Genotype stratification in diabetes treatment and prevention

Abstract

To provide an insulin autoantigen for use in immunotherapy for treatment or prevention of autoimmune diabetes in an individual.SOLUTION: The present invention relates to an insulin autoantigen for use in immunotherapy including: determining the HLA haplotype of an individual; and subjecting the individual to a treatment regimen based on the haplotype. An individual having any of (i) to (iii) in the following is subjected to the treatment using at least the insulin autoantigen: (i) an individual having a DR4-DQ8 haplotype and not having a DR3-DQ2 haplotype; (ii) an individual having an HLA DR3 / 4-DQ2 / 8 genotype; and (iii) an individual having an HLA-DR4 / 4-DQ8 / 8 haplotype.SELECTED DRAWING: None

Description

[Technical field]

[0001] The present invention relates to the technical field of medical therapy, in particular to methods for the immunotherapeutic treatment of patients based on their genetic profile, as well as compounds and compositions for use in such methods. [Background technology]

[0002] Type 1 diabetes mellitus (T1DM) is an autoimmune disease characterized by immune-mediated destruction of the insulin-secreting beta cells of the pancreas. T1DM often has an early onset, as early as childhood.

[0003] The production of autoantibodies against beta cells leads to the degradation of beta cells. The degradative process occurs over many years and ultimately results in metabolic abnormalities. These abnormalities initially manifest as glucose intolerance and progress to symptomatic hyperglycemia. Antibodies identified in association with the development of T1DM are antibodies against insulin (IAA), antibodies against GAD65 (GADA, including truncated GADA or tGADA), antibodies against IA-2 (IA-2A) and antibodies against ZnT8 (ZnT8A).

[0004] It has been suggested that administration of glutamic acid decarboxylase with alum may preserve beta cell function in patients with early-onset T1DM (Ludvigsson et al., N Engl J Med. 2012 Feb. 2;366(5):433-42).

[0005] Insulin has also been used as an antigen component in immunotherapy for T1DM (Ali et al., Sci Transl Med. 2017 Aug. 9; 9(402)).

[0006] The 6-year incidence of diabetes-associated autoantibodies in children at genetic risk is described by Krischer et al. (Diabetologia. May 2015; 58(5):980-7).

[0007] Immunomodulation by therapeutic agents intended for the treatment of diabetes and for the prevention of autoimmune diabetes is known in the art, in particular from EP1755631 and EP3151853. Summary of the Invention [Means for solving the problem]

[0008] The number and type of antibodies predict progression to diabetes. Patients with different genotypes have different sets and development of antibodies that cause beta cell degradation, which in turn leads to differences in disease progression based on which antibodies are induced in the patient.

[0009] By identifying the genotype and simultaneously measuring and quantifying the amount of antibodies to GAD65 and insulin, it is possible to individualize vaccines for the prevention or treatment of T1DM.

[0010] Thus, in one embodiment, the present invention relates to a method for the treatment or prevention of an autoimmune disease in an individual, comprising determining the HLA haplotype of the individual; and subjecting the individual to a treatment regimen based on said haplotype.

[0011] In one embodiment, the method comprises determining an individual's HLA haplotype; determining the specificity of early-occurrence autoantibodies associated with an autoimmune disease in the individual; and subjecting the individual to a treatment regimen based on the haplotype and the specificity of the early-occurrence autoantibodies.

[0012] In one embodiment, the disease is autoimmune diabetes, eg, type 1 diabetes mellitus. In one embodiment, an individual carrying the HLA DR3-DQ2 haplotype and optionally initially presenting with GADA is subjected to treatment with at least the GAD autoantigen.

[0013] In one embodiment, an individual with the HLA DR3 / 4-DQ2 / 8 genotype is subjected to treatment with both the GAD and insulin autoantigens in the same formulation or in separate formulations.

[0014] In one embodiment, an individual who has the DR4-DQ8 haplotype but not the DR3-DQ2 haplotype and optionally initially displays insulin autoantibodies is subjected to treatment with at least the insulin autoantigen.

