Lymphopenia made simpletriMS.online 2020

Gavin Giovannoni, MBBCh, PhD

Disclosures

● Over the last 5 years I have received personal compensation for participating in advisory boards in relation to clinical trial design, trial steering committees, and data and safety monitoring committees from:

○ AbbVie, Actelion, Atara Bio, Biogen, Celgene, Sanofi Genzyme, Genentech, GSK, MSD, Merck Serono, Novartis, Roche, Synthon BV and Teva

2

What is lymphopenia?

WHO grading system

Grade 0/normal > 1000/mm3

Grade 1 800–999/mm3

Grade 2 500–799/mm3

Grade 3 200–499/mm3

Grade 4 < 200/mm3

4

WHO grading system

Immunosuppression

Immune competence

Grade 0/normal > 1000/mm3

Grade 1 800–999/mm3

Grade 2 500–799/mm3

Grade 3 200–499/mm3

Grade 4 < 200/mm3

5

WHO grading system

Immunosuppression

Immune competence

Grade 0/normal > 1000/mm3

Grade 1 800–999/mm3

Grade 2 500–799/mm3

Grade 3 200–499/mm3

Grade 4 < 200/mm3

HPV, human papilloma virus; TB, tuberculosis; VZV, varicella zoster virus 6

Deficit Bacteria Fungi Viruses Parasites

Neutrophil deficitsa

• Enteric gram-negative bacteria

• Staphylococcus

• Candida• Mucormycosis• Aspergillus

Abnormal T cells or monocytes

• Mycobacteria• Nocardia• Listeria

• Cryptococcus• Histoplasmosis• Blastomycosis• Coccidioidomycosis

• Herpes: HSV1; HSV2; CMV; VZV

• JC virus

• Toxoplasmosis• Strongyloides

Disorders of humoral immunity

• Streptococcus pneumoniae

• Neisseria meningitidis• Haemophilus

influenzae

Risk of infections with MS treatments can vary depending on the effects on the immune system and specific immune cell types

Immune cells and infection types

7aAbsolute neutropenia or functional abnormalities. CMV, cytomegalovirus; VZV, varicella zoster virus; JC, John Cunningham Berger J: Neurological complications of systemic illness. Noseworthy J (ed.) Neurological Therapeutics: Principles and Practice. 2nd Edition. Informa Healthcare. 2006

Maintenance vs

immune reconstitution therapies

No treatments between courses

Immune reconstitution

ImmunodepletionImmune

reconstitution

MS MSwashoutLow-to-high efficacygradual-onset of action

EDA vs MEDA vs NEDA

Maintenance therapy (IFNβ, glatiramer acetate, natalizumab, fingolimod, dimethyl fumarate, teriflunomide, ocrelizumab)

Consolidation and/or maintenance therapy

Induction therapy (mitoxantrone followed by IFNβa/Glatiramer acetate)MS

NEDA

High efficacyinduction therapy

MS in remission (long-term/?cure)

MS in remission (long-term/?cure)

Immune reconstitution therapy (mitoxantrone, alemtuzumab, cladribine, HSCT) MS

Course 1Course 2

ImmunodepletionNEDA

Add-on low-to-high efficacy

MEDA vs NEDA

MS MSwashout

Low-to-high efficacygradual onset of action

EDA

Combination maintenance therapy (dimethyl fumarate etc.)

9EDA, evidence of disease activity; HSCT, haematopoietic stem cell transplantation; NEDA, no evidence of disease activity; MEDA, minimal evidence of disease activity. Giovannoni G. Curr Opin Neurol 2018;31:233–43

What is a maintenance therapy?

1. Onset of actionRapidity of onset of action of

immunomodulation or immunosuppression depends

on the type of therapy

2. Maintenance phaseVariable degrees of

immunomodulation or immunosuppression depending

on the type of therapy

3. Washout phaseReversal of immunological effects. This period varies

depending on type of therapy

1

2

4

4. Disease stateRecrudescence of the MS disease state. With some agents there is

rebound, i.e. disease activity greater than that seen at baseline

3ImmunocompetentMS disease activity

Giovannoni G. Curr Opin Neurol 2018;31:233–43 10

What is an immune reconstitution therapy (IRT)?

