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Chimeric monoclonal anti-CD4 antibody therapy in Crohn's disease
April 1995
Immunology, Microbiology, and Inflammatory Disorders A791
C H I M E R I C M O N O C L O N A L A N T I - C D 4 ANTIBODY THERAPY IN CROHN'S DISEASE. V.Canva-Delcambre (1), S Jacquot (2), E Robinet (3), M I~mann (2), C Drouet (1), JP Dessaint (4), C Rabian (5), R Modigliani (2), JF Revillard (3), JF Colombel (1). Services D'H6patoGastroent6rologie, H0pital Huriez. CHRU Lille (1) et H6pital St-Louis, Paris (3); Laboratoires d'Immunologie CHRU Lille (4) et St-Louis, Paris (5); [NSERM U80. Lyon (3). T-cells are considered to play a pivotal role in inflammatory bowel disease. Chimeric monoclonal CD4 antibodies have been recently proposed as a new immunosuppressant drug in their treatment (1-3). We here report an open clinical trial with a monoclonal chimeric antibody in severe refractory Crohn's disease (CD). Patients and Methods : 9 women, mean age 26.7 years (range 18-34), with active long standing intractable CD were treated for 7 consecutive days with chimeric monoclonal anti-CD4 antibody (BF-5, Diaclone, France) 0.5 mg/kg/d intravenously. Follow up examinations were carried out on day 8, 15, 22 and 30. Endoscopic evaluation was performed at day 0 and day 30 in 5/9 patients. Results : Immediately after the first infusion, one patient had dyspnea and tachycardia requiring to stop the treatment. Four patients had chills and fever and 3 a drop of blood pressure. Among the 8 patients who received the complete treatment, 1 had prolonged clinical improvement (5 months), 2 had partial clinical improvement and 5 had no benefit. A significant reduction of the C-reactive protein level (>50 % of initial level) was observed in 2 patients. There was no significant endoscopic improvement in any patient. No important decline of circulating CD4+ cells was observed. Conclusion : In this uncontrolled trial, monoclonal anti-CD4 antibody was not successfull in CD. Since circulating T-cells counts were not influenced by treatment, this discrepancy with previous studies might be partly explained by insufficient doses of anti-CD4 antibody. (1) Emmrich, Lancet 1991; II: 570-1. (2) Deusch, Gastroenterology 1992; 103: A615. (3) Stronkhorst, Gastroenterology 1993; 104: A784.
• CROHN'S DISEASE AND BONE LOSS. A KEY ROLE FOR FAT
MASS. P. Caradorma, R. Semeraro, P. Astazi, G. Benedetti, G.B. Gasbarrini. Istituto di Medicina Interna e Geriatria, Universita Cattolica S. Cuore, Rome, Italy. To study the prevalence and mechanism of bone loss in Crohn's disease, bone densitometry measurements were done in unselected patients (mean age 31.3_+12.7): 9 malus aged 19-66 years and 12 premenopausal females aged 19-46 years. The duration of disease ranged from 1-20 years (mean 5.6_+5.8).Eigth patients had never received steroids: in the remaining 13 the median lifetime dose was 10 gr. of prednisone. Bone densitometry performed on a Hologic 1000 (DEXA) showed 57% had osteopenia with Zscore of the spine (BMDs)<-1 and 24% had osteoporosis with BMDs 4;-2.5. Femoral neck measurements~'(BMDn) showed 43% had Z-seores<-I and 20% <-2.5. The newly diagnosed untreated patients (mean BMDs -1.970_+1.103, BMDn--0.910_+0.885) were as likely to have osteopenia as treated ones (BMDs-t.395-+l.396, BMDn-0.948+l.592). Therefore the osteopenia was not due to prednisone intake. In order to assess the contribution of nutritional status to BMD in our patients, energy metabolism and body composition assessment was performed in post-absorptive conditions in order to calculate BMI, waist-hip ratio, fat and lean body mass and energy expenditure (mean BMI 20.4 +_3.9, W/H 0.453 _+0.404, FBM 6.4 -+7.0 kg, LBM 28.1 +_22.9 kg, EE 926.6 _+756.9 Kcal/die). F a t body mass and energy expenditure was reduced in our subjects but their lean body mass did not differ from normal. Fat body mass was negatively related to disease dnration and positively related to BMD (p<.05). We do not found any correlation between LBM and both disease duration and BMD, but lean body mass was positively related to EE (p<.02).We conclude that glucocorticoid therapy was not a primary cause of bone loss in Crolm's disease, but the total body fat reduction related to inflammatory process itself is the most important predictor of BMD loss.
