Combination of immunomodulatory agent and TREG activator for the treatment of an autoimmune and autoinflammatory disease

Abstract

The present invention relates to immunologically effective combinations, comprising at least one immunomodulatory agent and a CD4-targeting activator of regulatory T cells (Treg activator), wherein the Treg activator is HIV-1 glycoprotein 120 (gp120) or a biologically active fragment thereof as an immunoregulatory agent for use in the treatment of an autoimmune disease. The immunomodulatory agent used in the invention is preferably a disease-modifying drug (DMD) that suppresses immune responses in a subject without specifically targeting immune tolerance mechanisms. Furthermore, the invention relates to pharmaceutical compositions, comprising an immunologically effective combination and the use of such pharmaceutical compositions in the treatment of an autoimmune disease.

Description

[0001] COMBINATION OF IMMUNOMODULATORY AGENT AND TREG ACTIVATOR FOR THE TREATMENT OF AN AUTOIMMUNE AND AUTOINFLAMMATORY DISEASE

[0002] Technical Field

[0003] The present invention relates to immunologically effective combinations, comprising at least one immunomodulatory agent and an CD4-targeting activator of regulatory T cells (Treg activator), wherein the Treg activator is HIV-1 glycoprotein 120 (gp120) or a biologically active fragment thereof as an immunoregulatory agent for use in the treatment of an autoimmune disease. The immunomodulatory agent used in the invention is preferably a disease-modifying drug (DMD) that suppresses immune responses in a subject without specifically targeting immune tolerance mechanisms. Furthermore, the invention relates to pharmaceutical compositions, comprising an immunologically effective combination and the use of such pharmaceutical compositions in the treatment of an autoimmune disease.

[0004] Background Art

[0005] Autoimmune diseases represent a broad and heterogeneous group of disorders characterized by an aberrant immune response in which the body's defense system mistakenly targets its own tissues. This loss of immune tolerance results in chronic inflammation and progressive tissue damage that can affect virtually any organ system. Common autoimmune diseases include of psoriasis, plaque psoriasis and psoriatic arthritis, rheumatoid arthritis, juvenile idiopathic arthritis, Sjogren’s syndrome, diabetes type-1, Crohn’s disease and ulcerative colitis, multiple sclerosis, systemic lupus erythematosus (SLE), non-infectious uveitis, systemic sclerosis, neurosarcoidosis, and others. Although the specific pathology varies from joint destruction in rheumatoid arthritis to demyelination in multiple sclerosis, the underlying mechanism generally involves complex interactions between innate and adaptive immune responses.

[0006] Central to these conditions is an immune dysregulation and the breakdown of self-tolerance, where autoreactive lymphocytes become activated. This leads to the production of autoantibodies and / or the release of inflammatory cytokines (e.g., TNF-alpha, IL-6, IL-17) that perpetuate inflammation and drive tissue injury. Some autoimmune diseases target specific organs such as the pancreas in diabetes type 1 or the myelin sheath in multiple sclerosis, while others, like systemic lupus erythematosus, involve multiple organs simultaneously.Although autoimmune diseases differ in their primary trigger, local environment and pathologies, all diseases lead to similar immunological cascades with similar signaling pathways and autoreactive lymphocytes. These components get activated and regulated to varying degrees depending on its underlying autoimmune trigger, the tissue localization and inflammatory environment.

[0007] The management of autoimmune diseases typically involves a combination of symptomatic relief and long-term immunomodulation with small molecules and biologies, called immunosuppressive drugs, disease-modifying drugs (DMDs), immunomodulating drugs or anti-inflammatory drugs. However, not all patients respond adequately to available treatments, and some may experience relapses or significant side effects.

[0008] US 10,729,742 B2 describes a method of treating an autoimmune inflammatory disease using HIV-1 glycoprotein (gp120) as Treg cell activator. However, the problem of autoimmune-mediated reactivity and inflammation has not been addressed and therefore patients still suffer of autoimmune responses.

[0009] CN 102552904 A describes a recombinant construct comprising a targeting fragment which can be an anti-CD4 antibody or a fragment thereof, or gp120 linked to a functional fragment which can be TGF-beta1, interleukin 2, or PGE2. The construct results in a Treg-promoting drug. The construct does not address immunoregulation directed at Tregs and immunomodulation directed at effector T cells.

[0010] US 2014 / 200332 A1 describes therapeutic agents for the treatment of rheumatoid arthritis using an TNF-alpha inhibitor which can be combined with a great variety of other compounds including anti-CD4 antibodies.

[0011] US 2014 / 093509 A1 describes the Treg activator gp120 for use in the treatment of autoimmune diseases including rheumatoid arthritis, diabetes type 1, Crohn’s disease, ulcerative colitis, multiple sclerosis, psoriasis, Sjogren’s syndrome.

[0012] Baker KF, Isaacs JD. Ann Rheum Dis (2018; 77:175-187) suggests therapies targeting Treg cells by stimulating Treg populations to abrogate autoimmunity. One area that has gained attention is the use of low-dose recombinant IL-2 to stimulate effector T cells and expand Treg populations.Bittner Stefan et al (“Neuroimmunotherapies Targeting T Cells: From Pathophysiology to Therapeutic Applications”, NEUROTHERAPEUTICS, SPRINGER INTERNATIONAL PUBLISHING, CHAM, vol. 13, no. 1, 12 November 2015, pages 4-19, XP036098799) and König Martin et al (“Tregalizumab - A Monoclonal Antibody to Target Regulatory T Cells”, FRONTIERS IN IMMUNOLOGY, vol. 7, 25 January 2016, XP055887494) also describe the use of Treg agonists for use in the treatment of a variety of autoimmune diseases.

[0013] Clinical data that are available so far show that blocking just one signaling pathway or inflammatory mediator is not enough to effectively control and stop inflammation in autoimmune diseases in all patients. And even combinations of anti-inflammatory drugs, immune modulatory drugs and disease-modifying drugs targeting different signaling pathways show no significant improvement to a monotherapy.

[0014] New strategies to attenuate autoimmune-mediated reactivity and inflammation are urgently needed to decrease and switch off the inflammatory response and to restore immune tolerance without comprehensively suppressing general immunity.

[0015] Object of Invention

[0016] Against this background, it is the object of the present invention to provide novel compositions and methods for the treatment of autoimmune diseases that are able to suppress immune responses in a subject without specifically targeting immune tolerance mechanisms, and to promote and restore immune tolerance by activating Tregs and thereby suppressing reactive T effector cells.

[0017] This object is solved by an immunologically effective combination, comprising at least one immunomodulatory agent and an CD4-targeting activator of regulatory T cells (Treg activator) as an immunoregulatory agent.

[0018] Disclosure of Invention

[0019] The present invention is based on the surprising finding that a combination of an immunomodulatory agent and the Treg activator (gp120) leads to attenuated inflammation, while a Treg activating activity downregulates autoimmune T cell response. As shown herein, these underlying mechanisms apply to any immunomodulatory agent that suppresses immune responses in a subject without specifically targeting immune tolerance. Based on these principles, the inventive immunologically effective combination provides a noveltherapeutic approach resulting in a synergistic effect, and is thus suitable in the treatment of a variety of autoimmune diseases, either by administering a therapeutically effective amount or pharmaceutically effective amount of at least one immunomodulatory agent prior to or concurrently with at least one Treg activator to a subject in need thereof. The administering may be repeated as necessary or desired to result in a desired level of attenuated inflammation and autoimmune T cell response.

[0020] An immunomodulatory agent as used herein is defined as a substance or drug that alters immune system activity by inhibiting immune responses depending on agent type. Known inhibitory immunomodulatory agents suppress or dampen excessive immune responses and are often used in autoimmune diseases, transplant rejection, or allergies to prevent tissue damage. The present invention focuses on immunomodulatory agents belonging to the subgroup of disease-modifying drugs (DMDs), often also referred to as disease-modifying treatment (DMT). A DMD or DMT is a therapeutic agent that targets the underlying pathophysiology or biological drivers of a disease state but produces only a reversible and non-permanent change in the clinical course or natural history of the autoimmune disease to be treated by the invention. Unlike symptomatic treatments, a DMD is characterized by its ability to slow, delay, or reverse disease progression, such as by reducing the rate of tissue damage or restoring lost biological function.

[0021] A DMD is therefore a therapeutic agent that addresses the underlying pathophysiology or biological drivers of a disease state to achieve a short term reduction of the inflammatory environment and the disease activity, a slowing of disease progression, or a change in the natural history of the autoimmune disease, as distinguished from a symptomatic treatment that primarily provides transient relief of symptoms.

[0022] In one aspect, the invention relates to a new combination of two immunologically effective agents that have not yet been combined. The combination according to the invention comprises an immunomodulatory agent (DMD) and an immunoregulatory agent (Treg activator). While the immunomodulatory agent DMD is given to a subject as part of a treatment of an autoimmune disease, it suppresses pathologic immune activity and thereby slows, modifies or halts the autoimmune disease. However, this effect is largely reversible: if the application of the drug is stopped and, if inflammation returns, damage progression resumes from that point forward. This means that the medication only causes a short-term improvement of the condition. However, the immunoregulatory agent (Treg activator) of the inventive combination has the potential for long lasting therapeutic effects. Treg-targeted strategies are the main path toward genuinely durable, mechanism-level long-term tolerance(as opposed to suppression) after a finite number of treatments. Preclinical work with antigen-specific TCR- or CAR-Tregs demonstrates complete, long-lasting reversal or prevention of autoimmunity in murine models and early human trials (e.g., CD19-CAR-Tregs, polyclonal Tregs) show drug-free remissions lasting months to a couple of years in small cohorts. This demonstrates that the combination according to the present invention will have a superior efficacy over all drug combinations of immunomodulatory agents and monotherapies thereof.

[0023] Preferred inhibitory immunomodulatory drugs used in the context of this invention are clinically validated inhibitory DMDs that are approved by health care authorities. An approved DMD is a drug that has successfully met the rigorous safety and efficacy standards of a national or regional regulatory body for a specific "disease-modifying" indication.

[0024] The invention in particular covers me-too drugs, biosimilars and generic drugs exhibiting inhibitory DMD activity.

[0025] As used herein, “me-too drugs” are new branded drugs in the same class with the same mechanism of action as an existing drug (e.g., multiple TNF-inhibitors with similar targets). They are not copies but alternative molecules in the same therapeutic class. These drugs may offer modest differences (PK, dosing, safety, route), but clinical outcomes are often very similar to first-in-class drugs.

[0026] As used herein, “biosimilars” are highly similar versions of a reference biologic that match the reference biologic closely in regard of mechanism of action, PK, dosing, safety and clinical outcome.

[0027] As used herein, “generic drugs” are exact (or essentially exact) copies of a small-molecule originator drug whose patent protection has expired. It is the same active substance with same bioequivalence, dose, route, and clinical effect as the reference product.

