Low-Dose IL-2 for Treating Moderate to Severe Alopecia Areata: A 52-Week Multicenter Prospective Placebo-Controlled Study Assessing its Impact on T Regulatory Cell and NK Cell Populations

The treatment of severe alopecia areata (AA) remains highly challenging. A breakdown immune privilege the hair follicle resulting in development an admixed infiltrate antigen-presenting cells and CD4+ CD8+ T lymphocytes is hypothesized to represent important driver AA (Pratt et al., 2017Pratt C.H. King Jr., L.E. Messenger A.G. Christiano A.M. Sundberg J.P. Alopecia areata.Nat Rev Dis Primers. 2017; 3: 17011Crossref PubMed Scopus (184) Google Scholar). deficiency regulatory (Tregs) might facilitate occurrence this breakdown. growing corpus data animal models, as well from blood skin patients with AA, emphasized likely key role Tregs pathomechanisms (Conteduca 2014Conteduca G. Rossi A. Megiorni F. Parodi Ferrera Tardito S. al.Single nucleotide polymorphisms promoter regions Foxp3 ICOSLG genes are associated areata.Clin Exp Med. 2014; 14: 91-97Crossref (23) Scholar; Hamed 2019Hamed F.N. Åstrand Bertolini M. Maleki-Dizaji al.Alopecia show FOXP3+CD39+ clonotypic restriction Treg TCRβ-chain, which highlights immunopathological aspect disease [published correction appears PLoS One 2019;14:e0222473].PLoS One. 2019; 14e0210308Crossref (13) McElwee 2005McElwee K.J. Freyschmidt-Paul P. Hoffmann R. Kissling Hummel Vitacolonna al.Transfer CD8(+) induces localized loss whereas CD4(+)/CD25(-) promote systemic CD4(+)/CD25(+) blockade onset C3H/HeJ mouse model.J Invest Dermatol. 2005; 124: 947-957Abstract Full Text PDF (103) Petukhova 2010Petukhova L. Duvic Hordinsky Norris D. Price V. Shimomura Y. al.Genome-wide association study implicates both innate adaptive immunity.Nature. 2010; 466: 113-117Crossref (494) Shin 2013Shin B.S. Furuhashi T. Nakamura Torii K. Morita Impaired inhibitory function circulating CD4+CD25+ areata.J Dermatol Sci. 2013; 70: 141-143Abstract (29) Tembhre Sharma, 2013Tembhre M.K. Sharma V.K. T-helper T-cell cytokines peripheral active areata.Br J 169: 543-548Crossref (66) IL-2 essential for homeostasis (Zorn 2006Zorn E. Nelson E.A. Mohseni Porcheray Kim H. Litsa al.IL-2 regulates FOXP3 expression human through a STAT-dependent mechanism expansion these vivo.Blood. 2006; 108: 1571-1579Crossref (554) Low-dose results recovery concomitant clinical improvement hepatitis C virus–induced vasculitis, graft-versus-host disease, lupus, autoimmune thrombopenia (He 2016He J. Zhang X. Wei Sun Chen Deng al.Low-dose interleukin-2 selectively modulates CD4(+) cell subsets lupus erythematosus.Nat 2016; 22: 991-993Crossref (300) Koreth 2011Koreth Matsuoka H.T. McDonough S.M. Bindra B. Alyea 3rd, E.P. al.Interleukin-2 disease.N Engl 2011; 365: 2055-2066Crossref (760) Saadoun 2011Saadoun Rosenzwajg Joly Six Carrat Thibault al.Regulatory responses low-dose HCV-induced vasculitis.N 2067-2077Crossref (544) 2018Zhang Ruan Xu Wang Tao Q. Lu al.Therapeutic potential thrombocytopenia: analysis 3 cases.Cytometry B Clin Cytom. 2018; 94: 428-433Crossref (9) Conversely, failed improve type 1 diabetes while efficiently increasing population (Hartemann 2013Hartemann Bensimon Payan C.A. Jacqueminet Bourron O. Nicolas N. interleukin 2 diabetes: phase 1/2 randomised, double-blind, placebo-controlled trial.Lancet Diabetes Endocrinol. 1: 295-305Abstract (248) Using similar approach, we reported partial regrowth 4 5 (Castela 2014Castela Le Duff Butori C. Ticchioni Hofman Bahadoran al.Effects recombinant T-regulatory areata.JAMA 150: 748-751Crossref (0) We conducted multicentric randomized trial 52-week follow-up period adult scalp. was registered French Health Authorities (Agence Nationale de Sécurité du Médicament registration number: 150355A-42) institutional review board Sud Méditerranée V (registration 15.039). Written informed consent obtained all patients. Patients received total four cycles subcutaneous or saline serum. Severity Tool score used primary criteria assess efficacy. NK carried out at baseline; final day fourth cycle; 1, 3, 6, 12 months (Supplementary Materials Methods). 