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UNIVERSITY OF FLORIDAModerator: Donna Setzer

01-18-12/9:00 am CTConfirmation # 21573824

UNIVERSITY OF FLORIDA

Moderator: Donna SetzerJanuary 18, 2012

9:00 am CT

Operator: We will now begin the Southeastern National TB Center's TNF Blockers and

Tuberculosis, a Case Presentation and Review of Literature Infection. To

provide information and an introduction of the speaker, we now turn to Karen

Farrell, Executive Nursing Director and Director of Education at A.G. Holley

Hospital.

Karen Farrell: Good morning and welcome to our first quarterly grand rounds for 2012. My

name is Karen Farrell, I am the Executive Nursing Director and Director of

Education here at A.G. Holley Hospital as well as the training coordinator for

the Southeastern National TB Center.

Before I turn today's session over to Dave Ashkin to introduce our speakers

and topics for today's grand rounds, there are a few housekeeping items I want

to review with our web audience. As you know, we encourage interaction

between our presenters and the audience.

If you have a question and want to submit it through the system, please use the

Question and Answer Button on your tool bar in Live Meeting. Type your

question and we will make sure to put it in for our speakers to respond to.



These instructions will be posted again before the question-and-answer

session, but you are welcome to post your questions throughout the

presentation.

If you want to ask a question by telephone, the operator will provide

instructions to the audience prior to the question-and-answer session.

Now let me turn the microphone over to David Ashkin.

Dr. David Ashkin:Okay thanks Karen and welcome everybody. Hope everybody's doing well,

Happy New Year. We're really happy to have everybody here for our first

grand rounds of the New Year and I think it's going to be an exciting one. You

know, we're - as always these grand rounds are always exciting for us - I

mean, because it brings together some very, very interesting topics and stuff

that I think is very, very clinically relevant to all of us.

But today especially for me is a very, very special day because I have a really,

really old friend who's going to join us today and that's Ivan Fuss. And Ivan as

we'll talk about in a second goes back a long with me. Me and Ivan went to

medical school together and we were in a carpool together. And Ivan has a lot

of really bad stories he can tell about me and we're hoping that during this

thing he doesn't talk about those stories.

But the bottom line it comes down to is that we also have Sundari with us,

Sundari Mase with CDC and we're all getting together because of a topic that,

you know, I got to see. I don't know about you, but being a big football fan,

being unfortunately a really big TV fan, this is a group of or a topic that's

brought TB into the news.



I mean, it's very interesting to me that while I’m relaxing before a game or

watching during the game, a familiar commercial comes on and I hear the

word TB, ask your doctor about TB. I don't know about you guys, but that's

not something you usually hear, we haven't heard for a long time.

And as you guys know what it's all about is these necrosis factor blockers

which have become a very, very potent and important tool for a lot of diseases

like ulcerative colitis, rheumatoid arthritis, thoracic arthritis. You hear all

these different things and people are now become aware of TB. People being

warned, hey look before you start these, think TB, something - a message that

we really need.

But I got to be honest with you, none of these things really, really were that

important until we had this case. And this case I believe really brings home

what it really means to think TB. And I'd like to present the case first and then

we would like to discuss, have an open discussion about two necrosis factors

including the basic immunology as well as the clinical implications.

So if I may, I'd like to start with a case. So the case is and in view of I want to

start by showing you this. Hey, you know, notice this, that Ivan's a handsome

guy. You know, I like that they put a picture of me next to Ivan so Ivan looks

really good, but notice that we don't put a picture of Sundari anywhere there

because we can't let Sundari make either one of us look bad, you know, so

Sundari's way too good looking for us, so we couldn't put him on the slide.

But all right, would you do me a favor? Donna, could you put up my slides

please? Thank you very much. Sorry about that.

All right, so the case is a - this was a 52-year-old guy, African American male.

He had a history of metastatic gout, non-insulin dependent diabetes, ulcerative



colitis and he had migraine headaches. He was admitted to a hospital in Ft.

Lauderdale on April 28, 2010 and at that time he came in with a chief

complaint of chest pain.

So we did the cardiac workup on him and it was unrevealing but while he was

hospitalized, he was complaining of a lot of abdominal pain. And he gave a

history of ulcerative colitis and was diagnosed in Georgia ten years prior. And

previously he'd been maintained on salicylic acid derivative. He denied any

prior history of any prior steroid use.

He had a colonoscopy performed while he was at the hospital and it showed

that he had severe colitis which was not responding to the therapy that they

were receiving, that he was getting in the hospital with Mesalamine and

Azathioprine. And it was recommended that he started on Infliximab, you

know, a Remicade IV infusion.

So they placed a PPD just like they saw on the TV commercials prior to

starting the Infliximab and the reaction was described by his GI physician as 2

cm nodule without erythema or skin reaction in 72 hours. And the GI

physician really wasn't sure if this was reactive or not.

And notice on the commercials, they really don't go over, right, how to test,

right, well what's a reaction? They just think TB, get tested. So he did. He

went to his doctor and they did a chest x-ray at that time. And the chest x-ray

showed an old granuloma in the left lung. He had a history of non-insulin

dependent diabetes for 20 years, he was born in the U.S., had no real

international travel.

He denied any history of previous TB exposure. He denied staying in jail or

prison, but he lived in a congregate setting for one year while he was



homeless. Then he also spent a great deal of time in prison. He worked a lot of

missionary work in the prison and did a lot of work in the prison. He denied

any history of a previous positive or reactive PPD in the past.

So the GI physician wasn't really sure is this was truly a positive reaction so

he asked an IG consultant. And the IG consultant thought that maybe this

reaction was a hematoma. And he still said it may have been reactive PPD

and they recommend that repeating the PPD and subsequently the test was

reported as "negative." There was just no description of what the reaction was

or how they came to that conclusion, it just said negative.

So at that time, they felt (unintelligible) was felt to be indicated prior to

starting the Infliximab. And I guess my first question to ask if I can is do you

agree with this? Do you think that any, you know, that maybe should we've

done anything else, so yes or no?

So as you guys can see, I thank you for voting guys. This is the fun part here.

But it looks like, you know, I don't want to say nothing, but this looks like the

odds of my Giants beating San Francisco. I mean, I just want to make this

clear that this is the same thing. The vast majority, actually that's what I really

have, will the Giants beat San Francisco this weekend, you know?

And as you see, the vast majority are saying no. It is this about, you know.

No, but as you can see, I think most people on this phone call are saying that

no, maybe they don't feel comfortable that this was not a positive.

And let's go on.

So if you feel that something else should've been done, what would you have

done? Do you think any other additional evaluation was indicated? Do



nothing, maybe get an IGRA, maybe do sputums for AFB, maybe do a CT of

the chest, treat for the LTBI given the risk factors regardless of what the PPD

or IGRA showed.

Or IGRA, sputum and CT, any of the above or two and four. This is kind of

like what the - right now the Republican primaries are looking like right now.

But I think what you'll see here and I think you again for voting guys, makes it

fun. But I think a lot of people are saying that they would work it up more.

A lot of people are saying that they would get an IGRA or an IGRA with

sputum and CT and I guess a lot of you are concerned which I do agree that

we don't have to just worry about is this LBTI, but what's the possibility

before we even start that this may be active disease? And I think the answers

are all relatively good.

I think, you know, further workup probably would be indicated.

So let's go on.

So he was started on Infliximab on May 4, 2010 and he was maintained on

injections every two months. And his colitis got much better. And after

discharge from the hospital, he claims he experienced a fall. It happened right

after, right in the end of May. And he said he had pain in his right shoulder

since then.

And he claims a month after this happened, an interesting thing happened to

him. He had an episode of back pain and he suddenly claims he could not

move his arms or legs. He said it lasted about an hour and it resolved on its

own. And he didn't seek any kind of medical attention. And he - just maybe it

just was weird that he just couldn't move.



And then approximately six months later in January of 2011, the right

shoulder pain was getting worse and worse. And they did an x-ray; there was

nothing they could find. It was unrevealing so they decided to get a second

opinion and he went to an orthopedic surgeon who recommended they do an

MRI of his neck and shoulders for this pain.

And what happened was that on March 18 according to the hospital records,

while he was being moved off the MRI table, he suddenly could not move his

arms and legs. He became suddenly quadriplegic. Interestingly enough at the

time, he had no difficulty breathing was noted, but he could not move. And he

was immediately transferred to a regional tertiary referral center.

I was talking to the patient, he will tell you that - and I can imagine - that MRI

staff were stunned. They didn't know what to do. I mean, he had suddenly out

of nowhere as they were moving him, suddenly couldn't move.

And what happened was he went to the other hospital with his MRI scan and

on the MRI, they found that he had erosion of his posterior C4 and C5

vertebral bodies with an accompanying infiltration of the surrounding soft

tissue consistent with an abscess.

And I’m going to show you the - what you can see here actually on C4 and

C5, this is vertebral body and you can literally see in the posterior section that

they're all inflamed here and there's an erosion. And you actually can see that

this abscess is actually compressing the spinal cord right here. So he has a

spinal cord compression.

So this is just again just the axial view and you can see how there's epidural

enhancement that surrounds the spinal cord. And again, you can see this



enhancement there. So there is a significant amount of disease in his spinal

cord that's definitely impinging on his spinal cord.

This is his chest x-ray; I know it's a little hard to see. But as you can see here

that he has this whole little granuloma in the left upper lung and otherwise

was read as pretty much not - it was not otherwise - not, what do you call it -

there was no other infiltrate. So he underwent an anterior cervical discectomy

of C4, C5 with decompression of the spinal cord and debridement of the

epidural abscess on March 19.

And the pathology was consistent with an acute osteomyelitis and they found

that he had fibrino-purulent exudate and necrotic material. And just real

quickly - I mean, I don't want to get too much into it because for the sake of

time, but the discectomy, all they essentially did was they removed the discs

and the material that was pressing on the nerve root.

And just, you know, essentially what they just do is they go in, in the anterior

part of the neck and then they take out a piece of the bone and they remove

the material to try to decompress any compression on the spine. This is

actually a herniated disc which is most commonly done for. But in this case,

they did it for an infection.

So he was placed on flagellant vancomycin and Ceftriaxone and he was

placed on a steroid taper. And post-operatively, he required mechanical

ventilation. He was having trouble breathing and he was on the mechanical

ventilator as you'll see for about two months. And was complicated by

frequent lung collapses, mucous plugging and he had to have a lot of

bronchoscopies.



He remained quadriplegic and then started having fevers. And again,

remember I wanted to start by telling you despite being on the -- as you

already know, but we'll go on -- despite being on the tumor necrosis factor

blockers, nobody at this point thought of TB. They were treating him purely

as a bacterial infection and he was not getting better.

So they repeated the CAT scan and it showed that he had an increase in the

abscess. And my question I guess is, what would you do now? Would you

continue therapy? Would you go back to training in order to become a

neurosurgeon? A lot of my staff always ask me to just leave and they don't

care if I went back to neurosurgical, but just get out of here. Or re-explore the

abscess and the specimens.

You guys already know surgeons already, you don't even have to go back to

training, you know. I think most of us agree that we would go back and re-

explore this and do further studies. I want to say one thing about this case,

remember this is a - this person's in a prominent tertiary hospital. I mean, so

this is not happening at some community hospital. And I guess what my

message is and going to keep repeating is think TB.

And that's one of the biggest problems we're going to have in these cases with

these two necrosis factor blockers because the majority of the community are

not thinking TB even though with all those fancy ads and all those beautiful

warnings. But they should have another anterior cervical discectomy and

decompression on March 30. And again, only bacterial studies were sent.

