccasion of World Cancer Day 2014. In2008, there were 36. These figures comefrom a study by Bionest for LEEM. Of the 49nanoproducts marketed, 7 are veterinaryproducts and 42 are intended for humanmedicine: 35 medicines and 7 medical devices.

In France, nearly twenty nanomedicines areon the market, most of which relate to cancer.For example Abraxane is a nanoparticleformulation of paclitaxel-albumin approvedfor the treatment of metastatic breast andpancreas. Cancer cells interacted with albumin, which will allow concentrate paclitaxel in tumor. The Transparency Commission ruled that Abraxane provides aminor improvement in actual benefit (IBA)compared to taxol in the treatment of breastcancer (median Progression-free survivalextended by one month and overall survivalof two months, but more side effects).

Many nanoproducts involve liposomes, whichalso have the interest to concentrate in cancer cells. Injected into the bloodstream,they cannot pass through a normal vascular

NanoAthero project: A new way to fight cardiovascular diseases

2

endothelium. However they pass throughthe endothelium of tumor vessels – thecells are less tightly joined – and into themalignant cells. The Daunoxome is a liposomal dispersion of daunorubicin forthe treatment of Kaposi’s sarcoma inpatients with AIDS. Myocet citrate liposome-encapsulated doxorubicin is indicated forthe treatment of metastatic breast cancer.It has less cardiac toxicity compared withdoxorubicin, but the IBA was consideredmodest.

These nanodrugs of first generation aresubject to the phenomenon of opsonizationthat leads to their rapid uptake by the liverand their degradation. The hepatic uptake isan asset when it comes to treating livercancer. However, it decreases the amount ofdrugs that happens to other target organs,since the plasma half-life is reduced. Toavoid opsonization, the second generationof nanocarriers have been developed that

are covered with polyethylene glycol (PEG).These nanoproducts, called “stealth” escapeuptake by liver macrophages. They staylonger in the bloodstream and reach more oftheir extra-hepatic targets. Caelyx, consistingof doxorubicin hydrochloride encapsulatedin pegylated liposomes, is available inFrance since 1996, especially for womenwith metastatic breast cancer with increasedcardiac risk. In this indication, it providesmoderate therapeutic benefit in terms ofcardiac safety as compared to free drug.

Nanocarriers of third generation are still inan experimental phase. They involve, inaddition to pegylation, a targeting molecule,which can be the ligand of a receptor or anantibody directed against a protein overex-pressed in the target tissue antibodies.These vectors are used to address the drugdirectly to the target, which gives hope forimproved efficiency, reduced toxicity andlower doses.

www.nanoathero.eu

Figure 1. Nanosystems for diagnostic or imaging

3

However, few products reached the testingphase I/II trials. The Bionest study identified122 nanomedicines in clinical developmentin the world, but among them, only 17 are inclinical phase II/III or III. Among them, oncologyrepresents the main part (70 products), farahead of infectious diseases (19 products)and cardiovascular disease (7 products).The potential toxicity of nanoparticles helpsto explain why the research is primarilyfocused on oncology. It is very difficult tomake an effective nanoparticle totallydevoid of toxicity to the cells. In the case ofcancer, this toxicity is less troublesome since,once reached its target, the nanoparticleshould destroy malignant cells. In total,taking into account the 49 nanoproductsalready on the market, there are 230 healthnanoproducts marketed or in clinical devel-opment, including 222 for human medicine:157 drugs and 65 medical devices.

Europe is very competitive in this area,with 1000 research groups and 500 SMEs.Various initiatives have been taken atEuropean level to stimulate translationalresearch in nanotechnology (see forinstance: http://www.etp-nanomedicine.eu).NanoAthero project, funded by the EuropeanCommission and coordinated by DidierLetourneur Inserm U1148, includes theconstruction of several nanosystems, theirevaluation, and clinical trials to evaluatethe contribution of nanosystems in thediagnosis and treatment of atheroscleroticplaques and ischemic stroke. The first trialbegan in the Netherlands, including patientswith carotid atheroma, to test the efficacyof a steroid (prednisolone) encapsulatedin pegylated liposomes. The objective is tostabilize the plaque against local inflammation.This nanomedicine administered intravenouslyhas proved efficacy in preclinical models of

NanoAthero project: A new way to fight cardiovascular diseases

Figure 2. Different types of polymer-based nanocarriers

4

atherosclerosis. Other systems are beingstudied to optimize these nanosystems, possibly with targeting agents or other drugs.

