A double-blind placebo-controlled (DBPC) clinical trial evaluated the use of a cocktail of wild type major allergens of timothy grass (Phleum pretense) - Phl p 1,.
Institute for vaccines
Allergen Products for Diagnosis and Therapy: Regulation and Sclenee 13th International Paul-Ehrlich-Seminar September 1,4-17,żOtI Hyatt Regency Washington on Capitol Washington DC, USA
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1
Current Status of Subcutaneous and Sublingual Immunotherapy with Recombinant Allergens Marek Jutel, Katarzyna Solarewicz-Madej ek, Sylwia Smolinska
lntroduction The quality of preparations used for allergy immunotherapy (AIT) largely determines its efficacy. The measures of the successful AIT include both, the reduction of the symptoms of allergic rhinitis and/or asthma as well as the use of symptom
relieving medication and the improvement of thę patient's quality of life. Longlasting beneficial effects should also be observed after cessation of the treatment. Moreover, AIT reduces the risk of new allergen sensitizalion [1] as well as prevents development of asthma in atopic subjects [2].
However well standardized for total allergenic activity and the major allergens content, currently used allergen extlacts contain different amounts of major and minor allergens [3]. In the variety of allergens only some sequences or sections (epitopes) are responsible for their immunogenicity and allergenicity. Decoding the molecular structure as well as function of allergens and their epitopes gave rise to the new developments for both, laboratory assessment and clinical studies of AIT. In addition, verified clinical relevance of a single allergen protein in a patient opens new possibilities of individuatly tailored AIT. Novel allergen vaccines do contain cocktails of recombinant allergens providing quality based on the precise quantity of relevant allergenic proteins as well as reproducibility of allergen parameters in the vaccine vials. Thus, problems with allergen standardżation are largely avoided. In addition, recombinant allergens do provide thebasis for production of hypoallergenic derivatives. Currently under investigation are either standard allergen cocktails derived from one allergen source (timothy grass) or vaccines containing a single relevant allergen,
d 1ftom cat dander ot Bet y 1 from birch pollen. Recombinant allergenin vitro assays give new opportunities to screen particular molecules of clinical based relevance in the defined groups of allergic patients in different areas as well as for ltke Fel
134
investigating of the mechanisms of tolerance induced by high allergen doses as used during AIT [4,5].
Recombinant allergen vaccines in clinical studies The first clinical studies with recombinant allergens provided promising data [6]. engineering created new opportunities to produce hypoallergenic derivatives with reduced lgE-reactivity but retaining their immunogenic activity. Although a number of allergens have been cloned for research pu{poses, only a few have been investigated in clinical AIT trials. Selected clinical studies both completed and ongoing with recombinant allergens are listed in table 1,a, Ib.
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Different allergen molecules and different vaccination routes are subjected toinvestigation and evaluation in clinical trials. Recombinant allergen molecules used in the clinical studies either retained the wild-type structure, or were processed to become hypoallergenic. Modification of IgE-dependent allergenic determinants reduces IgE-mediated side effects during allergen-specific immunotherapy. However, late-phasę reactions were observed, most likely resulting from retained T-celldependent immunogenic epitopes in the hypoallergenic derivatives [7,8].