11Giovannoni G. Curr Opin Neurol 2018;31:233–43

1. Reduction phaseVariable degrees of Immunosuppression

depending on the type depletion; selective vs non-selective

2. Repopulation phaseDynamic process, but variable

depending on the specific agent

Immune competentNo MS disease activity

3. Reconstitution phaseLong-term qualitative changes in

immune function

1 2

3

0. BaselineAbnormal immune system The 3 Rs

Immunosuppression and de-risking strategies

1) Interferon-β2) Glatiramer acetate3) Mitoxantrone4) Natalizumab (selective

compartment)5) Fingolimod and other S1P

modulators6) Teriflunomide7) Dimethyl fumarate8) Alemtuzumab9) Daclizumab10) Ocrelizumab (anti-CD20)11) Cladribine (purine analogue)

Immunosuppression: reduction of the activation or efficacy of the immune system

● This definition refers to short-term (IRTs) and long-term persistent immunosuppression (maintenance)

● For a drug to be considered an immunosuppressant it should: ○ cause significant lymphopenia

○ be associated with opportunistic infections

○ reduce the antibody response to vaccines

○ be associated with secondary malignancies

IRT, immune reconstitution therapy; S1P, sphingosine 1-phosphate 13

Short-term (e.g. alemtuzumab, cladribine, HSCT)Continuous (e.g. natalizumab, fingolimod)

Immunosuppression

14Refer to each respective Summary of Product Characteristics for full safety information. Az, alemtuzumab; Ca, carcinoma; HSCT, haematopoietic stem cell transplantation; PCP, pneumocystis pneumonia; TB, tuberculosis1. Sheikh-Taha M et al. Mult Scler 2017;23:872–4. 2. Yann et al. Mult Scler Relat Disord 2017;14:1–3

Basal Cell Ca

Zoster

Cumulative risk

Frontloading risk

Listeria

TB

Nocardia1

Lymphoma

Cryptococcosis

2° autoimmunity post- Az

Acute immunosuppression: innate and T-cellChronic immunosuppression

PCP2

1. Persistent immunosuppression

2. Risk increases with time (cumulative)

a. Increase risk of PML (complex pathogenesis)

b. Increased risk of other opportunistic infections

c. Increased risk of secondary malignancy

3. Live vaccines contraindicated

4. High-risk of exotic infections

a. Dengue fever

b. Zika virus

c. Etc.

5. Pregnancy not recommended

6. Long-term burden of pharmacovigilance

1. Short-term immunosuppression

2. Risk short-term (front-loaded)

a. Low risk of PML

b. Low risk of other opportunistic infections

c. Low risk of secondary malignancy

3. Live vaccines not necessarily contraindicated

4. Low-risk of exotic infections if travel occurs after immune reconstitution

5. Pregnancy safe post immune reconstitution

6. Less of a pharmacovigilance burden

Immunosuppression

15HSCT, haematopoietic stem cell transplantation; PML, progressive multifocal leukoencephalopathy

Short-term (e.g. alemtuzumab, cladribine, HSCT)Continuous (e.g. natalizumab, fingolimod)

WHO grading system

Grade 0/normal > 1000/mm3

Grade 1 800–999/mm3

Grade 2 500–799/mm3

Grade 3 200–499/mm3

Grade 4 < 200/mm3

Immunosuppression

Immune competence

16

WHO grading system: S1P-modulator fingolimod

17S1P, Sphingosine-1-phosphate1. Francis et al. Mult Scler 2014;20:471–80

Immunosuppression

Immune competence

Infections not linked to level of lymphopenia1; therefore you

need DMT-specific knowledge

Grade 0/normal > 1000/mm3

Grade 1 800–999/mm3

Grade 2 500–799/mm3

Grade 3 200–499/mm3

Grade 4 < 200/mm3

Lymphocyte dynamics

Natalizumab

Stop Natalizu

mab

LLN, lower limit of normal 19

Lym

phoc

yte

coun

t rel

ativ

e to

bas

elin

e (%

)

