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New Therapeutic Strategies for Treatment of Inflammatory Bowel Disease

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New Therapeutic Strategies for Treatment of Inflammatory Bowel Disease nature publishing group REVIEW New therapeutic strategies for treatment of inflammatory bowel disease R A t r e y a 1 a n d M F N e u r a t h 1 Although the precise etiology of inflammatory bowel disease (IBD) still remains unclear, considerable progress has been made in the identification of cytokine-mediated signaling pathways involved in the inflammatory process. Recent data have clearly shown that these pathways induce augmented intestinal T-cell activation and thus resistance to apoptosis, which is a central process in disease pathogenesis, as it impairs mucosal homeostasis. Therefore, novel therapeutic strategies aim at restoring activated effector T-cell susceptibility to apoptosis in the gut, based on a pathophysiological rationale. This development is best exemplified by the emergence of agents that target the TNF pathway, IL-6 trans-signaling, and the IL-12 / IL-23 pathway. These compounds give hope for the development of new strategies aiming at more effective and less toxic therapies for IBD. INTRODUCTION insufficient for a large subgroup of patients, as population-based Inflammatory bowel diseases (IBD) comprise Crohn ’ s disease studies have proven that a significant fraction of corticoster- and ulcerative colitis, which are defined as chronically relapsing oid-treated Crohn ’ s disease patients develop steroid dependency inflammations of the gastrointestinal tract not due to specific or even steroid-refractory illness, 5 while the need for surgical pathogens.1 While Crohn ’ s disease is a multifocal, transmural intervention has apparently remained unchanged. 6 The mod- inflammatory process that can affect any part of the digestive erate therapeutic effect and the possible association with severe tract, ulcerative colitis is characterized by a superficial, con- side effects of these drugs demonstrated the necessity for a more tinuous inflammation, which is limited to the large intestine. sustained therapeutic response, which can only be the result of a Although the precise etiology of IBD still remains obscure, more comprehensive approach in targeting critical points of signal extensive studies in the past decade have gradually unravelled transduction pathways involved in the inflammatory cascade. 7 several factors contributing to disease pathogenesis. Recent advances in understanding the underlying immuno- Genetic predisposition, environmental factors, infectious pathogenetic mechanisms of disease in IBD have led to the agents, impairment of local tolerance, and mucosal imbal- development of biological therapies, which selectively inhibit ance with ongoing activation of the intestinal immune system crucial mediators of the inflammatory process. These thera- have been implicated in IBD pathogenesis. 2 Current concepts peutic strategies are based on the conception that uncontrolled are based on a genetic susceptibility, which is modulated by activation of central effector cells in the gut is the pivotal patho- various environmental factors,3 resulting in the deregulation genic mechanism involved in the initiation and perpetuation of the host ’ s immune response to the indigenous intestinal of the inflammatory reaction.8,9 There is consensus that CD4 + flora. This leads to excessive activation of the intestinal immune T cells are the main activated immune cells involved in IBD system, which ultimately causes pathogenic gastrointestinal pathogenesis, which are characterized by enhanced prolifera- inflammation and tissue damage.4 tion and trafficking into the intestinal mucosa. 4 This aberrant The exact pathogenic mechanisms involved are nevertheless T-cell activation is also characterized by alterations in cytokine still incompletely understood and therapeutic strategies thus production, resulting in a disturbed balance between pro- and far have been limited to mostly evidence-based principles. The anti-inflammatory cytokines.10 Deregulated cytokine profiles conventional treatment options for IBD were corticosteroids and are currently an important focus of both clinical and basic immunosuppressive agents like azathioprine, which ameliorate research in IBD, which reflects their heightened importance the inflammatory process. However, corticosteroids have been for the development of new therapeutic strategies. 