[0015] In one embodiment, individuals who have the DR4-DQ8 but not the DR3-DQ2 haplotype are subjected to treatment with alum alone.

[0016] In one embodiment, an individual who has the HLA DR8 / 4-DQ4 / 8 haplogenotype and optionally initially displays insulin autoantibodies is subjected to treatment with at least the insulin autoantigen.

[0017] In one embodiment, individuals who have the DQ2 genotype and who initially exhibit GAD antibodies are subjected to treatment with a GAD antigen.

[0018] In one embodiment, individuals with the HLA-DR4 / 4-DQ8 / 8 genotype are subjected to treatment with an insulin antigen.

[0019] In one embodiment, individuals with the HLA-DR8 / 4-DQ4 / 8 genotype are subjected to treatment with an insulin antigen.

[0020] In one embodiment, individuals with the HLA-DR3 / 3-DQ2 / 2 genotype are subjected to treatment with a GAD antigen.

[0021] In one embodiment, individuals with the HLA-DR3 / 4-DQ2 / 8 genotype are subjected to treatment with a GAD antigen.

[0022] In one embodiment, administration of the GAD antigen is one of subcutaneous, intradermal or intralymphatic.

[0023] In one embodiment, the GAD antigen is formulated with alum. In one embodiment, administration of the insulin autoantigen is oral, sublingual, intramuscular, intradermal or intralymphatic.

[0024] In one embodiment, the insulin antigen is formulated with alum or in saline.

[0025] In one embodiment, administration of alum alone is subcutaneous, intradermal or intralymphatic. In one aspect, the invention relates to GAD for use as an autoantigen in the methods described above.

[0026] In one aspect, the invention relates to insulin for use as an autoantigen in the methods described above.

[0027] In one aspect, the invention relates to the use of GAD in the manufacture of a pharmaceutical composition for use in the methods described above.

[0028] In one aspect the invention relates to the use of insulin in the manufacture of a pharmaceutical composition for use in the methods described above.

[0029] definition All terms used herein are intended to have the meanings that would be given to them by one of ordinary skill in the art in the context of this disclosure. Certain terms are specifically defined below to avoid ambiguity.

[0030] The term "alum" refers to aluminum hydroxide, which is commonly used as an adjuvant in pharmaceutical compositions for use in immunotherapy. "Alum alone" refers to a composition containing alum but no antigen.

[0031] The term "GAD" refers to the protein glutamic acid decarboxylase and includes isoforms of GAD, such as GAD38, GAD65 and GAD67, and fragments thereof.

[0032] The term "insulin" when used in reference to insulin as an autoantigen should be taken to include preproinsulin, proinsulin and fragments thereof.

[0033] The term T1D includes all types of diabetes in which autoantibodies against beta cell autoantigens are present, such as type 1 diabetes mellitus (T1DM), 1,5 diabetes, LADA, LADY, SPIDDM, PIDM and others.

[0034] The terms "a" and "an" should be construed to include both the singular and the plural.

[0035] All references cited herein are expressly incorporated by reference in their entirety. DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS

[0036] The etiology of T1DM has yet to be elucidated, however the pathogenesis is indicated by autoantibodies against insulin (IAA), GAD65 (GADA), IA-2 (IA-2A) or ZnT8 (ZnT8A).

[0037] Recent studies have demonstrated that there are two main groups of children who develop islet autoantibodies; one group presents with IAA as the first autoantibody, often including young children with HLA genotypes that include the DR4-DQ8 haplotype, and the other group often presents with GADA or tGADA first, often including some of the DR3-DQ2 haplotype 2. It has been found that the prevalence of GAD-alum in children of 6- to 10 years of age is significantly higher in older children than in older adults, which is why the present inventors tested the efficacy of GAD-alum versus placebo in these HLA groups (see Example 2).

