Inflammatory Bowel Diseasesand Apheresis

Maurizio Vecchi

University of Milan

Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico

Immune Response Alteration

Chronic Inflammation

Dam

age

Increase of Pro-Inflammatory

Response

Disease

Dam

age

Weak Intestinal Barrier

Intestinal Barrier Integrity Loss

Disrupted Protective Barrier Layer

Pro-Inflammatory Cytokines

Inflammatory Bowel Diseases

Pro-Inflammatory

Mediators

Anti-Inflammatory Mediators

IBD: a relapsing-remitting, possibly severe and life-threatening, chronic inflammatory disease

• Diarrhea

• Abdominal pain

• Rectal bleeding

• Extraintestinal manifestations

• Dehydration, electrolyte imbalance

• Anemia

• Perforation

• Cancer

IBD: Treatment Options

MAIN GOALS

- Induce remission (periods of time that are symptom-free);

- Maintain remission (preventingflare-ups of disease);

- Improve patient's quality of life.

IBD: Treatment Options

Infliximab

Adalimumab

Golimumab

Vedolizumab Anti-α4β7 integrin

Ustekinumab Anti-IL23/IL12

Anti TNF

Role of MAdCAM-1 and α4β7 in lymphocyterecruitment at intestinal level

IBD & APHERESIS

Leukocytapheresis - anti-inflammatory andimmunomodulatory therapy, aimed at the removal fromthe bloodstream of cells responsible for the inflammatorystate in IBD.

Leukocytes, mainly Neutrophils and MonocytesGranulocytes, and also a part of Platelets are removedfrom the blood.

Many studies have investigated the efficacy ofLeukocytapheresis as an alternative or adjuvant therapy tothe conventional pharmacological treatments of IBD.

It is currently applied in the treatment of patients withmild to moderate IBD, non-responding / intolerant or inthose with contraindications to conventional therapies.

Leukocytapheresis with Hydrophilic Polysulfone

Why Hydrophilic Polysulfone?

• Resin coated with Polyvinilpirrolidone High Hemocompatibility.

• Resin already largely used in other clinical fields: widespread use of specific resinconfigurations in nephrology.

WINCHESTER JF et al. Replacement of Renal Function by Dialysis. Springer 2002.

• Specific structure based on short hollow fibers defined for Granulocyte, Monocyteand Platelet Adsorption.

ADSORPTION CAPACITY: IN VITRO TESTS

- 9 repeated tests with healthy human blood, single- Single pass treatments- Blood sampling catridge inflow and catridge outflow.

Percentage of Reduction % :(Cout / Cin) * 100

- Cout: target population’s blood concentration in thecatridge’s outflow, after 15 min of treatment,- Cin: target population’s blood concentration in thecartridge’s inflow.

Leukocytapheresis with Hydrophilic Polysulfone

M. Di Girolamo et al. Ther Apher Dial. 2016 Dec;20(6):668-676

IN VITRO AND EX VIVO STUDIES OF TWO LEUKOCYTAPHERESIS MATERIALSHYDROPHILIC POLISULFONE AND CELLULOSE ACETATE

HAEMOCOMPATIBILITY EVALUATION

Polysulfone effects were compared to the effects of one of the most used materials in leukocytapheresis’ therapies.

Experimental SettingIn vitro tests included healthy blood, while ex vivo evaluation was performed on IBD patients’ blood

POOL

No Treat(NT)

No Treat(NT)

Acetate(AC)

Polysulfone(PS)

2,32,0

0,5

2,5 2,4

0,5

0,0

0,5

1,0

1,5

2,0

2,5

3,0

3,5

4,0

NT AC PS NT AC PS

30 MIN 1 H

TNFa

(p

g/m

l)

Plasma TNFa

After 1 hour contact, PS exhibited lower monocyte activationas compared to AC and NT.

Av 3 tests ± s.e.m.

6,88,3

11,0

13,612,3

7,2

0

5

10

15

20

NT AC PS NT AC PS

30 MIN. 1 H

% M

ON

OC

YTE

S C

D8

6 p

os.

BUFFY COAT

IN VITRO TESTMonocytes Activation

92,6 92,8 96,6 94,6 95,9 93,5

0

20

40

60

80

100

120

NT AC PS NT AC PS

30 MIN 1 H

% G

ran

ulo

cyte

s M

PO

Po

s.

Granulocytes – Buffy Coat

15,7 15,9 15,4 15,316,4 15,8

0

5

10

15

20

25

NT AC PS NT AC PS

30 MIN. 1H

% B

Lym

ph

ocy

tes

CD

25

Po

s.

