Randomised clinical trial: vercirnon, an oral CCR9 antagonist, vs. placebo as induction therapy in active Crohn's disease.

BACKGROUND: Many patients with active Crohn's disease do not adequately respond to therapies, highlighting the need for new treatments. AIMS: To conduct a randomised, double-blind, placebo-controlled phase 3 study to assess the efficacy and safety of vercirnon, an oral inhibitor of CC chemokine receptor-9, for the treatment of patients with moderately-to-severely active Crohn's disease. METHODS: Patients with a Crohn's Disease Activity Index (CDAI) of 220-450, plus evidence of active disease (endoscopically confirmed or elevation of both C-reactive protein and faecal calprotectin), who had failed corticosteroid or immunosuppressant therapy were enrolled. Patients were equally randomised to receive placebo, vercirnon 500 mg once daily or vercirnon 500 mg twice daily. The primary endpoint was clinical response, defined as a 100-point decrease in CDAI from baseline to week 12. RESULTS: Six hundred and eight patients were randomised. Patient characteristics and baseline demographics were similar among the groups. The proportions of patients achieving a clinical response were 25.1%, 27.6% and 27.2% for placebo, once daily and twice daily respectively; treatment differences were not significant (2.5%; 95% confidence interval, CI -6.1% to 11.0%, P = 0.546 for once daily vs. placebo, and 2.1%; 95% CI -6.5% to 10.7%, P = 0.648 for twice daily vs. placebo). Adverse events were reported in 69.8%, 73.3% and 78.1% with serious adverse events in 8.9%, 5.9%, and 6.0% of patients in the placebo, once-daily and twice-daily groups, respectively. CONCLUSIONS: We did not demonstrate efficacy of vercirnon as an induction therapy in patients with moderately-to-severely active Crohn's disease; its effect in maintenance therapy was not addressed.

Response of the septic vasculature to prolonged vasopressor therapy with N(omega)-monomethyl-L-arginine and epinephrine in canines.

OBJECTIVE: To investigate the effect of blocking nitric oxide production on cardiovascular function and survival in canine septic shock treated with or without a conventional vasopressor. DESIGN: Randomized, controlled trial. SETTING: An animal research laboratory at the National Institutes of Health. SUBJECTS: Sixty purpose-bred beagles. INTERVENTIONS: Fibrin clots containing Escherichia coli were surgically placed into the peritoneal cavity. N(omega)-monomethyl-L-arginine (L-NMMA) 10 mg/kg followed by 0.5, 1.0, or 4.0 mg/kg/hr), epinephrine (1 microg/kg/min), both, or neither were infused for 24 hrs beginning 6 hrs after the onset of infection. All animals received fluid and antibiotic therapy. MEASUREMENTS AND MAIN RESULTS: Serum nitric oxide metabolites, nitrite and nitrate, increased with infection (p = .024) and decreased with L-NMMA (p = .004, all doses combined). Myocardial nitric oxide synthase activity was ranked as follows: nonsurvivors > survivors > noninfected controls (p < .01). Other tissues examined showed the same pattern. L-NMMA produced sustained increases in systemic vascular resistance index and mean arterial pressure 9 and 24 hrs after the onset of infection (p < or = .04). Left ventricular ejection fraction was depressed by septic shock (p = .01) and further decreased by L-NMMA (p = .02). However, control and L-NMMA cardiac index values were similar (p > .4), perhaps because L-NMMA increased pulmonary artery occlusion pressure (p = .02). From 9 to 24 hrs, epinephrine, in the absence or presence of L-NMMA, blunted recovery of cardiac index (p < .02) and had a diminishing vasopressor effect (p = .05). Neither L-NMMA nor epinephrine, individually or combined, significantly altered survival rates at the doses investigated (p > or = .69). CONCLUSIONS: The tested doses showed that nitric oxide production was inhibited by L-NMMA in canine septic shock, but mortality and myocardial depression were unaffected. These results suggest that if L-NMMA has a beneficial effect on survival rates in septic shock, it is small.

Xenogeneic ICAM-1 gene transfer suppresses tumorigenicity and generates protective antitumor immunity.