[0038] The HLA (human leukocyte antigen) gene family is a group of proteins known as the HLA complex. The HLA complex helps the immune system distinguish self from non-self. There are three basic classes of HLA complexes: MHC (major histocompatibility complex) class I, MHC class II, and MHC class III. The MHC class II genes include the HLA-D gene.

[0039] The TEDDY (The Environmental Determinants of Diabetes in the Young) substudy aimed to identify genetic and environmental factors that explain the induction of the initial islet autoantibodies.

[0040] The study investigated islet autoimmunity and the development of T1DM. Children from newborns up to 15 years of age with a genetic susceptibility to T1DM were enrolled in the study.

[0041] Participants were required to return to the clinic every 3 months. At each visit, blood was analyzed for GADA, IAA, IA-2A, ZnT8A, DNA, mRNA, infectious agents, HbA1c, PBMCs, red blood cells, and pooled plasma / serum. Urine samples, nasal swabs, tap water, toenail clippings, and salivary cortisol were also analyzed. Stool samples were collected monthly for the first 48 months and then every 3 months.

[0042] In addition to the analyses listed above, we interviewed mothers regarding pregnancy diet (food frequency questionnaire (FFQ) of selected foods), smoking; negative life events, parental anxiety, depression, infection records, medications, vaccinations, family history, DNA from first degree relatives (FDRs), and physical activity assessment. We also re-enrolled lost subjects.

[0043] The aim was to study prenatal factors that may influence the risk of HLA-dependent autoantibody appearance. Nondiabetic mothers of singleton infants (n=6,947) completed a questionnaire 3-4.5 months into pregnancy. Lower birth weight was defined as the lower 25% of birth weights of TEDDY infants.

[0044] Maternal factors such as smoking, BMI, alcohol consumption during the third trimester (>2 drinks / month) and maternal infections (lower respiratory tract infection, skin infection or rash, genital infection). After adjusting for country, T1DM in FDRs, HLA genotype and sex, none of these maternal factors was associated with first islet autoantibodies.

[0045] Among FDR children, IAA-only as the first autoantibody was more common than GADA-only at younger ages but not at older ages.

[0046] Compared with children with the HLA-DR3 / 4 genotype, children with the HLA-DR3 / 3 genotype showed a lower risk of exhibiting only IAA as the first islet autoantibody.

[0047] Among children with the HLA-DR4 / 4 and HLA-DR4 / 8 genotypes, the risk for first islet autoantibody only being GADA was low.

[0048] Among girls, there was a lower risk of first islet autoantibody presentation being IAA only, but not GADA only.

[0049] Among children born with lower birth weight, the risk of having only GADA as the first islet autoantibody was lower.

[0050] The occurrence of IAA alone was more common in boys and was associated with HLA-DR4 / 4-DQ8 / 8 and HLA-DR8 / 4-DQ4 / 8.

[0051] The occurrence of GADA alone was not associated with gender, but was associated with HLA-DR3 / 3-DQ2 / 2 and HLA-DR3 / 4-DQ2 / 8 and was less common in low birth weight infants.

[0052] We could conclude that the first islet autoantibody, GADA, is induced mainly in individuals with the HLA-DQ2 haplotype. Maternal factors affecting birth weight may influence the appearance of GADA as the first autoantibody.

[0053] Individuals with the genotypes HLA-DR4 / 4-DQ8 / 8 and HLA-DR8 / 4-DQ4 / 8 generally predominantly show the presence of IAA as the primary islet autoantibody.

[0054] Individuals with the genotypes HLA-DR3 / 3-DQ2 / 2 and HLA-DR3 / 4-DQ2 / 8 generally exhibit predominantly the presence of GADA as the primary islet antibody.

[0055] Surprisingly, the present inventors have been able to show that the administration of GAD autoantigen to T1DM patients with HLA haplotypes associated with GADA as the initial autoantibody can be preferably used in T1DM treatment / prevention regimens.The antigen to be used can therefore be determined based on the patient's genotype.

[0056] In addition, it has been shown that alum alone can delay the decline of stimulated C-peptide in patients with the DR4-DQ8, but not in patients with the DR3-DQ2 haplotype.