A clinical trial should start at Bichat hospital(Dr Dominique Le Guludec) by 2016, toevaluate a new imaging technique forischemic stroke. It uses a system developedfrom a polysaccharide extracted from brownseaweed (fucoidan), which specifically bindsto P-selectin, a protein expressed on thesurface of platelets and endothelial cellswhen they are activated. Associated with99mTc, this structure can visualize thrombiin preclinical imaging by SPECT scintigraphy.The idea is to detect early thrombotic events.

Didier Letourneur team also conducts worksin the hope of improving thrombolytictherapy for ischemic stroke. Moreover, theincidence of stroke is increasing, especiallyamong young people and women. The tissue plasminogen activator (tPA), a proteininvolved in the breakdown of blood  clots isused in human (actilyse®) but has a shorttherapeutic window. The goal is to improvethe treatment by combining a nanosystemthat would set specifically at the thrombusto release the active ingredient withoutleaving the vascular compartment. We mustfind a safe nanoparticle platform that maycombine enough rtPA without be metabo-lized. This is very complex because it is anenzyme that degrades very quickly.

In this new field of nanomedicine, there is alot of research, but very few products arrivedyet at the bedside. We have to ensure thesafety of components, to successfully putenough active products in a nanosystem, andto produce according to safety standardsGLP (Good Laboratory Practice). As forconventional medicines, this is a long wayfrom the design of a nanosystem to theclinical application.

Authors/Contact

INSERM UMRS 1148Laboratory for Vascular Translational  ScienceX. Bichat Hospital,  University Paris DiderotGalilee Institute, University Paris Nord 75018 Paris, France

Didier Letourneur, Ph.D.Head of Cardiovascular BioengineeringDirector LVTS – UMR 1148Tel: +33 1 40 25 86 00didier.letourneur@inserm.fr

Cédric Chauvierre, Ph.D.Researcher Inserm U1148Tel: +33 1 40 25 75 38cedric.chauvierre@inserm.fr

www.nanoathero.eu

Figure 3. Different types of imaging modalities for preclinical evaluation of nanosystems. From left toright : MRI, Ultrasounds, SPECT, PET (SFR X. Bichat, Paris Diderot-Inserm U1148)

5

In Europe, cardiovascular diseases cause over 4 million deaths and over 1.9 million deathsin the European Union, which equates to

47% of all deaths in Europe and 40% in the EU.According to the European Heart Network,1

death rates from cardiovascular heart disease(CHD) are generally higher in Central Europe,whereas death rates from stroke are muchhigher in Central and Eastern Europe. OverallCVD is estimated to cost the European Unioneconomy €196bn a year.

Cardiovascular diseases are all the diseases ofthe heart and circulation, including coronaryheart disease (angina and heart attack), heartfailure, congenital heart disease and stroke.There are many factors that increase the risk ofdeveloping a cardiovascular disease including;smoking, weight gain, diet, and lack of exercise.

Member of the European Society of Cardiology,and Clinical cardiologist and Professor of HealthSciences at Linnaeus University, Professor JoepPerk speaks to Laura Evans about the problemscardiolovascular diseases can cause throughoutEurope, and what more could be done todecrease fatalities.

“If we go back some way in time, cardiovascular diseases were fairly uncommon in the beginningof the past century,” Professor Perk begins.

“In Western Europe they started to show up inthe 1930s and 40s and culminate around 1970and 1980. In Western European countries there

has been a steady decrease over the past 20-30years. Research has shown that, of the 6-yearincrease in life expectancy between 1970 and2000, 65% of the increase – or almost 4 fullyears – is due to reductions in CVD mortalityalone. As positive as this scenario is, heart diseaseremains the leading cause of death and thenew epidemic has the potential to threaten theadvances made to date. Europe is currentlyfacing a series of emerging trends, such as thegrowing ageing population, that could createnew challenges for healthcare systems.”

“In Sweden, premature and early mortality inheart diseases has reduced to a third of what wehad in the 1980s, which is a tremendous differ-ence. At the same time as we see this loweringin Western Europe, we see some parts of EasternEurope still experiencing problems.”