He was not responding to therapy, he continued to have fevers and he was

continuing to be quadriplegic and on April 11 he had another procedure.

Again, they went in and they did the C3, C5 laminectomy, but this time they

sent the specimens for AFB and they were PCR positive for TB. He was



placed on four drugs after he was found to be - show no mutations on his

molecular drug susceptibility.

As you can see while he was intubated, now he starts to develop bilateral

infiltrate and you guys already know the answer. And you can see when - that

compared to when he had the granuloma when he first came in, now he has

bilateral infiltrate. And as you know, they went and they bronchoscoped him

being that he had AFB and the abscess and sure enough he had TB again.

So he had been sitting on a ventilator again with probably positive smears. He

denied any symptoms of fever, chills, night sweats, weight loss, prior to

hospitalization he was HIV negative. He began to recover some motion of his

legs and was able to be extubated on April 14 and he was transferred to us on

May 19. Real quickly on admission, he was noted that all he could really do

was wiggle the fingers of his left hand; that was about it.

He was able to breathe on his own, but that was about the only movement he

had. As you can see, the infiltrates had gotten better. He still had that

granuloma right here. Okay, we started him on a number of drugs including

four drugs, but you also added Cycloserine and Moxifloxacin. And if we have

time later, we can talk about it. We continued to use his medications for

ulcerative colitis.

I guess we can quickly ask this and then I want to go on, but we can talk about

this later. But two groups, TB regimen said yes, I wouldn't have started

Cycloserine. I wouldn't have started Moxifloxacin. I wouldn't have started

either one of them and then I think about what's important which I see you

guys already answering. I never agree with what David does. So thank you for

your support as always.



All right guys, I don't like that last one is really coming up. Wait, you don't

have to change. That's the cool thing about this voting, I'm actually pressuring

them into changing their votes here, you know.

Just real quick and we can talk, I mean the guy had involved and he had

osteomyelitis and Moxifloxacin is a very, very good - it has good penetration

of the bone. He also had involved of the spinal cord and again Cycloserine

added, but I do want to emphasize and I think you guys are right that there

was no evidence whatsoever that I can use to back up my decisions here.

It's just something we do here, but I don't think anybody would argue with you

to starting the fourth drug. And look, that's why I started talking. I never agree

with Dave so I only went up to all the way up. I mean, I don't like that. But the

bottom line is that he became smear culture negative since May 20th. We

found that because of all the decadron they put him on he had what looked

like probably iatrogenically induced Addison's disease.

We had to treat that. His serum level is below and again for the sake of this

case, it's not that important, but that is something common that we see in

diabetics. And I think in one of our future grand rounds, I think the whole role

of TB and diabetics and drug levels is important. But this is another one of

those cases I think all of us are seeing where diabetics don't respond the same

way.

And we increased his dosage, he did much better. And the bottom line is

instantly enough on admission, his QuantiFERON was positive. So his IGRA

tests were positive. With intensive PT, he's now actually walking. It's a

miracle. I mean, he is now walking with a walker, with a wheelchair and

interestingly enough, he will not allow us to do anymore MRI's. He's afraid of

MRI's; he won't let us near the MRI's.



But things seem to be getting better, but what's happening is he does have now

on the CT, it looks like he's starting to lose some height in his vertebrae from

the previous infection. Also he has severe narrowing of his disc space now as

you can see. So what's happening now is that he's being evaluated for spinal

reconstruction surgery down at the University of Miami to try to help that.

But interestingly enough and something that we can talk about later again is

since he's been on the TB meds and minimal amounts of medications for his

ulcerative colitis, we did not continue the tumor necrosis factor blocker. He's

had no flare whatsoever of his ulcerative colitis.

So we could maybe talk, but what I'd like to do is, you know, I think this case

really to us at A.G. Holley and to all of us, really brought home a very

important point that tumor necrosis factor blockers are really, really important

tools that we have for some horrible inflammatory diseases. But they're very

potent and that's what makes them good. But they're very potent and that's

what also makes them dangerous.

And I thought what we wanted to do today if it's okay with you is to kind of

talk about inflammation in TB. And what we'd like to do is go back to

something that I think most of you there that are listening are starting to

shiver. We're going to talk about basic immunology and for most of our

clinicians, you know, we shiver when we hear this. But the reality comes

down to is TB is mainly an inflammatory disease.

And so is some of the other diseases, especially a lot of our diseases that we

call autoimmune, we're not so quite sure what causes them. Inflammation

plays a very important role and I think we need to know about it. And I'm so

honored today to tell you that we have I think a distinguished friend who's



going to be joining us, Ivan Fuss. Yes that's right, me and Ivan actually went

to medical school together.

We went to a carpool. Ivan used to have to listen to me for three to three and a

half hours a day. Ivan went to a mental home for a little while, but he's doing

much - but no. But Ivan is a staff clinician in mucosal immunity at section at

the NIH.

His research interests include analysis of cytokine pathways, abnormalities

and their relationship to the occurrence of intestinal inflammation in both

experimental models and the human counterpart, inflammatory bowel disease.

These studies have allowed new approaches to the understanding and

treatment of such as these states as Crohn's disease and ulcerative colitis.

This has led to an innovative therapeutic avenue such as the use of anti-

interleukin 12 and the treatment of Crohn's. He's an active member of the

Crohn's and Colitis Foundation. He served on the CCFA Grant Review

Committee. He's a pediatric gastroenterologist - it says on there Affairs

Committee. He also is a research initiative council member and he's a review

for multiple journals.

He has won many, many awards and he was elected to the American Society

of Clinical Investigation 2008. And most importantly, if you get all this, this is

really, really very impressive. But most importantly, Ivan is a great clinician.

Ivan is a great teacher and most importantly Ivan's a great friend.

So what I'd like to do now, Ivan are you there?

Dr. Ivan Fuss: Yes I am.



Dr. David Ashkin:All right, so remember we had an agreement, no bad stories about me. Is that

correct?

Dr. Ivan Fuss: That's correct.

Dr. David Ashkin:Ivan is joining us from Bethesda, Maryland. For all you guys, you're not going

to be able to see him on video because I don't allow anybody who's better

looking to be on video than me.

But I'd like to turn it over to you Ivan. Thank you so much for joining us

today, I really appreciate it.

Dr. Ivan Fuss: My pleasure. I thank you for the opportunity to talk about inflammatory bowel

disease, but I also wanted to say unfortunately I couldn't vote on my end and I

have known Dave since college. And I would never agree with what Dave

would've picked. So I agree with the rest of you on Choice #5.

Starting that off, today we're going to talk about inflammatory bowel disease

and for those of you who are not familiar with IBD, essentially it's made up of

two disease entities that of ulcerative colitis and Crohn's disease.

And if you could turn to the next slide from the title slide.

As you'll see here, IBD in the United States, the prevalence is basically about

100 cases per 100,000. So although fairly prevalent, what we have started to

see is that the incidents have started to increase in both of these disease

entities, especially over the last 20 years. What we have noticed is that the

onset is actually although listed here as unimodal, it's actually bimodal. What

we see is predominately the peak occurs at about 10 to 19 years of age.



However, there is a second peak at about 60-70 years of age. It can occur in

young children, even that of less than 1 year of age. The main thing from the

slide, about a million cases is estimated to be seen here in the United States

and it's about a 50% split between ulcerative colitis and Crohn's disease.

Next slide.

On this next slide, you're basically going to be seeing what is the prevalence

of IBD around the world? And in the red, basically what you see here is the

more prevalent the disease is, the redder the area. What you should take away

from this slide is what we're seeing is that in the more industrialized nations or

as we've cleaned up the environment and the environment has gotten cleaner,

we have seen more incidents of IBD.

In third world nations, much less IBD. And in areas especially in

underdeveloped countries like Africa especially, very little incidents of IBD.

Well, you can take two things from this slide. One, that it may be related to

genetic factors.

However, more relevant what we're finding out is that the microbiome or the

bacteria that are housed within the intestine, what we've actually done is by

cleaning up the environment, we've changed that microbiome. And patients

with IBD are especially sensitive to this. So as we've changed it, we've

actually allowed their microbiome to change.

And in some sense, they've now had an increase reactivity to the microbiome

that is now prevalent. And you'll see why in a few slides, why that is relevant.

Could you change to the next slide please?



On this slide, basically we're looking at sort of etiology hypothesis that have

been put forth for IBD. Well, predominately people as you see on the left -

upper left-handed slide, persistent infection. People have been looking for, is

there a pathogen that is causing IBD? And on the top of this, you see

mycobacterium.

Well, why did that become prevalent? Well, if you go back to the early 1900s,

people started noticing in cattle, in sheep, in goats a disease called Johne's

disease. And essentially if you look at it, it's a granulomatous disease,

inflammatory in nature in the intestine of these cattle. And essentially, looks

very close to that of human IBD.

So people started looking at, is there a connection between mycobacterium

and IBD? Both granulomatous type diseases, both inflammatory diseases of

the intestine. Unfortunately, although a lot of studies have been done, no real

proof has been shown that there is actually a connection between

mycobacterium and IBD.

People have tried through RT-PCR as well as culture of the intestine of human

patients with IBD and really no significant long-term positive studies have

shown at least a correlation, at least as of yet. People have looked for other

types of bacteria, specifically Helicobacter.

Those of you who are not involved in clinical care, essentially patients with

Helicobacter infection can develop significant gastrointestinal type of

inflammation, specifically ulcerations. However again, when looking for it in

IBD, we haven't found it.

So unfortunately, although a lot of studies have been going on, we haven't

found that one pathogen that seems to correlate with the onset of IBD.



However, what we have seen is that there seems to be a defective mucosal

integrity meaning the mucosal barrier and the function of the barrier, meaning

if you look at the intestine, it should be a tight, tight junction, not allowing

things to go back and forth through the intestine unless it needs to.

What we find in the IBD patients is that this does not occur. They actually

have very loose junction between the cells of the intestine allowing bacteria as

well as other types of things to go through. So they actually have an impaired

what we call mucosal integrity. Well, why is this important? Well, that gets to

our last point in the right-hand corner, the dysregulated immune response.

What we find is that if we take the bacteria from a patient, say a normal

patient, and mix them with the lymphocytes from their intestine, they don't

react to it. They don't start proliferating and they don't produce what we call

cytokines or inflammatory cytokines. What this tells us is that a normal

individual is tolerant to the bacteria within the intestine.

However, when we take a look at the Crohn's or ulcerative colitis type

patients, what we find is that if we take their bacteria from their intestine and

mix it with their lymphocytes, some studies have shown that they actually

respond to it and they proliferate and they start producing cytokines. Now,

these bacteria that we're finding from their intestine are not pathogenic, but a

makeup of normal bacteria that is normally found in it.

So essentially, what this point from this slide shows is that there's what we

call a loss of tolerance meaning that these patients with IBD are actually

reacting to something within their body, in this case the microbiome within

the intestine and therefore autoreacting to it. And they should not be.

Next slide.



That brings us to this point, that the chronic inflammation of IBD is not really

due to a pathogenic organism, but a dysregulated immunal response to

antigens or bacteria found within the intestine that normally should be there.

So what is the reason why they're responding? Is there a genetic

predisposition to respond to these to type of organisms? Is there a problem

innately within the cells that make up their immune system?

Next slide please.

Well, what is Crohn's disease and where is it found? Well, Crohn's disease is

basically an inflammation that can actually occur although well-known for its

occurrence within the small intestine, it actually can occur anywhere from the

mouth all the way to the rectum. And as we see here, predominately it's found

in the small bowel as well as in the ileocecal area, but also can be found all the

way to the colonic area.

