Genotype stratification in the treatment and prevention of diabetes

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 drug therapy, in particular to a method for immunotherapy treatment of a patient based on the patient's gene profile, as well as compounds and compositions for use in such a method.

Background Art

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

[0003] The production of autoantibodies against beta cells causes the degradation of beta cells. The degradation process occurs over several years and ultimately leads to metabolic abnormalities. These abnormalities initially appear as impaired glucose tolerance and progress to symptomatic hyperglycemia. Antibodies that have been identified in relation to the onset of T1DM are antibodies against insulin (IAA), antibodies against GAD65 (GADA including cleaved GADA or tGADA), antibodies against IA-2 (IA-2A), and antibodies against ZnT8 (ZnT8A).

[0004] Administration of alum-formulated glutamic acid decarboxylase has been suggested to preserve beta cell function in patients with recent-onset T1DM (Ludvigsson et al., N Engl J Med. February 2, 2012; 366(5):433-42).

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

[0006] The 6-year incidence of diabetes-related autoantibodies in children with genetic risk has been described by Krischer et al. (Diabetologia. May 2015; Vol. 58 (No. 5): pp. 980-987).

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

[0008] The number and types of antibodies predict the progression to diabetes. Patients with diverse genotypes have different sets and developments of antibodies that cause beta cell degradation. This, 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 against GAD65 and insulin, it is possible to personalize vaccines for the prevention or treatment of T1DM.

[0010] Accordingly, in one embodiment, the present invention relates to a method for treating or preventing an autoimmune disease in an individual, comprising: determining the individual's HLA haplotype; and subjecting the individual to a treatment regimen based on the haplotype.

[0011] In one embodiment, the method comprises: determining the HLA haplotype of an individual; determining the specificity of early-developing 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-developing autoantibodies.

[0012] In one embodiment, the disease is autoimmune diabetes, for example, type 1 diabetes mellitus. In one embodiment, individuals having the HLA DR3-DQ2 haplotype and optionally first exhibiting GADA are subjected to treatment with at least a GAD autoantigen.

[0013] In one embodiment, individuals having the HLA DR3 / 4-DQ2 / 8 genotype are subjected to treatment with both GAD autoantigen and insulin autoantigen in the same or separate formulations.

[0014] In one embodiment, individuals having the DR4-DQ8 haplotype but lacking the DR3-DQ2 haplotype, and who are optionally selected to be the first to show insulin autoantibodies, are subjected to treatment with at least an insulin autoantigen.

[0015] In one embodiment, individuals having the DR4-DQ8 haplotype but lacking the DR3-DQ2 haplotype are subjected to treatment with Aram alone.

[0016] In one embodiment, individuals having the HLA DR8 / 4-DQ4 / 8 haplogroup and who are optionally selected to be the first to show insulin autoantibodies are subjected to treatment with at least an insulin autoantigen.

[0017] In one embodiment, individuals possessing the DQ2 genotype and initially exhibiting GAD antibodies are subjected to treatment with GAD antigen.

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

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

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

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

[0022] In one embodiment, administration of the GAD antigen is by 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 present invention relates to GAD for use as an autoantigen in the method described above.

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

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

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

[0029] Definitions All terms used herein are intended to have the meaning given to them by those skilled in the art in the context of the present disclosure. Some terms are specifically defined below to avoid ambiguity.

[0030] The term "aram" refers to aluminum hydroxide, which is typically used as an adjuvant in pharmaceutical compositions for use in immunotherapy. "Aram alone" refers to a composition that contains aram but does not contain the antigen.

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

[0032] When the term "insulin" is used in reference to insulin as an autoantigen, it should be interpreted 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 interpreted as including both singular and plural forms.

[0035] All references cited herein are incorporated more clearly by reference as a whole. [Modes for carrying out the invention]

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

[0037] Recent studies have revealed two main groups of children who develop islet autoantibodies: one group presents with IAA as the initial autoantibody and often includes young children with HLA genotypes including the DR4-DQ8 haplotype; the other group often presents with GADA or tGADA initially and often includes children with the DR3-DQ2 haplotype 2. It was known that the subjects were older children, and therefore the inventors of the present invention 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 between self and non-self. There are three basic groups of HLA complexes: MHC (major histocompatibility complex) class I, MHC class II, and MHC class III. MHC class II genes include the HLA-D gene.