[0057] According to the invention, the autoantigen may be administered by intralymphatic injection, direct injection into a lymph node, intradermal injection, subcutaneous injection, intramuscular injection, intraperitoneal injection, intravenous injection, subcutaneous injection, intranasal, transmucosal or sublingual application; or orally, including administration as a tablet, pellet, granule, capsule, lozenge, aqueous or oily solution, suspension, emulsion, spray, or as a dry powder form reconstituted with a liquid medium.

[0058] In one embodiment of the present invention, administration of the autoantigen is performed to lymph nodes or directly to the lymphatic system to allow resident APCs to present antigen peptides to the immune system. When administration of the autoantigen is performed to lymph nodes or directly to the lymphatic system, the dose is preferably 1-15 μg per autoantigen, more preferably 2-10 μg per autoantigen, or 2-5 μg per autoantigen. Formulation in alum is preferred.

[0059] According to certain embodiments, at least one autoantigen is administered intrainguinally, intranodally or intralymphatically. In some embodiments, the volume of an intrainguinal injection of the antigen is between 0.05 and 0.2 ml, more preferably between 0.05 and 0.15 ml.

[0060] According to certain embodiments, when at least one antigen is administered by intranodal or intralymphatic injection, the preferred dosage is 1-15 μg, more preferably 2-10, most preferably 2-5 μg per injection and autoantigen used, and such administration is at least twice, more preferably at least three times, most preferably at least four times. More preferably, the two assays are performed at least 14 days apart, and more preferably at least 30 days apart.

[0061] According to certain embodiments, the at least one antigen and the at least one IL-10 inducing compound are administered simultaneously. According to certain embodiments, the at least one antigen and the at least one IL-10 inducing compound are administered separately.

[0062] The method may further comprise pre-treatment of the individual to regulate serum vitamin D levels, such pre-treatment may comprise administration of vitamin D and / or a vitamin D analogue, and / or exposure to UVB radiation, preferably for 7 to 90 days prior to administration to said subject of a composition comprising at least one beta cell autoantigen, as described in EP3151853.

[0063] Working Example The following examples are intended to further illustrate the present invention and should not be construed as limiting the scope of the invention, which is defined by the appended claims.

[0064] Example 1: TrialNet Phase II Wherrett DK et al. (Lancet, July 23, 2011; Vol. 378 (Issue 9788): pp. 319-27) reported from a three-arm (A: 3sc × 20 μg GAD-alam (n=48); B: 2 × 20 μg GAD-alam and 1 alam (n=49); and C: 3 × alam (n=48)) randomized study in subjects aged 3-45 years diagnosed with T1D within 100 days that at 1 year, the 2-hour AUC of C-peptide adjusted for age, sex, and baseline C-peptide levels was 0.412 nmol / L (0.349-0.478) in the A GAD-alam group, 0.382 nmol / L (0.322-0.446) in the B GAD-alam + alam group, and 0.404 nmol / L (0.404-0.447) in the C GAD-alam + alam group. They reported that the mean C-peptide level at 1 year was 0.413 nmol / L (0.351-0.477) in the alam group, corresponding to a reduction in mean C-peptide at 1 year of 44%, 42% and 41% of the baseline mean for GAD-alam × 3, GAD-alam × 2 and alam × 3, respectively. The authors note that baseline and 1-year C-peptide levels mirrored findings in the control groups of three other TrialNet studies in subjects treated within 3 months of diagnosis, and that this indicates that alam alone has no effect on reducing insulin secretion at 12 months.

[0065] Thus the adjusted declines over 12 months are 3.7%, 3.5% and 3.42% per month. The unadjusted values ​​for up to 24 months are shown in the table below, where Groups A, B and C showed declines of 58.3%, 62.3%, 55.1% over two years, or declines of 2.42%, 2.6%, 2.3% per month. Alum is slightly better.