Impact of EID versus SID on PML risk

20The approved dosing schedule of natalizumab is 300 mg every 4 weeks CI, confidence interval; EID, extended interval dosing; HR, hazard ratio; PML, progressive multifocal leukoencephalopathy; SID, standard interval dosingZhovtis Ryerson Z et al. Neurology 2019;93:e1452-e1462

13132 7850 2775 2961988 1502 700 113

0 9 68 890 0 1 3

Number of patients at risk

Cumulative number of PML cases

94% reduction in PML riskHR (95% CI): 0.06 (0.014–0.225)

P < 0.001

0 12 24 3 6 4 8 6 0 72 8 4 9 6 10 8 120

Natalizumab exposure (months)Cum

ulat

ive

risk

of P

ML

(per

100

0)

Primary EID definitionTests whether dosing history in the last 18 months of

natalizumab treatment affects PML risk

Log-rank test: p < 0.0001

SID groupEID group

0

10

20

3 0

4 0

Receptor occupancy: SID vs EID

21The approved dosing schedule of natalizumab is 300 mg every 4 weeksEID, extended interval dosing; NTZ, natalizumab; RO, receptor occupancy; SID, standard interval dosingFoley J et al. Mult Scler Relat Disord 2019;31:65-71

RO is significantly reduced in the EID cohort

Serum concentrations roughly correlate with RO

𝛼𝛼4 in

tegr

in re

cept

or

occu

panc

y(%

of t

otal

)

𝛼𝛼4 in

tegr

in re

cept

or

occu

panc

y(%

of t

otal

)

87.4% 78.2

%

PK/PD data suggests that efficacy can be maintained with 70% saturation of α4-integrin

120

100

80

60

40

20

0

100

80

60

40

20

0

Range of α4 -inte grin binding value s

Me an α4 -inte grin binding

% of subje cts with Gd+ le s ions

Cum

ulat

ive

prop

ortio

n pa

tient

s w

ith >

1 G

d+ le

sion

, %

Med

ian α4

-inte

grin

bin

ding

, %

0 4 8 12 16 20 24 28

Time (weeks)

Analysis of patients who had received 300 mg natalizumab IV for > 12 months prior to the suspension of natalizumab dosing and then received placebo every 4 weeks for 28 weeks. The last natalizumab dose was administered on day 0. 4 integrin saturation was determined weekly in a subset of patients switched to placebo (n = 11). MRIs were performed every 4 weeks in all patents switched to placebo (n = 42)Gd+, gadolinium-enhancing; MRI, magnetic resonance imaging; PK/PD, pharmacokinetic/pharmacodynamicPlavina T et al. Neurology 2017;89:1–10

α

22

Lym

phoc

yte

coun

t rel

ativ

e to

bas

elin

e (%

)Fingolimod

Stop Fingolimod

rapid reconstitution

23LLN, lower limit of normal

Grade 0 / Normal

> 1,000/mm3

Grade 1 800-999/mm3

Grade 2 500-799/mm3

Grade 3 200-499/mm3

Grade 4 <200/mm3

Giovannoni et al. Pract Neurol. 2016 Oct;16(5):389-93.

3-4/52s - low risk of rebound

6-8/52s - high risk of rebound

E.g. cladribine, alemtuzumab, anti-CD20

Coss-Rovirosa F et al. MSARD 2020;40:101938 24

Dimethyl fumarate

Stop dimethyl fumarate

Slow reconstitution

25GDP, guanosine 5'-diphosphate; LNN, lower limit of normal

Lym

phoc

yte

coun

t rel

ativ

e to

bas

elin

e (%

)

ALCs following DMF discontinuation

DMF, delayed release DMF (also known as gastro-resistant DMF)ALC, absolute lymphocyte count; DMF, dimethyl fumarate; LLN, lower limit of normalFox RJ et al. Neurol Clin Pract 2016;6:1–10 26