[0039] The TEDDY (The Environmental Determinants of Diabetes in the Young) sub-study was conducted with the aim of identifying the genetic and environmental factors that explain the induction of the initial pancreatic islet autoantibodies.

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

[0041] Participants were required to visit the hospital every three months. At each visit, blood was analyzed for GADA, IAA, IA-2A, ZnT8A, DNA, mRNA, infectious pathogens, HbA1c, PBMCs, red blood cells, and stored 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 three months thereafter.

[0042] In addition to the analyses mentioned above, interviews were conducted regarding the mother's diet during pregnancy (Food Frequency Questionnaire (FFQ) for selected foods), smoking; negative life events; parental anxiety, depression; infection records; medication treatment; vaccinations; family history; DNA from first-degree relatives (FDR); and physical activity assessments. There were also re-enrollments of lost subjects.

[0043] The objective was to study fetal factors that may influence the risk of HLA-dependent autoantibody development. Non-diabetic mothers of single infants (n=6,947) completed a questionnaire between 3 and 4.5 months of gestation. Lower birth weight was defined as the lowest 25% of birth weights among TEDDY infants.

[0044] Maternal factors such as smoking, BMI, alcohol consumption during the third trimester of pregnancy (more than two drinking sessions per month), and maternal infections (lower respiratory tract infection, skin infection or rash, genital infection). After adjusting for country, T1DM in FDR, HLA genotype, and sex, none of these maternal factors were associated with the initial islet autoantibodies.

[0045] In FDR children, having only IAA as the initial autoantibody was more common at a young age than having only GADA, but this was not the case at older ages.

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

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

[0048] Among the girls, the risk of having only IAA as the initial islet autoantibody was low, but the risk of having only GADA as the initial islet autoantibody was not low.

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

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

[0051] The occurrence of GADA alone was not associated with sex, 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 were able to conclude that the presence of GADA as the sole initial islet autoantibody is primarily induced in individuals with the HLA-DQ2 haplotype. Maternal factors affecting birth weight may influence the appearance of GADA as the initial autoantibody.

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

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

[0055] Surprisingly, the inventors were able to demonstrate that administration of GAD autoantigens to T1DM patients with an HLA haplotype associated with the initial autoantibody being GADA can be favorably used in T1DM treatment / prevention regimens. Therefore, the antigen used can be determined based on the patient's genotype.

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

[0057] According to the present invention, autoantigens can be administered orally by intralymphatic injection, direct injection into lymph nodes, intradermal injection, subcutaneous injection, intramuscular injection, intraperitoneal injection, intravenous injection, subcutaneous injection, intranasal, transmucosal or sublingual application; or by administration as tablets, pellets, granules, capsules, lozenges, aqueous or oily solutions, suspensions, emulsions, sprays, or as a dry powder form reconstituted in a liquid medium.

[0058] In one embodiment of the present invention, the administration of the autoantigen is performed in the lymph nodes or directly in the lymphatic system in order to enable the commensal APC to present the antigen peptide to the immune system. When the administration of the autoantigen is performed in the lymph nodes or directly in the lymphatic system, the dose is preferably 1 to 15 μg per autoantigen, more preferably 2 to 10 μg per autoantigen, or 2 to 5 μg per autoantigen. Formulations in alum are preferred.

[0059] In certain embodiments, at least one autoantigen is administered intraguinally, intralymphatically, or intralymphatically. In some embodiments, the volume of intraguin injection of the antigen is 0.05–0.2 ml, more preferably 0.05–0.15 ml.

[0060] In a particular embodiment, when at least one antigen is administered by intra-lymph node or intra-lymphatic injection, the preferred dose is 1 to 15 μg, more preferably 2 to 10, most preferably 2 to 5 μg per injection and per autoantigen used, and such administration is at least 2, more preferably at least 3, most preferably at least 4 Each time, the procedure is carried out with at least 14 days between each other, and more preferably at least 30 days apart.

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

[0062] The method may further include pretreatment of an individual to modulate serum vitamin D levels, such pretreatment may include administration of vitamin D and / or vitamin D analogs and / or exposure to UVB irradiation for 7 to 90 days prior to administration to the subject of a composition preferably comprising at least one beta cell autoantigen, as described in EP3151853.