The big thing to notice is that the rectum is spared and this really differentiates

it as we're going to see if you turn to the next slide, that of the distribution of

ulcerative colitis. Essentially, you see a colonic disease of origin does not

affect anything but the colon.

And is predominately found in what we call the right-sided area or rectum and

sigmoid and spreading upward. So a continuous type of disease whereby we

have rectal involvement.

Next slide.

For those of you who have not seen ulcerative colitis, this is an endoscopic

view of UC. And essentially, what you take away from this, it's an ulcerating



lesion. It is very bloody, it is very continuous disease, what we call a

pancolitis or a lead-pipe type of appearance, meaning so you looked at it, the

normal architecture of the intestine is gone and it almost looks like a dilated

lead-pipe with a very ulcerating bleeding area that is continuous in nature.

That is in opposition if you turn to the next slide, to that of Crohn's disease.

And what you're looking at here in the left and the right is basically what you

see is that they're yes indeed again inflammation, not as bloody or bleeding in

nature. And they have what we call aphthous ulceration; those white streaking

areas basically are ulcerations that are occurring within the mucosa.

And if you turn to the next slide, a high power view of that ulcerating or

aphthous ulcers area. Now, why is that important? Well, if we in the next few

slides, when we get to the microscopic view, this aphthous ulcerations are

actually made up of lymphocytes and antigen-presenting cells, basically

macrophages or monocytes or a differentiated type of monocyte called

dendritic cells that are found in the intestine.

And basically a lot of these cells confluence to form what we call a

granuloma, very similar to what you see in tuberculosis.

Next slide.

If you look at the histology of ulcerative colitis and Crohn's disease,

remarkably different types of diseases. You see predominately a superficial

ulcerating lesion caused by as we're going to see a different type of T cell

whereas Crohn's disease, we're going to see a transmural lesion, meaning all

three layers of the intestine are involved with a lot of lymphoid aggregates,

meaning a lot of lymphocytes aggregate around each other with the formation

of granulomas.



There is crypt abscesses, in both you're going to see goblet cells diminished or

normal in nature. But one of the distinguishing features in Crohn's disease as

we see on the lower right; granuloma formation is very, very frequent.

Next slide. We can actually skip this one and go to the next one please. You

should now be on a slide were it says Crohn's disease and ulcerative colitis.

And essentially, what we're seeing here is a microscopic view of both Crohn's

and UC and that brings out the point that I spoke about last slide, that Crohn's

disease, a transmural disease affecting all three layers from the mucosa all the

way down to the submucosa and serosal layers, we find inflammation.

And as we see on the left, they're early formation of a granuloma within the

intestine, essentially an aggregate of these lymphocytes with antigen-

presenting cells like macrophages surrounding it. As opposed in UC, we find a

very superficial disease, very ulcerating in nature, but affecting the top layer.

It does not go down to the deep layers, it does not form granulomas.

And the reason why is as we're going to get to the immunology, hopefully

you'll get a better understanding of why we can form granulomas in Crohn's,

but not UC.

Next slide please.

Now we're on a slide which should say T cell differentiation. For those not

familiar with immunology, immunology is not actually that scary. It is very

basic. The main thing you need to take away from it is that cells can talk to

each other and activate each other. And once they're activated, what do they

do?



Well, if we look in the middle of this slide, we're going to see a cell called

Th0 and basically that's a naïve type of T cell, an undifferentiated T cell. Well,

this naive T cell can go along various pathways. It needs a certain activation

or kick to it to tell it to where it should go or where it should differentiate.

Well, if it's in the presence of a master cytokine called interleukin 12 as we

see on the top-hand part of this dichotomy, if that naive cell sees IL-12, it

could differentiate to a cell called Th1 type cell or an interferon-gamma

producing type cell. So essentially, it could diverge; form this Th1 if IL-12 is

there.

Well, if IL-12 is not there or it goes to what we call a default pathway or if it

has a kick or activation or in the presence of a different type of cytokine, as

we see on the bottom like interleukin 4, it could differentiate to an immune

Th2 type cell. Why is that important? Well, that cell can produce a large

amount of IL-4, IL-5, interleukin 13.

Why is that important? Well, if we look at the function of these two different

types of cells, Th1 cells producing predominately interferon-gamma can cause

the killing of bacteria or antigens or foreign particles if it's presented in the

body. So basically, it plays a very big role in host defense.

If something comes in that shouldn't be there in the body, the body responds

by making these interferon-gamma Th1 type cells to see that antigen

differentiate, attack it, kill it. However, the body has another way of

responding; essentially it can produce in the presence of interleukin 4 these

Th2 type cells producing a lot of what we call Th2 cytokines like IL-4, 5 and

13.



And they have a prominent role on B cell differentiation where they talk to B

cells. So again, you have this cross talk between cells and essentially why is

that important? Well, your B cells are very important in differentiating when

they see an activational factor into producing immunoglobulins. And the

immunoglobulins again, another way of your body responding to a foreign

type of attack and trying to clear it.

Next slide please.

Well, I talked about initially innate and adaptive immunity and you're kind of

figuring out what in the heck is he talking about? Well, it's very simple.

Again, immunology can be broken down into very simple talk. Cells talk to

each other. What is innate type of immune system?

Well, that's your macrophages, your monocytes, your dendritic cells, your

differentiated type of antigen-presenting cells meaning when foreign particles

come into your body, they're taken up by these antigen-presenting cells as

shown on the left. The DC, what it stands for is dendritic cell or a

differentiated type of macrophage or antigen-presenting cell.

It takes up that antigen, it gets activated. That dendritic cell can produce that

master cytokine interleukin 12 and that can tell the naïve T cell to become and

differentiate an interferon-gamma producing cell and go and attack that

foreign particle and kill it. Well, interferon-gamma as we see on the lower

right can have another function.

It can actually go back and talk to these antigen-presenting cells or

macrophages or Mac for short and they could become activated. And they

could produce factors like TNF alpha.



TNF alpha and interferon-gamma have very similar roles, they're types of

cytokines that are produced by various cells that can attack cells and kill it and

keep what we call host defense meaning if there is a foreign particle coming

in, it can go attack it and clear this particle so that the invading antigen is

cleared.

Next slide please.

Well, TNF alpha, as you saw from the previous slide, like interferon-gamma

can have some host defense mechanisms. It can in and of itself go and attack

an organism or a foreign type of antigen or invading type of pathogen and

clear it. It can also have an effect of what I call the zip code effect, meaning

you're in one zip code, but you really would like to be in another zip code.

You're sort of envious of that other area.

Well, TNF alpha can help you. What it can do is actually start when it hits a

cell, it could start making it produce certain factors that allow cells to migrate

from one area of the body or one zip code of the body to another zip code.

And why is this important? Well, to help clear infection.

You need a lot of different ways to clear that pathogen. Interferon-gamma is

great, it can start killing that pathogen in and of itself, but sometimes you need

a little bit of help. And what happens is TNF alpha can actually recruit cells to

start coming in to start clearing that infection.

Next slide.

Well, how do we put this together? Well, if you look at this slide, it's actually

a lot less complicated than it is. What this represents is actually when you get

immunized, what happens? Well, if you think of immunizations when we



were a kid or more recently if you've gotten one, what is it? You actually are

putting a foreign particle or a foreign antigen into the body.

Well, when you put that antigen into the body as we see on the top-hand part

of this slide, antigen-presenting cells that I talked about like macrophages or

monocytes or in the intestine dendritic cells take it up. And what happens is it

talks to another cell. That antigen-presenting cell talks to a T cell as we see

that Th cell. And what does that Th cell do? Well, it becomes activated.

As I said, when cells talk to each other, they become activated. And that T cell

starts proliferating. It starts making more copies of itself. And it starts

differentiating. And as I said, if you differentiate a cell, you could differentiate

it along different pathways.

Well, you could differentiate it to make cytokines as we see in the middle part

of the cell so that it can actually start clearing that antigen so your body

doesn't get overwhelmed by it. However, it can also talk to a B cell and

basically that B cell starts differentiating. And once it starts differentiating, it

turns into a very mature type of B cell called a plasma cell.

And that cell starts producing immunoglobulin. And the immunoglobulin can

also help fight in host defense. So a lot of the factors that I talked to you

about, basically in a normal immunization can occur and help us in host

defense.

Well, turn to the next slide.

What happens in IBD? What goes wrong in this immune cascade? It seems

very finely tuned, but yet these patients something goes wrong and they

develop inflammatory bowel diseases, specifically Crohn's disease.



Well, turn to the next slide. This should now read Key Inflammatory

Mediators in Crohn's Disease.

Well, if you look at this slide, it's actually the same slide that I talked to you

about, host defense. Basically cells like antigen-presenting cells or

macrophages and dendritic cells talking to T cells to differentiate them to

make interferon-gamma. And that interferon-gamma talking to macrophages

or Mac's and making things like TNF alpha.

Well, what we find in Crohn's disease is that there is an innate problem with

both their antigen-presenting cells like dendritic cells and macrophages as

well as their T cells. What starts happening is that when they're presented

with a foreign antigen, their dendritic cells, macrophages or monocytes

hyperproduce or increased amounts of IL-12 are found from their dendritic

cells.

And these increased amounts of IL-12 then work on T cells to become

differentiated and what we find is that they have a hyperproduction of

interferon-gamma which then works on their Macs or macrophages to start

making TNF alpha and hyperproduced TNF alpha.

So what has happened is a normal response which should occur is a hyper

response. So basically, they're hyper responding in their immune system along

the host defense pathway.

Next slide.

And as I call it, I like to call this a double hit. You don't need to really worry

yourself about the terminology, but if we look at the dendritic cell on the left-



hand side, what we find is that as we screen patients for genetic disorders,

we're finding that there's a fair amount of patients that can have a disorder

within their antigen-presenting cells.

Genetically, systematically prone to it to overproduce the master cytokines

like IL-12 which can work on these T cells which hyper respond to the IL-12

to become interferon-gamma producing cells.

Next slide.

And essentially, what we have found in this slide where it says Crohn's

disease results from the dysregulated immune response, what we find is that

what we may be hyper responding to is actually the microbiome within their

own intestine. This is one factor; it is not the only factor that they're probably

responding to.

But what we have found and as you may or may not know, as clinicians, many

patients and in this case particularly that they gave when we place people on

antibiotics and change the bowel flora, patients with IBD can get better.

So if you change that microbiome within the intestine, the patients seem to get

better. So we're taking out at least one of the initiating factors. We're trying to

cut that inflammatory cascade that has been set in motion.

Net slide.

Now, what is the immunologic factors in IBD, specifically ulcerative colitis?

Is IBD the same disease, meaning is Crohn's disease/UC and why don't we see

granulomas in UC?



Next slide.

Well, this slide, again a little complicated and a little busy, but follow and

walk me through. There's been a lot of animal models that have been put forth

of ulcerative colitis, one of them from Dr. Wendy Garrett and Laurie

Glimcher at Harvard, called the truck model.

Again, the basic immunology, really don't need to be concerned about, but

what we have found in this animal, basically where we have sort of messed up

their T cell receptor and that's what the TR stands for or a T cell receptor, T-

bet ulcerative colitis model. What we see is that as shown as Figure A, this

animal can develop ulcerative colitis type lesions.

Well, we see if we mess up the T cells and dysregulate them, we can get

inflammation resembling that of ulcerative colitis. If we look in part of the

slide just beneath that, histology, what we find in these animals is a very large

amount of TNF alpha being produced. So we see that TNF alpha can be

important, at least in this animal model.

Next slide.