[0066] [Table 1]

[0067] However, assuming that GAD as an immunomodulatory antigen is effective in the HLA group that usually shows GAD antibodies first, and that the insulin family of antigens is effective in the haplotype that often shows insulin antibodies first, when we reconsider the data from this study, we surprisingly found that in the DR3-DQ2 haplotype group that usually shows GAD antibodies first, GAD-alum is almost twice as effective as alum alone (2.35% vs. 4.45% change / month).In addition, the efficiency of GAD-alum in the group that includes DR4-DQ8 that usually shows IAA first (although the DR3 / DR4-DQ2 / DQ8 group can show either GADA or IAA first) is only 40% beneficial.It is particularly interesting that in the DR4-DQ8 haplotype group that is reported to include subjects that often show IAA first, the adjuvant alum (placebo) alone is more effective than active drug.

[0068] [Table 2]

[0069] Example 2: DiaPrevIt A randomized, double-blind, placebo-controlled study (DiaPREV-IT, ClinicalTrials.gov identifier: NCT01122446) in 50 healthy children with numerous islet autoantibodies but who did not yet have insulin-requiring diabetes found that prophylactic treatment with GAD-alum did not affect the progression to onset of clinical T1D.

[0070] The study was conducted in children aged 4 to 17.9 years (median age 5.2 years) with GADA and at least one additional islet autoantibody. Enrollment was completed in 2012, and follow-up was The follow-up period was 5 years. Eligible children from the DiPiS (Diabetes Prediction in Skane) and TEDDY (The Environmental Determinants of Diabetes in the Young) studies received two subcutaneous injections of 20 μg of GAD-alum (n=25) or placebo (n=25), 30 days apart. HLA DQB1 * Positivity for 06:02 was included in the exclusion criteria.

[0071] Islet cell autoantibodies predict clinical onset of T1D, and children with two or more islet autoantibodies have a 70% risk of developing T1D within 10 years. The sample size of 50 children randomized 1:1 to treatment with either GAD-alum (investigational drug) or alum alone (placebo) was based on the assumption that 50% of untreated children with two or more autoantibodies would show clinical T1D within a 5-year period. However, it was surprisingly found that although half of the children had impaired glucose metabolism at baseline, indicating a very high risk of progression to clinical disease, only 18 of 50 (36%) individuals showed clinical T1D during the 5-year follow-up period, not the expected 50%. In light of the overall non-significant results reported, an investigation was conducted to assess which subgroups, if any, could be the reason for the lower than expected incidence of overt T1D cases shown.

[0072] Twelve of the 18 / 50 children who progressed to T1D within the 5-year follow-up period (170-1830 days after the first injection of the study drug) were found to be girls, with a higher progression rate than boys (p=0.012). Progression to T1D was not influenced by being a first-degree relative (p=0.925), whereas children with impaired glucose metabolism at baseline, defined as plasma glucose ≥7.8mmol / L and <11.1mmol / L at 120 minutes of OGTT, plasma glucose ≥11.1mmol / L at 30, 60 and / or 90 minutes of OGTT, and / or FPIR <30 in IvGTT, had a higher progression rate than children with normal glucose tolerance (p=0.013).

[0073] Time to clinical diagnosis was not affected by treatment in the overall group (p=0.573) or within the strata with 2 or 3-6 autoantibodies (p=0.957 and 0.628, respectively). Furthermore, time to diabetes was not significantly affected by treatment within the normal and glucose metabolism disorder groups (p=0.359 and p=0.376, respectively) or by gender (p=0.079 for boys and p=0.400 for girls, respectively).

[0074] Recent research has reported that there are two main groups of children who develop islet autoantibodies; one group shows IAA as the first autoantibody, and this group often includes young children with HLA genotypes including DR4-DQ8 haplotypes, and the other group often shows GADA or tGADA first, and is often somewhat older children with DR3-DQ2 haplotype 2; therefore, the inventors of the present invention tested the efficacy of GAD-alum vs. placebo in these HLA groups. In this study, six different HLA genotypes were shown, including only those individuals with high risk of showing clinical T1D. Of these, three groups, HLA DQ2 / 2; DQ2 / X; and DQ X / X, included too few subjects (n=2, 2, 1) to be considered in any analysis. The remaining three HLA groups included DQ2 / 8 (n=25) (of which 10 subjects received GAD-alam and 15 received placebo); DQ8 / X (n=11) (six subjects received GAD-alam and five received placebo); and DQ8 / 8 (n=9) (five individuals received GAD-alam and four received placebo).