43 were randomized, whom 21 assigned receive 22 placebo. Nine did not complete study. flow diagram baseline characteristics presented Supplementary Figure S1 Table S1, respectively. At after end treatment, 50% reduction achieved 14.3% group versus 9.1% placebo (P = 0.66) intention-to-treat analysis. evolution during 1. No significant observed groups body nails. Dermatology Life Quality Index satisfaction change significantly between 6 groups, no statistical difference two Tables S2 S3). Adverse events encountered S4 S5. Flu-like syndrome most frequent adverse event group, 66.7% presenting symptoms least once compared 13.6% 0.0005). Eosinophilia eight (38.1%) arm none 0.0014). All side effects transient. (CD3+CD4+CD25++CD127low) increased time points (except months); last cycle 0.0063); month < 0.0001), 0.0012), 0.084) (Figure 1a). variation any point baseline. Similarly, ratio 0.0004, P 0.0001, 0.0013, 0.0051 months, respectively) 1b). increase only involved naive subpopulation (CD45RA+ CD197+) 0.005, 0.0123, 0.0077, 0.08 1c). relative percentage central memory (CD45RA− 1d), effector CD197−) 1e), CLA+ CCR4+ CCR10+ DR+ 1f) decreased arm. absolute number points, other subtypes Tregs. transiently but treatment; however, reach significance 0.08). count then returned levels comparable S2a). Analysis CD158 (KIR) CD314 (NKG2D) markers showed that 158+/314− corresponded subset influenced by IL-2, decrease 0.036), 158–/314+ without reaching statistically level 0.23) S2b–e).Table 1Evolution SALT ScoreW0 (n 22)W3 22)W6 22)W9 22)1 MonthFollow-Up 22)3 MonthsFollow-Up 22)6 22)12 12)Placebo, median (IQR)84 (56.6–100)81.9 (61.9–100)81 (68.4–100)80.1 (67.4–100)91.5 (44.8–100)93 (44.8–100)82.9 (48.2–100)72.2 (44–100)W0 21)W3 21)W6 21)W9 21)1 21)3 21)6 21)12 21)Low-dose (IQR)100 (76.4–100)100 (69.5–100)100 (61.2–100)100 (64.4–100)100 (90–100)96.8 (70.3–100)Abbreviations: IQR, interquartile range; LOCF, Last Observation Carried Forward; SALT, Tool; W, week.W0: Baseline; W3, W6, W9: weeks 9, respectively, treatment. Data imputed using LOCF. Open table new tab Abbreviations: week. W0: Despite encouraging pilot initially Scholar), large prospective further support efficacy treating regimen elicit proliferation recruitment However, despite Tregs, stimulate regrowth. mild transient does involvement failure limitation overall subset, populations homing capabilities, probably explains, partially, lack AA. New generations long-lived more specific currently developed tested early stages several inflammatory disorders (Peterson 2018Peterson L.B. Bell C.J.M. Howlett S.K. Pekalski M.L. Brady Hinton al.A mutein activates expands therapy disease.J Autoimmun. 95: 1-14Crossref (47) Our emphasize importance characterization different necessity assessing if expanded express tissue setting organ-specific diseases. raw available on reasonable request Dr Eric Fontas ( [email protected] ) research purposes only. This ClinicalTrials.gov (NCT01840046). Florence Duff: http://orcid.org/0000-0002-0540-4990 Jean-David Bouaziz: http://orcid.org/0000-0002-4993-2461 Fontas: http://orcid.org/0000-0002-1849-9626 Michel Ticchioni: http://orcid.org/0000-0002-9949-0411 Manuelle Viguier: http://orcid.org/0000-0001-9049-8700 Olivier Dereure: http://orcid.org/0000-0001-8736-1922 Pascal Reygagne: http://orcid.org/0000-0002-6062-2122 Henri Montaudié: http://orcid.org/0000-0002-0528-4829 Jean-Philippe Lacour: http://orcid.org/0000-0001-7663-2053 Sandrine Monestier: http://orcid.org/0000-0003-4189-3127 Marie-Aleth Richard: http://orcid.org/0000-0002-0870-9132 Thierry Passeron: http://orcid.org/0000-0002-0797-6570 Novartis provided Proleukin discounted price authors state conflicts interest. funded Programme Hospitalier Recherche Clinique Région SUD . Conceptualization FLD, MT, JPL, TP; Curation: EF, Formal Analysis: Funding Acquisition: Investigation: JDB, MV, OD, PR, HM, SM, MAR; Methodology: EF; Project Administration: Resources: Software: Supervision: Validation: Writing - Original Draft Preparation: Review Editing: MAR, TP nationwide Departments Nice, Paris, Marseille, Reims, Montpellier University Hospitals January 2016 February 2019. (ANSM NCT01840046). main objective compare low doses year follow-up. secondary objectives QOL, patient’s satisfaction, hair, tolerance also assessed. diagnosis (ophiasis, totalis, universalis forms) defined severe, is, affecting scalp aged 18 60 considered inclusion. flare must have occurred less than years before Any topical (topical steroids, calcineurin inhibitors, minoxidil) should been discontinued Phototherapy treatments (systemic ciclosporin, methotrexate, immunosuppressive drugs) stopped Contraindication IL-2; pregnant breast feeding women; positive status HIV, virus, virus; kidney liver insufficiency; infection exclusion criteria. Each included five consecutive days injections either aldesleukin (Proleukin, Novartis, Basel, Switzerland) serum according randomization, followed 16 additional injection. During first cycle, 1.5 MUI/day used, three cycles. (Olsen al, 2004Olsen V.H. Roberts J.L. Shapiro Canfield investigational assessment guidelines--Part II. National Areata Foundation.J Am Acad 51: 440-447Abstract assessed independent physicians standardized pictures consensus-based matter (HM, TP). indicator success, completion calculated arms endpoint. nail (when applicable) investigator global semiquantitative scale: −1, worsening; 0, change; slight improvement; 2, moderate marked 4, quality life calculation. graded visual analog scale. each visit Institute classification. Blood samples injections. Additional analyses performed cycle. count, test, urea, creatinemia analyzed points. Flow cytometry lymphocyte, cell, collected EDTA labeled within 48 hours. Briefly, immunophenotypical 8-color (FACSCanto II, BD Biosciences, San Jose, CA). following antibodies study: FITC-conjugated CD16, CD56, CD8, CD162; phycoerythrin-conjugated CD25 CD152b; peridinin chlorophyll protein-Cy5.5–conjugated CD4; phycoerythrin-Cy7–conjugated CD19 CD127; allophycocyanin-conjugated CD45RA, HLA-DR, CD314; allophycocyanin-H7–conjugated CD3; V450-conjugated CD197; BV421-conjugated CD194, CCR10; V500-conjugated CD45, purchased Biosciences. Instrument set up France Standard Operating Procedures (Solly 2019Solly Angelot-Delettre Geneviève Rambaud Baseggio al.Standardization cytometric immunophenotyping hematological malignancies: FranceFlow Group experience.Cytometry 1008-1018Crossref (12) Identification done combination scatter forward properties CD45 expression. gating strategy based CD3+CD4+ CD3+CD8+ lymphocytes, gate CD127wkCD25+ being negative control (Liu 2006Liu W. Putnam A.L. Xu-Yu Z. Szot G.L. Lee M.R. Zhu al.CD127 inversely correlates FoxP3 suppressive reg cells.J 203: 1701-1711Crossref (1996) Subpopulations naive, memory, effector, identified CD45RA CD197 (Maecker 2012Maecker McCoy Nussenblatt Standardizing Human Immunology Project.Nat Immunol. 2012; 12: 191-200Crossref (626) According literature, anticipated success rate 10% (Delamere 2008Delamere F.M. Sladden M.M. Dobbins H.M. Leonardi-Bee Interventions areata.Cochrane Database Syst Rev. 2008; : CD004413PubMed Assuming our preliminary (145) 80% power, 5% I error, bilateral hypothesis, 25 per needed. lost follow-up, effective 56 retained. randomly 1:1 randomization process centralized methodological center Nice Hospital. list established blocks method nQuery Advisor v7.0. outcome modified principle. who underwent took one dose medication submitted Missing values Forward procedure. Per-protocol performed, considering completed entire violation protocol adequate compliance (at 20 scheduled). First, (50% infusion) Fisher exact test. Then, nails Wilcoxon rank sum Covariance inclusion 12, adjusted value score. Satisfaction measured Student’s t-test, rates lymphocyte subpopulations t-test paired data. Two-sided P-values 0.05 significant. Statistical SAS Enterprise Guide software, version 7.1 (SAS Institute, Inc, Cary, NC). D, day; Diff, difference; DLQI, Index; M, month. D0 represents 0. M6 6-month M12 12-month M3 3-month n event.