But more importantly, what we find in this animal model is that if we treat

them as we see in Part A with antibiotic therapy, we can actually knock down

the disease. So if we change the innate bowel flora within this animal, we can

actually start treating this animal model. And indeed, the TNF alpha level start

to decrease.

But more importantly, what Dr. Garrett showed is if we look at the bottom

half of the slide, what they show is they look at the microbiome of this animal

and they found that there was particular organisms that were produced that



seem to be very prevalent in the animal with inflammation as opposed to an

animal without inflammation.

But what it showed is that these types of organisms were innately found in

both the animal without and with the inflammation, but more so in the animal

with inflammation. So again, the takeaway from the slide is that the animal

seemed as in humans possibly responding to the innate microbiome and that it

set in motion because of factors maybe genetic in origin, still to be proven.

But we know that if we mess up the ability of their cells like the antigen-

presenting cells or the T cells to respond, they could hyper respond to an

innate factor within the intestine.

Next slide.

Well, if we turn to another animal model, one that I and a colleague (Monica

Boirivant) looked at some years ago. We take a chemical called oxazolone

and we usually this in skin sensitivity type reactions, if we give it instead of

painting the skin and looking for a reaction, if we give it intrarectally to a

mouse, if we look on the right, low and behold we find inflammation very

similar to ulcerative colitis, meaning ulcerating lesions as shown in the middle

part of the slide and bottom part.

And a very superficial edematous type of mucosa as shown on the top. But

most importantly, if we turn to the next slide, what we find is that this type of

animal model is driven not by normal T cells as I've talked about like Th1 and

Th2 type cells which can differentiate according to what cytokine it sees from

that naïve Th0 cell, we find that it is actually involved by what we call natural

killer or NKT cells.



And why is this important? Well, NKT cells are very old type of way of

dealing with pathogens. It is a initial responder; it is a cell that can produce

both interferon-gamma and IL-13. In the case of the NKT cell in ulcerative

colitis, what we find is that there's a special type of glycolipid or antigen that

activates these NKT cells.

Well again, why is that glycolipid important? Well, if you go back to your

microbiology, glycolipid is actually the cell wall of bacteria. When the

bacteria gets killed and the cell wall is released, you get glycolipid

inflammation. Well, these glycolipids can activate NKT cells.

So again, what we're seeing from that truck model from the slides before and

the slides here is that we find innate response to the microbiome that seems

heightened so it is not pathogenic type of organisms, but maybe the innate

type of cells or antigens within the intestine that cells within the body which

maybe again have the ability to respond in the case of ulcerative colitis, NKT

cells hyper respond and go and attack the epithelial cells causing ulcerations.

Next slide. I won't get into this, next slide.

And next slide.

Let me know if you don't see, it should say IL-13 enhances cytotoxicity. The

reason this is important is these NKT cells as I've said, what they can do is in

the presence of this IL-13 that is produced by the NKT cells, it forms a

cascade that feeds upon itself.

And by feeding upon and activating the NKT cell, this cell becomes activated

and what we're seeing here is that if you put these cells in culture with

epithelial cells as shown on the right-hand part of each of these slides, as you



add in IL-13, the ability of the cell or NKT cell to attack the epithelium and

destroy it becomes heightened.

So again, what we're seeing is an ulcerative colitis. Again, an autoimmunity

type disease meaning the body is self-responding to some thing in a

heightened way with its own innate cells for host defense and attacking the

cells within the body. In this case, NKT cells through IL-13 and TNF alpha

causing tissue destruction. In the case of Crohn's disease, interferon-gamma

and TNF alpha causing tissue destruction.

Next slide and that brings us to the last part of the immunology at least part.

We see that Crohn's disease and you see that very different type of histology,

very different types of immunology responses as I've said. But what happens?

Well, when you form an interferon-gamma and TNF alpha response, you

basically try and form an attack response against that pathogen. And what

happens is you draw in cells to start coming around and confluence around

that foreign particle and trying to clear it, i.e. you form a granuloma.

Where as in ulcerative colitis, you predominately have an NKT cell producing

13 causing inflammation and causing the release of TNF alpha from other

cells like macrophages and therefore causing tissue destruction and ulcerating

lesions, but not granuloma formation. And an ability to form granuloma

formation due to this particular type of immunologic response.

Next slide. Next slide. Let me know if you're not - you should be on a slide

called Biological Treatment now and Strategies.

Well, with a little understanding of the immunology, how do we treat IBD?



Next slide.

Well, initial treatment starting looking at, well we know in at least Crohn's

disease, there seems to be a very large Th1 response or at least one part

inflammatory response in Crohn's disease seems to be this IL-12 interferon-

gamma TNF alpha driven type response. Well, if we try to inhibit that

response by giving patients monoclonal antibodies directed against those

types of cytokines, can we make a dent in this disease process?

Next slide.

Well, that gets us to the generations of TNF alpha antibodies and really to the

heart of the talk today. As we see on the left, we initially started out with a

mouse antibody. A lot of the studies were done in animal models as I've

shown you and what we saw on these animal models is if we use a

monoclonal antibody directed against TNF alpha, we can actually inhibit the

disease or at least ameliorate a large portion of Crohn's and UC patients, their

disease process.

We then got to what we call a chimeric antibody and that in sense is

Infliximab or Remicade. Chimeric antibody, what it stands for is that part of it

is mouse and part of it is human. And it forms a chimerism or a joint fusion

between the mouse and the human antibody. And then finally we got to the

fully humanized antibody on the right at, Adalimumab, which contains no

mouse protein and essentially is fully human.

Next slide.

If we look at these anti-TNF biological agents up close, we see Infliximab

which basically has the mouse portion and then the human portion as shown



in the yellow. Adalimumab, fully humanized antibody contains no mouse

portion. And then we have a third type of anti-TNF alpha monoclonal

antibody that you may have heard of called Certolizumab. Certolizumab, very

different type of antibody as I've tried to show you on this structure.

Instead of the usual what we call a FAB portion or what we call the praying

hand area of the top area or the FC portion which binds other cells found on

the bottom of each of the Infliximab and Adalimumab areas, Certolizumab

only contains the FAB portion, the top area. It contains no FC or binding

capacity to other cell portion. And that's going to be very important later on as

I'm going to show you.

Next slide.

Well, this is just to show you Infliximab had a very big influence on IBD. As

big of a risk as we've seen from the case today, why do we treat patients with

Infliximab with Crohn's and/or ulcerative colitis? Well, in this case study, this

was one of the initial study results from treating patients with Crohn's disease

with Infliximab. If we gave them three doses at two, four and six weeks, we

can see a response rate up to 64% and a remission rate in about 1/3 of the

patients.

And these were really the worst of the worst type of non-responsive type of

Crohn's patients. So again, a very big response in patients who hadn't really

responded to other medical therapies at least at that time in the 1990s.

Next slide.

And indeed, if we looked at the ability to keep patients in remission as shown

in this slide and take them off steroids, what we find is that both Adalimumab



that we see here as well as Infliximab and Certolizumab as compared to

placebo had very similar types of results, about a 60 something to almost 65%

response rate.

And at least about 1/3 to about 40% of the patients going into remission. So

many of these drugs despite their similar nature meaning Adalimumab and

Infliximab looking very similar in structure as compared to Certolizumab

which has a remarkably different type of structure, still had very similar rates

of activity and amelioration of disease process.

Next slide.

If we get into does this work and you see, well we know it works in Crohn's.

Did it work in ulcerative colitis also despite being immunological factors

occurring? Well, if we look at the trials...

Next slide please. We should be on a slide called Act 1 and Act 2.

This is the test results from treating patients who had really been refractory

UC type of patients with the different anti-TNF alpha type inhibitors. And

what we find as indeed although the response wasn't as great and the

remission not as great as Crohn's, you still had a marked response and a

marked inhibition in ulcerative colitis patients telling us that in both Crohn's

and in UC, these anti-TNF alphas inhibitors can have a marked amelioratory

type response.

Next slide.

Well, just getting back to UC, why should it work in UC? In Crohn's we sort

of knew, well you get that T naïve type of cell that when it sees an activational



factor, becomes an interferon-gamma producing cell and then it starts

activating macrophages to producing TNF alpha. And downstream you get

marked response by inhibiting or getting rid of that TNF alpha response.

Well, why does it work in UC also? Well, as we see on this slide again going

back to that immunology type of response, again we don't have to be that

concerned with the nuts and bolts of it. But as I said, that glycolipid, at least

we think activates that NKT cell to produce IL-13 which can start a cascade

and activate, and activate, and activate the NKT cell to start killing that

epithelial layer and causing tissue destruction.

Well, TNF alpha in combination with IL-13 actually up-regulates the

receptors on these NKT cells to become responsive to activation. So if we take

away that TNF alpha, one we take away a very deleterious type of cytokine

causing tissue destruction. We also take away an ability of those NKT cells to

become activated because we no longer have the ability to up-regulate those

receptors.

So what we're trying to do as I said in the first part, cells talk to each other.

Let's try to find a way to disconnect that crosstalk and that's what sometimes

this anti-TNF alpha seems to be doing.

Well, next slide.

If we look at the anti-Th1 biologics meaning if we look at Infliximab,

Adalimumab, we saw in the previous slides that they seem to have a very

similar effect on at least Crohn's disease patients. Well, there is another type

of TNF inhibitor called Etanercept. Many of you have used it, used very

widely in rheumatoid arthritis type patients.



Well, Etanercept is basically a molecule that has the ability to bind to TNF

alpha and stop it up if you want to say in the peripheral blood and therefore

takes away TNF alpha from the body. So yes it can have anti-inflammatory

type effects by taking away that deleterious type of cytokine causing tissue

destruction.

But yet as we see in this slide, Etanercept only had about a 10% ability of

putting patients in remission whereas Infliximab and Adalimumab had

anywhere from 35-40% ability to put patients in remission. So clearly,

Etanercept although it had the ability to clear TNF alpha, did not have the

same amount of ability of treating Crohn's patients. Why?

Next slide please.

That gets us to how do these anti-TNF alpha type of monoclonals work? Well,

as I said before, cells talk to each other. They give signals to each other. Well,

these monoclonal antibodies also can talk as well as give signals as well as

ability to interact with other types of cell types. Initially the thought was that

Infliximab causes what we have termed apoptosis or normal cell death of

cells.

Cells have a natural lifespan and they naturally undergo cell death at a

programmed time. Well, the question is in IBD and in other disease states, is

that program time delayed? Is it affected to the point where cells don't die?

And is it affected because they don't get a signal to die? And are these

monoclonal antibodies to TNF alpha or these TNF inhibitors working by

affecting those principles?

Well, as we see here in the middle, that is essentially a TNF alpha type of

monoclonal antibody, that fork-shape type of structure. And what it's doing to



its bottom area or that FC portion is it's actually going and attacking cells and

adhering to it and giving it a signal. Well, what are those signals and why are

they important?

Next slide.

If you look at Crohn's patients and their lamina propia, what this shows is if

we look on the left-hand side, controls are just normal patient cells that we've

taken from the intestine of normal patients. And then we activate them in a

Petri dish. And essentially when we activate them, a lot of the cells as we see

from this curve going upward undergo cell death.

The y-axis is apoptosis or programmed cell death or ability for cells to

undergo death when given a stimulus. So a normal person when they get an

antigen exposure, they become activated, they do their job and then they die.

Well, in Crohn's patients, what happens? If we look in the middle portion of

this slide, when we activate their cells in a Petri dish, they don't do anything.

They don't undergo cell death, they just stay there.