[0028] As used herein, a “subject in need thereof” refers to any subject or individual who could benefit from the administration of an immunologically effective combination or method of treatment described herein. In certain embodiments, a subject in need thereof is a subject predisposed for the development of an autoimmune disease; a subject having one or more disorders related to an autoimmune disease but not exhibiting any clinical symptoms; and / or a subject exhibiting symptoms of an autoimmune disease. In one aspect “the subject in need thereof” refers to a vertebrate, such as a mammal. Mammals include, but are not limited to,humans, other primates, rodents (i.e., mice, rats, and hamsters), farm animals, sport animals and pets. In one embodiment, the subject is a mammal such as a human. In certain embodiments, the combinations and methods find use in experimental animals, in veterinary application, and / or in the development of animal models for disease.

[0029] A “therapeutically effective amount” or “pharmaceutically effective amount” means the amount of an immunologically effective combination that, when administered to a subject for treating an autoimmune, is sufficient to affect such treatment. Thus a “therapeutically effective amount” is an amount indicated for treatment while not exceeding an amount which may cause significant adverse effects. The “therapeutically effective amount” will vary depending on the specific immunologically effective combination, and will also be determined by physical and physiological factors such the age, body weight, and / or clinical history of the subject to be treated. Methods for evaluating the effectiveness of therapeutic treatments are known to those of skill in the art.

[0030] “An immunologically effective combination” means a single composition containing at least one immunomodulatory agent (DMD) and at least one Treg activator, or two distinct compositions, wherein the first composition contains at least one immunomodulatory agent, and the second composition contains at least one Treg activator. The compositions are configured for administering to a subject in need thereof a therapeutically effective amount or a pharmaceutically effective amount of the at least one immunomodulatory agent prior to or concurrently with at least one Treg activator. In some embodiments, the immunologically effective combination can be a combination preparation or a combination product of an immunomodulatory agent and gp120 as immunoregulatory agent.

[0031] The immunomodulatory agents as used in invention are characterized in that they target signalling pathways in T cells and Tregs only. Consequently, autoimmune diseases can be treated which are either T cell mediated or where T cells are involved in pathogenesis.

[0032] All immunomodulatory agents of the present invention have the ability to reduce the activity of pro-inflammatory cytokines, to decrease the activation and proliferation of autoreactive immune cells, and to limit the release of mediators that drive inflammation and tissue damage. It is preferred though that the immunomodulatory agents of the invention qualify as DMD, in particular as an DMD that is approved in the treatment of an autoimmune disorder (see Table 7). The combination of such DMD with activated Tregs as immunoregulatory agent results in a synergistic effect in that the combination is more effective than a monotherapy with single components. In particular, as shown herein, the inventivecombination is superior to any monotherapy in the treatment of autoimmune disease.

[0033] The immunomodulatory agents of the present invention contribute to a reduced inflammatory environment, a reduced immune-mediated tissue injury and the modification of the progression of immune-driven diseases. They do not focus on enhancing or restoring regulatory immune tolerance-promoting mechanisms. This is in contrast to immunoregulatory agents that specifically boost regulatory pathways controlled by Tregs and allow to restore immune tolerance.

[0034] The inventive combination enables to rebalance a dysregulated network of immune and inflammatory signals in autoimmune diseases, thereby resolving autoimmune responses and re-establishing immune-inflammatory homeostasis and immune tolerance.

[0035] By using a combination therapy, a broader mechanistic coverage is achieved which benefits treatment. The combination targets biological pathways and mechanisms of disease processes that a single agent does not fully manage. The combined, synergistic effect of the combination of an immunomodulator and a Treg activator is greater than the sum of their individual effects. This synergy will improve treatment outcomes, particularly in complex autoimmune diseases where multiple pathways are involved. A monotherapy may only target one specific component of a disease pathway. However, many autoimmune diseases involve multiple pathways or redundant systems that can bypass a single blockade. The therapeutic application of the combination according to the present invention can cover a wider range of these processes because distinct drugs are used with different mechanisms and modes of action.

[0036] In a first preferred embodiment, the immunomodulatory agent modulates, suppresses or modifies immune responses in a subject without specifically targeting immune tolerance mechanisms.

[0037] The invention covers immunomodulatory agents, in particular DMDs, that uses pharmaceutical substances or active pharmaceutical ingredients falling under the International Nonproprietary Names (INN). INN facilitate the identification of pharmaceutical substances or active pharmaceutical ingredients. Each INN is a unique name that is globally recognized and is public property. A nonproprietary name is also known as a generic name. Examples of INN used in the present invention include, but are not limited to Tocilizumab, Sarilumab, (IL6R inhibitors), Ixekizumab, Secukinumab, Bimekizumab, Brodalumab (IL17 inhibitors), Adalimumab, Etanercept, Infliximab, Certolizumab pegol, Golimumab,Balinatunfib (TNF-alpha inhibitors), Nerandomilast, Apremilast, Roflumilast, Zatolmilast, Orismilast, PF-07038124 (PDE4 inhibitors).

[0038] In preferred embodiments, the immunomodulatory agent is selected from the group consisting of IL-6R inhibitor, IL-17 inhibitor, TNF-alpha inhibitor, PDE4 inhibitor, Interferonbeta, fumarate, methotrexate.

[0039] In some embodiments, the IL-6R inhibitor is an anti-IL6R antibody.

[0040] In some embodiments, the IL-17 inhibitor is an anti-IL17R antibody.

[0041] In some embodiments, the TNF-alpha inhibitor is an anti-TNF-alpha antibody.

[0042] In some embodiments, the Interferon is Interferon-beta.

[0043] In further preferred embodiments, the IL-6R inhibitor is Tocilizumab, Sarilumab.

[0044] In further preferred embodiments, the IL-17 inhibitor is Secukinumab, Ixekizumab, Bimekizumab, Brodalumab.

[0045] In further preferred embodiments, the TNF-alpha inhibitor Adalimumab, Etanercept, Infliximab, Certolizumab pegol, Balinatunfib, or Golimumab.

[0046] In further preferred embodiments, the PDE4 inhibitor is Nerandomilast, Apremilast, Roflumilast, Zatolmilast, Orismilast, PF-07038124.

[0047] In further preferred embodiments, the Interferon-beta is Interferon beta-1 a, peginterferon beta-1 a, Interferon beta-1 b.

[0048] In further preferred embodiments, the fumarate dimethyl fumarate (DMF), diroximel fumarate, monomethyl fumarate, fumaric acid ester mixtures.

[0049] In preferred embodiments, the folate antagonist is methotrexate.

[0050] A Treg activator of the present invention is an immunoregulatory agent that promotes and restores immune tolerance by activating Tregs and thereby suppressing reactive T effector cells. The Treg activator of the invention is gp120 or a biologically active fragment thereof. Abiologically active fragment of gp120 has the ability to bind to its respective CD4 binding site and to promote Treg activation. The invention also comprises polypeptides or proteins bearing the CD4 binding sites of gp120. The invention furthermore comprises variants, mutants and modified versions of gp120.

[0051] The immunologically effective combination of the invention is also suitable to be used in a method of treatment of an autoimmune disease. The invention therefore relates to methods of treating an autoimmune disease comprising the administration of an immunologically effective combination, comprising at least one immunomodulatory agent and a gp120 as Treg activator to a subject in need thereof, wherein said immunomodulatory agent is a disease-modifying drug (DMD) that suppresses immune responses in a subject without specifically targeting immune tolerance mechanisms. Preferably, the immunomodulatory agent and the Treg activator in the immunologically effective combination are provided in a single dose form or in two distinct dose forms. In a preferred embodiment, the at least one immunomodulatory agent is provided in a first dosage form and the Treg activator is provided as a second dosage form, wherein a dosage regimen provides for the first dosage form to be administered to a subject simultaneously with or prior to the second dosage form. In preferred embodiments, the autoimmune disease to be treated is psoriasis or multiple sclerosis.

[0052] The present invention also comprises the administration of more than one immunomodulatory agent as described herein. Preferably, the autoimmune disease is any one of psoriasis, plaque psoriasis, psoriatic arthritis, rheumatoid arthritis, juvenile idiopathic arthritis, Sjogren’s syndrome, diabetes type-1, Crohn’s disease and ulcerative colitis, multiple sclerosis, systemic lupus erythematosus (SLE), non-infectious uveitis, systemic sclerosis, neurosarcoidosis.

[0053] In preferred embodiments, for the treatment of

[0054] a. psoriasis and plaque psoriasis, the immunomodulatory agent is TNF-alpha inhibitor, IL-6R inhibitor, IL-17 inhibitor, PDE4 inhibitor, Interferon-beta, fumarate or folate antagonist;

[0055] b. rheumatoid arthritis and juvenile idiopathic arthritis, the immunomodulatory agent is TNF-alpha inhibitor, IL-6R inhibitor, IL-17 inhibitor, PDE4 inhibitor, or methotrexate;

[0056] c. Sjogren’s syndrome, the immunomodulatory agent is PDE4 inhibitor, or methotrexate;

[0057] d. diabetes type-1, the immunomodulatory agent is PDE4 inhibitor;e. Crohn’s disease and ulcerative colitis, the immunomodulatory agent is TNF- alpha inhibitor, IL-6R inhibitor, PDE4 inhibitor, or methotrexate; f. multiple sclerosis, the immunomodulatory agent is TNF-alpha inhibitor, IL-6R inhibitor, IL-17 inhibitor, PDE4 inhibitor, Interferon-beta, fumarate, or methotrexate;

[0058] g. psoriatic arthritis, the immunomodulator agent is TNF-alpha inhibitor, IL-17 inhibitor, PDE4 inhibitor, fumarate or folate antagonist;

[0059] h. systemic lupus erythematosus (SLE), the immunomodulatory agent is PDE4 inhibitor, or methotrexate;

[0060] i. non-infectious uveitis, the immunomodulatory agent is TNF-alpha inhibitor, PDE4 inhibitor, or methotrexate;

[0061] j. systemic sclerosis, the immunomodulatory agent is methotrexate; k. neurosarcoidosis, the immunomodulatory agent is TNF-alpha inhibitor, or methotrexate.