Grass pollen allergen studies
A double-blind placebo-controlled (DBPC) clinical trial evaluated the use of a cocktail of wild type major allergens of timothy grass (Phleum pretense) - Phl p 1, Recombinant wild-type allergens
Birch pollen
Grass pollen
Betv1
With seasonal ]hinsonjundivhis individuals
Peanut
scr, DaPc, phase !, safetyand efii6ry
Arahl,Arah2,Arah3
NCTOM10930,[18]
and/or mild asthma
iili,-oipc-, pń"i" l,
---
peanut-alle18ic
reatal, phase
individuals
NcT00850668
§afety, tolerabiltry and pharma.odynamic €tfecB
individuals with birch pollen indlced atle]gic .hinitis
Nfro0395149
sF,
1, Phl p 2,
phase l,
sf€ł, tolerabllfrY and phalma.odynamic efieds Nm0889460, [20l
Phl p 5a, Ph| sclT, D8Pc, phase lll, safety and efficacy
I
-
Nfroo309036 sclr,
-ońć,
p-ń.iiri
-
$fety and effi€cy individuaaś with
-
aller8ic
phisji
-
§afety and efficacf,
rhinoconiundivitis, with orwithout aśthma
NcT00671268 śclf.-o-sipć,
dose response -
NcT00566341
iĆlióipc, pń"
-
saf€ty and effi@cy'1-1, sLlT, DBPc, pha§e ll,
with birchPollen.related,__ allergic rhinoconiundivitis individuals
safety and €fficacY
l1o9o|ri
sL[, oBPc
sclT, DBPC, I9]
llb/lll No009o1914 phal€
indictttic.ln of their phase, clinicalTrials.gov ID, and route of administration of recombinant wild-type allergen vaccines. DBPC - double blind placebo, controlled, SCIT - subcutaneous itnmunotherapy, SLI'l- - sublingual immunotherapy, NCT - ID based on National Institutes of Health Cli.nical. trial. datąbase - (http://clinicaltrials.gov and t7])
Table 1a. Immunotherap1l trials with
,gen doses aS used
romising data [6]. rgenic derivatives
ivity. Although a
Hypoallergens
Birch pollen Betvlfoldingvariant SCIT, OC, phase ll,
i a few have been rpleted and ongore subjected toin-
n molecules used vere processed to nic determinants
safety and efficacy NcT00266526
individuals allergic to birch pollen allergens
ated the use of a
NcT00841516
śoi-óspć-
l8], [12],
ll3l,[l4|,
_ _ _ _ _I_15J:t_191_ _ _ _ .
sclT, DBPC, phase lll,
individuals with allergic rhinoconjunctivitis
,etense)-Phlp1,
histological evaluation
---
rotherapy. Hown retained T-cells [7,8].
p}tinili' '.';,-§gĘ, immunological and
§afety and efficacy NcT00309062
Śc-lib-sic-,
pń"r.lli
safety and efficacy NcT0o554983
route Tabte 1b. Immunotherapy trials with indication of their phase, clinicalTrials,gov ID, and _ _ OC placebo-controlled, blind double DBPC of administration of hypóallergen vaccines. Institutes open controlled, SCIT'- subruton"o^ immunotherapy, NCr - lD based on National if nealtn Chnical tńal database - (http://clinicaltrials.gov and [7]), rass pollen ,
Phl p 5a, Phl p 5b, Phl p 6 sclT, DBPC, phase lll, śafety and e{fiecy
___}9ry:9r9i6_
__
sclT, DBPC, phas€ lll, $fety and efficacl NcT@671268
:h
sclT, DBPC, phase ll, safety and efłiacy, dose rBponse
itis,
-
NcT0o666341
ićrióópc, ińJn-l,
-
safety and erfi@c}
___]_q0_1J:3]:5____ sclT, DBPC, 19l
s,gov
ID, and route
ńle blind placebonunotherapy, NCT inicaltriak.gov and
Phl p 2, Phl p 5a, Phl p 5b and Phl p 6 in the treatment of allergic rhinitis. Sixtytwo grass pollen allergic patients suffering from rhinoconjunctivitis with or without asthńa wóre subjecteó tó afiergen desensitżation, and for the first time the clinical efficacy of a recómbinant vaccine was feported [9]. The vaccine was administered subcutaneously for 18 months. A combined symptom_medication Score (SMS) treat_ assessed as thó primary end-point showed a 39Yo improvement in the active sig_ grorrp, highly verum In the (p < 0,0a1). placebo ment group, in óompaiison tó concentraantibody pollen-specific grass nificant inóreases in both IgG1 and IgG4 tions together with a significant decrease in IgE were observed. However, specific IgE levóls were not significantly diffęrent between groups at the beginning of the siudy, there was a downward trend during AIT with values significantly lower than the baseline in the active treatment group. Adverse events related to the treatment were observed after 78 injections (10.7%) in the active treatment group and after 44 injections (5.9%) in the placebo gro,tlp. No drop-out due to adverse events was observed during the treatment. The vaccine showed a favorable safety profile when compared with other immunotherapy studies. The first DBPC SCIT-DRF with the
136 same recombinant Phl p 1, 2, 5a, 5b, ó-mixture in patients with rhinoconjunctivitis plus/minus asthma showed no major side effects at very high doses up to 120 pg [10]. Some other approaches were also presented [11], including a recombinant single hybńd allergenic vaccine molecule encoding four major grass pollen allergens and containing most of the B-cell epitopes of grass pollen. The molecule seems to be useful also in the allergy diagnostics in 98% (n = 652) of patients allergic to grass pollen.