TREATMENT OF SEVERE ACUTE ULCERATIVE COLITIS WITH. INTRAVENOUS CYCLOSPORINE. ~ 1 , A Boruckowicz 2, B Duelos 3, JC Soul64, E Lerebours 5, M I.&narm6, J Belaicbe7, JP Gendre 1. Services de Gastrcent~r01ogie : 2Lille, 3Strasbourg. 4Colombes, 5Rouen, 7Liege, 6Saint-Louis and 1Rothschild, Pads, France.
LOCALIZED iNCREASE IN INTESTINAL T~ TCR+ AND CD8+ LYMPHOCYTE POPULATIONS AND ENHANCED CLASS H ANTIGEN EXPRESSION: INDEPENDENT FEATURES OF COELIAC DISEASE J. Carton. L Madrigal, D. P. O'Dono~ue, C. O'Farretly. ERC & The Gastroenterology Unit, St. Vincent's Hospital, Dublin 4.
Intravenous cyclosporine (Cy) has proven effective in the treatment of acute colitis with severe symptoms (NEJM 1994;330:1841). The present study reports the experience of several centers in the treatment of severe acute colitis with Cy, taking into account morphological signs of severity and long-term follow-up. ~ethods :
Background: Activation of specific sub-populations of T lymphocytes may play a significant role in the pathogenesis of coeliac disease. Identification and quantification of these populations in sub-compartments of the small intestine is now possible using flow cytometry. Objective: The aim of this study was to examine phenotype and class II expression of CD3+ lympbocytes from the lamina propria and intraepithelial sub-eompamnents in patients with active coeliac disease. Methods: Small intestinal biopsies were taken from 30 patients, 11 with active cocliac disease and 19 with normal small intestinal histology. A single cell suspension was obtained from the epithelial layer (EL) which was removed using chelating and reducing agents; the lamina propria (LP) was digested using cullagenase. Mean yields of 0.68xl061ympbocytes were obtained from the EL and 0.72x106 from the LP compartments. These cells were stained with antibodies specific for CD3, CI~, CD8, yrTCR and HLADR molecules and analyzed using flow cytometry. Results: Class I! antigen expression was detected on a significant percentage of lympbocytes from normal small intestinal EL (mean 34.87%; range 3.80-50.09) and LP (mean 20.00%; range 11.76-26.26). A significant increase was seen in the proportion (mean 52.41%; range 22.78-86.34) of EL lymphocytes expressing I-ILA-DR antigens from patients with active coeliac disease (P<0.01) when compared with controls. Class I1 antigen expression was similarly increased (P< 0.05) on lamina pmpfia lymphocytes (mean 38.45%; range 14.39-68.76) when compared with controls. T cell phenotypic studies showed an increase (mean 26.29%: range 14.5851.80) in the CD3+ 76 TCR+ population in the EL (P<0.05) when compared with control patients (mean 9.57%; range 0-25.70). Surprisingly, the T6 infiltrate into the LP of coeliac patients was much less marked (mean 3.43%; range 0-6.92; controls: mean 0.79%; range 0-2.40). Similarly, a significant change in the CIM:CD8 ratio seen in the coeliac epithelium (ratio !:22; control epithelium, mtiol:8) was not mirrored in the LP where the CIM:CD8 ratios remained similar (1.3:1 in coeliac preparations and 1.4:1 in controls): Conclusion: High class II antigen expression by coeliae intestinal T deLls was common to both LP and EL. The increase in the 76 TCR+ and CD8+ populations, however, was significantly more marked in the EL than in the LP suggesting that these features may be independent.