That's telling us they have a defective ability to undergo cell death or ability to

undergo programmed type of normal response when seeing an antigen. So if

they see an antigen, they see it and they keep responding to it because they

don't die.

Next slide.

Well, in the initial studies some time ago, when they looked at Infliximab

treated patients with Crohn's disease and they looked at the intestine and they

took slides from the intestine and made histology and looked for apoptosis

meaning are cells undergoing cell death. As we see in the bottom half of this



slide, those little red dots, those are basically T cells that are undergoing or

have undergone cell death.

So as you treat a patient with Infliximab, they seem to regain the ability to

undergo cell death or die.

Next slide.

Well, the T cells not only look like they had the ability to undergo cell death

when they saw Infliximab, but also the antigen-presenting cells like

monocytes and macrophages as I've told you that produce that IL-12. Master

cytokines that direct the T cells to make interferon-gamma as well as the Macs

or macrophages that produce that TNF alpha, what we see on this slide in the

gray shaded bar.

As these patients got TNF alpha inhibitors and we looked at their

macrophages, monocytes, dendritic cells that produce these cytokines, they

started to undergo cell death and had the ability to undergo cell death. So we

saw, we not only affected the innate immune response like the APCs, the

Macs and the monocytes and dendritic cells, but the adaptive immune

response meaning the T cells that produce the gamma and the TNF alpha.

Next slide.

Now, you're looking at this and going, "Oh my god." Well, this is pathways

that are involved in cell death, but again it is a very simple type of theory if

you think about it. Cells talk to each other and as I like to call it, this type of

slide, it's called Red light, Green light, Go meaning you have various

pathways and molecules within cells that talk to each other.



And they give a signal from one to the other to finally give a signal or a green

light for the cell to undergo apoptosis as we see on the lower left-hand side.

But there are stop areas meaning that red area, caspase 3, master type of

molecule that can - if it doesn't get the correct signal, it won't die. It won't give

that final signal; it'll give a stop signal or a red light and won't allow the cell to

die.

Well, as we see, there are various molecules as we see in the top right that

start off this process within the cell, one called Bcl-2 which basically is a

long-lived factor. The more you have it around, the longer if you think about it

the L portion of that term, the cells live longer or L for living longer. Well,

you can have stop portions again, not only at the end of the cell, but at the

beginning of the cell.

If you get a signal not for the cell to die, you could stop it right then and there.

Well, what happens in the Crohn's patients?

Next slide. Next slide.

Studies by my good friend (Monica Boirivant), what she showed is that the

Crohn's patients not only had an inability to undergo programmed cell death

or a natural way of dying in the cell, if we looked at it in the Crohn's patients

on the right or CD, when we activated the cell, they actually turned on that

long-lived protein called Bcl-2.

So we're seeing innately the cells in these patients with IBD are screwed up.

They don't get the correct signals. They get the singles actually to hang around

and to be around and to hyper respond to these antigens.



And is it because they don’t die and the best way of treating the patient is a

way of giving them a signal for these cells to undergo cell death so that they

could then clear these types of cells that are hyper responding.

Next slide.

Well if you look at this slide again what is the take home message? What does

Infliximab do?

Well if we look on the right hand side of this slide where it says CD3 and

CD28 stimulated type cells again we take cells from the intestine of a patient

who have been treated with Infliximab.

And what we find is that if we look at the top hand portion of the right part of

this slide the Y-axis is called Bax/Bcl2.

What we’re looking at is the stop signal that backs is a stop type of signal to

that long live molecule.

So again what it’s doing is giving us that red light. It’s telling us stop that

Bcl2 from being produced and now allowing the cell to undergo cell death.

So we’re changing the internal structure or we’re changing the signals of these

pathways to figure out the cell can finally say to itself I need to die, I need to

undergo cell death.

Next slide.

And what we find is that when we treat the patients with Infliximab you

finally -- as we see on the right hand side if you just put Infliximab cultured



with cells from the intestine of patients which Crohn’s disease they get that

final signal cast space three and it allows it to get a green light and it goes in

and dies.

So beforehand they didn’t have the signal now you’re opening the floodgate

for the cell to finally recognize that it undergo cell death.

Next slide.

Well Etanercept we say before didn’t have as much potency as the Infliximab or

Adalimumab in the treatment of Crohn’s. Why?

Well what we saw if we look at this slide is Etanercept although it has the

ability to bind to TNF and sop it up so it can have some anti-inflammatory

properties it doesn’t have the ability to bind to a cell to give it a signal to

undergo apoptosis and undergo cell death.

And what we see here the Y-axis again cell program death or apoptosis and as

we see in the open types of squares that is cells treated with Etanercept they

are undergo to any large degree cell death.

Whereas in the dark black circles we see Infliximab treated patients can

undergo cell death.

So one of the big differences between the anti-TNF at least so far can they

induce apoptosis or cell death?

Next slide.

And essentially if you look at the machinery remember I told you the red light

green light go type molecules when they talk to each other you finally get to



that final molecule cast space three which can give that light for the cell to

undergo cell death.

What we find if we look at Infliximab treated patients in the black bar they get

that signal as we saw before and as we see here increased amounts of cap

space three are now made.

But Etanercept as shown in the striped types of bars right next to it don’t get

the same signal they don’t get that final kick to talk and tell the cell to undergo

cell death.

Next slide.

Well does what happens in tuberculosis? There was a paper a little while ago

that Dr. (Ashkin) had alerted me to by Dr. (Wallace) and essentially what Dr.

(Wallace) did is if he took normal peripheral blood cells and infected them

with mycobacterium or basically cold cultured cells with active

mycobacterium and then added in in vitro Adalimumab Infliximab or

Etanercept, what happened?

Well he saw a marked difference. If we look at the Y-axis if interferon gamma

productions from these cells now as I said when a cell or a (Th-0) cell sees an

antigen it could differentiate and starts making gamma.

While in mycobacterium it’s not infection it’s not dissimilar to what we saw

in Crohn’s. What we’re seeing is that mycobacteria comes in it activates cells

to start producing interferon gamma to start trying to quell that infection and it

starts bringing in other cells through TNF alpha to migrate or change its zip

code to come.

melvet, 02/09/12,

Cold cultured, not pole cultured.



And what happens is these all these cells coalesce around the organism to try

to kill it and try to clear that infection or (reform) in the case of the

mycobacterium the granuloma the makeup of large amounts of lymphocyte or

T cells producing gamma and TNF alpha and these antigen presenting cells

producing TNF alpha.

Well when you give the Adalimumab and Infliximab you actually see as

shown on this slide on the bottom half of the slide in the open circle and open

squares that the interferon gamma production from the lymphocytes does

down.

So somehow you’re clearing by giving anti TNF alpha you’re clearing either

T cells making gamma or you’re clearing their ability to make gamma.

But as we see in the top hand diamond black diamond and Etanercept has little

response and has little ability to clear the interferon gamma. Very similar to as

I showed you in the responses of cell death in the Crohn’s patients.

Next slide.

Well Dr. (Wallace) looked at apoptosis and early on statistically due to the

(wide arrow bars) he did not see any differences at least in apoptosis between

the different types of TNF inhibitors but he did see as time went on and that

there was a possible difference between Infliximab and Adalimumab versus

Etanercept.

The way he put it is he did not see direct apoptosis of the cell of cells

undergoing cell death but he couldn’t exclude that the TNF inhibitors were

binding to the membrane portion of a cell and causing it to undergo cell death



and as we see as time goes on and you get more and more stimulation maybe

the cells do indeed undergo apoptosis of cell death.

And that gets me to the next slide.

Bringing you back to that slide we’ve seen so far that that fork shaped type of

monoclonal Adalimumab or Infliximab combine to cells kill them or give

them signals to actually undergo cell death but on the right hand side we also

see that Infliximab can bind onto TNF alpha which can be found on various

types of cells and also give it a signal to undergo cell death.

And this also may be a possibility which maybe occurring in tuberculosis that

actually cells are being (coated) and show TNF alpha on the surface the anti-

TNF’s go and they either give it a signal to kill or they bind onto the TNF on

the surface and they give a reverse signal to it to undergo cell death and tell it

to undergo cell death.

Next slide.

Well if we use these TNF inhibitors do we need to be concerned? As we’ve

seen from this case study this patient actually had a significant mycobacterium

infection.

Well listed here are the possible side effects of using anti-TNF alpha. The

most common is initially when you give anti-TNF reagents they can have an

infusion site reaction or develop a serum sickness type of illness after the

infusion of the monoclonal antibody.

However, what we have also seen and the most significant that we as

gastroenterologist myself are concerned with is infections whether mild or

melvet, 02/09/12,

Typing error.



serious demyelinating disorders like aponeurosis or a myositis which again the

neurological complications that we saw initially when you gave the anti-TNF

would you think that was due to TB because they can indeed have a

reactivation of latent TB or serious infections.

Or was it a demyelinating type disorder that we were initially seeing from the

anti-TNF therapy and wouldn’t have even thought of TB?

Well what I need to instill into you, you need to think of all of these types of

reaction -- infection neurological complication and long term as we see on the

bottom right hand of the slide malignancy.

Next slide.

Well are serious infections more common in patients taking anti-TNF

inhibitors?

At least what we see in Crohn’s and IBD you see type patients if they’re on a

single med like for their ulcerative colitis or Crohn’s like steroids the odds

ratio of having a serious infection is two point nine.

However, if we start adding in other immunomodulators like 6-

mercaptopurine or these anti-biologics like anti-TNF alpha inhibitors we start

seeing that odds ratio of having a significant serious infection go up

dramatically.

Next slide.

Well what is the risk of dying from sepsis? This is in IBD patients these I told

were the largest studies done.



We see that the risk of death from sepsis or just general sepsis from any

organism about four per one thousand patient years. So it is prevalent you

need to think about it. Is it as common as we thought?

We need to think about it. We need to know it’s there. Do we need to be

afraid of it? Yes but with the right type of screening we can actually hopefully

not be involved with these serious infections.

Well what are these opportunistic infections these patients can develop? As

we see here again there are a variety of different type of infections and as we

see in the middle a typical mycobacterium can occur.

But again what we’re looking at is per one thousand patient years. So again

putting this perspective how much probability is this is if we look at the

probability as one of my good friends Dr. (Corey Segal) would say these odds

ratios or risk ratio it’s about the same risk of dying in a car crash.

So it is there you need to think about it. Is it going to happen everyday? No.

Well next slide.

Well what type of patients are dying from anti-TNF inhibitors? The usually

older type of patients they usually have comorbidity and again as I showed

you before they usually are on multiple different types of immunosuppressive

drugs.

The young healthy type of patient that you start the anti-TNFs to begin with

may not be as at risk as these type of patients.

Next slide.



Well we’ve seen the acute problems. The long term problems of anti-TNF

inhibitors that of lymphoma or specifically non-Hodgkin’s lymphoma again

can happen about six point one per ten thousand patient years.

So again can happen we need to think about it but again if we look at the next

slide one of the other types of malignancies that can occur are paddle splenic

T cell lymphoma.

These types of lymphomas can occur but if we look at it in all the patients that

have been infused with Infliximab we have seen that there are now 16 cases in

all the patients that have been infused and we’re talking hundreds of

thousands almost millions of patients that have been infused with this type of

anti-biologic.

So again what we have to note as shown on the next slide paddle-cellular T

cell lymphoma again can occur as we see in the light blue we see about 16

cases now total.

What we see is that most of these types of patients had been on other types of

immunomodulators. What we have seen is that patients who have gotten co-

treated with 6-MP and anti-TNF are at risk for this paddle-cellular T cell

lymphoma but more importantly -- (Warren) I’ll be there in about 15 minutes.