Birch pollen allergen studies Potently reduced immediate type skin reactions with rBet v 1 fragments as well
as Bet v 1 dimer and trimer were shown [12]. These compounds were then investigated in the first DBPC study by Niederberger and colleagues [13]. Active treat-
ment induced protective IgG antibodies that inhibited allergen-induced release of inflammatory mediators. Clinically, a reduction in cutaneous hypersensitivity as well as a tendency of reduced symptom score in actively treated patients was observed.
In addition, allergen-specific IgE increase following the seasonal birch pollen exposure was significantly reduced in vaccinated patients [13]. In another DBPC study, genetically modified derivatives of Bet v 1 (Bet v 7-trimer, Bet v l-fragments) were applied. Vaccination with genetically modified Bet v 7 derivatives, but not with placebo, induced Bet v l-specific IgG1, IgGZ and IgG4 and low IgA antibodies in serum, as well as in nasal secretions. The levels of therapy-induced Bet v l-specific IgG4 antibodies in nasal secretions were correlating (P < 0.05) with reduced nasal sensitivity to natural, birch pollen-derived Bet v 7, as determined by controlled nasal provocation experiments [14]. Vaccination with the use of Bet v 1 fragments or Bet v 1 trimers increased IgG1, IgGZ and IgG4 specific to cross-reactive allergens, like alder pollen, hazel pollen, celery, carrot and apple, as shown in another study by Niederberger et al [15]. Subsequently, a clinical improvement in oral allergy syndrome symptoms mainly inthe verum group patients was observed [15]. Pree et al [16] demonstrated that vaccination with recombinant folded and unfolded allergen derivatives of Bet y 1 induced IgG against the new epitopes. Allergic individuals were treated with either Bet v ] trimer or Bet v 1 fragments. The Bet v 1 trimers retained more of the folded configuration of natural Bet v 1, compared with Bet v l fragments, and the trimers induced the production of Bet v 1-specifc IgE more effectively than the fragments [17]. In another multicenter, randomized, DBPC study by Pauli [18] recombinant Bet v 1, standard birch pollen extract, natural purified birch pollen allergen and aluminum hydroxide as placebo were compared in 134 patients during a two-year desensitization period. All three verum groups demonstrated significant and equal improvement in symptoms, decreased medication use and skin test reactivity in both pollen seasons compared to the placebo group. rBet v-tręated individualsshowed agteatc.ł increaseinBetv /-specificIgGI,IgGZ,andIgG4 levels as well as a greater decrease in the skin test reactivity than the other verum groups. However, new sensitizations were reported in the patients treated with the extract [18]. In a three-arm DBPC study with a recombinant Betv 1 trimer and an equimolar mixture of two recombinant Bet v 1 fragments together, single courses of injection immunotherapy with Bet v 1 allergen derivatives showed trends towards improved well-being and reduced reactivity to specific allergen provocation, However, no
significant improv
observed. Therap1 dence of local side systemic reactions
Very promising
ing the clinical effi
rBetvlvańanth
with allergic rhinit tion in symptom-n vaccine was well-t, ies with rBet v 1-c, (SLIT) were also study, patients wel for 2 weeks. The o [20]. In another st III follow-up stud.
cebo, respectively.
approximately 259 adjusted symptom
Other allergens An attempt
has
Fel d 1. A recomt translocation dom pathway
(MAT-F,
intra-lymph node
Specific immun under investigatiol gens (Ara h 1, Ar, designed for recta]
conclusions The new recon
immunotherapy
a(
collected during stl very promising. Il major allergens pr, resolved approach were successful, pJ the treatment can
137
significant improvement in the combined symptom-medication score (SMS) was observed. Therapy with the trimer preparation was associated with increased incidęnce of local side effects, whereas the Bet v l fragments were more likely to induce systemic reactions
[8].