[0063] Examples The following embodiments are intended to further illustrate the present invention. These embodiments should not be considered to limit the scope of the present invention as defined by the accompanying claims.

[0064] Example 1: TrialNet Phase II Wherrett DK et al. (Lancet, July 23, 2011; Vol. 378 (No. 9788): pp. 319-327) reported that in a 3-arm randomized study of subjects aged 3–45 years diagnosed with T1D within 100 days (A: 3 sc × 20 μg GAD-alum (n=48); B: 2 × 20 μg GAD-alum and 1 alum (n=49); and C: 3 × alum (n=48)), the 2-hour AUC of C peptide adjusted for age, sex, and baseline C peptide levels at 1 year was 0.412 nmol / L (0.349–0.478) in the A GAD-alum group, 0.382 nmol / L (0.322–0.446) in the B GAD-alum + alum group, and C The C peptide level in the aram group was 0.413 nmol / L (0.351–0.477), corresponding to a 44%, 42%, and 41% decrease in the mean C peptide at 1 year for GAD-aram x3, GAD-aram x2, and aram x3, respectively, compared to the baseline mean. The authors note that the baseline and 1-year C peptide levels reflect findings in the control groups of three other TrialNet studies in subjects treated within 3 months of diagnosis, and that this indicates aram alone is ineffective against the decline in insulin secretion at 12 months.

[0065] Therefore, the adjusted declines over 12 months are 3.7%, 3.5%, and 3.42% per month. Unadjusted values ​​for up to 24 months are shown in the table below. Here, groups A, B, and C showed declines of 58.3%, 62.3%, and 55.1% over 2 years, or 2.42%, 2.6%, and 2.3% per month. Aram is slightly better.

[0066] [Table 1]

[0067] However, assuming that GAD as an immunomodulatory antigen is efficient in the HLA group that typically first shows GAD antibodies, and that the insulin family of antigens is efficient in the haplotypes that often first show insulin antibodies, when we reconsidered the data from this study, we were surprised to find that GAD-alum was almost twice as effective as alum alone in the DR3-DQ2 haplotype group that typically first shows GAD antibodies (2.35% vs. 4.45% change / month). In addition, the efficiency of GAD-alum in the group including DR4-DQ8, which typically first shows IAA (the DR3 / DR4-DQ2 / DQ8 group may first show either GADA or IAA), was only 40% beneficial. It was particularly interesting that adjuvant alum (placebo) alone was more effective than the active agent in the DR4-DQ8 haplotype group, which is reported to often include subjects that first show IAA.

[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 without insulin-requiring diabetes showed that prophylactic treatment with GAD-Alum did not affect progression to the onset of clinical T1D.

[0070] The study was conducted in children aged 4–17.9 years (median 5.2 years) with GADA and at least one additional islet autoantibody. Enrollment was completed in 2012, and follow-up was also performed. The intervention period was 5 years. Eligible children from the DiPiS (Diabetes Prediction in Skane, Sweden) 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 * The positive result for 06:02 was included in the exclusion criteria.

[0071] Pancreatic islet cell autoantibodies predict the 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, which randomized 50 children 1:1 to either GAD-Alam (investigational drug) or Alam alone (placebo), was based on the assumption that 50% of untreated children with two or more autoantibodies would develop clinical T1D within a 5-year period. Surprisingly, however, while half of the children had impaired glucose metabolism at baseline and were at very high risk of progression to clinical disease, only 18 out of 50 (36%) developed clinical T1D during the 5-year follow-up period, not the predicted 50%. In light of the reported overall non-significant results, we investigated which subgroups might be responsible for the lower-than-predicted incidence of the shown overt T1D cases, if any, to assess.

[0072] Of the 18 out of 50 children who progressed to T1D during the 5-year follow-up period (170–1830 days after the first injection of the investigational drug), 12 were girls and had a higher progression rate than boys (p=0.012). Progression to T1D was not affected by being a first-degree relative (p=0.925). On the other hand, children with impaired glucose metabolism, defined as plasma glucose levels of 7.8 mmol / L or higher and / or FPIR less than 30 at 120 minutes of OGTT, 11.1 mmol / L or higher at 30, 60, and / or 90 minutes of OGTT, and / or FPIR less than 30 at 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 all groups (p=0.573) or within the stratified groups 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 impaired glucose metabolism groups (p=0.359 and p=0.376, respectively) or by sex (p=0.079 for boys and p=0.400 for girls, respectively).

