Role of JAK Inhibitors in Controlling Inflammation and HIV

Role of JAK Inhibitors in Controlling Inflammation and HIV Reactivation
C Gavegnano1,2, F Dupuy3, J Brehm3, SJ Hurwitz 1,2, RP Sekaly3, and RF Schinazi1,2
1Center for AIDS Research, Laboratory of Biochemical Pharmacology, Department of Pediatrics, Emory University, Atlanta, GA 30322, USA; 2Veterans Affairs Medical Center, Decatur, GA 30033, USA, and 3Case Western Reserve University, Department of Pathology, Cleveland OH, USA. 1
Background: 1. Current ART cannot eradicate HIV‐1. 1. Current ART cannot address inflammation driven obstacles to eradication, including elevated levels of IL‐6, sCD14/sCD163, IL‐1/, etc. Unmet clinical need = Safe, specific, targeted inhibition of HIV‐induced inflammation. Enter tofacitinib and ruxolitinib….
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FDA approved for rheumatoid arthritis •
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FDA approved for chronic long‐term use for myelofibrosis. 43 ongoing clinical trials for inflammatory disorders. These data build upon a recent publication by our group: Gavegnano et al. Ruxolitinib and tofacitinib are potent and selective inhibitors of HIV‐1 replication and virus reactivation in vitro. Antimicrob Agents Chemother. 2014;58(4):1977‐86. 2
Jak inhibitors confer inhibition of multiple pro‐HIV cytokines
Modified from: O’Shea and Laurence et al. Janus Kinase Inhibitors of Autoimmune Diseases. Ann Rheum Dis. 2013 April ; 72(0 2): ii111–ii115. doi:10.1136/annrheumdis‐2012‐202576. 3
Our studies were designed to answer the following questions: YES
1.
Is there a correlation between elevated pSTATs in vivo and disease progression? 1.
Do Jak inhibitors block viral replication in vitro and ex vivo?
1.
Do Jak inhibitors block HIV‐induced upregulation of CCR5/CXCR4? 2.
Do Jak inhibitors block HIV‐induced activation and proliferation?
1.
Do Jak inhibitors block maintenance of the HIV reservoir (T cell)? 1.
Do Jak inhibitors block bystander infection in T cells? 1.
Are these events occurring at physiologically relevant concentrations? 4
In vivo, elevated pSTAT5, CD127, and CD25 correlate with establishment and/or maintenance of T cell reservoirs and plasma viral load
Integrated HIV DNA
3000
2500
2000
1500
1000
500
0
0
1
2
3
4
5
11000
10000
9000
8000
7000
6000
5000
4000
3000
2000
1000
0
6
r=-0.3074
p=0.0114
0
1
5000
3
4
5
10000
IL-7R MFI in CD4+ cells
r=0.3945
p=0.0170
4500
2500
2
2000
1500
1000
500
0
6
1
2
3
4
5
r=-0.3694
p=0.0021
0
6
r=-0.2693
p=0.1123
7500
5000
2500
0
1
2
3
4
5
6
2
3
4
5
6
65
60
55
50
45
40
35
30
25
20
15
10
5
0
r=-0.4193
p=0.0109
0
1
2
3
4
5
6
HIV DNA (log) per million CD4
HIV DNA (log) per million CD4
HIV DNA (log) per million CD4
1
HIV DNA (log) per million CD4
0
0
CD25
65
60
55
50
45
40
35
30
25
20
15
10
5
0
HIV DNA (log) per million CD4
D
Viral load
IL-7R MFI on CD4+ cells
pSTAT5 MFI in CD4+ cells
Aviremic
donors
HIV DNA (log) per million CD4
% CD25+ in CD4+ cells
r=0.3136
p=0.0098
C
CD127
% CD25+ in CD4+ cells
4500
B
pSTAT5
IL-7R MFI in CD4+ cells
pSTAT5 MFI in CD4+ cells
Viremic
donors
A
11000
10000
9000
8000
7000
6000
5000
4000
3000
2000
1000
0
r=-0.3804
p=0.0290
0
1
2
5
3
4
Log VL
5
6
7
JAK inhibitors block viral replication and production in vitro and ex vivo
In vitro acute infection
Ex vivo, chronic infection 6
Ruxolitinib and Tofacitinib inhibit HIV‐induced CCR5 upregulation
A
B
7
Ruxolitinib and Tofacitinib inhibit HIV‐induced T‐cell activation and proliferation
A
B
C
D
8
JAK inhibitors block maintenance of HIV T cell reservoir
Viremic, HIV‐infected donors CD4 T cells isolated from individuals integrated viral DNA quantified on day 5 post culture +/‐ tofacitinib or ruxolitinib maintained in cultures
9
Ruxolitinib Inhibits bystander infection in CD4+ T cells A
B
DMSO (M)
Ruxolitinib (M)
10
Pharmacokinetic simulation for 10 mg and 20 mg bid dosing of ruxolitinib in humans: Anti‐HIV effects occur at physiologically relevant concentrations in vivo
Data for models obtained from Shi, et al., J Clin Pharmacol 2012;52:809‐818.