DMF 240 mg tid (n = 3) on drugDMF 240 mg bid (n = 6) postdosing

DMF 240 mg tid (n = 3) postdosing

DMF 240 mg bid (n = 6) on drug

Cell lysis● Cytokine release syndrome● Moderate to severe IFRs● Need for corticosteroids

Anti-CD20 (ocrelizumab)

27IFR, instantaneous wave-free ratio

Ocrelizumab

28Ca, cancer; PML, progressive multifocal leukoencephalopathy; VZV, varicella zoster virus1. Crawford A et al. J Immunol 2006;176:3498–506; 2. Bar-Or A et al. Ann Neurol 2010;67:452–61; 3. Lisak RP et al. J Neuroimmunol 2012;246:85–95; 4. Weber MS et al. Biochim Biophys Acta 2011;1812:239–45; 5. Serafini B et al. Brain Pathol 2004;14:164–74; 6. Magliozzi R et al. Ann Neurol 2010;68:477–93

Carry-over PML

Breast Ca

VZV & herpes

Pre-vaccination

Geo

met

ric m

ean

titre

(IgG

IU/m

L)

4 weekspost-vaccination

8 weekspost-vaccination

Anti-tetanus titre

Protective titre level

Humoral responses to antigens present but attenuated following anti-CD20 (ocrelizumab) treatment

29Triangles denote KLH administration. DMT, disease modifying treatment; Ig, immunoglobulin; IFN, interferon; KLH, keyhole limpet; OCR, ocrelizumab;PPV, pneumococcal polysaccharide vaccine1. Stokmaier D et al. Presented at AAN 2018 (Platform presentation S36.002); 2. Ocrelizumab Summary of Product Characteristics, Sept 2018

Positive response to number of S. pneumoniaeserotypes 4 weeks after 23-PPV administration

Number of S. pneumoniae serotypes

100

100

100

100

Prop

ortio

n of

pa

tient

s (%

)

≥2 ≥3 ≥4 ≥5 ≥12 A/California/7/2009(H1N1)

B/Phuket/3073/2013

A/Switzerland/9715293/2013

(H3N2)

B/Brisbane/60/2008

A/Hong Kong/4801/2014

2535

2233

2030

1018

45

3233

2531

2527

1216

56

Seroprotection to individual influenza strains

Post-administration week

Prior Week 4 Week 12Week 8

Geo

met

ric m

ean

titre

uni

ts (I

gM) IgM responses to KLH neoantigen

OCR (all)Control (IFNβ or no DMT)

Rituximab-induced changes in hematolymphoid tissues

30H&E, hematoxylin and eosinCioc et al. Am J Clin Pathol 2008;130:604–12

Control Anti-CD20 (rituximab)

H&E H&E CD79a

CD3 CD3Pax5 Pax5

CD79a

Measles, mumps and rubella (MMR)

MMR: children vaccinated in England, 2007-08 to 2017-18 Credit: PA Graphics 31

Cell lysis● Cytokine release syndrome● Moderate to severe IFRs● Need for corticosteroids

Immunosuppression● Herpes reactivation

● HSV, Zoster● CMV reactivation

• PCP

T-cell dynamicsNo cell lysis - death due to apoptosis● No IFRs● No steroids

No T-cell immunosuppression● VZV● No opportunistic infections

CMV, cytomegalovirus; HSV, herpes simplex virus; IFR, instantaneous wave-free ratio; LLN, lower limit of normal; PCP, pneumocystis pneumonia; VZV, varicella zoster virus 32

