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New Mechanisms and Expanded Indications for Biologic Therapies: a Perspective on Immunology Research and Development

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New Mechanisms and Expanded Indications for Biologic Therapies: a Perspective on Immunology Research and Development New mechanisms_Layout 1 27/09/2010 13:57 Page 87 Therapeutics New mechanisms and expanded indications for biologic therapies: a perspective on immunology research and development Over the past decade, the introduction of biologic therapies has had a profound impact for millions of patients with immune-mediated arthritides, inflammatory bowel diseases and plaque psoriasis. Today, five anti-Tumor Necrosis Factor (TNF) therapies are approved in the United States and many countries around the world, and innovations in the TNF class continue more than a decade after the initial approval. Several other biologic therapies targeting distinct immune cell receptors or cytokines have been approved for immunologically mediated diseases, and many promising new biologic medicines are in various stages of clinical development. n this article I will provide an overview of adalimumab (HUMIRA®) for rheumatoid arthri- By Dr Susan B. Dillon some of the current trends influencing the tis (RA) in 1998 and 2002, respectively, the devel- I development of new biologics for immune- opment of anti-TNF biologics has continued. mediated and inflammatory diseases including Infliximab is now approved for 15 indications in 1) the continued clinical development of biologics the US (Table 1)1. In 2009, golimumab (SIM- targeting TNF-␣; 2) new mechanisms in inflamma- PONI®), a human monoclonal antibody (mAb) tion that are being explored in clinical trials and with once-monthly subcutaneous (SC) dosing 3) recent advances in the application of new bio- received approvals for RA, psoriatic arthritis logic therapies to an expanded list of indications (PsA) and ankylosing spondylitis (AS). Another with high unmet medical need. agent, certolizumab (CIMZIA®) was also approved for RA in 2009, bringing the total num- Continued development of TNF ber of approved anti-TNF therapies to five agents biologics for immune-mediated disease (Table 2)2-5. Thus, it has been firmly established Since the initial approval of infliximab (REMI- that TNF is an important pathogenic mediator in CADE®) for Crohn’s disease in 1998 and the sub- a number of autoimmune and inflammatory dis- sequent approvals of etanercept (ENBREL®) and eases, a fact that was not fully appreciated before Drug Discovery World Fall 2010 87 New mechanisms_Layout 1 27/09/2010 13:57 Page 88 Therapeutics Table 1: Infliximab approved indications1 predict the likelihood that an individual will have both an initial and durable response to anti-TNF DATE INDICATION therapy. A variety of potential demographic, clini- cal, radiological, blood, genetic or synovial tissue 1998 Crohn’s disease – luminal and fistulising markers has been studied. High local (synovial) and systemic levels of TNF-␣ appear to be corre- 1998 Rheumatoid arthritis signs and symptoms (MTX failures) lated with good clinical response although valida- tion by further studies is needed8,9. 2000 Rheumatoid arthritis structural damage Molecular profiling and genetic association (MTX failures) studies have potential for identification of markers which predict response to treatment. While these 2002 Rheumatoid arthritis physical function approaches have produced tantalising results, pub- (MTX failures) lished studies to date have been small and remain to be prospectively validated in large clinical 2002 Crohn’s disease maintenance (luminal) cohorts10-12. The paradigm of identifying respon- 2003 Crohn’s disease maintenance (fistulising) der populations may also be applicable to inflam- matory bowel diseases, where gene expression sig- 2004 Rheumatoid arthritis signs and symptoms, natures have been identified that correlate to TNF- x-ray progression, physical function ␣ response and non-response in ulcerative colitis (MTX naïve) (UC) patients treated with infliximab13. 2004 Ankylosing spondylitis signs and symptoms The failure of many patients to initially respond or maintain a response to therapy with an anti- 2005 Psoriatic arthritis signs and symptoms TNF agent has also led to research into the poten- tial of switching within the class. Patients who fail 2005 Ulcerative colitis to respond to one or more anti-TNF therapies may respond to another, as was demonstrated by results 2006 Pediatric Crohn’s disease of the G0-AFTER study of golimumab in RA 2006 Psoriatic arthritis structural damage patients previously treated with one or more TNF inhibitors14. More than a third of the patients 2006 Psoriatic arthritis physical function whose prior anti-TNF therapy had been discontin- ued due to lack of efficacy achieved an ACR20 2006 Chronic severe plaque psoriasis response to golimumab. A recent report of infliximab