32 patients with severe acute colitis (14F, 18M;median age:33.5) treated with Cy (3.2
= 0.9 mg/kg/d during 15=14 days; mean Cy serum level : 279=94 ng/ml) were studied retrospectively. 26/32 patients had received high-dose corticosteroids before Cy. 25/29 patients had endoscopic and/or radiulogical signs of severity (3 patients were non responders, so and were colectomized before. Day 30. 20/32 (62.5%). e0 patients were responders, 16 ~ of them had a complete] remission. 15/18 responders, bad a frank improvement at~
sigmoidosenpy hydrusoluble enema.
4o . . . . . . . . . . . . . . . . . . . . . . ~
Do ~ -
-
20
or ~ 7/20
0 20 60 100 140 180 220 were Time (days) en!eetomized between day 30 and day 140 under oral Cy (n=6) or azathioprine (n=l) responders
for relapse (n=5) or aggravation (n=2). One responder was culeetomized at day 14, in complete remission. 12/20 responders were in complete remission after a median follow-up of 6.5 months. 11 patients had reversible side-effects of Cy. One colonic perforation at day 8 and one postoperative death occured in non respenders. Sedimentation rate was higher end mean serum albumin was lower in non reponders than responders (65--.21 vs 44=22 and 26=4 vs 30=5 ; p<0.02 and p<0.01 respectively) but no parameter (duration of the disease or the attack, number of attacks, clinieo-biological signs, dose end duration of Cy, Cy serum level, morphological signs of severity) allowed to predict the response to Cy. Co~cinsion : In this study, 62.5% of patients responded to Cy. At 6 months, only 30% of patients avoided coleetomy end remained in complete remission. The risk of delayed enlectomy must be taken into account in non responders.
Immunology, Microbiology, and Inflammatory Disorders A791
C H I M E R I C M O N O C L O N A L A N T I - C D 4 ANTIBODY THERAPY IN CROHN'S DISEASE. V.Canva-Delcambre (1), S Jacquot (2), E Robinet (3), M I~mann (2), C Drouet (1), JP Dessaint (4), C Rabian (5), R Modigliani (2), JF Revillard (3), JF Colombel (1). Services D'H6patoGastroent6rologie, H0pital Huriez. CHRU Lille (1) et H6pital St-Louis, Paris (3); Laboratoires d'Immunologie CHRU Lille (4) et St-Louis, Paris (5); [NSERM U80. Lyon (3). T-cells are considered to play a pivotal role in inflammatory bowel disease. Chimeric monoclonal CD4 antibodies have been recently proposed as a new immunosuppressant drug in their treatment (1-3). We here report an open clinical trial with a monoclonal chimeric antibody in severe refractory Crohn's disease (CD). Patients and Methods : 9 women, mean age 26.7 years (range 18-34), with active long standing intractable CD were treated for 7 consecutive days with chimeric monoclonal anti-CD4 antibody (BF-5, Diaclone, France) 0.5 mg/kg/d intravenously. Follow up examinations were carried out on day 8, 15, 22 and 30. Endoscopic evaluation was performed at day 0 and day 30 in 5/9 patients. Results : Immediately after the first infusion, one patient had dyspnea and tachycardia requiring to stop the treatment. Four patients had chills and fever and 3 a drop of blood pressure. Among the 8 patients who received the complete treatment, 1 had prolonged clinical improvement (5 months), 2 had partial clinical improvement and 5 had no benefit. A significant reduction of the C-reactive protein level (>50 % of initial level) was observed in 2 patients. There was no significant endoscopic improvement in any patient. No important decline of circulating CD4+ cells was observed. Conclusion : In this uncontrolled trial, monoclonal anti-CD4 antibody was not successfull in CD. Since circulating T-cells counts were not influenced by treatment, this discrepancy with previous studies might be partly explained by insufficient doses of anti-CD4 antibody. (1) Emmrich, Lancet 1991; II: 570-1. (2) Deusch, Gastroenterology 1992; 103: A615. (3) Stronkhorst, Gastroenterology 1993; 104: A784.