What we see is that patients with -- that had not been treated with -- that have

been treated with anti-TNF alone do not seem to have the ability to develop

this paddle-cellular T cell lymphoma.

So again it seems to be the co-immunosuppression. We don’t know fully the

immunologic responses that are putting these patients at risk but the take



home from this slide is that these types of things need to be thought about as

we need to think about serious infections but in the long term how prevalent

are they?

Next. Wrapping up and why -- think about what happens when a patient

comes to you? Well we see a lot of primary immunodeficiency type patients

here at the INH.

When they come to us they have a variety of immune disorders. Well how

does this relate to IBD and how does this relate to mycobacterium type

infections?

Well we see a large portion of our patients that can develop as we see on the

right with mycobacterial infections. Predominately what we start seeing in

these patients is that they have T cell type defects.

And what this chart basically shows is that what types of cells are affected and

what types of infections can you get?

Well with mycobacterium infections predominately the T cell and the

monocyte seem to be screwed up and as we’ve seen from the immunology

from IBD and the normal host homeostasis interferon gamma plays an

important role and specifically T cells from that make interferon gamma

producing cell play a predominant role in curbing an antigen or a pathogen

response like mycobacterium.

And monocytes which produce TNF alpha also have a distinct role in trying to

curb that infection. Well next slide.



Well what types of patients when we see the mycobacterium in patients with

mycobacterium what types of immune defects should they have?

Well as we see in the middle portion of the slide it looks like a lot of mumbo

jumbo but what we take home from it predominately they have IFN which

stands for interferon gamma, they have interferon gamma receptor

abnormalities, they have aisle 12 receptor abnormalities.

So basically they have a screw up in the aisle 12 interferon gamma pathway.

So when you screw up that pathway you screw up the ability to respond and

kill the mycobacterium.

Well how does this play a role? Next slide.

Well putting this in perspective again cells talk to each to other. When as we

see on the left hand portion of this slide where it says microorganism we think

about it.

When mycobacterium comes into the cell it comes into an antigen presenting

cell like microphages or monocytes they take it up they become activated.

They give a signal. They release cytokines. Well in a normal response this cell

becomes activated and as we see on the bottom half of this slide they produce

cytokines like aisle 12 one of the mastic cytokines as well as other types of

cytokines which help.

As we see on right hand side the T cell to differentiate it make interferon

gamma as we see on the top hand portion of this slide come back interact with

its receptors those little diamonds on the left hand side where it says

underneath macrophages.



The interferon gamma is bound to its receptor activates the macrophage seizes

that antigen and it gives it the signal finally to kill it.

Well next slide. What happens if you had those immune defects? If you have a

screw up in interferon gamma or a screw up in aisle 12 or inability for that

macrophage or antigen presenting cell to activate the T cell to make gamma.

Well what those lightning bolts show is that each of these areas we see an

immunodeficiency type of patient we’ve taken care of which develop

mycobacterium which had an abnormality either in the ability for aisle 12 or

interferon gamma.

As we see on the left hand side of the slide TNF alpha acts very similar to

gamma when macrophages are activated they make gamma they can make

TNF alpha.

When you use an inhibitor or you knock it out or you’re immunodeficient and

have the inability to make these pathways to make gamma or TNF you leave

the body open to have persistent mycobacterium infection.

Well next slide. In a patient that we saw from South America who had gotten

a BCG type of vaccination as I said in the initial (plexus) of our slide when

they were vaccinated you make a normal host response and a memory

response to deal with that antigen.

Well in these patients with primary immunodeficiency as you see here they

actually develop mycobacterium infection. And this patient actually had an

aisle 12 receptor defect.



So inability for that aisle 12 to function normally to activate T cells to make

gamma.

And we see on the next slide initially they started making caseating

granulomas all around and when we treated them actually with interferon

gamma as we see on the right we got rid of the granulomas.

So immune system is a double-edged sword. Activate it too much we get

autoimmune disease like Crohn’s disease and ulcerative colitis. Try to inhibit

it with anti-TNF inhibitors we down modulate or as a good friend and

colleague Dr. (Stefftoggen) calls it we reset that rheostat. We reset that

thermostat down to normal.

So we go from a heightened response down to a normal response. But if we

take a patient who has a normal response and now they’re immunodeficient by

knocking out those immune regulating pathways they’re now open to the

inability to respond to microorganisms in particular one like this

mycobacterium.

Next slide and we’re almost done. Well is this important? Should we not treat

as we saw the patient here he developed mycobacterium infection?

Should we not treat patients with IBD because we’re afraid of these

infections? Well as you see here as we’ve treated patients in the biological era

pretreatment horrendous disease.

After a few treatments we see a normal bowel. So again this type of treatment

has had a marked marked response on the treatment and therapy of IBD

patients as well as other patients with autoimmune disease.



We can’t be afraid of it but we have to know what we’re doing and use it

cautiously. Last slide please.

And this is just to let you know what we’ve talked about today is in that red

box. We’ve seen how cells can become activated and respond to dendritic

cells with BCs or antigen preventing cells to make your T cells respond and

fight off pathogens.

If they hyper respond we start making autoimmune disease states. Why

Crohn’s disease? If we knock it out by knocking out TNF alpha with TNF

alpha specific inhibitors we could down modulate that inflammatory response.

But that’s not the only way of treating patients. And as I’ve shown here in the

age of immunology it’s becoming more exciting because as I said cells talk to

each other as we’ve understood how the cells talk to each other we’re now

trying to work out ways to knock out their inability to become activated as

shown on the left to transport itself as shown in the middle and to respond in

other inflammatory cascades as shown on the right.

Thank you.

Dr. David Ashkin:Ivan that was absolutely fantastic. You know, I don’t want to say nothing Ivan

but from somebody from Brooklyn like you to have make somebody from

Brooklyn like me understand this was quite remarkable.

I mean Ivan is fantastic and, you know, I don’t want to say nothing but also

from Brooklyn how the hell do you say all these terms like (Adalimumab)?

Dr. Ivan Fuss: Exactly it took me a while to practice it, okay?



Dr. David Ashkin:Yes don’t you think it should just be called (Joey), you know, (Joey) they and

there should be a lot of (Vinnie) (unintelligible), right?

I mean I don’t know how we can name these things.

Dr. Ivan Fuss: Exactly.

Dr. David Ashkin:But I really want to thank you fantastic it’s tremendously and hopefully if you

can stay on if we have questions at the end but...

Dr. Ivan Fuss: Sure.

Dr. David Ashkin: ...I think one of the most important things that Ivan has put forward I mean is

that obviously these are very, very powerful tools and these are tools that

really can change these diseases.

But in the process of doing it just like Ivan said I agree with him we can’t be

afraid to use them. But what we need to do is we need to at least be able to

know what maybe a potential.

How we can maybe screen for it and prevent it before it happens. And that’s

why I have the tremendous honor of introducing Sundari Mase. And as you

guys know Sundari’s the medical officer from the CBC.

Sundari works with us at the RTMCCs and she’s our medical consultant and

really has tremendous (unintelligible) which helped all of us and Sundari’s

going to talk now from a clinical aspect on tumor necrosis factor blockers and

TB and how to further what Ivan said what do we need to do to try to screen

these and potentially treat them.



So Sundari thank you so, so much for joining us today.

Sundari Mase: All right thank you so much for having me here. Dave and Southeastern

National TB Center. And also thanks to Dr. Fuss for an amazing presentation

and setting sort of the background for the clinical talk.

Of course, David is a very hard act to follow and I’ll do my best. And I agree

that the hardest part of this talk is pronouncing these drugs’ names because I

can’t.

So what I’d like to do is let’s see if I can figure out how to advance these.

Right click?

Oh okay, got it. Okay.

Dr. David Ashkin:Right click and then push (unintelligible), okay. There you go.

Sundari Mase: Okay. So over the course of the next 15 minutes or so what I’d like to do is to

discuss the association between an (epee) of TNF inhibitors and tuberculosis

specifically.

I know we’ve already discussed some of this already. Discuss the challenges

of diagnosing latent TB infection in these patients that have underlying

immunodeficiencies prior to starting TNF inhibitors.

I’d like to discuss the use of tuberculin skin tests versus egress in diagnosing

these patients with LTBI and then talk about some about risk factor

assessment for tuberculosis and how that plays a role as well in the treatment

of these patients.



I discuss some potential recommendations for LTBI screening of the

population prior to placing on TNF inhibitors. And then hopefully we’ll have

time for a short case presentation.

There we go. All right so this is just a great chest x-ray classic for reactivation

TB.

So first I just want to talk about a more common immunosuppressive agent

prednisone glucocorticoid and the association between those and tuberculosis.

The risk of reactivation TB is poorly defined even in this setting and is based

on anecdotal reports from the 50s and 70s but the CDC 2000 TB statement

does state that patients who are on greater than or equal to 15 milligrams a day

of prednisone for one month or more are at increased risk of progression to

active TB and should be carefully screened and followed.

And this is the dose that’s been shown to suppress tuberculin skin test

reactivity as well.

There’s no real observational protected data that supports this that

retrospective studies in low incidence areas have been unable to demonstrate

any risk of TB.

So this is a challenge. So more on prednisone and TB from (unintelligible) the

data is from the general practice research database in the UK and TB cases

were looked at between 1990 to 2001 at with controls.

And current glucocorticoid use showed there was an odds ratio of four point

nine in those patients to progression to active TB. And if you looked at the



subset of patients receiving less than or equal to 15 milligrams a day the odds

ratio dropped to two point eight.

And then those receiving the higher dose of 15 milligrams a day or more the

odds ratio was higher at seven point seven supporting the hypothesis that

indeed these drugs do predispose towards progression to active tuberculosis.

Of course, we don’t know whether they’re causals versus the severity of the

underlying disease. These cases and controls are matched in common other

risk factors body mass index , lung disease, diabetes, other TB receptors but of

course, patients are receiving glucocorticoids were sicker because they are

(unintelligible) deficient medication for underlying -- excuse me.

Woman: I’m sorry.

Sundari Mase: So now let’s look at biologic drugs. TB is only one condition or one illness

that’s associated with these drugs. As you can see there are many other

infectious and noninfectious conditions that are associated with the use of

these drugs and I think Dr. Fuss mentioned many of those.

Woman: Okay.

Sundari Mase: So I know we’ve heard a lot about TNF and I probably don’t need to go into

this particular slide and in fact I’ll skip it since we’ve heard a lot about it.

But I do want to say that the over expression of TNF alpha does lead as you

saw in the last presentation to inflammation and tissue destruction and

immune mediated inflammatory diseases -- rheumatoid arthritis, IBD,

psoriasis, ankylosing spondylitis, other such illnesses.



And we’ve already seen from the last presentation what the rewards of TNF

alpha blockade are in the highly successful treatment with these drugs.

So again I’m not going to go into great detail since Dr. Fuss really covered

this area well. There is many such agents and there is monoclonal antibodies

as well as Etanercept which we’ve heard about the difference in mechanism

action.

So actually I want to reflect some on what happened with Infliximab. So when

it was noted that this drug predisposed towards progression active TB in

October of 2001 the FDA modified the labeling to include a warning about

Infliximab associated active TB that included instructions to screen for latent

TB infections prior to starting the medication. And also had a statement about

potential continued screening afterwards at some interval but the interval was

not specified.

So after that FDA warning came out between November of 2001 and May of

2006 there were 130 reports received by the FDA of patients developing

active TB on Infliximab and of these 130 patient’s, 19 of them died. So it’s a

real problem.