Tumorigenicity in Fischer rats was not significantly reduced when the rat ICAM-1 gene was overexpressed in the rat tumor cell lines, JM-1 and SST-2. When these rat tumor cell lines were genetically modified with a gene encoding human ICAM-1, tumorigenicity was dramatically reduced. Expression of xenogeneic ICAM-1 did not alter the growth rate, expression of the major histocompatibility complex, nor morphological appearance of the cells. However, it did facilitate a tumor-specific immunological recognition and rejection of the genetically modified tumor cells. This effect resulted in a tumor-specific, long-term protective immunity directed against genetically unmodified tumor cells. Most importantly, administration of tumor cells genetically modified with genes encoding xenogeneic ICAM-1 can facilitate an immunological response to genetically unaltered pre-existing tumors. Transferring splenocytes from animals 'vaccinated' with the xenogeneic ICAM-1 gene altered tumor cells was able to transfer the antitumor response into recipient animals. Furthermore, transfer of CD8+ T lymphocytes produced the same result. These results suggested that tumors specific CD8+ T lymphocytes were activated by the xenogeneic altered tumor cells. THis activation generated the long-term, tumor-specific immunity.

3-deazaadenosine inhibits leukocyte adhesion and ICAM-1 biosynthesis in tumor necrosis factor-stimulated human endothelial cells.

Previous reports demonstrate that cultured human umbilical vein endothelial cells (HEC) treated with TNF and other inflammatory mediators show an increased capacity to adhere human neutrophils. This increase is associated with the up-regulation of intercellular adhesion molecule 1 (ICAM-1) and other adhesion molecules on the HEC surface. We have found that 200 microM 3-deazaadenosine (c3Ado) prevented this TNF-induced increase in HEC adhesiveness. This effect resulted from interactions of c3Ado with HEC and not with polymorphonuclear neutrophils. Transport of c3Ado into the HEC was required for its activity, as evidenced by antagonism with the nucleoside transport inhibitor, nitrobenzylthioinosine. Treatment of HEC with c3Ado led to the intracellular buildup of S-adenosylhomocysteine and to the metabolic formation of S-3-deazaadenosylhomocysteine and 3-deazaadenosine 5'-triphosphate, events that appeared not to contribute to c3Ado activity. Exogenous L-homocysteine potentiated c3Ado activity, and this potentiation was prevented by the S-adenosylhomocysteine hydrolase inhibitor, periodate-oxidized adenosine. By using the mAb RR1/1, we have determined that c3Ado also inhibited the TNF-induced expression of ICAM-1 on the surface of the HEC, as well as cytosol-associated ICAM-1. Northern blot and in vitro translation analyses of poly(A+) RNA from c3Ado-treated HEC revealed that this nucleoside analog selectively decreased steady-state levels of ICAM-1 mRNA. The capacity of c3Ado to selectively inhibit HEC adhesiveness, ICAM-1 production, and steady-state levels of ICAM-1 mRNA may contribute to the drug's activity as an anti-inflammatory agent.

Inhibition of neutrophil adherence to endothelial cells by 3-deazaadenosine.

Treatment of cultured human umbilical vein endothelial cells (HUVE) with tumor necrosis factor alpha (TNF-alpha) increases their capacity to adhere human neutrophils. We have found that 3-deazaadenosine (c3Ado), when added in conjunction with TNF-alpha, inhibited this increase in neutrophil adherence. This activity of c3Ado was potentiated by the addition of L-homocysteine thiolactone (Hcy). The ability of c3Ado to inhibit neutrophil adherence to HUVE may contribute to the anti-inflammatory activity of this nucleoside analogue.

Identification of a receptor for high molecular weight human B cell growth factor.

Regulation of the proliferation of human B lymphocytes is under the control of several different signals. Various B cell growth factors (BCGF) have been described including a 60-kDa BCGF called high m.w. BCGF (HMW-BCGF). In this paper we describe a mAb BA5 that blocks the proliferation of normal activated human B lymphocytes in response to HMW-BCGF and does not affect the proliferation of T cells in response to PHA or IL-2. BA5 shows minimum binding to resting B cells, significantly enhanced binding to resting B cells, significantly enhanced binding to activated B cells and essentially no binding to resting or activated T cells. BA5 recognizes a 90-kDa protein from solubilized membranes of activated B cells. 125I-HMW-BCGF cross-linked to its binding site on activated B cells produces a 150-kDa R-protein complex. Unlabeled HMW-BCGF cross-linked to its binding site on activated B cells produces a 150-kDa band recognized by both BA5 and BCGF/1/C2 (a mAb to HMW-BCGF) using Western blotting. Thus, BA5 recognizes a molecule intimately associated with the receptor for HMW-BCGF which includes a binding site for HMW-BCGF. BA5 can be used to explore the role of HMW-BCGF and B cell proliferation in various aspects of human B cell physiology.

Leukotriene C4 produced by a human T-T hybridoma suppresses Ig production by human lymphocytes.