• CROHN'S DISEASE AND BONE LOSS. A KEY ROLE FOR FAT
MASS. P. Caradorma, R. Semeraro, P. Astazi, G. Benedetti, G.B. Gasbarrini. Istituto di Medicina Interna e Geriatria, Universita Cattolica S. Cuore, Rome, Italy. To study the prevalence and mechanism of bone loss in Crohn's disease, bone densitometry measurements were done in unselected patients (mean age 31.3_+12.7): 9 malus aged 19-66 years and 12 premenopausal females aged 19-46 years. The duration of disease ranged from 1-20 years (mean 5.6_+5.8).Eigth patients had never received steroids: in the remaining 13 the median lifetime dose was 10 gr. of prednisone. Bone densitometry performed on a Hologic 1000 (DEXA) showed 57% had osteopenia with Zscore of the spine (BMDs)<-1 and 24% had osteoporosis with BMDs 4;-2.5. Femoral neck measurements~'(BMDn) showed 43% had Z-seores<-I and 20% <-2.5. The newly diagnosed untreated patients (mean BMDs -1.970_+1.103, BMDn--0.910_+0.885) were as likely to have osteopenia as treated ones (BMDs-t.395-+l.396, BMDn-0.948+l.592). Therefore the osteopenia was not due to prednisone intake. In order to assess the contribution of nutritional status to BMD in our patients, energy metabolism and body composition assessment was performed in post-absorptive conditions in order to calculate BMI, waist-hip ratio, fat and lean body mass and energy expenditure (mean BMI 20.4 +_3.9, W/H 0.453 _+0.404, FBM 6.4 -+7.0 kg, LBM 28.1 +_22.9 kg, EE 926.6 _+756.9 Kcal/die). F a t body mass and energy expenditure was reduced in our subjects but their lean body mass did not differ from normal. Fat body mass was negatively related to disease dnration and positively related to BMD (p<.05). We do not found any correlation between LBM and both disease duration and BMD, but lean body mass was positively related to EE (p<.02).We conclude that glucocorticoid therapy was not a primary cause of bone loss in Crolm's disease, but the total body fat reduction related to inflammatory process itself is the most important predictor of BMD loss.
TREATMENT OF SEVERE ACUTE ULCERATIVE COLITIS WITH. INTRAVENOUS CYCLOSPORINE. ~ 1 , A Boruckowicz 2, B Duelos 3, JC Soul64, E Lerebours 5, M I.&narm6, J Belaicbe7, JP Gendre 1. Services de Gastrcent~r01ogie : 2Lille, 3Strasbourg. 4Colombes, 5Rouen, 7Liege, 6Saint-Louis and 1Rothschild, Pads, France.
LOCALIZED iNCREASE IN INTESTINAL T~ TCR+ AND CD8+ LYMPHOCYTE POPULATIONS AND ENHANCED CLASS H ANTIGEN EXPRESSION: INDEPENDENT FEATURES OF COELIAC DISEASE J. Carton. L Madrigal, D. P. O'Dono~ue, C. O'Farretly. ERC & The Gastroenterology Unit, St. Vincent's Hospital, Dublin 4.