Oh and so looking at this particular slide there this is a study looking at the

UK of Biologic Registry. And basically showed that in patients receiving

Infliximab, monoclonal antibodies that is there is a three to four times risk of

developing active TB over those receiving Etanercept. Again showing that the

monoclonal antibodies appear to be more of a risk factor for progression to

active TB disease than Etanercept.



And the general case rate in the UK at this time was 12 to 14 prior to 1000.

You can see that in those patients receiving anti-TNF agents the case rate was

95 per 100,000 and cases of TB that occurred over this time period was 27.

And this is basically showing the exact same data in a graphic form. Again

showing that of these three agents Etanercept had the less likelihood of having

patients progress to active TB than the monoclonal antibodies.

Here is a U.S. population-based study, Kaiser Permanente, Northern

California that backgrounds rate of TB in this population of Kaiser patients is

2.8 per 100,000 and the background ratio of non-Tuberculosis micro-bacterial

infection was 4.1 per 100,000.

But then you can see in those patients receiving TNF inhibitors their rate was

much higher. And you can see again the same thing with Etanercept having,

being less of a risk for progression active TB than Infliximab and

Adalimumab, I think I said that correctly.

So we’ve actually heard a lot already on this topic of, you know, why

potentially there’s more TB risk with monoclonal antibodies. My friend and

colleague (Kevin Winthrop) who is probably one of the leading experts in this

area believes then of course that the Interferon-gamma down regulation and

differential granuloma penetration which we heard in the last talk plays a role

in why these monoclonal antibodies might have carried more of a risk for

progression to active TB.

But here are some of the mechanisms that have been proposed. And I know

that Dr. Fuss actually went into this in great detail. So I’m going to go ahead

in the interest of time skip this so we can get to the clinical piece. And I’ll skip

this slide as well. Okay, all right.



Well I want to really underline and highlight the importance of screening

patient’s for risk factors for Tuberculosis when deciding whom to test, whom

to treat. Obviously all, any patient that’s going to go on these drugs needs to

be tested for latent TB infection.

And if the testing suggests that they have latent TB infection active TB

disease must be ruled out with a chest x-ray, symptom review prior to placing

the patient on treatment for latent TB infection with one drug.

Risk factors here are very important to be aware of and to ask patient’s about.

Knowing their prior exposure obviously to an active TB case, birth or

extended residence in a country where TB is present and endemic, a history of

living or working in congruent settings like we saw in the presentation by

Dave jail or prison, homeless shelter’s, health care centers that treat TB

patient’s - anything that puts the patient at higher risk.

And then the history suggestive of prior LTBI diagnosis, prior positive TB

skin test or IGRA, chest x-ray finding suggestive of sort of old or scarred TB.

Of course in that setting you’d need to get sputa to rule out active TB prior to

placing the patient on LTBI treatment. But this is very important in proving to

the process of evaluating these patients.

Okay so let’s talk some about Interferon-Gamma Release Assay’s. And just a

quick background, you know, the Interferon-Gamma is a component of the

cell-mediated immune response, the antigen-specific secretions stable and

measurable. That’s kind of the background for how these tests are applicable.

We know there are different tests, Interferon-Gamma Release Assay for TB,

there is QuantiFERON TB and it’s into right now that’s used that measure the



change in the Interferon-Gamma concentration, measuring the Interferon-

Gamma by ELISA technique and there is T-SPOT or LE-SPOT for the actual

change in number of cells losing Interferon-Gamma is measured by counting

spots and I could go into more detail into this but in the interest of time I’m

going to move on. If there’s questions we can take them afterwards.

So let’s see. So let’s compare the IGRAs and TSTs quickly. Of course the

IGRA is performed outside of the human body and the TST is performed in-

vivo or in the human body.

IGRA use TB specific antigens whereas the tuberculin skin test is basically

just mulched up TB and so there is multiple organisms of purified protein

derivative. You don’t have to worry about boosting when using IGRA

whereas boosting can be of relevance when using a tuberculin skin test.

IGRAs require one patient visit for a result and two patient visits for a

tuberculin skin test. And the results unless batched are within 24 hours with

IGRA whereas as you know with a tuberculin skin test patients return two or

three days later and there is inter-reader variability of the tuberculin skin test

whereas potentially more consistent readings with IGRAs.

So how is this different in this set of patients? Well the specificity should not

be different at all. The fact that when patients have had prior BCG or prior

exposure to non-tuberculin bacteria that they might have a false positive TST

is something that applies to all patients.

And we think that because the IGRA’s are targeting TB specific antigens that

you have much greater specificity. So the patient had BCG it would hopefully

not be positive with an IGRA even though they could have a false positive

tuberculin skin test.



How about the relative sensitivity with TST for LTBI? A study performed by

(unintelligible) 2007 with the patient’s who largely received BCG and had

inflammatory rheumatic conditions, were treated with anti-TNF agents and

12% of the patient’s were QuantiFERON positive versus 40% that were TST

positive.

And the QuantiFERON In-Tube test more closely was associated with LTBI

risk factors suggesting that in these patients for the many of them had false

positive TSTs as a result of having PCG. Again and we see this in other

populations as well but it does support the use of IGRA’s in this situation.

Here’s a study from Peru. Again a very high BCG use in both the cases and

the controls. Cases of patient’s with rheumatoid arthritis and controls were

patients without rheumatoid arthritis. And as you can see here it appears like

the prevalence in this setting was about 68% TST positivity, that’s what was

expected in this community setting.

And in the controls you see about 66% of them were positive by TST. But in

those with rheumatoid arthritis and immuno-deficient conditions only 27%

had a positive TST. The controls QuantiFERON correlated well with TST

being 59% of patients had a positive QuantiFERON and did not correlate that

well with TST in the patients with rheumatoid arthritis. So the thinking here,

the bottom line is perhaps QuantiFERON is picking up patient’s who really

have latent TB infections better than tuberculin skin tests.

There are numerous other studies that show these findings and I’m not going

to be able to go through all of them but the take home message is you can

have anergy with tuberculin skin tests and with IGRA’s in patients that have



immuno-deficient conditions. Those are the patient’s that we’ve been talking

about.

Indeterminate results do occur and are difficult to interpret and it’s very

important though that we have the best sensitivity in this situation because we

were actually trying to find patient’s with latent TB infection and treat them

before putting them on these drugs. So the test that has the greater sensitivity

is the most important.

Okay. This is just a slide that’s quickly showing what’s happening in different

parts of the world. You can see that different countries are doing different

things. Britain and, is using risk assessment and have no initial screening test.

They don’t use IGRA’s or tuberculin skin tests but use chest radiographs and

actually empirically treat with INH for those from high prevalence countries

which is a very interesting approach.

Other countries, Switzerland, France and Germany use IGRA’s to screen these

patient’s in addition to risk assessment and chest radiograph and Spain they’re

using two-step TST. All these settings were of course risk factor assessment if

very important. And as you can see the American College of Rheumatology,

CDC and Canada we’re using, recommend the use of Tuberculin skin test in

the study.

So let me just quickly go through this and then we should move on to the case.

So what do you do when you have a patient that you need to start, that you’re

thinking of starting on a TNF-alpha blocker inhibitor? Careful history for the

TB risk factors that we discussed.



TST and/or interferon-gamma release assay. If there are no TB risk factors,

and the tests are all negative, then you presume the patient is uninfected with

tuberculosis, latently infected.

If the TST is positive and the IGRA is negative then you might want to take

into account BCG history. If the patient has a history of BCG presume they're

uninfected. With no history of BCG, diagnose TB infection. If the IGRA is

positive, diagnose TB infection.

Now let's just say we have TB risk factors, those risk factors that we

discussed, exposure is likely, then still the patient is negative on both of these

tests, TST and interferon-gamma release assays, presume they're uninfected.

If either is positive, diagnose TB infection.

So that's just sort of a - an algorithm. It's not in any guideline. It's not a CDC

recommendation by any means. However, it is an approach to the patient that

might be quite useful.

So how about TNF inhibitors and TB disease? Anecdotally in a few case

theories that I was able to find, it stated that these patients are more likely to

have extra-pulmonary disease like other immunosuppressed patients, HIV

patients, that sort of thing.

Diagnosis is more difficult as a result of it being extra-pulmonary and the

presentation could be quite severe like we saw in (Dave's) case. Patients may

be more likely to have immune reconstitution inflammatory syndrome. Drug

resistant TB might be harder to diagnose because it's hard to get a

bacteriological diagnosis and discontinuation of the TNF inhibitor may

worsen the underlying condition.



So let me move on. I think the next thing I have is a case. And I want to note

that, you know, I have seen many patients actually who have progressed to

active TB, who've been on the TNF blockers over the last ten years or so, and

the presentation is difficult. The diagnosis is difficult, because it's not the

typical presentation.

So this is a patient that I recently saw in my clinic, 70-year-old white female,

long history of rheumatoid arthritis, treated with Embrel or Etanercept

injections every week since 2003. Her rheumatologist did screen her per the

FDA recommendation with a TST and it was negative prior to starting

treatment.

She had no risk factors at all for TB except for a few cruises she'd taken. And

she presented with left neck swelling in the supraclavicular area, fevers, chills,

night sweats, a 10-pound weight loss, slight cough, interestingly enough, and

general malaise. She looked awful when I saw her.

She was referred by her rheumatologist to a surgeon, because he thought that

she was at risk for lymphoma. TB was not in his differential at that point. The

Etanercept was stopped. There was surgical full excision of the nodes, and as

we know, in these settings, surgeons rarely send these specimens for any kind

of microbiologic testing.

So the patient just, you know, I mean the tissue was placed in formalin.

Lymphoma was excluded but the path revealed caseating granulomas and

inflation. She remained TST negative but her QuantiFERON was

indeterminate.

Chest X-ray was normal. Exam was normal except for the biopsy site and of

course, the general symptoms she was having, and her sputa was collected



anyhow, even with the normal chest X-ray, it's very important to exclude

pulmonary disease.

And let's - what would people do at this point? Would you refer her for a

bronch for further diagnostic purposes, treat empirically of MAC, treat with

standard four drugs, empirically for TB, send the specimen for PCR and treat

empirically for MAC or send specimens for PCR and treat with standard four

drugs for TB?

Okay. It's interesting. So most of you decided to do what I did, which is

basically to send the specimen for PCR and treat with standard four drugs for

TB. And it would not have been incorrect to add treatment potentially for

MAC as well.

So special ascent for PCR, patient started on standard four drugs. Her

rheumatoid arthritis however was disabling at this point. She was not able to

get out of bed barely, wanted to be put back on Etanercept.

So what would you do? When to restart the TNF inhibitor? Would you wait

until her TB treatment is complete, start the Etanercept once the patient has

completed the initiation phase of treatment for TB, start it right away, or

switch to another TNF inhibitor?

Interesting. Okay. Well, keep in mind, she's clinically deteriorated to a point

where she can't get out of bed. So waiting until TB treatment complete,

although we might want to do that, is - wasn't an option.

So what I did was I called (Kevin Winthrop) who I told you was the expert in

this area , said, "(Kevin), what would you do?" And she said - he said,



"Basically since she's not smearing culture positive pulmonary, just you can

restart - just restart it right now, you know, because she's so debilitated."

So I went ahead and restarted it right away, and she did quite well. Just a

second. So let's see here. Hold on. So PCR negative. And I've had very bad

luck with PCR for TB on specimens that are in formalin. I've had a very low

yield. I know (Dave's) had a better yield.

The etanercept was restarted, and then she felt terrible with arthralgias and

myalgias that were debilitating. She was on a standard four-drug regimen at

this time, I didn't expect any microbiologic thing. This is - so what would you

do at this point? Check RFTs, check her uric acid, stop all the TB meds or

stop the Pyrazinamide?

