Supporting the gastrointestinal microenvironment during high-dose chemotherapy and stem cell transplantation by inhibiting IL-1 signaling with anakinra

Abstract

High-dose chemotherapy causes intestinal inflammation and subsequent breakdown of the mucosal barrier, permitting translocation of enteric pathogens, clinically manifesting as fever. Antibiotics are mainstay for controlling these complications, however, they are increasingly recognized for their detrimental effects, including antimicrobial resistance and dysbiosis. Here, we show that mucosal barrier injury induced by the mucotoxic chemotherapeutic agent, high-dose melphalan (HDM), is characterized by hyper-active IL-1b/CXCL1/neutrophil signaling. Inhibition of this pathway with IL-1RA, anakinra, minimized the duration and intensity of mucosal barrier injury and accompanying clinical symptoms, including diarrhea, weight loss and fever in rats. 16S analysis of fecal microbiome demonstrated a more stable composition in rats receiving anakinra, with reduced pathogen expansion. In parallel, we report through Phase IIA investigation that anakinra is safe in stem cell transplant patients with multiple myeloma after HDM. Ramping-up anakinra (100-300 mg administered intravenously for 15 days) did not cause any adverse events or dose limiting toxicities, nor did it change time to neutrophil recovery. Our results reinforce that strengthening the mucosal barrier may be an effective supportive care strategy to mitigate local and systemic clinical consequences of HDM. We are now conducting a Phase IIB multicenter, placebo-controlled, double-blinded trial to assess clinical efficacy of anakinra (AFFECT-2).Trial registration: ClinicalTrials.gov identifier: NCT03233776.

Conflict of interest statement

The authors declare no competing interests.

© 2022. The Author(s).

Figures

Figure 1

Melphalan causes hyperactivation of the CXCL1 (GROα) / IL-1β axis in rats. (A) CXCL1 and (B) Il-1β were assessed in repeated blood samples collected after melphalan treatment. Data presented as mean ± SEM. N = 8/group, all analyzed longitudinally using a mixed-effects model with Geisser-Greenhouse correction for multiple comparisons.

Figure 2

Anakinra mitigates melphalan-induced mucosal barrier injury and clinical manifestations of gut toxicity. (A) Mucosal barrier injury defined by plasma citrulline showed a significant decrease in MEL + ANA at D + 2 and D + 4 compared to melphalan only. (B–C) Anakinra prevented melphalan-induced weight loss and food intake (D–E). Data presented as mean ± SEM. N = 8/group, all analyzed longitudinally using a mixed-effects model with Geisser-Greenhouse correction, with the exception of panel (E) which used a one-way ANOVA with Tukey’s post-hoc.

Figure 3

Anakinra does not impair the myeloablative properties of melphalan but controls fever. (A) Neutrophils, (B) lymphocytes and (C) monocytes assessed in whole blood at termination. Melphalan induced fever (D), which was controlled by anakinra. Data presented as mean ± SEM. N = 8/group with all data analyzed using mixed-effects model with Geisser-Greenhouse correction for multiple comparisons.

Figure 4

Anakinra reduces mucosal barrier injury-associated dysbiosis and controls enteric pathogen expansion. Melphalan caused compositional changes in the fecal microbiota that persisted for the entire experimental period (A). MEL + ANA rats only showed significant PCoA changes at day 4 (B). Taxonomic analysis (C) showed expansion of Enterobacteriales in MEL only rats, with increases in E.Coli (D), Bacteroidetes vulgates (E) and Clostridium sp (F). Data shown as individual samples, with the exclusion of Panel C which shows mean relative abundance. N = 8/group, all analyzed longitudinally via repeated stool collection. All statistical analyses for microbiota data are outlined in supplementary methods.

Figure 5

Anakinra promotes commensal stability and controls pathogen expansion. Melphalan alone depleted key commensal microbes and caused expansion of pathogens at day 4 (A), 7 (B) and 10 (C), each of which were minimized by anakinra. Data show median difference between groups (median ± 95% CI). All statistical analyses for microbiota data are outlined in supplementary methods.

Figure 6

Clinical assessments in Phase IIA AFFECT-1 cohort treated with 100, 200 or 300 mg anakinra. (A) Neutrophils, (B) temperature with data on antbiotic use, (C) CRP and (D) albumin were assessed longitudinally in all participants. No differences were detected in any parameter. Data shown as individual participant trajectories.