Very promising results have been obtained in several clinical studies investigating the clinical efficacy and safety of a hypoallergenic folding variant of Bet v 1.Thę rBet v 7 variant has been investigated in a phase III DBPC trial. In 2ż6 patients with allergic rhinitis with or without asthma a significant, clinically relevant reduction in symptom-medication score was observed after 18 months of treatment. The vaccine was well-tolerated, with no untoward adverse reactions [19]. Clinical studies with rBet v 1-containing tablets for sublingual allergen specific immunotherapy (SLIT) were also performed in birch pollen-allergic patients. In a dose-response study, patients were randomized to receive doses ranging from tż.5 slg and 300 pg for 2 weeks. The optimal tolerated dose of rBet v ] ranged between Iż.5 1lg to 50 pg [20]. In another study, 483 patients were randomżed for treatment in a phase IIb/ III follow-up study with tablets containing 12.5,ż5.0, and 50 mg of Bet v 1 or placebo, respectively.The treatment was clinically efficacious. Significant reduction of approximately 25o/" over the whole pollen season was demonstrated in the average adjusted symptom score. The vaccine was well tolerated [21].
Other allergens An attempt has been made to treat allergy to cats with the single major allergen Fel d 1. A recombinant Fel d 1 allergen has bęen fused to a TAT-dęrived protein translocation domain and a truncated invariant chain to target the MHC class II pathway (MAT-Fel d 1_). The construct was administered by using a course of three intra-lymph node injections [żż]. Specific immunotherapy for food allergy using recombinant allergens is also under investigation. In a phase I clinical study recombinant modified peanut allergens (Ara h 1, Ara h 2, Ara h 3) were encapsulated in heatiphenol-killed E. coli, designed for rectal application [7].
conclusions The new recombinant technology in vaccine production for allergen-specific immunotherapy advocates an individualizęd approach to the patients. Clinical data collected during studies on the recombinant allergens for allergy immunotherapy are very promising, In the mono-sensitised patients, the standard cocktails of relevant rnajor allergens provide optimal cure. In the polysensitized subjects, the component resolved approach could be more effective. Although several phase II clinical trials were successful, phase III studies are much more challenging but necessary before lhe treatment can be offered as the clinical routine.
20. Winther L. Poulsr
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1
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Asthma Immunol
S,
v 1 (rBet v
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-
18. Pauli G, Larsen TH, Rak S, Horak F, Pastoreilo E, Valenta R, Purohit A, Arvidsson M, Kavina A. Schroeder J,W, Mothes N, Spitzauer S, Montagut A, Galvain S, Melac M, Andre C, Poulsen LK, Mailing HJ. Efficacy of recombinant birch pollen vaccine for the tleatment of birch-allergic rhinri conjunctivitis. J Allergy Clin Immunol żOOB,, 12ż: 9-51 -960, 19. Ketiner J, Meyer H, Narkus A, Cromwell O, Jost K. Specific immunotherapy with recombinant bilcll pollen allergen rBet v 1-FV is clinically efficacious-results of a phase III study [abstract]. Allcrl',1'
(rBet v 1) tablel
s215.
E
t
n .: ,:
]i a:
-: U,
,,
20_
139 L, Robin B. Nlelac M, Malling H. Safety and Tolerability of Recombinant Bet v (rBet v 1) tablets in sublingual imrnunotherapy (SLIT). J Allergy Clin Immunol Ż009;123 (Suppl):
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żż, Senti G, Crameri R, Kuster D. Johansen P, Martinez-Gomez JM, Graf N, Steiner M, Hothorn LA, Grónlund H, Tivig C. Za]eska A. Soyer O, van Hage NI, Akdis CA, Akdis M, Rose H, Kiindig TM. Intralynrphatic inrmuncltherapy for cat allergy induces tolerance after only 3 injections. J AllergY Clin Immunol. 2012,^ Iż9: 1290-1296.