You know, again, I don't think any of these are wrong, but the - if you stopped

all meds, then you would just restart sequentially. But in this case since it

wasn't hepatotoxicity, and I really thought the PZA was what was the

problem, I went with stopping the PZA. And you know, again, I don't think

any of things is wrong necessarily to do.

And a second. Okay, there we go. PZA was stopped. She was immediately

much improved. Really interesting how PZA affected her so significantly.

Treated with three drugs for two months and then just INH and rifampin for

the next six months, and she had one month to go. So in other words, she's

going to have nine months of standard regimen. She's much improved, has

gained 10 pounds, back to swimming and normal activities of daily living.

So I guess I'll end there. Yes, I want to acknowledge all these folks, especially

my good friend (Kevin Winthrop) for helping so much with the presentation,

and thank you very much.



Dr. David Ashkin:Sundari, thank you very, very much. You can't go anywhere though, Sundari.

You know, what I’d like to do now for a second I know we’re running late.

We’re going to go probably another five minutes or so to just entertain some

questions. And if you have any questions two things you could do operator

would you mind explaining how to unmute and ask a question by phone?

Operator: Sure, thank you. Ladies and gentlemen if you would like to register a question

please press the 1 followed by the 4 on your telephone. You will hear a three

tone prompt to acknowledge your request.

Your line will then be accessed from the conference to obtain your

information. If your question has been answered and you’d like to withdraw

your registration please press the 1 followed by the 3. If you are using a

speakerphone please lift your handset before entering your request. One

moment please for the first question.

Dr. David Ashkin:Operator is there a question there?

Operator: There is no question at this time.

Dr. David Ashkin:Okay fine. And then on the other way if you would like to just ask a question

via the chat if you push on the top where it says Q&A and follow the

directions on the screen right now. Click Q&A, type the question, click ask

and then we’ll be happy to answer it too.

Sundari, fantastic and thank you very much. You know, when you hear these

presentations, these case presentations to me there’s two things in common.

One is interestingly enough I think the good news is the word’s gotten out. I

think people for the most part are thinking TB and trying to screen for it.



The bad news is the same thing we face in TB is having a good test to screen

for TB. And what I think makes it worse actually is that we do TB all day

long, we feel comfortable with the inconsistencies of the skin test or

inconsistencies or the IGRA’s so we’re learning more.

What I think is making it more and more difficult right now is that a lot of the

people doing the screening are not familiar with TB, they’re not familiar with

skin tests, you know, rheumatologists, gastroenterologists and I wonder what

your opinion is? I think we may need to, how do we get the word out more

and how do, what do you think are some of the issues how we can improve it?

Sundari Mase: Yeah I think that’s a great point because these patient’s aren’t coming to us in

public health and TB control. They’re being seen in the community. And so

training and education for these groups of gastroenterologists, rheumatologists

in the community is a key thing.

But, you know, one could also argue that possibly these patient’s should be

referred to public health for evaluation or at least there should be consultation

with public health and TB control when the patient’s are seen in the private

office setting.

Dr. David Ashkin:Because I think one of the biggest problems is, you know, I think what we

really need is a definitive yes, no. The skin test I think for all the leaves a lot

of to desires, you know, like is that really a, you know, is that induration or is

it not or is it erythema or vice versa.

I mean one of the hardest things at least for my case as a TB person he had

risk factors, he had an x-ray. I probably would have started him no matter

what any of these tests but that’s something of years of experience, you know?



What about the IGRA’s? I think one advantage may even be that the IGRA’s

even though they may not be more sensitive or may be one of the nice things

they either for the most part are or not or even if they’re indeterminate it says

same TB still. What do you think about that?

Sundari Mase: Yeah. No I agree with you 100% and I don’t, you know, having reviewed the

literature I still don’t have a really good sense of which tests is necessarily

better. I mean when some places would use the skin test first if it’s positive

you’re done essentially you would think potentially if there is risk factors. I

don’t know what do you think about that the use of IGRA’s versus TST in this

setting?

Dr. David Ashkin:You know, I would almost say that in a high risk patient or a patient I’m really

concerned I may even try both.

Sundari Mase: Yeah.

Dr. David Ashkin:You know, and I agree but I’d also like to get it to somebody who has

experience. And I think one of the problems we’re having right now to be

honest with you and I’ve seen going forward, you know, we’re having a

rheumatologist, somebody - and nothing against them I mean but they don’t

do skin tests everyday. Our health departments do hundreds of skin tests a

month, you know?

Sundari Mase: Yeah.

Dr. David Ashkin:But the flop is on and then the answer is yes or no. I agree with Ivan I think

these are even though we don’t have to really lose sleep worry about but it is

concerning. I think we do need to screen adequately and I think we need a



better algorithm. And I do agree with you I think if there’s a question, there’s

a risk factor, you’re not so sure I think they need to get help.

Sundari Mase: Yeah I also think that in the setting of where you’re going to put someone on a

drug that significantly increases the risk of progression of the active disease

should we really be thinking false positive? I mean if you have a positive TST

this, although there are risks associated with treating LTBI it would be a hard

call to not treat it.

Dr. David Ashkin:I agree and here’s, you know, we’re getting some questions I’d like to read

some, you know, so it goes along where some of the questions we’re seeing

more patients who are having both the skin test and the IGRA for TB. What’s

your thought about this approach?

Sundari Mase: Right. I think as Dave just said, great approach I think if you’re able to do that

because the additive value of both tests is there.

Dr. David Ashkin:Well and I think again I think we’ve always got to look at in this situation just

like in HIV we’re looking for a high sensitivity, we’re looking for an excuse

to treat.

Sundari Mase: Exactly.

Dr. David Ashkin:And I would add not only just I think you’d agree skin tests and IGRA but in

this kind of case I do think there is a role for x-ray and risk factors. And I

think we need a simpler way to list those risk factors quick and this is what

you do because again we need a really high sensitivity. We really almost want

to almost opt towards treating.

Sundari Mase: I totally agree.



Dr. David Ashkin:So how, you know, again they kind of asked this question and you kind of

touched on it I think it was a great point. So how long would you start to, you

know, how long would you wait to restart the tumor necrosis factor and...

Sundari Mase: Yeah. Well this is the one where I had to, you know, call (Kevin Winthrop)

and he really felt in the setting of somebody that has a higher bacteriologic

burden waiting at least until culture conversion to ensure the person is going

in the right direction and ruling out drug resistant disease prior to starting the

TNF inhibitor is very important.

Dr. David Ashkin:And if I may from the lecture we heard today from Ivan remember something

very important, the immune system for the most part it doesn’t look like really

in most cases can kill TB, all it’s trying to is contain it. And that’s what the

inflammatory response is all about, that’s what the granuloma’s all about.

And what’s happening by using the tumor necrosis factor blocker or steroids

we’re stopping the body from being able to contain the infection, the infection

grows. But the antibiotics on the other hand they truly do kill TB.

So I think as long as we can get adequate amounts in there, you know, I guess

all of us would feel better if we gave it at least two weeks because two weeks

you’ve really declined the number of organisms tremendously. But if you

have no other alternative again all we’re doing is stopping the inflammation,

we’re not necessarily...

Sundari Mase: Right.

Dr. David Ashkin: ...causing it to grow more as long as the person is taking the meds and they’re

adequate meds.



Sundari Mase: Yes.

Dr. David Ashkin:And that’s why just real quickly another thing in these kind of cases I think

there is a role for rapid molecular therapy.

Sundari Mase: Absolutely, yeah.

Dr. David Ashkin:Because one thing you do need to do you need to make sure you’re getting

this person on adequate therapy...

Sundari Mase: Exactly, right.

Dr. David Ashkin: ...fast.

Sundari Mase: Right.

Dr. David Ashkin:And that’s why in my opinion in a case like this we need to know if a person

INH or, you know, rifampin sensitive because if they’re not you may need to

add more drugs.

Sundari Mase: Right before, definitely before restarting a TNF inhibitor.

Dr. David Ashkin:And, you know, and again I think there are a lot of questions which we totally

agree is the CDC implies to use one or the other, either IGRA or TST. Using

both as a compliment to each other seems a better approach, are there any

guidelines? And again...

Sundari Mase: There are no guidelines and for, I think it’s something that actually should

happen. I think that but, you know, guidelines are based on evidence-based



data and there isn’t a lot of evidence-based data. But it’s a great thought that

CDC should look at this like they looked at guidelines for the use of IGRA

that sort of thing and come up with some recommendations.

Dr. David Ashkin:And, you know, and for the last just because we’re running out of time I really

want to say something. Please if you have questions, if you, you know, if you

e-mail them to us or use the chat function we will answer them or at least as

best we can.

But I think it’s a great question to end this because I want to put you on the

spot, I want you to sweat. You know, you’ve come so far from Atlanta, it’s 30

degrees up there. I want to show you how hot -- you always hear about hot

Atlanta, I’m going to show you hot Florida.

Here’s a question for you and I’m running out of the room. (Sheila Allen) in

Tennessee says there’s a great interest in using the new 3HP regimen for

treating LTBI.

Sundari Mase: No.

Dr. David Ashkin:And given the study limitations, the study 26 in terms of representation of

immuno-compromised patient’s do you think it’s appropriate to use 3HP right

now in immuno-suppressed individuals like on Prednisone and tumor

necrosis? And actually I think actually (Sheila) - I like this (Sheila) asked it

but it’s actually from (John). And we got to get back at (John) this is a dirty

question.

Sundari Mase: I think so definitely. And I think you should run out of the room and I should

too. But well there was not a population that was studied in study 26 and so it



would be remiss to make a recommendation to use in this kind of population

until it’s studied and maybe it needs to be studied in an operational setting.

Dr. David Ashkin:You know, I want to tell you guys this is a hot topic and it’s something that I

think we’ll continue to see and we’re learning more and more. But I really do

think that the real challenge is not going to be on us, I think the real challenge

is that it’s happening in the community.

And again this is where I think the TB community, all of us who are listening

because right now we’re preaching to the choir I believe for the most part.

This is where we got to stand up I think and really prove or at least provide

the support that’s necessary to our community because again it’s all part of

TB control.

If we do not identify this population - these drugs are great drugs. They’re, as

you saw in your case they’re saving people’s lives, they’re making them

mobile again, they’re decreasing their suffering so much. But again like

anything there’s risk and we need to step up to make sure we minimize those

risks.

And so I’d like to really stop now and thank all of you so much for attending,

for being part of this and doing everything you do in TB control to try to fight

this disease which you do everyday.

I want to very much thank Ivan Fuss. Ivan did a great job I think in really

reviewing a very, very difficult topic and Sundari thank you for really

reviewing the clinical aspects so much. So first thanks to all of you. Thank

you very, very much.

Sundari Mase: Thank you.



Operator: Ladies and gentlemen...

Dr. David Ashkin:At 12:30 we’re going to have M and M. Please do me a favor, please

remember to fill out the evaluation so you can get your CMEs and CEUs. But

more importantly we really use these evaluations to make these programs

better. We really appreciate you joining us today.

In about 15 to 20 minutes we’ll be back for M and M a very, very interesting

case. We hope you can join us. Remember that what you have to do is you

have to sign off and then sign on to the URL, the address that’s been provided

to join us for M and M. Again we hope to really see all you guys here real

soon and thank you for participating. Have a great day. Thank you.

Operator: Ladies and gentlemen that does conclude the Webinar for today. We thank

you for your participation and ask that you please disconnect your line.

END

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