B Lymphocytes – Buffy Coat

24,1

36,5 35,6 34,3 35,8 35,9

0

10

20

30

40

50

60

NT AC PS NT AC PS

30 MIN. 1 H

%Ly

mp

ho

cyte

s T

CD

25

Po

s.

B Lymphocytes – Buffy Coat

71,0 71,9 74,5

63,3 62,5 64,5

0

10

20

30

40

50

60

70

80

90

NT AC PS NT AC PS

30 MIN 1 H

% L

ymp

ho

cyte

s In

t. b

7 P

os.

Gut Homing Lymphocytes

NO differences between AC, PS and NT. IL-4, IFNg, IL-17, IL.-10 levels

IN VITRO TESTLymphocytes and Granulocytes Activation

Ave 3 tests. ± s.e.m.

A strong platelets reduction in PS treated samples.

PLATELETS ACTIVATION

Ave 3 tests. ± s.e.m.

55,5

67,4

25,1

54,660,3

16,3

0,0

10,0

20,0

30,0

40,0

50,0

60,0

70,0

80,0

NT AC PS NT AC PS

30 MIN 1 H

%C

ells

CD

62

p P

OS.

Buffy Coat

IN VITRO TEST

The Ex Vivo Results confirm minor complement systemactivation with PS, both on buffy coat and plasma C3alevels.

No differences between the treatments in terms oflymphocytes and granulocytes activation.

The capacity of PS to determine markedly reducedplatelet activation confirmed PS vs AC vs NT (46.4±9.3vs. 69.3±6.8 vs. 70.8±5.6%)

EX VIVO TEST

68,6

55,567,4

25,1

54,6

60,3

16,3

0

10

20

30

40

50

60

70

80

TO NT AC POLI NT AC POLI

30 MIN 1 H

% P

late

lets

CD

62

p P

OS.

Platelets Activation – Buffy Coat

Ave 3 tests. ± s.e.m.

And what about clinical experience of polysulfone Leukocyteapheresis in IBD?

Leukocytapheresis with Polysulfone in IBDPROMISING CLINICAL RESULTS: PILOT STUDY

- 10 UC, 8 CD non-responder to conventional therapy (CCS, Tiopurine, Anti-TNFα) with mild/moderate activity.

-8/18 with Extra-Intestinal manifestations

- Standard Protocol (1 session/week for 5 weeks; 30 ml/min blood flow for 60 min); 1 year follow up.

M. Di Girolamo et al. Ther Apher Dial. 2016 Dec;20(6):668-676

Efficacy of a Novel Granulocyte Monocyte Apheresis Adsorber Device in the treatment of Inflammatory Bowel Diseases: a Pilot Study

Leukocytapheresis with Polysulfone

M. Di Girolamo et al. Ther Apher Dial. 2016 Dec;20(6):668-676

*2 drop out

0,00

2,00

4,00

6,00

8,00

10,00

12,00

14,00

16,00

1 2 6 7 8 11 13 14 16 17

MAYO SCORE Baseline

T3

F1S

F1M

F6M

F12M

0,00

50,00

100,00

150,00

200,00

250,00

300,00

350,00

3 4 9 10 12 15

CDAI SCORE Baseline

T3

F1S

F1M

F6M

F12M

- Clinical Benefits achieved in all (16) patients who completed the treatment during the study

- Diseases Activity Indexes Reduction registered (Mayo Score 9,4±1,43 vs 5,1±1,44; CDAI 209,5±31,36 vs 68,33±24,83)

- No adverse effects registered

PROMISING CLINICAL RESULTS: PILOT STUDY

Leukocytapheresis with PolysulfonePROMISING CLINICAL RESULTS: Case Report

Patient Profile

45 y-old woman with UC

Steroid dependency & Failure to anti-TNFs

Treatment Protocol

Vedolizumab monotherapy maintenance +

Leukocytapheresis standard protocol

Results

No adverse events.

Azathioprine stopped.

Clinical Symptoms Improvement after 4th apheresis session.

Steriod-free remission at 6th month of follow-up

The adjunct of apheresis to biologics could represent a valid option in UC patients

difficult to treat.

Therapy Administration

Standard Treatment Schedule:1 session/week60 min/session, 30 ml/min -> 1.8L/session of blood5 weeks

Attempt to personalized management based on patients’ profiles

IBD & APHERESIS

CONVENTIONAL STANDARD THERAPY SCHEDULE

A need to use Different Treatment Doses in order to obtainbetter Efficacy

Tomorrow Insights

Beyond the current knowledge….

…….Patient-Tailored, Diversified, Treatment Schedules:

1. The Dose-Effect Concept validation: towards thePersonalization of Leukocytapheresis Treatment.

2. Use of Leukocytapheresis in a Combination therapy with mAb:

a Synergistic action of pharmacological and apheretictreatment.