Reversibility of the effects of natalizumab on peripheral immune cell dynamics in MS patients

Tatiana Plavina, Kumar Kandadi Muralidharan, Geoffrey Kuesters, Daniel Mikol, Karleyton Evans, Meena Subramanyam, Ivan Nestorov, Yi Chen, Qunming Dong, Pei-Ran Ho, Diogo Amarante, Alison Adams, Jerome De Sèze, Robert Fox, Ralf Gold, Douglas Jeffery, Ludwig Kappos, Xavier Montalban, Bianca Weinstock-Guttman, Hans-Peter Hartung, Bruce A C Cree, Tatiana Plavina, Kumar Kandadi Muralidharan, Geoffrey Kuesters, Daniel Mikol, Karleyton Evans, Meena Subramanyam, Ivan Nestorov, Yi Chen, Qunming Dong, Pei-Ran Ho, Diogo Amarante, Alison Adams, Jerome De Sèze, Robert Fox, Ralf Gold, Douglas Jeffery, Ludwig Kappos, Xavier Montalban, Bianca Weinstock-Guttman, Hans-Peter Hartung, Bruce A C Cree

Abstract

Objective: To characterize the reversibility of natalizumab-mediated changes in pharmacokinetics/pharmacodynamics in patients with multiple sclerosis (MS) following therapy interruption.

Methods: Pharmacokinetic/pharmacodynamic data were collected in the Safety and Efficacy of Natalizumab in the Treatment of Multiple Sclerosis (AFFIRM) (every 12 weeks for 116 weeks) and Randomized Treatment Interruption of Natalizumab (RESTORE) (every 4 weeks for 28 weeks) studies. Serum natalizumab and soluble vascular cell adhesion molecule-1 (sVCAM-1) were measured using immunoassays. Lymphocyte subsets, α4-integrin expression/saturation, and vascular cell adhesion molecule-1 (VCAM-1) binding were assessed using flow cytometry.

Results: Blood lymphocyte counts (cells/L) in natalizumab-treated patients increased from 2.1 × 109 to 3.5 × 109. Starting 8 weeks post last natalizumab dose, lymphocyte counts became significantly lower in patients interrupting treatment than in those continuing treatment (3.1 × 109 vs 3.5 × 109; p = 0.031), plateauing at prenatalizumab levels from week 16 onward. All measured cell subpopulation, α4-integrin expression/saturation, and sVCAM changes demonstrated similar reversibility. Lymphocyte counts remained within the normal range. Ex vivo VCAM-1 binding to lymphocytes increased until ≈16 weeks after the last natalizumab dose, then plateaued, suggesting reversibility of immune cell functionality. The temporal appearance of gadolinium-enhancing lesions was consistent with pharmacodynamic marker reversal.

Conclusions: Natalizumab's effects on peripheral immune cells and pharmacodynamic markers were reversible, with changes starting 8 weeks post last natalizumab dose; levels returned to those observed/expected in untreated patients ≈16 weeks post last dose. This reversibility differentiates natalizumab from MS treatments that require longer reconstitution times. Characterization of the time course of natalizumab's biological effects may help clinicians make treatment sequencing decisions.

Classification of evidence: This study provides Class III evidence that the pharmacodynamic markers of natalizumab are reversed ≈16 weeks after stopping natalizumab.

Copyright © 2017 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Neurology.