[0075] Surprisingly, in 25 subjects in the DQ2 / 8 group, 2 of 10 subjects in the GAD-alum group showed a 50% improvement compared with 8 of 15 individuals (53%) who received placebo. (20%) were found to develop T1D within the 5-year period (Table 3), indicating that GAD-Alam is effective in delaying T1D in high-risk individuals with the DQ2 / 8 haplotype. Similar findings were not seen in the DQ8 / X or DQ8 / 8 groups, in which placebo was found to perform better than GAD-Alam-treated subjects.

[0076] [Table 3]

[0077] Example 3: DiagNode-1 As described by Tavira et al. (Journal of Diabetes Research, 2018, article number 9391845), an open study was conducted in 12 onset early T1D patients, in which 4 μg of GAD formulated in alum was directly injected into the inguinal lymph node three times, with a period of 30 days between each injection. In line with the subject matter of the present invention, it was found that treatment of patients with the DR3-DQ2 haplotype resulted in better HbA1c and stimulated C-peptide area under the curve data than patients without the DR3-DQ2 haplotype.

[0078] [Table 4]

[0079] [Table 5]

Claims

1. 1. A method for treating or preventing an autoimmune disease in an individual, comprising: - determining the HLA haplotype of said individual; - subjecting said individual to a treatment regimen based on said haplotype; The method includes:

2. - determining the HLA haplotype of said individual; - determining the specificity of early occurring autoantibodies associated with said autoimmune disease in said individual; - subjecting said individual to a treatment regimen based on said haplotype and the specificity of said early occurrence autoantibodies; The method of claim 1 , comprising:

3. 2. The method of claim 1, wherein the disease is autoimmune diabetes, e.g., type 1 diabetes mellitus.

4. The method according to any one of claims 1 to 3, wherein an individual carrying the HLA DR3-DQ2 haplotype and optionally initially presenting with GADA is subjected to treatment with at least a GAD autoantigen.

5. The method of any one of claims 1 to 3, wherein an individual with the HLA DR3 / 4-DQ2 / 8 genotype is subjected to treatment with both the GAD and insulin autoantigens in the same formulation or in separate formulations.

6. The method according to any one of claims 1 to 3, wherein an individual carrying the DR4-DQ8 haplotype but not the DR3-DQ2 haplotype and optionally initially exhibiting insulin autoantibodies is subjected to treatment with at least an insulin autoantigen.

7. The method according to any one of claims 1 to 3, wherein individuals who have the DR4-DQ8 but not the DR3-DQ2 haplotype are subjected to treatment with alum alone.

8. The method according to any one of claims 1 to 3, wherein an individual carrying the HLA DR8 / 4-DQ4 / 8 haplogenotype and optionally initially exhibiting insulin autoantibodies is subjected to treatment with at least an insulin autoantigen.

9. The method of any one of claims 1 to 8, wherein administration of the GAD antigen is one of subcutaneous, intradermal, or intralymphatic.

10. The method of any one of claims 1 to 9, wherein the GAD antigen is formulated with alum.

11. The method according to any one of claims 1 to 8, wherein administration of the insulin autoantigen is oral, sublingual, intramuscular, intradermal or intralymphatic.

12. The method of claims 1 to 9 or 11, wherein the insulin antigen is formulated with alum or in saline.

13. The method according to any one of claims 1 to 8, wherein the administration of alum alone is subcutaneous, intradermal or intralymphatic.

14. GAD for use as an autoantigen in the method according to any one of claims 1 to 13.

15. Insulin for use as an autoantigen in the method according to any one of claims 1 to 13.

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