Multiple signals are involved in the regulation of Ig production by human B lymphocytes. Leukotrienes, especially LTB4, have been shown to inhibit Ig production by increasing the number and function of suppressor lymphocytes. Production of leukotrienes has been demonstrated by mast cells, basophils, eosinophils, polymorphonuclear leukocytes, monocytes, and macrophages. In this paper we demonstrate that a human T-T hybridoma grown at 5 x 10(5) cells/ml constitutively produces 5 ng/ml of LTC4. Furthermore, we demonstrate that either the supernatant from this hybridoma containing 0.5 to 10 ng/ml LTC4 or purified LTC4 in the range of 0.5 to 5 ng/ml can suppress 50 to 70% of Ig production by unfractionated human mononuclear cells, by normal human cells stimulated with Staphylococcus aureus Cowan I and B cell differentiation factors, and by the EBV-transformed B cell line SKW.6 in the presence of B cell differentiation factors. Thus, LTC4 can have direct effects on B cells and may have a role in normal B cell regulation.

Activated human T cells can present denatured antigen.

The requirements for activated, Ia-positive human T cells to present antigen were examined. Although activated T cells could present allo-Ia antigens, activated T cells could not present native, soluble protein antigens. We have now shown that activated T cells can present denatured protein antigens to stimulate proliferation of antigen-specific T-cell lines. Since denatured antigen may represent a processed form of antigen, the data suggest that activated T cells can present antigen but may not be able to process antigen as efficiently as other presenting cells. We have also shown that antigen-specific T-cell lines, which are also Ia positive, are able to present antigen to themselves, if the antigen is in a denatured form. Autopresentation requires a critical minimal cell number to stimulate proliferation, even with denatured antigen. The ability of activated T cells to present antigen may reflect an important amplification or feedback mechanism of immune regulation.

Production of B cell growth factor by normal human B cells.

Although it has been demonstrated that malignant human B cell lines are capable of producing B cell growth factor (BCGF), production of BCGF by normal B cells has not been shown. In this study, we demonstrate BCGF production by normal B cells, achieved by using human peripheral blood B cells prepared by a positive selection technique and stimulated with Staphylococcus aureus Cowan I (SAC) for 12 hr. SAC was removed from the supernatants by anti-SAC-coupled Sepharose. Supernatants absorbed with this antibody were functionally free of SAC, as demonstrated by their inability to activate resting B cells. B cells stimulated with SAC for 12 hr produced BCGF activity that was generally unmeasurable in supernatants by 36 hr. Characterization of BCGF produced by SAC-stimulated B cells revealed a m.w. of 32,000 by high-performance liquid chromatography sieving and sodium dodecyl sulfate-polyacrylamide gel electrophoresis; this BCGF was found to have an isoelectric point of 6.7. Furthermore, this BCGF lacked interleukin 1, interleukin 2, interferon, and B cell differentiation factor activity. This observation that BCGF can be produced by normal human B cells is significant because it demonstrates for the first time that normal B cells have the ability to provide their own growth factors or the growth factors for other B cells.

Activated human T cells can present alloantigens but cannot present soluble antigens.

Human T cells, when activated by antigen or mitogen, express Ia antigens. We have examined the capacity of activated T cells to stimulate autologous and allogeneic T cells and their ability to present soluble antigen. Interleukin 2-dependent T-cell lines (TCL), free of accessory cells, were used for antigen-presenting cells. These activated T cells were potent stimulators in an autologous mixed lymphocyte reaction (AMLR), more so than autologous irradiated non-T mononuclear cells. Activated T cells were also able to stimulate proliferation of allogeneic T cells in the absence of any other accessory cells, and this stimulation was blocked by anti-Ia antibodies. Resting unstimulated T cells were unable to stimulate autologous or allogeneic responses. Thus, activated T cells were able to present self antigens and alloantigens. However, activated T cells could not present soluble antigens to autologous T cells or to antigen-specific TCL even if exogenous interleukin 1 was added to cultures. The ability of activated T cells to stimulate an AMLR in vitro may reflect an important immunologic amplification mechanism in vivo. The ability of activated T cells to present alloantigens but not soluble antigens suggests an inability to process antigen, and this may provide further insights into the complexities of antigen presentation.

Purification to homogeneity of a high molecular weight human B cell growth factor; demonstration of specific binding to activated B cells; and development of a monoclonal antibody to the factor.

High molecular weight B cell growth factor (HMW-BCGF) produced by a T cell line was purified to homogeneity and demonstrated to bind specifically to activated human B cells. A monoclonal antibody to HMW-BCGF was developed that (a) specifically inhibited the activity of HMW-BCGF in enhancing B cell proliferation, (b) specifically bound to HMW-BCGF in Western blots, (c) specifically absorbed HMW-BCGF activity from culture supernatants, and (d) specifically absorbed an internally labeled protein from T-ALL supernatant which comigrates with HMW-BCGF on sodium dodecyl sulfate-polyacrylamide gels. This antibody should help in cloning the gene for HMW-BCGF and further exploring the physiologic roles of HMW-BCGF.