Figures

Figure 1. Pharmacokinetic and pharmacodynamic assessments over…
Figure 1. Pharmacokinetic and pharmacodynamic assessments over the 28 weeks of randomized treatment in RESTORE
Least squares means estimates ± 95% confidence interval for (A) natalizumab concentration, (B) leukocyte percentage α4-integrin saturation, (C) leukocyte α4-integrin (CD49d) expression, and (D) serum vascular cell adhesion molecule (sVCAM) expression in patients continuing natalizumab or with a treatment interruption. The arrow represents the last dose before the 24-week interruption period. For percentage α4-integrin saturation (B), the gray dashed line indicates saturation prior to natalizumab treatment in the Safety and Efficacy of Natalizumab in the Treatment of Multiple Sclerosis (AFFIRM) natalizumab treatment arm (2.8%), as shown in figure e-1B. MFI = mean fluorescence intensity; RESTORE = Randomized Treatment Interruption of Natalizumab. *p < 0.001. aMean natalizumab levels were not analyzed once ≥33% of patients had values below the lower limit of quantification.
Figure 2. Total lymphocyte, lymphocyte subset, and…
Figure 2. Total lymphocyte, lymphocyte subset, and hematopoietic progenitor counts over the 28 weeks in RESTORE
Least squares (LS) mean estimated counts ± 95% confidence interval (CI) for (A) total lymphocytes, (B) CD4+ T cells, (C) CD8+ T cells, (D) CD19+ B cells, (E) CD3−/CD16+/CD56+ natural killer (NK) cells, and (F) CD34+/CD45+ hematopoietic progenitor cells. Total lymphocyte counts in RESTORE patients stratified by demographics and disease activity. LS mean estimates ± 95% CI are shown for patients continuing and discontinuing natalizumab classified by (G) age, (H) disease activity, and (I) sex. The arrow represents the last dose before the 24-week interruption period. The shaded area shows the range of normal lymphocyte counts (total lymphocyte counts: 0.91–4.28 × 109 cells/L [Safety and Efficacy of Natalizumab in the Treatment of Multiple Sclerosis (AFFIRM)]; CD4+ T cells14: 491–2,000 cells/mm3; CD8+ T cells14: 314–2,087 cells/mm3; CD19+ B cells14: 64–800 cells/mm3; CD3−/CD16+/CD56+ NK cells14: 27–693 cells/mm3; CD34+/CD45+ hematopoietic progenitor cells11: 1.4–2.2 cells/mm3). For total lymphocytes (A, G, H, I), the gray dashed line indicates total lymphocyte counts prior to natalizumab treatment in the AFFIRM natalizumab treatment arm (2.08 × 109 cells/L), as shown in figure e-1C. Lymphocyte subsets were not assessed in AFFIRM. RESTORE = Randomized Treatment Interruption of Natalizumab. *p < 0.05. **p < 0.001.
Figure 3. Functional activity of CD3+ T…
Figure 3. Functional activity of CD3+ T cells, CD19+ B cells, and monocytes from RESTORE patients
Least squares mean estimates ± 95% confidence interval are shown for ex vivo binding of cells to vascular cell adhesion molecule–1 (VCAM-1). The arrow represents the last dose before the 24-week interruption period. MESF = molecules of equivalent soluble fluorochrome; RESTORE = Randomized Treatment Interruption of Natalizumab. *p = 0.001 for T cells; p < 0.001 for B cells and monocytes. **p < 0.001 for T cells, B cells, and monocytes.
Figure 4. Relationship of α4-integrin saturation and…
Figure 4. Relationship of α4-integrin saturation and the incidence of gadolinium-enhancing (Gd+) lesions over time after the last natalizumab dose
The median α4-integrin saturation level and the cumulative percentage of patients with a natalizumab treatment interruption developing Gd+ lesions are shown. The last natalizumab dose was administered on day 0. Patients with >1 Gd + lesion, %, represents the cumulative percentage of study patients with Gd + lesions out of all patients not treated with natalizumab who remained in the study at that time point.