[0062] Preferred immunomodulatory DMD agents are summarized in Table 1 for the indicated medical indications in combination with the Treg activator gp120:

[0063] Table 1:

[0064] Psoriasis and Plaque psoriasis

[0065] TNF-alpha Inhibitors Adalimumab, Etanercept, Infliximab, Certolizumab pegol, Balinatunfib, Golimumab

[0066] IL-6R Inhibitors Tocilizumab, Sarilumab

[0067] IL-17 Inhibitors Secukinumab, Ixekizumab, Bimekizumab, Brodalumab

[0068] PDE4 Inhibitors Nerandomilast, Apremilast, Roflumilast, Zatolmilast, Orismilast, PF-07038124 Interferon-beta Interferon beta-1 a, peginterferon beta-1 a, Interferon beta-1 b Fumarates dimethyl fumarate, diroximel fumarate, monomethyl fumarate, fumaric acid ester mixtures

[0069] Folate antagonist Methotrexate

[0070] Rheumatoid Arthritis and Juvenile idiopathic arthritis

[0071] TNF-alpha Inhibitors Adalimumab, Etanercept, Infliximab, Certolizumab pegol, Balinatunfib, Golimumab

[0072] IL-6R Inhibitors Tocilizumab, Sarilumab

[0073] IL-17 Inhibitors Secukinumab, Ixekizumab, Bimekizumab, Brodalumab

[0074] PDE4 Inhibitors Nerandomilast, Apremilast, Roflumilast, Zatolmilast, Orismilast, PF-07038124 Folate antagonist Methotrexate

[0075]

[0076] Folate antagonist Methotrexate

[0077] PDE4 Inhibitors Nerandomilast, Apremilast, Roflumilast, Zatolmilast, Orismilast, PF-07038124Diabetes Type-1

[0078] PDE4 Inhibitors Nerandomilast, Apremilast, Roflumilast, Zatolmilast, Orismilast, PF-07038124

[0079] Crohn’s Disease and Ulcerative Colitis

[0080] TNF-alpha Inhibitors Adalimumab, Etanercept, Infliximab, Certolizumab pegol, Balinatunfib, Golimumab

[0081] IL-6R Inhibitors Tocilizumab, Sarilumab

[0082] Folate antagonist Methotrexate

[0083] PDE4 Inhibitors Nerandomilast, Apremilast, Roflumilast, Zatolmilast, Orismilast, PF-07038124

[0084] Multiple Sclerosis

[0085] TNF-alpha Inhibitors Adalimumab, Etanercept, Infliximab, Certolizumab pegol, Balinatunfib, Golimumab

[0086] IL-6R Inhibitors Tocilizumab, Sarilumab

[0087] IL-17 Inhibitors Secukinumab, Ixekizumab, Bimekizumab, Brodalumab

[0088] PDE4 Inhibitors Nerandomilast, Apremilast, Roflumilast, Zatolmilast, Orismilast, PF-07038124 Interferon-beta Interferon beta-1 a, peginterferon beta-1 a, Interferon beta-1 b Fumarates dimethyl fumarate, diroximel fumarate, monomethyl fumarate, fumaric acid ester mixtures

[0089] Folate antagonist Methotrexate

[0090] Psoriatic Arthritis

[0091] TNF-alpha Inhibitors Adalimumab, Etanercept, Infliximab, Certolizumab pegol, Balinatunfib, Golimumab

[0092] IL-17 Inhibitors Secukinumab, Ixekizumab, Bimekizumab, Brodalumab,

[0093] PDE4 Inhibitors Nerandomilast, Apremilast, Roflumilast, Zatolmilast, Orismilast, PF-07038124 Fumarates dimethyl fumarate, diroximel fumarate, monomethyl fumarate, fumaric acid ester mixtures

[0094] Folate antagonist Methotrexate

[0095] Systemic Lupus Erythematosus

[0096] PDE4 Inhibitors Nerandomilast, Apremilast, Roflumilast, Zatolmilast, Orismilast, PF-07038124 Folate antagonist Methotrexate

[0097] Uveitis, non-infectious

[0098] TNF-alpha Inhibitors Adalimumab, Etanercept, Infliximab, Certolizumab pegol, Balinatunfib, Golimumab

[0099] Folate antagonist Methotrexate

[0100] PDE4 Inhibitors Nerandomilast, Apremilast, Roflumilast, Zatolmilast, Orismilast, PF-07038124

[0101] Systemic Sclerosis

[0102] Folate antagonist Methotrexate

[0103] NeurosarcoidosisTNF-alpha Inhibitors Adalimumab, Etanercept, Infliximab, Certolizumab pegol, Balinatunfib,

[0104] Golimumab

[0105] Folate antagonist Methotrexate

[0106] Table 1 summarizes possible selections of immunomodulatory agents together with a Treg activator (gp120). The invention also comprises the selection of more than one immunomodulatory agent for a combination therapy with a Treg activator for the treatment of the indicated autoimmune diseases.

[0107] For example, for the treatment of psoriasis and plaque psoriasis, the use of any one of TNF-alpha Inhibitors such as Adalimumab (mAb), Etanercept (Fusion protein TNFR-lg), Infliximab (mAb), Certolizumab pegol (mAb-PEG conjugate), Balinatunfib (small molecule), Golimumab (mAb); IL 17 Inhibitors such as Secukinumab (mAb IL17A), Ixekizumab (mAb IL17A), Bimekizumab (mAb IL17A / F), Brodalumab (mAb IL17 RA); PDE4 Inhibitors such as Nerandomilast, Apremilast, Roflumilast, Zatolmilast, Orismilast, PF-07038124; Interferonbeta such as Interferon beta-1 a, peginterferon beta-1 a, Interferon beta-1 b; Fumarates such as dimethyl fumarate, diroximel fumarate, monomethyl fumarate, fumaric acid ester mixtures; Folate antagonists such as methotrexate in combination with the Treg activator gp120, a biologically active fragment or modified version thereof is preferred.

[0108] As a further example, for the treatment of multiple sclerosis, the use of any one of IL 17 Inhibitors such as Secukinumab (mAb IL17A), Ixekizumab (mAb IL17A), Bimekizumab (mAb IL17A / F), Brodalumab (mAb IL17 RA); Fumarates such as dimethyl fumarate, diroximel fumarate, monomethyl fumarate, fumaric acid ester mixtures; IL-6R Inhibitors such as Tocilizumab (mAb, IL6R), Sarilumab (mAb, IL6R); TNF-alpha Inhibitors such as Adalimumab (mAb), Etanercept (fusion protein TNFR-lg), Infliximab (mAb), Certolizumab pegol, (mAb-PEG conjugate) Balinatunfib (small molecule), Golimumab; PDE4 Inhibitors such as Nerandomilast, Apremilast, Roflumilast, Zatolmilast, Orismilast, PF-07038124; Interferonbeta such as Interferon beta-1 a, peginterferon beta-1 a, Interferon beta-1 b in combination with a Treg activator gp120, a biologically active fragment or modified version thereof is preferred.

[0109] As a further example, for the treatment of rheumatoid arthritis or juvenile idiopathic arthritis, the use of any one of TNF-alpha Inhibitors such as Adalimumab, Etanercept, Infliximab, Certolizumab pegol, Balinatunfib, Golimumab; IL-6R Inhibitors such as Tocilizumab, Sarilumab; Folate antagonists such as methotrexate; PDE4 Inhibitors such as Nerandomilast, Apremilast, Roflumilast, Zatolmilast, Orismilast, PF-07038124 in combination with a Treg activator such as gp120, a biologically active fragment or modified versionthereof is preferred.

[0110] As a further example, for the treatment of systemic sclerosis, the use of methotrexate in combination with a Treg activator such as gp120, a biologically active fragment or modified version thereof is preferred.

[0111] Interestingly, despite the distinct molecular interactions (mechanism of action), the immunomodulatory agents have a common mode of action i.e., ameliorating the inflammatory environment, attenuate cellular activation and / or proliferation of reactive immune cells and reduction of pro-inflammatory cytokines or mechanisms. Since these inflammatory processes are characteristic for autoimmune diseases, these agents are suitable for use in various autoimmune indications. This transferability and generalization of agents having a common mode of action is also evident when comparing the standard therapies for autoimmune diseases. Many agents such as TNF-alpha inhibitors are used in the context of different autoimmune diseases, including, but limited to psoriasis, rheumatoid arthritis, Crohn’s disease and ulcerative colitis, and multiple sclerosis.

[0112] The inflammatory environment plays a major role in both the development of autoimmune diseases and the failure of immunological regulation. Inflammation can convert normally harmless self-recognition into a pathogenic immune response and can also weaken the mechanisms that normally maintain immune tolerance. Thus, inflammation is not only a consequence of autoimmunity but also a key driver of immune dysregulation.

[0113] This transferability of agents is also shown by the data presented herein. The panel of agents applied in this patent application have different mechanisms of action, but a common mode of action and subsequently show synergistic efficacy on T cells from healthy donors and autoimmune patients. Interestingly, the data show that some agents only become effective in additional diseases through the combination with Treg activating agents.

[0114] The present invention also relates to pharmaceutical compositions, comprising an immunologically effective combination as defined herein and a pharmaceutically acceptable carrier or diluent.

[0115] In one aspect, the pharmaceutically composition comprises an immunologically effective combination as defined herein and a pharmaceutically acceptable carrier or diluent for the use in the treatment of an autoimmune disease.In a preferred embodiment, the pharmaceutical composition comprises an immunologically effective combination comprising at least one immunomodulatory agent and gp120 as Treg activator, wherein said immunomodulatory agent is a disease-modifying drug (DMD) that suppresses immune responses in a subject without specifically targeting immune tolerance mechanisms and wherein said disease-modifying drug (DMD) is selected from the group consisting of IL-6R inhibitors, IL-17 inhibitors, TNF-alpha inhibitors, PDE4 inhibitors, Interferon, fumarates, folate antagonists.

[0116] In a preferred embodiment, the immunomodulatory agent and the Treg activator in the immunologically effective combination are provided in a single dose form or in two distinct dose forms. The one embodiment, the single dose form contains both the immunomodulatory agent and the Treg activator. In an alternative embodiment, one dose form contains the immunomodulatory agent and another dose form contains the Treg activator.

[0117] The pharmaceutical composition may be formulated with any known pharmaceutically acceptable carrier or diluent as well as any other known adjuvants and excipients in accordance with conventional techniques. The pharmaceutically acceptable carriers, diluents, adjuvants and excipients should be suitable for the chosen inductor of the present invention and the chosen mode of administration. A pharmaceutical composition of the present invention may also include diluents, fillers, salts, buffers, detergents (e. g., a nonionic detergent), stabilizers (e. g., sugars or protein-free amino acids), preservatives, tissue fixatives, solubilizers, and / or other materials suitable for inclusion in a pharmaceutical composition.

[0118] The pharmaceutical compositions of the present invention can be formulated by methods known to those skilled in the art. For example, such pharmaceutical compositions can be used parenterally, as injections which are sterile solutions or suspensions including the compositions along with water or another pharmaceutically acceptable liquid. For example, such compositions may be formulated as unit doses that meet the requirements for the preparation of pharmaceuticals by appropriately combining the compositions with pharmaceutically acceptable carriers, diluents, adjuvants or excipients, specifically with sterile water, physiological saline, a vegetable oil, emulsifier, suspension, surfactant, stabilizer, flavoring agent, excipient, vehicle, preservative, binder or such. In such preparations, the amount of active ingredient is adjusted.

[0119] The invention also covers methods of treating an autoimmune disease comprising the administration of an immunologically effective combination, comprising at least oneimmunomodulatory agent and gp120 as Treg activator to a subject in need thereof, wherein said immunomodulatory agent is a disease-modifying drug (DMD) that suppresses immune responses in a subject without specifically targeting immune tolerance mechanisms.