Homeostatic B-cell hyperproliferation● Bone marrow derived naive

Hypothesis: no T-cell regulation● Substrate for secondary autoimmunity

T-cell and B-cell dynamics

33

No B-cell hyperproliferationB cells more sensitive than T cells to cladribine

T-reg therefore not 2°autoimmunity

Qualitative changes: alemtuzumab and cladribine suppress memory B cells

34IRT, immune reconstitution therapy

Non-selective IRT Selective IRT

Persistent depletion of memory B cells

Qualitative innate immune changes: alemtuzumab and cladribine

35IRT, immune reconstitution therapy

Minimal impact on innate immunity therefore no acute bacterial infection signalAcute monocytopenia in combination with lymphopenia

is the substrate for increased risk of Listeriosis within the first 4 weeks

Non-selective IRT Selective IRT

36www.clinicspeak.com

Listeria

Nocardia

PCP

www.theabn.org 37

Adaptive immunity (memory)

T cells

B cells

Innate immunity (hard-wired)

Neutrophils

Monocytes

Dead cells

Regulatory cells

Cell lysis (heat-seeking missile)

Apoptosis (slow death from poisoning)

Alemtuzumab vs Cladribine vs Ocrelizumab

Semi-selectiveNon-selective Selective38

De-risking

De-risking immunosuppressionBaseline

1. FBC – leukocytes/platelets2. LFTs, U&E, TFTs, urine3. Pregnancy tests4. Immunoglobulin levels5. Serum protein electrophoresis6. Serology

a. JCVb. HIV-1&2c. Hepatitis B&Cd. VZVe. Syphilisf. TB Elispotg. ?MMR

7. Cervical smear8. Vaccinations

a. VZVb. ?HPVc. ?MMR

9. MRI10. LP - CSF analysis sequencing11. Listeria, PCP, Nocardia prophylaxis

a. Dietb. Prophylactic antibiotics

Infusion-DMTs & IRTs1. Infusion reactions

a. Corticosteroidsb. Antihistaminesc. Antipyretics

2. Antibioticsa. Anti-herpes

i. Valacyclovirii. Famciclovir

b. Listeria/PCP prophylaxisi. Co-trimoxazole

Monitoring

1. Bloodsa. FBC - leukopeniab. TFTs, LFTs, U&E etc.

2. Urinea. Autoimmuneb. Renal dysfunction

3. MRIa. Disease activityb. PML

4. Infectiona. Serologyb. CSF

5. Disease activity6. Pregnancy7. Malignancy

a. Skin, cervical, breastb. Etc.

1

2

3

40

A new DMT classification system

Immunomodulation ▪ ▪ ▪ ▪ Immunosuppression

Non-de-risked immunosuppressive METFingolimod

Ocrelizumab

MET that results incontinuous immunomodulation

Non-immunosuppressiveInterferonβ

Glatiramer acetate

Potentially non-immunosuppressive

Teriflunomide

MET that results in continuous immunosuppression

Chronic therapy that is maintained and/or escalated over time resulting in changes in immune function only during active treatment

Maintenance/escalation therapy (MET) Immune reconstitution therapy (IRT)

Short course therapy resulting in long-term qualitative changes in immune function

CladribineMitoxantroneAlemtuzumab

HSCT

IRT that affects both theinnate and adaptive immune

systems

IRT that selectively affects the adaptive immune system

Non-selective IRT(NIRT)

Selective IRT(SIRT)

De-risked immunosuppressive METNatalizumab

Dimethyl fumarate

New classification of DMTs for relapsing forms of MS

DMT, disease-modifying therapy; IRT, immune reconstitution therapy; HSCT, haematopoietic stem cell transplantation; MET, maintenance/escalation therapyGiovannoni G. Curr Opin Neurol 2018;31:233–43

42

Conclusions

● Changing therapeutic landscape (more complex and more choice)● DMTs can be classified as being either maintenance or IRTs

○ IRTs (selective or non-selective)

● DMTs immunomodulatory and/or immunosuppressive○ Long-term/maintenance vs. short-term/induction

● Lymphopenia important○ Context specific (level, qualitative changes, duration, environment, age etc.)

○ DMT specific knowledge (different lymphocyte dynamics)

● De-risking strategies (baseline screening, monitoring, timely switching etc.)● Databasing (pharmacovigilance monitoring, pregnancy, registries)● Education

43