References

    1. Tysabri (Natalizumab) [prescribing information]. Cambridge, MA: Biogen, Inc.; 2016.
    1. Rudick RA, Sandrock A. Natalizumab: alpha 4-integrin antagonist selective adhesion molecule inhibitors for MS. Expert Rev Neurother 2004;4:571–580.
    1. Yednock TA, Cannon C, Fritz LC, Sanchez-Madrid F, Steinman L, Karin N. Prevention of experimental autoimmune encephalomyelitis by antibodies against alpha 4 beta 1 integrin. Nature 1992;356:63–66.
    1. Benkert TF, Dietz L, Hartmann EM, et al. . Natalizumab exerts direct signaling capacity and supports a pro-inflammatory phenotype in some patients with multiple sclerosis. PLoS One 2012;7:e52208.
    1. Miller DH, Khan OA, Sheremata WA, et al. . A controlled trial of natalizumab for relapsing multiple sclerosis. N Engl J Med 2003;348:15–23.
    1. Khatri BO, Man S, Giovannoni G, et al. . Effect of plasma exchange in accelerating natalizumab clearance and restoring leukocyte function. Neurology 2009;72:402–409.
    1. Defer G, Mariotte D, Derache N, et al. . CD49d expression as a promising biomarker to monitor natalizumab efficacy. J Neurol Sci 2012;314:138–142.
    1. Harrer A, Wipfler P, Einhaeupl M, et al. . Natalizumab therapy decreases surface expression of both VLA-heterodimer subunits on peripheral blood mononuclear cells. J Neuroimmunol 2011;234:148–154.
    1. Millonig A, Hegen H, Di Pauli F, et al. . Natalizumab treatment reduces endothelial activity in MS patients. J Neuroimmunol 2010;227:190–194.
    1. Polman CH, O'Connor PW, Havrdova E, et al. . A randomized, placebo-controlled trial of natalizumab for relapsing multiple sclerosis. N Engl J Med 2006;354:899–910.
    1. Bonig H, Wundes A, Chang KH, Lucas S, Papayannopoulou T. Increased numbers of circulating hematopoietic stem/progenitor cells are chronically maintained in patients treated with the CD49d blocking antibody natalizumab. Blood 2008;111:3439–3441.
    1. Fox RJ, Cree BA, De Seze J, et al. . MS disease activity in RESTORE: a randomized 24-week natalizumab treatment interruption study. Neurology 2014;82:1491–1498.
    1. Kaufman M, Cree BA, De Seze J, et al. . Radiologic MS disease activity during natalizumab treatment interruption: findings from RESTORE. J Neurol 2015;262:326–336.
    1. Valiathan R, Deeb K, Diamante M, Ashman M, Sachdeva N, Asthana D. Reference ranges of lymphocyte subsets in healthy adults and adolescents with special mention of T cell maturation subsets in adults of South Florida. Immunobiology 2014;219:487–496.
    1. Kubes P, Niu XF, Smith CW, Kehrli ME Jr, Reinhardt PH, Woodman RC. A novel beta 1-dependent adhesion pathway on neutrophils: a mechanism invoked by dihydrocytochalasin B or endothelial transmigration. FASEB J 1995;9:1103–1111.
    1. Francis G, Kappos L, O'Connor P, et al. . Temporal profile of lymphocyte counts and relationship with infections with fingolimod therapy. Mult Scler 2014;20:471–480.
    1. Lemtrada (Alemtuzumab) [prescribing information]. Cambridge, MA: Genzyme Corporation; 2016.
    1. Bar-Or A, Calabresi PA, Arnold D, et al. . Rituximab in relapsing-remitting multiple sclerosis: a 72-week, open-label, phase I trial. Ann Neurol 2008;63:395–400.
    1. Kappos L, Li D, Calabresi P, et al. . Long-term safety and efficacy of ocrelizumab in patients with relapsing-remitting multiple sclerosis: week 144 results of a phase II, randomised, multicentre trial. Presented at the 28th Congress of the European Committee for Treatment and Research in Multiple Sclerosis; October 10–13, 2012; Lyon, France; P362.
    1. Hill-Cawthorne GA, Button T, Tuohy O, et al. . Long term lymphocyte reconstitution after alemtuzumab treatment of multiple sclerosis. J Neurol Neurosurg Psychiatry 2012;83:298–304.
    1. Selby R, Brandwein J, O'Connor P. Safety and tolerability of subcutaneous cladribine therapy in progressive multiple sclerosis. Can J Neurol Sci 1998;25:295–299.
    1. Harrer A, Pilz G, Einhaeupl M, et al. . Lymphocyte subsets show different response patterns to in vivo bound natalizumab: a flow cytometric study on patients with multiple sclerosis. PLoS One 2012;7:e31784.
    1. Harrer A, Pilz G, Wipfler P, et al. . High interindividual variability in the CD4/CD8 T cell ratio and natalizumab concentration levels in the cerebrospinal fluid of patients with multiple sclerosis. Clin Exp Immunol 2015;180:383–392.
    1. Koudriavtseva T, Sbardella E, Trento E, Bordignon V, D'Agosto G, Cordiali-Fei P. Long-term follow-up of peripheral lymphocyte subsets in a cohort of multiple sclerosis patients treated with natalizumab. Clin Exp Immunol 2014;176:320–326.
    1. Krumbholz M, Meinl I, Kumpfel T, Hohlfeld R, Meinl E. Natalizumab disproportionately increases circulating pre-B and B cells in multiple sclerosis. Neurology 2008;71:1350–1354.
    1. Mattoscio M, Nicholas R, Sormani MP, et al. . Hematopoietic mobilization: potential biomarker of response to natalizumab in multiple sclerosis. Neurology 2015;84:1473–1482.
    1. Mellergard J, Edstrom M, Jenmalm MC, Dahle C, Vrethem M, Ernerudh J. Increased B cell and cytotoxic NK cell proportions and increased T cell responsiveness in blood of natalizumab-treated multiple sclerosis patients. PLoS One 2013;8:e81685.
    1. Vennegoor A, Rispens T, Strijbis EM, et al. . Clinical relevance of serum natalizumab concentration and anti-natalizumab antibodies in multiple sclerosis. Mult Scler 2013;19:593–600.
    1. Zohren F, Toutzaris D, Klarner V, Hartung HP, Kieseier B, Haas R. The monoclonal anti-VLA-4 antibody natalizumab mobilizes CD34+ hematopoietic progenitor cells in humans. Blood 2008;111:3893–3895.
    1. Kivisakk P, Healy BC, Viglietta V, et al. . Natalizumab treatment is associated with peripheral sequestration of proinflammatory T cells. Neurology 2009;72:1922–1930.
    1. Jentsch-Ullrich K, Koenigsmann M, Mohren M, Franke A. Lymphocyte subsets' reference ranges in an age- and gender-balanced population of 100 healthy adults: a monocentric German study. Clin Immunol 2005;116:192–197.
    1. Semra YK, Seidi OA, Sharief MK. Disease activity in multiple sclerosis correlates with T lymphocyte expression of the inhibitor of apoptosis proteins. J Neuroimmunol 2002;122:159–166.
    1. Kister I, Corbory JR. Reducing costs while enhancing quality of care in MS. Neurology 2016;87:1617–1622.
    1. Zhovtis Ryerson L, Frohman TC, Foley J, et al. . Extended interval dosing of natalizumab in multiple sclerosis. J Neurol Neurosurg Psychiatry 2016;87:885–889.
    1. Stüve O, Marra CM, Jerome KR, et al. . Immune surveillance in multiple sclerosis patients treated with natalizumab. Ann Neurol 2006;59:743–747.

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