[0120] The two immunologically active components of the combination of the present invention, i.e., the immunomodulatory agent and the Treg activator can be combined in a single composition for use in the treatment of an autoimmune disease. In alternative embodiments, the immunomodulatory agent and the Treg activator gp120 are provided separately in two distinct compositions.

[0121] In a first aspect, the composition containing the immunomodulatory agent and the composition containing the Treg activator can be combined prior to administration to a subject in need thereof. In a second aspect, the composition comprising the immunomodulatory agent and the composition comprising the Treg activator are administered as a single dose or repeated dose to a subject in need thereof. In a third aspect, the composition comprising the immunomodulatory agent and the composition comprising the Treg activator are administered to a subject in need thereof within a desired time interval. For example, the composition comprising the immunomodulatory agent is given to a subject in need thereof at a first time point, while the composition comprising the Treg activator is given to a subject in need thereof at a second time point within a given time interval. It is important to suppress the inflammation / inflammatory environment sufficiently by the pre-treatment with the immunomodulatory agent before administration of the Treg activator as immunoregulatory agent. A highly inflammatory environment interferes with Treg function and reduces Treg suppressive activity. Only the immunomodulator efficacy makes the Treg activator efficacy possible resulting in a combined synergistic impact. Preferably, the time interval for administering a single or repeated dose of the first composition comprising the immunomodulatory agent and administering a single or repeated dose of the second composition comprising the Treg activator is a simultaneous administration, 24 hours, 7 days, preferably at least 14 days, more preferably at least 30 days. In more preferred embodiments, the time interval for administering a single or repeated dose of the first composition comprising the immunomodulatory agent and administering a single or repeated dose of the second composition comprising the Treg activator is at least 4 weeks, preferably between 4 weeks and 6 weeks. The administration of the first and / or second composition can be repeated several times. In addition, the number of administrations, the composition and concentration of the compositions comprising the immunomodulatory agent and / or Treg activator can vary. For example, the individual doses given to a subject may vary and depend, inter alia, from gender, age, constitution and state of illness.In some embodiments, in the pharmaceutical composition of any one of embodiments disclosed herein, the immunomodulatory agent is in the same dosage form as the Treg activator such that the immunomodulatory agent is administered concurrently with the Treg activator. In a preferred embodiment, the dosage form is a single fluid. In some embodiments, the dosage form including the immunomodulatory agent and the Treg activator is prepared by combining a composition including the immunomodulatory agent and a composition including the Treg activator. In some embodiments, in the pharmaceutical composition of any one of embodiments disclosed herein the immunomodulatory agent is in a separate dosage form from the Treg activator such that the immunomodulatory agent can be administered before or after the Treg activator. A delayed administration of the Treg activator relative to the immunomodulatory agent is preferred.

[0122] The invention also relates to the use of an immunologically effective combination comprising at least one immunomodulatory agent and an CD4-targeting activator of regulatory T cells (Treg activator) for the manufacturing of a medicament that promotes and restores immune tolerance in a human or animal subject. The manufacturing process can involve the preparation of a first dosage form, in which the immunomodulatory agent is provided, and the preparation of a second dosage form, in which the Treg activator is provided, while both dosage forms are prepared to be administered to a subject in need thereof.

[0123] Brief Descriptions of Drawings

[0124] Figure 1: Synergistic effects of combinations of different modulators and gp120 on proliferation of T cells from healthy controls.

[0125] T cells from healthy donors (HC) were co-cultured with allogeneic dendritic cells (mixed lymphocyte reaction) in the absence or presence of gp120. Additionally, different modulators were added to these cultures. A) summarizes all combinations of modulators and gp120 that exhibited synergistic effects. From left to right: anti-human TNF-alpha (anti-TNF-alpha, 50 ng / ml), PDE4 inhibitor (PDE4i, 2 pM), Dimethyl fumarate (DMF, 2 pM), methotrexate (MTX, 10nM). B) summarizes all combinations of modulators and gp120 that did not exhibit synergistic effects. From left to right: recombinant human IFN-b (IFN-beta 1 IU / ml), antihuman IL-6R (anti-IL-6R, 30 ng / ml), anti-human IL-17 (anti-IL-17, 50 ng / ml). T cell proliferation was measured either on day 4 of culture by3H-Tdr incorporation using a liquid β-scintillation counter or on day 6 by analysis of CFSE dilution using flow cytometry. Bars represent mean proliferation (%) ± SEM.Figure 2: Synergistic effects of combinations of different modulators and gp120 on proliferation of T cells from patients with multiple sclerosis.

[0126] T cells from multiple sclerosis patients (MS) were co-cultured with allogeneic dendritic cells (mixed lymphocyte reaction) in the absence or presence of gp120. Additionally, different modulators were added to these cultures. All tested combinations of modulators and gp120 exhibited synergistic effects. Upper row from left to right: anti-human TNF-alpha (anti-TNF-alpha, 50 ng / ml), recombinant human IFN-b (IFN-beta 1 IU / ml), PDE4 inhibitor (PDE4i, 2 µM); lower row from left to right: Dimethyl fumarate (DMF, 2 µM), anti-human IL-6R (anti-IL-6R, 30 ng / ml), anti-human IL-17 (anti-IL-17, 50 ng / ml). T cell proliferation was measured on day 4 of culture by ³H-Tdr incorporation using a liquid β-scintillation counter. Bars show mean proliferation (in %) ± SEM.

[0127] Figure 3: Synergistic effects of combinations of different modulators and gp120 on proliferation of T cells from patients with psoriasis.

[0128] T cells from psoriasis patients (PSO) were co-cultured with allogeneic dendritic cells (mixed lymphocyte reaction) in the absence or presence of gp120. Additionally, different modulators were added to these cultures. A) summarizes all combinations of modulators and gp120 that exhibited synergistic effects. Upper row from left to right: anti-human TNF-alpha (anti-TNF-alpha, 50 ng / ml), recombinant human IFN-β (IFN-beta 1 IU / ml), PDE4 inhibitor (PDE4i, 2 µM); lower row from left to right: Dimethyl fumarate (DMF, 2 µM), anti-human IL-17 (anti-IL-17, 50 ng / ml). B) shows the combination of anti-human IL-6R (anti-IL-6R, 30 ng / ml) and gp120, which did not exhibit synergistic effects. T cell proliferation was measured on day 4 of culture by ³H-Tdr incorporation using a liquid β-scintillation counter. Bars show mean proliferation (in %) ± SEM.

[0129] Description of Embodiments

[0130] The present invention is further illustrated in the following examples. By no means shall the present invention be restricted to these specific examples. Also, the combination of features or even embodiments are encompassed by the spirit of the present invention.

[0131] Figure 1 shows the synergistic effects of gp120 with various immunomodulatory agents onproliferation of T cells from healthy controls.

[0132] T cells from healthy donors (HC) cocultured with allogeneic dendritic cells (mixed lymphocyte reaction) in the absence or presence of 1 pg / ml gp120 are shown. Different modulators were added to these cultures. A) summarizes all combinations of modulators and gp120 that exhibited synergistic effects. From left to right: anti-human TNF-alpha (anti-TNF-alpha, 50 ng / ml), PDE4 inhibitor (PDE4i, 2 pM), Dimethyl fumarate (DMF, 2 pM), methotrexate (MTX, 10 nM). B) summarizes all combinations of modulators and gp120 that did not exhibit synergistic effects. From left to right: recombinant human IFN-beta (IFN-beta 1 IU / ml), antihuman IL-6R (anti-IL-6R, 30 ng / ml), anti-human IL-17 (anti-IL-17, 50 ng / ml).

[0133] T cell proliferation was measured using two different methods. On day 4 of culture, 37 kBq [3H] Thymidine (3H-Tdr) was added to each well and cells were incubated for an additional 16 h. T cell proliferation was then quantified by measuring3H-Tdr incorporation using a liquid beta-scintillation counter. In some experiments, T cell proliferation was assessed on day 6 by analyzing CFSE dilution using flow cytometry. Bars show mean proliferation (in %) ± SEM.

[0134] Column 1 (black) is a positive control and equals to the optimal proliferation of T cells from healthy donors, stimulated with allogenic dendritic cells (DC). The effect of the immunomodulatory agent DMD and / or the Treg activator gp120 is shown as reduced proliferation in % of optimal proliferation. No modulating effect means that there is no reduced proliferation of T cells.

[0135] Column 2 (gray) shows the T cell modulating effect of the immunomodulatory agent DMD as evident from the reduced proliferation of T cells.

[0136] Column 3 (black-and-white striped) shows the T cell modulating effect of the Treg activator gp120 as evident from the reduced proliferation of T cells.

[0137] Column 4 (gray-and-white striped) shows the synergistic effect of the immunomodulatory agent DMD and the Treg activator gp120 on T cell activity, which only occurs in the presence of both components. A synergistic effect can also be postulated if no effect on T cell proliferation was measured in the presence of only one component (i.e., DMD or gp120). This can be explained in that both components use different surface markers and signaling pathways on the T cells (e.g., TNF receptor and CD4), which independently trigger a signaling cascade. While a single component may be too weak to measurably modulate T cells, the addition of both effects still leads to a stronger modulation than would bemeasurable with the 2nd component alone.

[0138] Figure 1 A on the left shows that the optimal proliferation of T cells is reduced by approximately 50% by blocking TNF signal transduction (anti-TNF-alpha, gray bar). The Treg activator gp120 alone reduces T cell proliferation to nearly the same extent. The synergistic effect of anti-TNF-alpha and gp120 leads to a significantly greater suppression of T cells of up to 80%. The data show that anti-TNF-alpha and gp120 synergistically inhibit the activation of T cells. Figure 1 A in the middle shows the individual suppressive effects of PDE4 inhibitors and gp120, as well as the combined suppressive effect of PDE4 inhibitor plus gp120. The results clearly demonstrate that gp120 also inhibits the activation of T cells synergistically with PDE4 inhibitors. T cell proliferation is suppressed by up to 80%, a value that cannot be achieved by one factor alone.

[0139] The next diagram in Figure 1 A shows that, in contrast to gp 120, DMF has only a weak inhibitory effect on the activation of T cells (approx. 15% for DMF). However, it is observed that DMF in combination with gp120 suppresses significantly more than DMF or gp120 alone. Here, too, a synergistic effect of DMF and gp120 is observed.

[0140] Figure 1 A on the right shows the influence of methotrexate (MTX) and gp120 on the proliferation of activated T cells. MTX reduces T cell proliferation by approximately 35%, whereas gp120 exhibits a slightly stronger inhibitory effect of approximately 55%. However, both factors together show a synergistic effect and suppress T cell proliferation more strongly than either factor alone.

[0141] Figure 1 B displays all combinations of modulators and gp120 that did not exhibit synergistic effects. Figure 1 B on the left shows that gp120 and IFN-beta alone suppress T cell proliferation to nearly the same extent (approximately 50%). The combination of both factors inhibits the proliferation of T cells more strongly than either factor alone. However, the enhanced suppression with the combination of gp120 plus IFN-beta represents only an additive effect (see also Table 2 and 3).

