Rhinovirus Induces Th2 cytokines and chemokines in the Airways in Asthma

David JacksonClinical Research Fellow

Department of Respiratory MedicineNational Heart and Lung Institute

Imperial College London

Introduction

• Asthma is a chronic condition characterised by reversible airflow obstruction, airway hyper-responsiveness, and airway inflammation

• Affects 1 in 12 of the UK population• NHS costs are ~£1bn/yr• Asthma exacerbations are the major cause for morbidity, mortality and

healthcare costs in asthma

• Respiratory viruses are the most frequent trigger for exacerbations– Rhinovirus identified in the majority of episodes

– Johnston BMJ 1995 … many studies since.

RV

Human Model of Rhinovirus Induced Acute Exacerbations of Asthma

↑ RV-induced lower airway involvement in mild asthmatics compared to healthy volunteers

↑symptoms, ↓lung function and ↑AHR. - Corne, Lancet 2002; Message, PNAS 2008

Human Model of Rhinovirus Induced Acute Exacerbations of Asthma

Mild Well controlled

Steroid naïve

N = 14

ModeratePoorly controlled

On maintenance inhaled corticosteroids

N = 18

Healthy

N = 14

Infection confirmed by demonstration of RV16 RNA by RT-PCR in nasal lavage and serum titre of RV-16 specific antibodies ≥ 1:4 on day 42.

N = 11 N = 11 N = 17

Human Model of Rhinovirus Induced Acute Exacerbations of Asthma

Day -15 -14 0 2 3 4 5 7 10 42

RV 16

• Daily spirometry and symptom scores throughout study

• Nasal lavage and Nasosorption at every visit

(PC)20 (PC)20 • BAL• Bronchial brushings • Bronchial biopsies• Bronchosorption

‘Nasosorption’ and ‘Bronchosorption’:A new technique for measuring nasal and bronchial mucosal lining

fluid.

• Accurate measurement of proteins in nasal lavage and BAL is extremely difficult.– Variable recovery of saline– Variable dilutions – Many proteins below limits of detection

• BAL can lead to bronchospasm in asthmatics• Large proportion of patients complain of a fever following BAL• In paediatrics even nasal lavage considered too invasive and difficult for some age

groups.

Nasosorption

Synthetic Absorptive Matrix (SAM) ‘Leukosorb’ ( Pall Life Sciences)

Bronchosorption Device

Bronchosorption

Sheath SAM advanced Absorbing mucosal lining fluid

RML bronchus RLL bronchus

Kraft M. NEJM 2011

RV

Allergic asthma considered a Th2 mediated disease

Th1 inflammation induced following viral infection in both healthy and asthmatic subjects

Bronchial CCL22 (MDC) correlates with upper and lower respiratory symptoms during RV-infection in asthma

Increased CCL22 (MDC) and CCL17 (TARC) during RV infection with greatest levels in asthma

Kraft M. NEJM 2011

RV

IL-5 is induced by RV in both the upper and lower airway in asthma

Th2 cytokines induced by RV in asthma

IL-13 IL- 4

IL-13 correlates with RV-induced symptoms in asthma

No difference in induction of IFN-gamma (Th1) between asthma and healthy subjects

RV

IL-33Initiator of Type 2 inflammation

Induction by influenza in mice.Chang, Nat Immunol 2011

IL- 33 correlates with Th2 cytokines and chemokines during RV infection in asthma

IL-33 correlates with upper and lower airway symptoms in asthma

Is RV induction of Th2 pathways in asthma clinically relevant?

• Mepolizumab (anti-IL-5 mAb) → fewer severe exacerbations in subjects with severe refractory eosinophilic asthma. (RR 0.57; p = 0.02) – Haldar, Pavord NEJM 2009

• Lebrikizumab (anti-IL-13 mAb) → rate of exacerbations 60% lower in ‘high-Th2’ subgroup only (p = 0.03). No significant effect on other asthmatics. – Corren, Matthews NEJM 2011

Baseline levels of Th2 cytokines predict levels during exacerbation

Great potential to use nasosorption in the clinic to identify suitable patients for anti- IL-5 / anti IL-13 drugs

Summary

• Bronchosorption and nasosorption allows measurement of previously undetectable proteins

• Induction of IL-33 and the Th2 pathway by virus in asthma in vivo and relationships to clinical outcomes – provides explanation for effectiveness of anti-IL-5 and anti-IL-13 mAb’s in

preventing exacerbations in selected asthmatics

• Baseline levels of IL-5 and IL-13 predict magnitude of induction by virus – possibility to identify suitable asthmatics for mAb therapies

• Correlation between upper and lower airway protein levels at baseline and following RV infection in asthma

• Asthma is heterogeneous – new treatments needs to be targeted

Acknowledgements

• Prof Sebastian Johnston• Dr Trevor Hansel• Belen Trujillo-Torralbo• Jerico del Rosario• Johnston group• Dr Onn Min Kon• Hunt Developments Ltd• Novartis • GSK

Correlation between Upper and Lower Airway Protein Levels in Asthma

Protein

Bronchial D4 Nasal D2

Bronchial D4Nasal D3

Bronchial D4Nasal D4

IL-33 + + -IL-5 +++ + +

IL-13 ++ + -IL-17 + - -IFN-g +++ ++ +IL-15 + +++ -I-TAC - ++ +IP-10 - ++ -IL-6 ++ - -IL-8 +++ ++ -

TNFa +++ ++ +TNF R2 - - -MDC + + -TARC - - -

Eotaxin +++ - -Eotaxin-3 - - -RANTES + ++ +++

IL-2 + - -IL-10 + ++ -

MCP-1 + - -MCP-4 + + -

GM-CSF - - -MIP-1a + ++ -MIP-1b ++ ++ -MIP-3a ++ + -

IL-12p40 + + -IL-1b - - -IL-16 ++ ++ -

+, p = <0.05++, p = <0.01 +++, p = <0.001

Lower Respiratory Symptoms

* P <0.05 Mild compared to moderate asthma

Change in PEF

* P <0.05, ** P <0.01 Poorly-controlled compared to well-controlled# P <0.05, Poorly-controlled compared to partially-controlled