1 Institute of Molecular Medicine and I. Medical Clinic, University of Mainz, Mainz , Germany . Correspondence: MF Neurath ([email protected] ) Received 21 December 2007; accepted 31 January 2008; published online 5 March 2008. doi:10.1038/mi.2008.7 MucosalImmunology | VOLUME 1 NUMBER 3 | MAY 2008 175 REVIEW Augmented lamina propria T-cell activation, and thus resist- findings were supported by results from another group showing ance to apoptosis, has been identified as a key factor in IBD that infliximab induced apoptosis in a CD3 / CD28-stimulated pathogenesis, as it impairs mucosal homeostasis and leads T-cell line (Jurkat T-cells), whereas this effect was not visible to unrestrained accumulation of activated lymphocytes that in unstimulated cells. Upon anti-TNF treatment the stimulated perpetuate the inflammatory response. 9,11,12 On the basis of Jurkat T cells showed heightened levels of Bax expression, result- these findings, which have elucidated the main cellular and ing in an increased Bax / Bcl2 ratio and subsequent apoptosis.28 molecular mechanisms involved in gut inflammation, novel These data are supported by recent findings indicating that therapeutic strategies evolved that specifically modify the aber- adalimumab is also able to induce apoptosis in vitro i n rant immune response. In the following sections, therapeutic peripheral blood monocytes. 29 implications of recent advances made in the understanding of Further experiments also examined the effect of infliximab on the mechanisms that confer resistance to apoptosis in intestinal lamina propria T cells at the site of intestinal inflammation. For CD4 + T cells in IBD are discussed and potential targets for that purpose, intestinal biopsies were taken from macroscopi- future therapeutic strategies are presented. cally inflamed areas of Crohn ’ s disease patients before and 24 h after a single infusion of infliximab. It could be shown that this INDUCING APOPTOSIS BY TARGETING TNF- treatment similarly leads to induction of intestinal T-cell apop- The proinflammatory cytokine tumor necrosis factor- (TNF- ) tosis. 28 These data were confirmed by other data showing that is mainly produced by activated macrophages and lymphocytes infliximab induced sustained apoptosis in lamina propria T cells and exists as a transmembrane protein (membrane-bound TNF of patients with Crohn ’ s disease, which was still detectable four (mTNF)), from which the soluble form (sTNF) is released via weeks after the last application. Correspondingly, infliximab also proteolytic cleavage by the TNF- -converting enzyme. Secreted induced apoptosis in cultured intestinal T cells from Crohn ’ s TNF exerts its biological functions via two distinct cell surface disease patients in a Fas-independent manner.30,31 These data receptors, tumor necrosis factor receptor 1 (TNFR1) (p55) and led to the concept of an apoptosis-inducing effect of anti-TNF- TNFR2 (p75).13,14 mTNF can further activate target cells via antibodies in lamina propria mononuclear cells, explaining cell – cell contact via TNFR2. Moreover, TNFR2 is able to ligate their clinical efficacy in the treatment of Crohn ’ s disease. In this mTNF on the opposing cell and subsequently trigger signal concept, reverse signaling through mTNF in intestinal T cells, transduction from the mTNF molecule to the nucleus. Due to elicited by mTNF-bound -TNF antibodies, results in the induc- its bipolar function, mTNF can not only act as a ligand, but also tion of caspase-dependent induction of apoptosis in intestinal confer reverse signaling into cells expressing this molecule.14 T cells in Crohn ’ s disease27,32,33 ( Figure 1 ). In accordance with its implication as a mediator of inflam- In contrast to this predominant paradigm, other data could mation in many autoimmune diseases, several studies have not show induction of apoptosis in infliximab-treated peri- demonstrated that the production of the proinflammatory pheral blood monocytes from Crohn ’ s disease patients, cytokine TNF- is elevated in the intestinal mucosa and serum thereby contradicting the results of the groups mentioned of IBD patients.15 – 18 Accordingly, this cytokine has been consid- above. 34 Furthermore, the clinically effective anti-TNF agent ered as an attractive target for the treatment of IBD, and several certolizumab,23 in contrast to other anti-TNF- agents tested anti-TNF agents have subsequently been developed. Among (infliximab, adalimumab, and also etanercept), did not mediate these, infliximab (a chimeric IgG1 monoclonal antibody), adali- increased levels of apoptosis in peripheral blood monocytes or mumab (a recombinant human IgG1 monoclonal antibody), and lymphocytes. 35 On the other hand, perhaps the most compel- certolizumab pegol (a pegylated humanized Fab ’ fragment ling evidence for the apoptosis-inducing modality of - T N F monoclonal antibody) have proven their therapeutic effect in agents in Crohn ’ s disease comes from a very recent study imag- several studies of patients with Crohn ’ s disease. 19 – 24 This thera- ing apoptosis in vivo. This method relies on the use of labeled peutic strategy has meanwhile established itself as an important annexin V, which binds to apoptotic cells and is imaged by option to induce
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