[0142] Figure 1 B in the middle shows the influence of anti-l L-6R and gp120 on the proliferation of activated T cells. In contrast to gp120, anti-IL-6R alone only slightly suppresses T cell proliferation. The combination of both factors does not result in an enhanced effect, as T cell proliferation is suppressed to nearly the same extent as with gp120 alone.

[0143] Figure 1 B on the right shows the effect of anti-IL-17 and gp120 on T cell proliferation, either individually or in combination. gp120 suppresses T cell proliferation by approximately 55%, whereas anti-IL-17 alone slightly increases T cell proliferation. The combination of anti-IL-17and gp120 does not further enhance suppression and does not exhibit a synergistic interaction.

[0144] In summary, the data in Figure 1 show that gp120 can inhibit the activation of T cells synergistically with a variety of biologies that modulate T cell activation in different cellular signaling pathways.

[0145] Most drug-discovery platforms use PBMC from multiple healthy donors to profile immunosuppressive effects on T-cell activation and proliferation, because they are standardized, easier to obtain, than patients PBMC and cover broad HLA diversity. For using MLR / proliferation as a surrogate of in vivo disease modification, healthy-donor PBMC are sufficient for primary pharmacology, but patient PBMC become important to analyze disease-specific sensitivity or resistance. Autoimmune patients often have altered T-cell activation thresholds and defective regulation; T cells from MS or psoriasis patients, for example, can show reduced sensitivity or altered responses to cell-mediated suppression compared with healthy controls.

[0146] Figure 2 shows the synergistic effects of gp120 with various immunomodulatory agents in the suppression of T cells from the blood of MS patients. The synergistic effect (gp120 plus biologies) is evident for all six biologies to varying degrees.

[0147] T cells from multiple sclerosis patients (MS) were cocultured with allogeneic dendritic cells (mixed lymphocyte reaction) in the absence or presence of 1 pg / ml gp120. Different modulators were added to these cultures. Upper row from left to right: anti-human TNF-alpha (anti-TNF-alpha, 50 ng / ml), recombinant human IFN-beta (IFN-beta 1 lU / ml), PDE4 inhibitor (PDE4i, 2 µM); lower row from left to right: Dimethyl fumarate (DMF, 2 µM), anti-human IL-6R (anti-IL-6R, 30 ng / ml), anti-human IL-17 (anti-IL-17, 50 ng / ml).

[0148] On day 4 of culture, 37 kBq [3H] Thymidine (3H-Tdr) was added to each well and cells were cultured for an additional 16 h. T cell proliferation was measured by3H-Tdr incorporation using a liquid beta-scintillation counter. Bars show mean proliferation (in %) ± SEM.

[0149] gp120 acts synergistically with anti-TNF-alpha, anti-IL-6R, anti-IL-17, DMF, IFN-beta and PDE4 inhibitors in the suppression of T cell activity from the blood of MS patients.

[0150] The marginal effect of the biologies alone and the reduced effect of gp120 alone compared to HC as shown in Figure 1 is due to the dysregulated activity of T cells from MS patients described in the literature. In this case, the synergistic effect of the biologies with gp120appears to be particularly valuable for the therapeutic effect of the combination compared to the individual components. Figure 2 shows again that gp120 acts synergistically with a variety of biologies that block different signaling pathways in T cells and significantly increases the desired outcome (reduced proliferation).

[0151] Figure 3 shows the influence of various immunomodulatory agents and the Treg activator gp120 on the proliferation of T cells isolated from the blood of psoriasis patients.

[0152] T cells from psoriasis patients (PSO) were co-cultured with allogeneic dendritic cells (mixed lymphocyte reaction) in the absence or presence of 1 µg / ml gp120. Additionally, different modulators were added to these cultures. A) summarizes all combinations of modulators plus gp120 that exhibited synergistic effects. Upper row from left to right: anti-human TNF-alpha (anti-TNF-alpha, 50 ng / ml), recombinant human IFN-beta (IFN-beta 1 lU / ml), PDE4 inhibitor (PDE4i, 2 µM); lower row from left to right: Dimethyl fumarate (DMF, 2 µM), anti-human IL-17A (anti-IL-17, 50 ng / ml). B) shows the combination of anti-human IL-6R (anti-IL-6R, 30 ng / ml) and gp120, which did not exhibit synergistic effects.

[0153] On day 4 of culture, 37 kBq [3H] Thymidine (3H-Tdr) was added to each well and cells were cultured for an additional 16 h. T cell proliferation was measured by3H-Tdr incorporation using a liquid p-scintillation counter. Bars show mean proliferation (in %) ± SEM.

[0154] While anti-TNF-alpha, the PDE4 inhibitor and gp120 significantly suppress the proliferation of T cells, this modulating effect is only slight for IFN-beta and not detectable for anti-IL-17 and DMF. However, all biologies, including anti-IL-17 and DMF, show a synergistic suppressive effect in combination with gp120.

[0155] The data again show that the combination with gp120 has a synergistic effect in suppressing T cell activity, even if the biologic alone (here anti-IL-17 and DMF) is not potent enough to efficiently inhibit the proliferation of T cells.

[0156] In summary, the data show that the combination of gp120 and immunomodulatory agents synergistically increases the effect of various single immunomodulatory agents used to treat excessive immune responses involving T cells. This synergistic effect is not toxic and has no measurable influence on the viability of the stimulated T cells. In its ability to suppress the activation of T cells, gp120 shows synergistic effects with immunomodulatory agents such as anti-TNF-alpha, anti-IL-6R, DMF, IFN-beta, methotrexate and PDE4 inhibitors. These biologies intervene in different, independent signaling pathways. One mechanism that theimmunomodulatory agents have in common is that they intervene in signaling pathways that are important for the activation of T cells. The immunomodulatory agents thus exert their effect by suppressing individual signaling pathways for T cell activation. gp120 can synergistically enhance the inhibition of all these signaling pathways and thus inhibit the activation of T cells to a greater extent.

[0157] The data shown in Figures 2 and 3 demonstrate the synergistic effects of immunomodulatory agents in combination with the Treg activator gp120 on proliferation of T cells from patients suffering of multiple sclerosis (Fig. 2) or psoriasis (Fig. 3). The data show that gp120 can be used as an enhancer of the mechanistic effects of many DMDs in different indications. The decisive factor for this synergistic effect is an excessive immune reaction involving T cells. This applies for multiple sclerosis (MS), psoriasis (PSO), and a variety of other autoimmune diseases listed in Table 1. The data also show that a combined application of an immune-modulatory agent and a Treg activator is superior to any monotherapy in the treatment of autoimmune disease.

[0158] The experimental results described above were further analyzed to quantify synergistic interactions between the modulators and gp120. For this purpose, the Bliss independence model was applied (Ma and Motsinger-Reif, 2019). The calculated Bliss scores (often also referred to as “Excess over Bliss”) of modulators in combination with gp120 across the different disease contexts multiple sclerosis and psoriasis, as well as healthy donors are summarized in Table 2:

[0159] Table 2:

[0160] Bliss score

[0161] HC MS PSO

[0162] anti-TNFa 0.06 0.16 0.07

[0163] IFNp -0.04 0.18 0.08

[0164] PDE4i 0.07 0.31 0.10

[0165] DMF 0.07 0.35 0.17

[0166]

[0167] anti-IL-6R 0.01 0.23 -0.13

[0168] MTX 0.07 NP NP

[0169] anti-IL-17 -0.05 0.37 0.14

[0170]

[0171] Table 2 shows the Bliss synergy scores for combinations of different modulators and gp120 across different disease contexts.This Table summarizes Bliss scores calculated for combinations of different modulators with gp120. The analysis includes interaction effects across different donor backgrounds, including patients with multiple sclerosis (MS), psoriasis (PSO), and healthy controls (HC), NP = not performed. Bliss analysis was based on the suppressive effects of modulators and gp120 on T cell proliferation. The expected combined effect was calculated assuming independent activity of both components according to the Bliss independence model, and compared with the experimentally observed suppression. In the Bliss independence model, values close to zero indicate additive effects. Considering the biological variability inherent to assays using primary human cells from different donors, values between -0.05 and 0.05 were considered additive. Additionally, values >0.05 indicate a synergistic trend, whereas values <-0.05 indicate antagonistic interactions.

[0172] According to the Bliss independence model, the expected combined effect (here referred to as Eexp) of two independently acting agents (here modulator or gp120) is calculated from the individual effects of each agent (effect of modulator = EA, effect of gp120 = EB). The expected combined effect is determined based on the suppression values observed for each component alone using the following formula: Eexp= EA+ EB- (EAx EB)

[0173] The experimentally observed effect EABof the combination is then used together with the expected combined effect Eexpto calculate the Bliss score (“Excess over Bliss”, EBNSS = EAB-Eexp). A Bliss score greater than zero indicates a synergistic interaction between the tested components, whereas values close to zero indicate additive effects and negative values indicate antagonistic interactions. Considering the biological variability inherent to assays using primary human cells from different donors, Bliss scores between -0.05 and 0.05 were considered additive. Additionally, values >0.05 indicate a synergistic trend, whereas values <-0.05 indicate antagonistic interactions.

[0174] Example:

[0175] Reference is made to Figure 2,

[0176]

[0177] row on the left, setting: anti-TNF-alpha + gp120 Suppression of modulator anti-TNF: 35%

[0178]

[0179] EA= 0.35

[0180] Suppression of gp120: 15% -> EB= 0.15

[0181] Suppression of anti-TNF + gp120: 61% -> EAB = 0.61

[0182] Eexp= EA+ EB- (EA x EB)

[0183]

[0184] Eexp = 0.35 + 0.15 - (0.35 x 0.15) = 0.45

[0185] EBHSS = EAB - Eexp = 0.61 - 0.45 = 0.16According to the Bliss independence model, the combination of anti-TNF and gp120 shows synergistic interactions in suppressing the proliferation of T cells isolated from the peripheral blood from MS patients.

[0186] Based on the calculated Bliss scores, synergistic interactions were further classified according to their magnitude: > 0.05-0.10: weak synergy; > 0.10-0.20: moderate synergy; > 0.20: strong synergy. Table 3 summarizes this qualitative interpretation of Bliss scores obtained from combinations of different modulators with gp120 across the different disease contexts.

[0187] Table 3:

[0188] Synergism

[0189] HC MS PSO

[0190] anti-TNFa weak moderate weak

[0191] IFNp no moderate weak

[0192] PDE4i weak strong weak

[0193] DMF weak strong moderate

[0194]

[0195] anti-IL-6R no strong no

[0196] MTX weak NP NP

[0197] anti-IL-17 no strong moderate

[0198]

[0199] Table 3 shows the interpretation of Bliss synergy scores for combinations of different modulators and gp120 across different disease contexts.