Intravenous cyclosporine (Cy) has proven effective in the treatment of acute colitis with severe symptoms (NEJM 1994;330:1841). The present study reports the experience of several centers in the treatment of severe acute colitis with Cy, taking into account morphological signs of severity and long-term follow-up. ~ethods :
Background: Activation of specific sub-populations of T lymphocytes may play a significant role in the pathogenesis of coeliac disease. Identification and quantification of these populations in sub-compartments of the small intestine is now possible using flow cytometry. Objective: The aim of this study was to examine phenotype and class II expression of CD3+ lympbocytes from the lamina propria and intraepithelial sub-eompamnents in patients with active coeliac disease. Methods: Small intestinal biopsies were taken from 30 patients, 11 with active cocliac disease and 19 with normal small intestinal histology. A single cell suspension was obtained from the epithelial layer (EL) which was removed using chelating and reducing agents; the lamina propria (LP) was digested using cullagenase. Mean yields of 0.68xl061ympbocytes were obtained from the EL and 0.72x106 from the LP compartments. These cells were stained with antibodies specific for CD3, CI~, CD8, yrTCR and HLADR molecules and analyzed using flow cytometry. Results: Class I! antigen expression was detected on a significant percentage of lympbocytes from normal small intestinal EL (mean 34.87%; range 3.80-50.09) and LP (mean 20.00%; range 11.76-26.26). A significant increase was seen in the proportion (mean 52.41%; range 22.78-86.34) of EL lymphocytes expressing I-ILA-DR antigens from patients with active coeliac disease (P<0.01) when compared with controls. Class I1 antigen expression was similarly increased (P< 0.05) on lamina pmpfia lymphocytes (mean 38.45%; range 14.39-68.76) when compared with controls. T cell phenotypic studies showed an increase (mean 26.29%: range 14.5851.80) in the CD3+ 76 TCR+ population in the EL (P<0.05) when compared with control patients (mean 9.57%; range 0-25.70). Surprisingly, the T6 infiltrate into the LP of coeliac patients was much less marked (mean 3.43%; range 0-6.92; controls: mean 0.79%; range 0-2.40). Similarly, a significant change in the CIM:CD8 ratio seen in the coeliac epithelium (ratio !:22; control epithelium, mtiol:8) was not mirrored in the LP where the CIM:CD8 ratios remained similar (1.3:1 in coeliac preparations and 1.4:1 in controls): Conclusion: High class II antigen expression by coeliae intestinal T deLls was common to both LP and EL. The increase in the 76 TCR+ and CD8+ populations, however, was significantly more marked in the EL than in the LP suggesting that these features may be independent.
32 patients with severe acute colitis (14F, 18M;median age:33.5) treated with Cy (3.2
= 0.9 mg/kg/d during 15=14 days; mean Cy serum level : 279=94 ng/ml) were studied retrospectively. 26/32 patients had received high-dose corticosteroids before Cy. 25/29 patients had endoscopic and/or radiulogical signs of severity (3 patients were non responders, so and were colectomized before. Day 30. 20/32 (62.5%). e0 patients were responders, 16 ~ of them had a complete] remission. 15/18 responders, bad a frank improvement at~
sigmoidosenpy hydrusoluble enema.
4o . . . . . . . . . . . . . . . . . . . . . . ~
Do ~ -
-
20
or ~ 7/20
0 20 60 100 140 180 220 were Time (days) en!eetomized between day 30 and day 140 under oral Cy (n=6) or azathioprine (n=l) responders
for relapse (n=5) or aggravation (n=2). One responder was culeetomized at day 14, in complete remission. 12/20 responders were in complete remission after a median follow-up of 6.5 months. 11 patients had reversible side-effects of Cy. One colonic perforation at day 8 and one postoperative death occured in non respenders. Sedimentation rate was higher end mean serum albumin was lower in non reponders than responders (65--.21 vs 44=22 and 26=4 vs 30=5 ; p<0.02 and p<0.01 respectively) but no parameter (duration of the disease or the attack, number of attacks, clinieo-biological signs, dose end duration of Cy, Cy serum level, morphological signs of severity) allowed to predict the response to Cy. Co~cinsion : In this study, 62.5% of patients responded to Cy. At 6 months, only 30% of patients avoided coleetomy end remained in complete remission. The risk of delayed enlectomy must be taken into account in non responders.