Models correct for plasma protein binding. 10 mg bid simulation
20 mg bid simulation
Simulation of in vivo pharmacokinetics of 10 mg (A) or 20 mg (B) bid ruxolitinib demonstrates that all pro‐HIV
events that were inhibited by ruxolitinib in vitro occur at or below concentrations within the steady state
plasma concentrations observed in vivo for 10 mg bid (A), and 20 mg bid (B). Dotted lines denote IC50 at
which ruxolitinib confers inhibition in vitro, and notations of A‐D denote: CD3 zeta and pSLP76, A; inhibition of
Bcl‐2 activation, B; inhibition of maintenance and expansion of the T cell reservoir, and antiviral potency
against chronic and acute infection, C; inhibition of proliferation/activation (CD25, CD38/HLADR, PD1),
downregulation of CCR5, inhibition of pSTAT5 by IL‐2, IL‐7, IL‐15, inhibition of bystander infection, D.
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Potential concerns for Jak inhibitors in vivo: Safety in HIV‐infected cohort 1. Jakafi is not contraindicated in HIV‐infected individuals (Jakafi package insert)
2. Will Jak inhibition confer increase in viral loads? 12
Non human primate study with Jakafi in chronically SIV infected monkeys Dose modeled to mimic 10 mg bid dose in humans, which will be used for the clinical study in humans
PK sampling
PK sampling
1, 2, 4, 8, 12 hr Week
‐1 0
1
1, 2, 4, 8, 12 hr 2
Collect 2.1 mg/kg oral Sample Jakafi
For viral bid
load
Collect plasma to quantify Jakafi levels (PK)
3
4
5
6
7
8
Add HAART regimen
Collect plasma to quantify Jakafi levels (PK)
* To be conducted to ensure that addition of HAART does not modify Jakafi PK
Withdraw all drugs
Microarray or proteomics= up to three time points pending cytokine results above (up to three time points). 13
Jakafi treatment of chronically SIV‐infected non human primates does NOT increase viral loads
110
100
90
80
70
60
50
40
30
20
10
0
Jakafi + HAART
No drugs
RWl13
% of baseline viral load
% of baseline viral load
Reo‐8
Baseline 346,674 HIV‐1 RNA copies/ml
Jakafi only
11 7 14 21 28 35 42 49 56
2
3
4
5
6
7
8
9
110
100
90
80
70
60
50
40
30
20
10
0
Days post drug treatment
% of baseline viral load
% of baseline viral load
RHs‐13
Baseline 400,000 HIV‐1 RNA copies/ml
1 7 14 21 28 35 42 49 56
1
2
3
4
5
6
7
8
9
Days post drug treatment
1 7 14 21 28 35 42 49 56
1
2
3
4
5
6
7
8
9
Days post drug treatment
RRn‐11
110
100
90
80
70
60
50
40
30
20
10
0
Baseline 108,171 HIV‐1 RNA copies/ml
110
100
90
80
70
60
50
40
30
20
10
0
Baseline 174,000 HIV‐1 RNA copies/ml
11 7 14 21 28 35 42 49 56
2
3
4
5
6
7
8
9
Days post drug treatment
= 2.1 mg/kg Jakafi bid = 2.1 mg/kg Jakafi + HAART (Kaletra + (‐)‐FTC + PMPA + Raltegravir = No drugs 14
Study Design: A5336‐ A Randomized, Pilot Study of Ruxolitinib in Antiretroviral‐
Treated HIV‐Infected Adults
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Randomized, open label study
•
Population:
•
•
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HIV‐infected male and female subjects ≥ 18 years of age
CD4+ T cell count > 350 cells/mm3
Stable ART containing either NNRTI or INSTI who have:
•
•
•
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Not pregnant; no active hepatitis B or C infection
Sample size: 60 subjects
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Virologic suppression
No other medical conditions, or concomitant medications, prohibiting the use of a JAK/STAT inhibitor
40 on ruxolitinib + ART (Arm 1); 20 on ART (Arm 2)
Study duration:
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5 weeks of intervention
7 weeks of follow-up
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Intervention: ruxolitinib 10 mg bid
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Primary objectives: safety, IL-6
Secondary objectives:
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sCD14, tumor necrosis factor alpha (TNF‐α), IL‐1α, IL‐1‐β, IL‐18, macrophage colony stimulating factor (mCSF), neopterin, HLA‐DR, CD38, and both the distribution of monocyte subsets (defined by expression of CD14 and CD16)
HIV‐1 2 LTR circles, integrated viral DNA, plasma viral RNA (single copy assay) 15
Conclusions
• Jak inhibitors do not increase viral loads in chronically
SIV infected non‐human primates.
• Jak inhibitors inhibit multiple pro‐HIV, pro‐
inflammatory events in vitro and ex vivo that are
associated with disease progression, HIV‐associated
neurocognitive impairments, and mortality.
• These data provide a mechanistic framework for an
upcoming phase 2a funded NIH‐ACTG study with
ruxolitinib in HIV‐infected individuals.
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Acknowledgments
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Emory University
• Raymond F. Schinazi, PhD, DSc
• Selwyn J. Hurwitz, PhD
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Laboratory of Rafick Sekaly
• Rafick Sekaly, PhD
• Jessica Brehm, PhD
• Franck Dupuy, PhD
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Support
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Emory University CFAR; CFAR
- Young Investigator
- NIH AIDS Clinical Trial Group
- Vincent Marconi, MD
- Steven Deeks, MD
- Michael Lederman, MD
- Others
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