[0200] This Table summarizes the qualitative interpretation of Bliss synergy scores obtained from combinations of different modulators with gp120. Bliss scores were categorized to facilitate interpretation of the interaction effects observed in the proliferation assays (NP = not performed). A Bliss score >0.05 was considered indicative of a synergistic trend. Synergistic interactions were further classified based on their magnitude:

[0201] > 0.05-0.10: weak synergy

[0202] > 0.10-0.20: moderate synergy

[0203] > 0.20: strong synergy

[0204] As described above, gp120 can be used to enhance the mechanistic effect of various DMDs across different indications. A key prerequisite for this synergistic effect is the presence of anexcessive T cell-mediated immune response, reflecting an inflammatory environment. To further support this hypothesis, an additional series of experiments was conducted in which immune cells from the peripheral blood of healthy donors were pre-incubated with a high dose of the pro-inflammatory cytokine IL-6, a driver of the inflammatory environment of T cells (Jones et al. 2018).

[0205] gp120 enhances the activity of DMDs particularly in an inflammatory, T cell–driven environment.

[0206] PBMC from healthy donors were either cultured overnight untreated (0) or pre-incubated with IL-6. On the following day, T cells were isolated and co-cultured with allogeneic dendritic cells (mixed lymphocyte reaction) in the absence or presence of gp120. In addition, different modulators were added to these cultures: anti-human TNF-alpha (Balinatunfib, 2 pM), antihuman IL-6R (Tocilizumab, 30 ng / ml), or PDE4 inhibitor (Nerandomilast, 2 pM). After 6 days of culture, T cell proliferation was analyzed by flow cytometry based on CFSE dilution. The results are summarized in Table 4.

[0207] For each condition (untreated and IL-6 pre-incubated), Table 4 lists the percentage of suppression induced by the modulator alone, gp120 alone, and the combination of modulator + gp120. Based on these values, Bliss independence scores were calculated to evaluate potential synergistic interactions between gp120 and the respective modulators. A Bliss score >0.05 was considered indicative of a synergistic trend. Synergistic interactions were further classified based on their magnitude:

[0208] > 0.05-0.10: weak synergy

[0209] > 0.10-0.20: moderate synergy

[0210] > 0.20: strong synergy

[0211] Table 4:

[0212] anti-' ’NFa _ antj4 nn E4i „ _ IlBIlBliM IL-3 0 IL-8 0 IL-6 Suppression o' modulator (!t i 5060 46.50 1 35 11.40" ’ 40.10 ’ 41 20 Suppression c* gp *20 |\) 2920 18.40 2920 18.40 29.20 1840 Suppression of modulator - gp“20 ( i 55,20 71 55 3495 5060 7095 6560

[0213] Bliss score 0.002 0.152 0.048 0.229 0,134 0,136

[0214]

[0215] S«nergism no moderate no strong moderate moderate

[0216] Table 4 shows the Bliss independence analysis of selected gp120-modulator combinations in untreated vs. IL-6 pre-incubated PBMC from healthy donors.The Table summarizes the suppression of T cell proliferation (in %) observed with the modulator alone, gp120 alone, the respective combinations (modulator + gp120) in both experimental settings (untreated T cells 0 vs. IL-6 pre-incubated T cells), as well as the calculated Bliss scores.

[0217] gp120 alone reduced the proliferation of untreated T cells by approximately 30%. In IL-6 preincubated T cells, this suppressive effect of gp120 was less pronounced, with gp120 alone reducing proliferation by only about 20%. The modulator anti- 1 L-6R slightly reduced the proliferation of IL-6 pre-incubated T cells by approximately 10%, whereas no relevant effect was observed in untreated T cells. When gp120 was combined with anti-IL-6R, T cell proliferation of untreated T cells was reduced by approximately 35%. In contrast, in IL-6 preincubated T cells the inhibitory effect of the combination increased to approximately 50%, representing a markedly stronger suppression compared to either agent alone.

[0218] Calculation of Bliss independence scores confirmed these findings. While the combination of gp120 and anti-IL-6R did not indicate a synergistic interaction in untreated T cells, a pronounced synergistic effect was observed in IL-6 pre-incubated T cells, supporting the concept that DMDs particularly in inflammatory, T cell-driven inflammatory environments enhance gp120 activity resulting in synergistic effects. This leads to the conclusion that immunomodulator plus immunoregulator combinations are particularly effective under autoinflammatory conditions by taking into account the relevant drivers of the inflammatory environment and therefore will have a very good therapeutic effect in autoimmune diseases.

[0219] A similar trend was observed for the combination of anti-human TNF-alpha and gp120. However, pre-incubation of T cells with IL-6 had no effect on the interaction between PDE4 inhibitors and gp120, as no improvement of the synergistic effect was observed under these conditions.

[0220] Materials and Methods

[0221] Isolation and culture of human immune cells

[0222] PBMC from either multiple sclerosis (MS) patients, psoriasis (PSO) patients, or healthy donors (HC) were isolated from peripheral blood within 16 h after blood collection using density gradient centrifugation. Blood was kept at room temperature before PBMC enrichment. After isolation, human cells were cultured in X-VIVO-15 (Lonza, Belgium).

[0223] Generation of dendritic cellsDendritic cells (DC) were generated from isolated PBMC from the peripheral blood of healthy donors. 10-15x106PBMC (per well) were seeded in a 6-well culture plate in 2 ml RPMI + 1.5% heat-inactivated plasma and incubated for 30 minutes in an incubator at 37 °C and 5% CO2. During this incubation time, monocytes adhered to the plastic surface. The nonadherent cells were washed off several times with 1 ml pre-warmed PBS and the purity of the monocyte culture was visually checked under a light microscope. Afterwards monocytes were cultured in X-VIVO-15 (3 ml / well) supplemented with 1% heat-inactivated plasma + 400 IU / ml rh GM-CSF (Sargramostim / Leukine) + 200 IU / ml rh IL-4 (Immunotools) for 6 days. On days 2 and 4 of the culture, cells were fed by removing 1 ml of medium per well and replacing it with 1 ml of culture medium supplemented with 800 lU / ml rh GM-CSF. DC were stored frozen in aliquots until use.

[0224] Isolation and CFSE labeling of CD3+T cells

[0225] Untouched CD3+T cells were isolated using Pan T cell isolation kit (Miltenyi Biotec) according to manufacturer's instructions. The purity of the isolated CD3+T cells was checked by flow cytometry. For this purpose, cells were stained with the following antibodies: antihuman CD3 FITC (UCHT1), anti-human CD4 PE-Cy7 (RPA-T4), anti-human CD8 APC (RPA-T8), all from BD Pharmingen. Stained cells were measured on LSRII with FACS Diva Software (BD Bioscience) and analyzed using FlowJo software.

[0226] In some experiments, isolated CD3+T cells from healthy donors were stained with the proliferation dye CFSE. Therefore, CD3+T cells were resuspended in pre-warmed PBS to a final concentration of 2x107 / ml and stained with 1 pM CFSE for 20 minutes at 37 °C in the dark. Afterwards, cells were washed twice with X-VIVO-15 / 10% HSA and further stored at 37 °C until use in X-VIVO-15.

[0227] Mixed leukocyte reaction

[0228] A mixed leukocyte reaction served as the basis for the investigations. For this purpose, CD3+T cells from healthy donors, MS patients or PSO patients were co-cultured with allogeneic DC (TC: DC ratio of 20:1) in the absence or presence of gp120 (ActiTrexx GmbH / Polymun Scientific GmbH) (1 pg / ml). In further approaches, different modulators were added to these cultures to investigate possible synergistic effects on T cell proliferation.

[0229] Pre-incubation of human immune cells with IL-6

[0230] For selected experiments (see Table 4), isolated PBMC from healthy donors (HC) were preincubated in X-VIVO-15 medium (Lonza) supplemented with 500 ng / ml rh IL-6 (Miltenyi) for16 hours at 37 °C and 5% CO2. PBMC from the same healthy donors cultured under identical conditions without IL-6 served as corresponding control cells.

[0231] Table 5 summarizes the drugs that were used as immunomodulatory agents (Table 5):

[0232] Table 5:

[0233] Modulator Supplier Concentration Abbreviation Tocilizumab Roche 30 ng / ml anti-IL-6R (RoActemra®),

[0234] human IL6R inhibitor

[0235] Ixekizumab (Taltz®), Eli Lilly 50 ng / ml anti-IL-17 human IL-17A

[0236] inhibitor

[0237] Adalimumab Amgen 50 ng / ml anti-TNF (Amgevita®), human

[0238] TNF-alpha inhibitor

[0239] rh IFN-beta-1a Miltenyi Biotec 1 IU / ml IFNb Nerandomilast, Hycultec 2 pM PDE4i

[0240] PDE4 inhibitor

[0241] Dimethyl fumarate Merck 2 pM DMF Balinatunfib, human MedChem Express 2 pM TNFRIi

[0242] TNF-alpha inhibitor

[0243] Methotrexate Hycultec 10 nM MTX

[0244]

[0245] Measurement of CD3+T cell Proliferation

[0246] T cell proliferation was analyzed using two methods equally suitable for evaluating the experiments:

[0247] a) Incorporation of3H-Tdr:

[0248] On day 4 of culture,3H-Tdr was added to each well (37 kBq / well) and cells were cultured for an additional 16 h in an incubator at 37 °C and 5% CO2. CD3+T cell proliferation was measured by3H-Tdr incorporation using a liquid beta-scintillation counter.

[0249] b) Flow cytometric analysis of CFSE-labeled CD3+T cells:

[0250] Some experiments were performed using CFSE-labeled CD3+T cells. On day 6 of culture, cells were harvested and stained with the viability dye Zombie NIR (Biolegend) and antihuman CD4 PE-Cy7 (RPA-T4) antibody (BD Pharmingen). Stained cells were measured onLSRII with FACS Diva Software (BD Bioscience) and analyzed using FlowJo software. The viability dye Zombie NIR enabled the distinction between live and dead cells, while CD4 staining differentiated CD4+T cells from CD4-T cells (equivalent to CD8+T cells). The CFSE signal was assessed within the viable CD4+and CD4-T cell populations.

[0251] Non-proliferating cells exhibited a strong CFSE signal. With each cell division, the CFSE fluorescence intensity was progressively halved in the daughter cells. Thus, the gradual reduction of the CFSE signal served as an indicator of T cell proliferation.

[0252] Bliss independence analysis

[0253] To quantify synergistic interactions between modulators and gp120, combination effects were analyzed using the Bliss independence model. According to this model, the expected combined effect (here referred to as Eexp) of two independently acting components is calculated from the effects of each component applied individually (effect of modulator = EA, effect of activated Tregs = EB). The expected effect of the combination Eexpwas calculated using the formula:

[0254] Eexp= EA+ EB- (EAx EB),

[0255] where EAand EBrepresent the suppression of T cell proliferation induced by modulator or gp120 alone, respectively.