[0074] Recent studies have identified two main groups of children who develop islet autoantibodies: one group presents with IAA as the initial autoantibody and often includes younger children with HLA genotypes including the DR4-DQ8 haplotype, and the other group often presents with GADA or tGADA initially and often includes somewhat older children with the DR3-DQ2 haplotype 2. Therefore, the inventors of this invention tested the efficacy of GAD-allam versus placebo in these HLA groups. In this study, six different HLA genotypes were presented, including only individuals at high risk showing clinical T1D. Of these, three groups, HLA DQ2 / 2;DQ2 / X; and DQ X / X, contained too few subjects (n=2, 2, 1) to be considered in any analysis. The remaining three HLA groups included DQ2 / 8 (n=25) (10 subjects received GAD-alum and 15 received placebo); DQ8 / X (n=11) (6 subjects received GAD-alum and 5 received placebo); and DQ8 / 8 (n=9) (5 individuals received GAD-alum and 4 received placebo).

[0075] Surprisingly, among the 25 subjects in the DQ2 / 8 group, 2 out of 10 subjects in the GAD-Aram group showed a positive result, compared to 8 out of 15 individuals (53%) who received a placebo. (20%) showed T1D within the 5-year period (Table 3), demonstrating that GAD-Arum is effective in delaying T1D in high-risk individuals with the DQ2 / 8 haplogroup. Similar findings were not observed in the DQ8 / X or DQ8 / 8 groups, and in these groups, placebo was found to be superior to the GAD-Arum treatment group.

[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 early-onset T1D patients in which 4 μg of GAD formulated in alum was directly injected into the inguinal lymph nodes three times, with a 30-day interval between each injection. Consistent with the subject of this invention, it was found that treatment of patients with the DR3-DQ2 haplotype resulted in better HbA1c data and stimulated C-peptide area under the curve data than patients without the DR3-DQ2 haplotype.

[0078] [Table 4]

[0079] [Table 5]

Claims

1. A pharmaceutical composition for use in immunotherapy for the treatment of autoimmune diabetes in an individual having the DR4-DQ8 haplotype but not the DR3-DQ2 haplotype, The aforementioned pharmaceutical composition contains an insulin autoantigen. The immunotherapy comprises administering the pharmaceutical composition to an individual having the DR4-DQ8 haplotype but not the DR3-DQ2 haplotype.

2. The aforementioned immunotherapy, To determine the HLA haplotype of the aforementioned individual, To determine the specificity of the initial autoantibodies associated with autoimmune diabetes in the aforementioned individual, The pharmaceutical composition for use according to claim 1, comprising subjecting the individual to a treatment regimen based on the haplotype and the specificity of the initial developmental autoantibody.

3. The pharmaceutical composition for use according to claim 1, wherein the autoimmune diabetes is selected from the group consisting of type 1 diabetes mellitus, 1,5 diabetes mellitus, LADA, LADY, SPIDDM, and PIDM.

4. A pharmaceutical composition for use according to any one of claims 1 to 3, wherein the individual has the DR4-DQ8 haplotype but does not have the DR3-DQ2 haplotype.

5. The pharmaceutical composition for use according to claim 4, wherein the individual first exhibits insulin autoantibodies.

6. A pharmaceutical composition for use according to any one of claims 1 to 3, wherein the individual has the HLA DR8 / 4-DQ4 / 8 haplotype.

7. The pharmaceutical composition for use according to claim 6, wherein the individual first exhibits insulin autoantibodies.

8. The individual has the HLA-DR4 / 4-DQ8 / 8 haplotype, and is a pharmaceutical composition for use according to any one of claims 1 to 3.

9. A pharmaceutical composition for use according to any one of claims 1 to 8, wherein the administration of the insulin autoantigen is by oral, sublingual, intramuscular, intradermal, or lymphatic means.

10. A pharmaceutical composition for use according to any one of claims 1 to 8, wherein the insulin autoantigen is formulated together with alam or in physiological saline.

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