in the Study of 2006 Ulcerative colitis maintenance Biologic and Immunomodulator Naïve Patients in Phase III Pediatric ulcerative colitis Crohn’s (SONIC) compared infliximab, azathio- prine and the combination of both drugs in Indications refer to approvals from the Food and Drug Administration (FDA) for the US only patients with moderate to severe Crohn’s disease who had not received prior immunosuppressive or biologic therapies. Patients receiving infliximab- the era of anti-TNF biologic therapies. Even with containing regimens were more likely to experience these advances, however, there is still great poten- clinical remission without the use of steroids and tial for further innovations with the TNF class. demonstrated improved mucosal healing15. Based In RA, approximately 60% of biologic naïve on this landmark study, the American College of patients with an inadequate response to disease Gastroenterology guidelines on the management of modifying anti-rheumatic drugs (DMARDs) Crohn’s disease now recommend infliximab with (depending on the specific patient population, ther- or without azathioprine as more effective than aza- apeutic, trial design and other variables) achieve a thioprine alone in the treatment of patients with 20% improvement in disease activity according to moderate to severe Crohn’s disease who have failed the American College of Rheumatology criteria to respond to first-line steroid or 5-aminosalicylic (ACR20) with anti-TNF treatment6, and even acid (5-ASA) therapy16. fewer (less than 20%7) achieve clinical remission, Anti-TNF agents have transformed treatment of defined as maintenance of an ACR70 response for immune disease. After more than a decade of suc- at least six months. This, and the fact that many cessful application of anti-TNF treatment in a mul- patients lose response over time, has prompted titude of inflammatory diseases, we continue to research into the identification of biomarkers to study and to learn more about these drugs. Clinical 88 Drug Discovery World Fall 2010 New mechanisms_Layout 1 27/09/2010 13:57 Page 90 Therapeutics investigations are currently under way in new indi- bodies and receptor fusion proteins with alterna- cations and to extend use paradigms in approved tive (non-TNF-␣) mechanisms that have received indications. Basic research studies continue to approvals in many of the same indications for define exactly how these agents work to modulate which infliximab was approved. Rather than dis- the immune system, and biomarker efforts are in cuss the mechanisms for these therapeutics, which progress to identify predictive markers of response. are extensively reviewed elsewhere, this report will All of these investigations provide new data to focus on new mechanisms in clinical development. optimise and extend usage of these powerful ther- Cytokines involved in both innate immune apeutic agents. responses and in the regulation of B and T lym- phocyte adaptive immune responses, such as IL-12, Targeting new mechanisms in IL-23, IL-17 and IL-6, have become the focus for inflammation new antibody targets. IL-12 was initially identified The successes achieved with anti-TNF biologics for as a factor involved in several immune activities the treatment of a collection of immune-mediated including the induction of cytotoxic T lymphocytes diseases impacting the joints, intestinal tract and (CTL) and lymphokine-activated killer cells skin have encouraged the search for new therapeu- (LAKs) and the augmentation of natural killer cell tic targets that may impact these organ systems and mediated toxicity21,22, and it is now recognised as others that are affected in immunologic disorders. an important cytokine in driving differentiation of TNF-␣ is produced by multiple cell types, most Th1 cells. The hallmark cytokine produced by Th1 notably by macrophages as part of the innate cells, Interferon ␥, along with TNF-␣, play an immune response to pathogens and other inflam- important role in protecting against infection and matory stimuli. In addition to playing an impor- in contributing to autoimmune disease pathology. tant role in host defence against infection and can- The more recent discovery of the IL-12 family cer, TNF-␣ has many biologic activities that pro- member IL-23 was crucial to the identification of mote inflammation, including increasing the Th17 cells, which also contribute to autoimmuni- expression of adhesion molecules (ICAM, VCAM) ty23. The genetic and human translational studies on keratinocytes and endothelial cells17, inducing implicating Th1 and Th17 cells in diseases has led the expression of other inflammatory cytokines to the focus on antibodies blocking the activities of (such as IL-1, IL-6 and, IL-8)18, and inducing IL-12, IL-23 and IL-17. VEGF expression, which increases angiogenesis at sites of inflammation19. All of these activities have IL-12/IL-23 the combined effect of increasing
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