[0256] The experimentally observed effect (here referred to as EAB) obtained for the combination of both components was compared with the expected effect Eexpcalculated according to the Bliss independence model. A Bliss score (often also referred to as “Excess over Bliss”, EBHSS) was determined as the difference between the observed effect EAB and the expected effect Eexp:

[0257] Bliss Score EBliss= EAB- Eexp

[0258] Positive Bliss scores indicate a synergistic interaction between the tested components, values close to zero indicate additive effects, and negative values indicate antagonistic interactions. Considering the biological variability inherent to assays using primary human cells from different donors, values between -0.05 and 0.05 were considered additive.

[0259] Additionally, values >0.05 indicate a synergistic trend, whereas values <-0.05 indicate antagonistic interactions.

[0260] Example:

[0261] Suppression of modulator anti-TNF: 35% EA = 0.35

[0262] Suppression of gp120: 15% -> EB= 0.15

[0263] Suppression of anti-TNF + gp120: 61% -> EAB = 0.61

[0264] Eexp= EA+ EB- (EAx EB) Eexp= 0.35 + 0.15 - (0.35 x 0.15) = 0.45EBliss = EAB - Eexp= 0.61 - 0.45 = 0.16

[0265] The calculated Bliss scores EBlisswere categorized to facilitate interpretation of the interaction effects observed in the proliferation assays. A Bliss score EBliss>0.05 was considered indicative of a synergistic trend. Synergistic interactions were further classified based on their magnitude:

[0266] > 0.05-0.10: weak synergy

[0267] > 0.10-0.20: moderate synergy

[0268] > 0.20: strong synergy

[0269] Generalization of results

[0270] The autoimmune diseases to be treated are not or only partially autoinflammatory

[0271] The invention addresses the treatment of autoimmune diseases by the inventive combination. All listed diseases in Table 6 below are primarily autoimmune (adaptive immunity dysfunction with autoantibodies or T cell autoreactivity). Some have autoinflammatory components (innate overlap); none are purely autoinflammatory. The synergistic effect by the inventive combination is most likely based on common mechanisms that link these autoimmune diseases together. All diseases exhibit a more or less pronounced inflammatory environment. They use the same drivers of the inflammatory environment and same approved drugs. Furthermore, they are T cell driven and exhibit a good preclinical efficacy of Tregs, in some cases also good clinical efficacy. And lastly, there is a high probability of transfer to selected diseases.

[0272] Table 6:

[0273] Disease Autoimmune Autoinflammatory Notes

[0274] Rheumatoid arthritis Yes No Classic; autoantibodies (RA) (RF / ACPA), T / B cells Juvenile idiopathic Yes No Pediatric autoimmune arthritis (JIA) arthritis

[0275] Psoriatic arthritis (PsA) Yes Partial Adaptive (Th17 / IL-23);

[0276] innate skin component Plaque psoriasis Yes Partial Th17-driven;

[0277] keratinocytes innate trigger

[0278]

[0279] Crohn's disease (CD) Yes Partial Mixed; Th1 / Th17 + innate IL-23 / IL-1 p Ulcerative colitis (UC) Yes Partial Th2 / IL-13 + innate barrier dysfunction

[0280] Non-infectious uveitis Yes Partial T-cell mediated; IFN- (NIU) y / TNF-a

[0281] Systemic lupus Yes No Hallmark autoantibodies erythematosus (SLE) (ANA / anti-dsDNA) Sjogren's syndrome Yes No Anti-SSA / SSB; B-cell driven

[0282] Systemic sclerosis Yes No Autoantibodies (anti- (SSc) Scl70); fibrosis T-cell Neurosarcoidosis Partial Yes Innate granulomatous > adaptive

[0283] Multiple sclerosis (MS) Yes No Th17 / CD20+ B cells;

[0284] demyelination

[0285] Type 1 diabetes (T1 D) Yes No Autoantibodies (anti- GAD); CD8+ T cells

[0286]

[0287] Spectrum: RA / SLE / MS / T1 D pure autoimmune; neurosarcoid leans autoinflammatory;

[0288] CD / PsA "mixed."

[0289] Approved DMD drug classes for autoimmune diseases

[0290] The following Table 7 summarizes the immunomodulatory agents (DMDs) used in the inventive combination and their approved application in the treatment of autoimmune or immune-mediated diseases.

[0291] Table 7:

[0292] Drug / class Examples Approved autoimmune /

[0293] immune-mediated diseases (major) IL-6R Tocilizumab, sarilumab RA, systemic JIA, polyarticular JIA, giant inhibitors cell arteritis, cytokine-release syndromes. IL- 17 Secukinumab, ixekizumab, Psoriatic arthritis, plaque psoriasis, axial inhibitors bimekizumab spondyloarthritis (radiographic and non-radiographic).

[0294]

[0295] TNF-alpha Infliximab, adalimumab, RA, psoriatic arthritis, axial inhibitors etanercept, golimumab, spondyloarthritis, juvenile idiopathic certolizumab pegol arthritis, Crohn’s disease, ulcerative colitis, psoriasis.

[0296] PDE4 Apremilast Psoriatic arthritis, plaque psoriasis. inhibitors

[0297] InterferonIFN-pia, IFN-pib, Relapsing forms of multiple sclerosis. beta peginterferon-pia

[0298] Fumarates Dimethyl fumarate, diroximel Relapsing multiple sclerosis; plaque fumarate; other fumarates for psoriasis (various oral fumarate psoriasis formulations).

[0299] Folate Methotrexate RA, psoriatic arthritis, juvenile idiopathic antagonists arthritis; also used in many other immune-mediated diseases (e.g., vasculitis).

[0300]

[0301] Generalization and transferability of a combination concept across autoimmune diseases

[0302] The Table 8 below summarizes that the autoimmune diseases to be treated by the inventive combination are based on a more or less pronounced inflammatory environment. All claimed autoimmune diseases are more or less T cell driven and show at least preclinical and even clinical efficacy of regulatory T cells. Furthermore, the main the drivers for such an inflammatory environment are mentioned. It is shown that the approved drugs for these diseases are identical suggesting that the inventive combination can be transferred not only to one particular autoimmune disease, but to other autoimmune diseases indicated above.

[0303] All data in Table 8 are verified against sources: drivers from pathogenesis reviews; DMARDs from EULAR / AGA / ASAS 2022-2025 guidelines / approvals; Treg from ClinicalTrials.gov / PMC (phase l / ll as of 2026); T cell-driven from TCR / repertoire studies; severity from cytokine / PASI / DAS correlations.

[0304] Table 8:

[0305] Disease Inflammatory Main Therapy Options T Cell- Treg Environment Driver(s) with Driven? Data DMDs / DMARDs [Verified]

[0306]

[0307] Rheumatoid +++ (synovial TNF-a, MTX, HCQ, Yes is Clinic arthritis (RA) storm) IL-6, IL- SSZ, LEF; TNF- phase l / ll:

[0308] -1 P LUL21 i, |L-6i, ™ Partially effective LSI

[0309] Juvenile ++ IL-6, MTX, SSZ, LEF; Yes HI Precl: idiopathic arthritis (joint / systemic TNF-a, TNF-i, Partially (JIA) sJIA) |L-1 El tocilizumab121effective [sources] Psoriatic arthritis ++ IL-23 / IL- MTX, LEF; TNF- YQS Precl: (PsA) (entheseal / skin- -|7 / \ ricin 11 i, IL-17i, IL-23i Partially joint) 1121 effective

[0310] Plaque psoriasis ++ (dermal +++ IL-23 / IL- MTX, apremilast; Yes1121Precl:

[0311] cytokines) 17A, TNF-i (2nd), IL- Partially TNF-a 17 / 231 HH effective 11511161

[0312] Crohn’s disease +++ (mucosal IL-12 / IL- Anti-integrins, Yes Clinic (CD) fistulizing) 23, TNF- ustekinumab, phase 1:

[0313] Q 1121 TNF-i [AGA] Partially effective

[0314] Ulcerative colitis ++ (mucosal IL-13, IL- Anti-integrins, Partial Precl: (UC) continuous) 17, TNF- ustekinumab, Partially a 1121 TNF-i, [AGA] effective Non-infectious ++ (intraocular) TNF-a, TNF-i Yes Precl: uveitis (NIU) IL-6, IFN- (adalimumab), Partially y 1211 MTX1211effective Systemic lupus ++ (multi-organ Type 1 HCQ, Partial Clinic erythematosus IFN) IFN, belimumab, phase 1: (SLE) TNF-a1221anifrolumab (no Partially TNF-i) [EULAR] effective

[0315] Sjogren’s + (glandular IFN-a / y, HCQ, MTX, Yes1221Precl: syndrome focal) TNF-a ES rituximab Partially [EULAR] effective

[0316] 1261

[0317]

[0318] Systemic + (vascular Type I MTX, MMF, Partial Precl: sclerosis (SSc) fibrosis) IFN, IL-6 tocilizumab Partially [sources] [EULAR] effective Neurosarcoidosis ++ IFN-Y, MTX, TNF-i Partial Precl: No (granulomatous) TNF-Q I2Z1 (infliximab)1221effect Multiple sclerosis ++ (CNS IFN-Y, IL- Ocrelizumab, Yes Precl: (MS) plaques) 171281 fingolimod (no Effective TNF-i) [AAN]

[0319] Type 1 diabetes + (islet- IFN-Y, IL- Teplizumab (no Yes Clinic (T1D) localized) 1P 1281 TNF-i) phase l / ll:

[0320] Partially effective

[0321]

[0322] References (Table 8):

[0323] All entries match primary sources (PMC, guidelines, trials).1132®1™

[0324] 1■ https: / / www.hopkinsarthritis.org / arthritisdnfo / rheumatoid-arthritis / ra-pathophvsiologv-2 / 2. https: / / pmc.ncbi.nlm.nih.gov / articles / PMC6410649 / 3

[0325]

[0326] - https: / / www.ncbi.nlm.nih.gov / books / NBK507863 / 4. https: / / ard.bmj.eom / content / 82 / 1 / 3

[0327] 5- https: / / pubmed.ncbi.nlm.nih.gov / 39920282 /

[0328] 6- https: / / pmc.ncbi.nlm.nih.gov / articles / PMC9009914 /

[0329] 7. https: / / pmc.ncbi.nlm.nih.gov / articles / PMC6i. U7.'2!