Professor Perk explains there are some areas ofEurope where cardiovascular disease is still rife.For example in Eastern Europe, the problemseems to be bigger than Western Europe, whichPerk believes is due to lifestyle differences.

“Cardiovascular diseases are becoming a problemin middle and low income countries like India,Pakistan and Brazil, with 80% more early cardio-vascular deaths being recorded.

“It is very much to do with public health; smoking,physical activity, what you eat, stress and oursleeping habits. In several Western Europeancountries we have seen two thirds of a drop in

Professor Joep Perk of Linnaeus University, and a member of theEuropean Society of Cardiology, speaks to Editor Laura Evans aboutthe importance of reducing cardiovascular diseases in Europe andhow this can be achieved…

Eradicating cardiovascular diseases for good

Editorial Feature

6

mortality over the past 25 years, which is due tothe fact that people are smoking less, and areslightly more physically active.

“A country like Bulgaria for example has a hugeproblem. People are getting fatter, they aresmoking more, move around less, and havemore stressful lives which leads to a directincrease in mortality.”

The difference in mortality rates has a lot to dowith developed countries having more effectivetreatment to hand. For underdeveloped nations,mortality rates are higher due to effectivetreatments or quality of care not being available,as Professor Perk explains.

“If you look at the risk factors, the number ofpeople overweight and smoking is a biggerproblem in richer countries. In poor countries,the quality of care, especially the follow up, isstill undeveloped. For example, if you have aheart attack in Bangladesh, the survival rate isfar worse than if you had one in the UK. If youlook at the risk level for the average Britishcitizen who is overweight and less active, whenthey have a heart attack they still have a betterchance of surviving than the lean non-smokerin Bangladesh.”

Cardiovascular diseases remain the prime causeof premature deaths under the age of 75, andProfessor Perk believes if we can tackle theproblem head on, 80% of all cardiovasculardiseases could be eradicated which is a hugeachievement in itself.

Perk believes that education and legislationcould play a key part in eradication. If peoplehad the correct information and knowledgeabout these diseases, mortality rates could bea lot less.

“On a political level – more legislation onsmoking, the amount of salt in food, access tofresh fruit and vegetables and physical activityis needed,” said Professor Perk. The EACPRissued an interesting paper about this.2

“People need to be informed that heart attacks

are something that at least 80% of people caninfluence through their own behaviour. Werecently conducted a study and discovered thebasic knowledge on how people could preventthis disease is lacking. There is a need for goodpublic knowledge so people can take responsi-bility for their own health.

“On these 2 levels (public and personal) wecan further eradicate cardiovascular disease.We know there is a significant difference ofcardiovascular disease between the higher andlower income countries. If you make fruit andvegetables a lot cheaper, you give people withless resources a better chance of getting anti-oxidants into their diet, which can help to keepyou healthy.”

Perk believes it is important to try and eradicatecardiovascular problems now, in order toprevent the next generation from developingthe diseases.

“The main aim is to help the next generationwho I would like to see active in sports. Theyhave a body that has a reasonable guarantee toget to 90 years old. We have lots of children thatare failing at school, they don’t sleep enough,and they don’t eat the right foods, and that isone of the main challenges in Europe.

“Because I am professor of health science I workmainly on trying to transfer the knowledge wealready have. We need to educate people andtell them these diseases are a waste of our timeand we don’t need them.” �

1 http://www.ehnheart.org/cvd-statistics.html

2 Population-level changes to promote cardiovascular health. Eur J

Prev Cardiol. 2012 May 9.

http://cpr.sagepub.com/content/early/2012/05/09/204748731244

1726.full.pdf+html

Professor Joep PerkClinical cardiologist and Professor of Health SciencesLinnaeus University, Sweden, and member of theEuropean Society of Cardiologyjoep.perk@lnu.se www.escardio.org

7

INSERM UMRS 1148 – Laboratory for Vascular Translational  ScienceX. Bichat Hospital,  University Paris Diderot, 46 rue H. Huchard 75018Paris & Galilee Institute, University  Paris Nord, 99 avenue JB Clément9340 Villetaneuse, FranceSecretary: +33 (0) 1 40 25 86 00 Fax: +33 (0) 1 40 25 86 02Website:  http://www.u1148.fr/Website:  http://www.nanoathero.eu/

NanoAthero project: A new way to fight cardiovascular diseases www.nanoathero.eu