Modulation of human B cell responses by a monoclonal antibody to an activation antigen 4F2.

Antigen specific human antibody responses can be modulated in vitro by the addition of 4F2 antibody, a monoclonal antibody (MoAb) which recognizes an antigen on activated T cells and B cells. Specific antibody responses induced with the antigen are suppressed by the addition of 4F2. However, specific antibody responses induced with the polyclonal activator, pokeweed mitogen (PWM), are significantly enhanced by the addition of 4F2. Proliferative responses to both antigen and PWM are suppressed by the addition of 4F2. The enhancement of PWM stimulated responses by 4F2 is mediated by T cells. However, in the absence of T cells, 4F2 can directly inhibit antigen specific B cells. Polyclonal Ig production stimulated by PWM was also enhanced by 4F2. Thus, the immunomodulating effects of the 4F2 MoAb are the result of a balance of enhancement and suppression mediated at the T cell and the B cell level, respectively.

Hydrocortisone-mediated inhibition of monocyte antigen presentation: dissociation of inhibitory effect and expression of DR antigens.

The suppressive effects of hydrocortisone (HC) on the human immune system are well known. The mediation of the immunosuppressive effects of HC on lymphocyte responses via inhibition of monocyte function has been examined by monocyte-dependent, antigen-induced lymphocyte proliferation. Monocytes that were first treated with HC and then washed were unaffected in their subsequent ability to present antigen. However, there was a dramatic inhibition of lymphocyte proliferative responses if HC was present while monocytes were pulsed with antigen. This was directly related to the dose of HC present. HC-mediated inhibition of monocyte antigen presentation could not be overcome by the addition of interleukin-1 (IL-1) to cultures, and thus inhibition of monocyte IL-1 secretion cannot totally account for the inhibition of monocyte antigen presentation. Although HC inhibits monocyte antigen presentation, HC increases the expression of HLA-DR antigens on monocytes. Other monocyte stimulants, including lipopolysaccharide (LPS), lymphokine, and gamma interferon, were examined for their effect on monocyte DR expression and their effect on monocyte antigen presentation. No correlation was found between the ability to increase monocyte DR antigen expression and the effect on antigen presentation. While HC, lymphokine, and gamma interferon all increased the expression of DR antigens on monocytes, HC, LPS, and lymphokine, but not gamma interferon, inhibited monocyte antigen presentation. Although HC can exert profound immunosuppressive effects via monocytes, it is not the only mechanism of inhibition. HC added to cultures after monocytes had been pulsed with antigen was also inhibitory.

Increased expression of HLA-DR antigens in hydrocortisone-treated monocytes.

Human peripheral blood monocytes incubated overnight with hydrocortisone had an increased expression of HLA-DR antigens. This change was noted as an increased proportion of DR-positive staining monocytes at greater fluorescence intensities as determined on a fluorescence-activated cell sorter. Hydrocortisone treatment of monocytes did not alter the expression of another Ia antigen on monocytes, HLA-DS. Neither did hydrocortisone treatment alter the expression of either Mac 120 antigen or monocyte .2 antigen on monocytes. Thus, the effect of hydrocortisone on monocyte DR antigens may be somewhat selective. Hydrocortisone also caused an increase in monocyte cell size after 3 to 4 days as compared to untreated controls.

Differential effect of monoclonal anti-DR antibody on monocytes in antigen- and mitogen-stimulated responses: mechanism of inhibition and relationship to interleukin 1 secretion.

A differential role for DR antigens on monocytes in antigen-stimulated as opposed to mitogen-stimulated human lymphocyte responses has been observed. A monoclonal anti-DR antibody used to treat monocytes caused inhibition of antigen-induced T-cell responses and of T-cell-dependent B-cell responses. However, anti-DR antibody treatment of monocytes did not inhibit mitogen-induced responses. Anti-DR treatment of monocytes did not induce suppression, as antigen-induced responses could be reconstituted with untreated monocytes. Anti-DR treatment of monocytes did not merely block interleukin 1 (IL-1) secretion since addition of IL-1 could not restore antigen-induced responses. Monoclonal anti-DR antibody did not directly inhibit monocyte secretion of IL-1. DR-negative monocytes, selected by antibody and complement, could not present antigen, even though they were capable of secreting IL-1. Thus, this monoclonal anti-DR antibody sterically blocks antigen presentation by monocytes without induction of suppression or inhibition of IL-1 secretion. Monocyte DR antigens appear essential for stimulation of antigen-induced responses, but DR antigens on monocytes may not be essential for mitogen-stimulated responses and do not appear to be related to the ability of monocytes to secrete IL-1.