[0330] 8- https: / / www.arthritiswa.org.au / iia / disease-modifving-anti-rheumatic-drugs-dmards-for- iia /

[0331] 9- https: / / www.bms-immunologie.de / rheumatische-erkrankungen

[0332] 10. htps: / / pmc.ncbi.nlm.nih.gov / articles / PKk / !! 0 '66 /

[0333] 11. https: / / pmc.ncbi.nlm.nih.gov / articles / PMC6788885 /

[0334] 12. htps: / / pmc.ncbi.nlm.nih.gov / articles / Phk / !!! 03320 /

[0335] 13. https: / / www.springermedizin.at / an-overview-of-psoriatic-arthritis-epidemiologv-clinical- feature / 14914874

[0336] 14. https: / / pmc.ncbi.nlm.nih.gov / articles / PMC10884248 /

[0337] 15. https: / / pmc.ncbi.nlm.nih.gov / articles / PMC12697396 /

[0338] 16. https: / / www.bioinformation.net / 021 / 973206300212803.pdf

[0339] 17. https: / / www.sciencedirect.com / science / article / pii / S0190962216014869

[0340] 18. https: / / pmc.ncbi.nlm.nih.gov / articles / Phk / 2!. 1586 /

[0341] 1

[0342]

[0343] 9. https: / / pmc.ncbi.nlm.nih.gov / articles / PMC5438231 /

[0344] 20. https: / / clinicaltrials.gov / studv / NCT03185000

[0345] 21. https: / / pubmed.ncbi.nlm.nih.gov / 40550324 /

[0346] 22. https: / / www.nature.com / articles / s41392-025-02168-0

[0347] 23. https: / / pmc.ncbi.nlm.nih.gov / articles / Ph

[0348] 24. https: / / pmc.ncbi.nlm.nih.gov / articles / Phk1!! 39237 /

[0349] 25. https: / / pmc.ncbi.nlm.nih.gov / articles / PMC2762015 /

[0350] 26. https: / / pmc.ncbi.nlm.nih.gov / articles / Ph

[0351] 27. https: / / pmc.ncbi.nlm.nih.gov / articles / PMC12664804 /

[0352] 28. https: / / pmc.ncbi.nlm.nih.gov / articles / PMC7588284 /

[0353] 29- htps: / / clinicaltrials.gov / study / NCT02772679The present disclosure provides evidence-based justification for the therapeutic generalization and transferability of the drug combinations described herein across a defined group of autoimmune diseases. As demonstrated by the data provided (see, e.g., Tables 4 and 5), the selected autoimmune diseases share a common pathological profile driven by identical inflammatory cytokines, cellular mediators, and underlying mechanisms of action. Specifically, it is shown that these cytokines and cells interact in an additive or synergistic manner within the inflammatory environment. Consequently, the technical effects observed for a specific combination, such as a particular TNF inhibitor in conjunction with a gp120, are reasonably expected to be representative of the entire class of TNF inhibitors. For example, where a synergistic effect is demonstrated for the combination of Adalimumab and a Treg-targeting agent, this effect is inherently applicable to other TNF inhibitors (including, but not limited to, the six TNF inhibitors currently approved for rheumatoid arthritis), as these agents all address the same TNF-alpha-mediated driver of the disease.

[0354] The justification for this evidence-based transferability is further supported by the data in Table 5, which identifies identical drivers of the inflammatory environment across the selected indications, and Table 4, which demonstrates the consistent efficacy of the same disease-modifying drugs (DMDs) across these pathologies. Furthermore, as the immunoregulatory component specifically targets T-cell-driven mechanisms, a hallmark of all autoimmune diseases categorized herein, the intervention is particularly effective and appropriate for the treatment of this broader group of T-cell-mediated inflammatory conditions.

[0355] In summary, all diseases claimed and listed in Table 1 relating to a certain drug class fulfill the requirements for a limited evidence-based generalization / transferability of the disclosed drug combinations. A skilled person expects class wide effects of the drug classes in the selected autoimmune diseases without undue experimentation and a significant contribution of the Treg-targeted immunoregulatory component.Non-patent literature

[0356] Jones BE, Maerz MD, Buckner JH. IL-6: a cytokine at the crossroads of autoimmunity. Curr Opin Immunol. 2018 Dec;55:9-14. doi: 10.1016 / j.coi.2018.09.002. Epub 2018 Sep 21. PMID: 30248523; PMCID: PMC6286200.

[0357] Ma J, Motsinger-Reif A. Current Methods for Quantifying Drug Synergism. Proteom Bioinform. 2019 Jul;1(2):43-48. Epub 2019 Jul 22. PMID: 32043089; PMCID: PMC7010330.

Claims

CLAIMS:

1. An immunologically effective combination, comprising at least one immunomodulatory agent and an CD4-targeting activator of regulatory T cells (Treg activator) as immunoregulatory agent, wherein the Treg activator is HIV-1 glycoprotein 120 (gp120) or a biologically active fragment thereof, for use in the treatment of an autoimmune disease, wherein said immunomodulatory agent suppresses immune responses in a subject without specifically targeting immune tolerance mechanisms.

2. The immunologically effective combination for the use according to claim 1, wherein said immunomodulatory agent is a disease-modifying drug (DMD) that is selected to target the underlying pathophysiology or biological drivers of a disease state to modify the clinical course or natural history of the autoimmune disease.

3. The immunologically effective combination for the use according to claim 1 or claim 2, wherein said immunomodulatory agent is selected from the group consisting of IL-6R inhibitor, IL-17 inhibitor, TNF-alpha inhibitor, PDE4 inhibitor, Interferon, fumarate, folate antagonist.

4. The immunologically effective combination for the use according to claim 3, wherein saida. IL-6R inhibitor is an anti-IL6R antibody,b. IL-17 inhibitor is an anti- 1 L17RA antibody or an anti- 1 L17A antibody, c. TNF- alpha inhibitor is an anti-TNF- alpha antibody, a TNFR-IgG fusion protein, mAb-PEG conjugate or a small molecule,d. Interferon is Interferon-beta,e. Fumarate is dimethyl fumarate (DMF), monomethyl fumarate, diroximel fumarate or fumaric acid ester mixtures,f. Folate antagonist is methotrexate.

5. The immunologically effective combination for the use according to claim 3, wherein said IL-6R inhibitor is Tocilizumab, Sarilumab;said IL-17 inhibitor is Ixekizumab, Secukinumab, Bimekizumab, or Brodalumab; said TNF-alpha inhibitor is Adalimumab, Etanercept, Infliximab, Certolizumab pegol, Golimumab, Balinatunfib, Golimumab;said PDE4 inhibitor is Nerandomilast, Roflumilast, Apremilast, Zatolmilast, Orismilast, PF-07038124;said Interferon-beta is Interferon beta-1 a, peginterferon beta-1 a, Interferon beta-1 b.

6. The immunologically effective combination for the use according to any one of claims 1 to 5, wherein the at least one immunomodulatory agent is provided in a first dosage form and the Treg activator is provided as a second dosage form, wherein a dosage regimen provides for the first dosage form to be administered to a subject concurrently with or prior to the second dosage form.

7. The immunologically effective combination for the use according to any one of claims 1 to 6, wherein the autoimmune disease is any one of psoriasis, plaque psoriasis and psoriatic arthritis, rheumatoid arthritis, juvenile idiopathic arthritis, Sjogren’s syndrome, diabetes type-1, Crohn’s disease and ulcerative colitis, multiple sclerosis, systemic lupus erythematosus (SLE), non-infectious uveitis, systemic sclerosis, neurosarcoidosis.

8. The immunologically effective combination for the use according to claim 7, wherein for the treatment ofa. psoriasis and plaque psoriasis, the immunomodulatory agent is TNF-alpha inhibitor, IL-6R inhibitor, IL-17 inhibitor, PDE4 inhibitor, Interferon-beta, fumarate or folate antagonist;b. rheumatoid arthritis and juvenile idiopathic arthritis, the immunomodulatory agent is TNF-alpha inhibitor, IL-6R inhibitor, IL-17 inhibitor, PDE4 inhibitor, or methotrexate;c. Sjogren’s syndrome, the immunomodulatory agent is PDE4 inhibitor, or methotrexate;d. diabetes type-1, the immunomodulatory agent is PDE4 inhibitor;e. Crohn’s disease and ulcerative colitis, the immunomodulatory agent is TNF- alpha inhibitor, IL-6R inhibitor, PDE4 inhibitor, or methotrexate;f. multiple sclerosis, the immunomodulatory agent is TNF-alpha inhibitor, IL-6R inhibitor, IL-17 inhibitor, PDE4 inhibitor, Interferon-beta, fumarate, or methotrexate;g. psoriatic arthritis, the immunomodulator agent is TNF-alpha inhibitor, IL-17 inhibitor, PDE4 inhibitor, fumarate or folate antagonist;h. systemic lupus erythematosus (SLE), the immunomodulatory agent is PDE4 inhibitor, or methotrexate;i. non-infectious uveitis, the immunomodulatory agent is TNF-alpha inhibitor, PDE4 inhibitor, or methotrexate;j. systemic sclerosis, the immunomodulatory agent is methotrexate;k. neurosarcoidosis, the immunomodulatory agent is TNF-alpha inhibitor, or methotrexate.

9. A pharmaceutical composition, comprising an immunologically effective combination comprising at least one immunomodulatory agent and an CD4-targeting activator of regulatory T cells (Treg activator), wherein the Treg activator is HIV-1 glycoprotein 120 (gp120) or a biologically active fragment thereof, wherein said immunomodulatory agent is a disease-modifying drug (DMD) that suppresses immune responses in a subject without specifically targeting immune tolerance mechanisms and wherein said disease-modifying drug (DMD) is selected from the group consisting of IL-6R inhibitor, IL-17 inhibitor, TNF-alpha inhibitor, PDE4 inhibitor, Interferon, fumarate, folate antagonist.

10. The pharmaceutical composition according to claim 9, comprising an immunologically effective combination according to any one of claims 1 to 6.

11. The pharmaceutical composition according to claim 9, wherein the immunomodulatory agent and the activated Tregs in the immunologically effective combination are provided in a single dose form or in two distinct dose forms.

12. A pharmaceutical composition, comprising an immunologically effective combination according to any one of claims 1 to 6 and a pharmaceutically acceptable carrier or diluent for the use in the treatment of an autoimmune disease.

13. The pharmaceutical composition for the use according to claim 12, wherein the immunomodulatory agent and the activated Tregs in the immunologically effective combination are provided in a single dose form or in two distinct dose forms.

14. A method of treating an autoimmune disease comprising the administration of an immunologically effective combination, comprising at least one immunomodulatory agent and an CD4-targeting activator of regulatory T cells (Treg activator), wherein the Treg activator is HIV-1 glycoprotein 120 (gp120) or a biologically active fragment thereof to a subject in need thereof, wherein said immunomodulatory agent is a disease-modifying drug (DMD) that suppresses immune responses in a subject without specifically targeting immune tolerance mechanisms.

15. The method according to claim 14, wherein the immunologically effective combination is any one as defined in claims 1 to 6.

16. The method according to claim 14, wherein and the disease is any one as defined in claims 7 and 8.

17. The method of claim 14, wherein the immunomodulatory agent and the Treg activator in the immunologically effective combination are provided in a single dose form or in two distinct dose forms.

18. The method of claim 14, wherein said immunomodulatory agent is selected from the group consisting of IL-6R inhibitor, IL-17 inhibitor, TNF-alpha inhibitor, PDE4 inhibitor, Interferon, fumarate, folate antagonist.

19. The method according to claim 14, wherein said autoimmune disease is psoriasis or multiple sclerosis.

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