The Charcot Project: Antiviral Therapies for MS

Gavin Giovannoni

Version 2.0

Disclosures

Over the last 15 years I have received personal compensation for

participating in advisory boards in relation to clinical trial design, trial steering

committees, and data and safety monitoring committees from: Abbvie,

Almirall, Atara Bio, Bayer-Schering Healthcare, Biogen, Canbex, Eisai, Elan,

Fiveprime, Genzyme, Genentech, GSK, GW Pharma, Ironwood, MSD, Merck

Serono, Novartis, Pfizer, Roche, Sanofi, Synthon BV, Teva, UCB Pharma and

Vertex Pharmaceuticals

The case for MS being due to a virus

To cure MS do we need to know the cause?

EBV, HERVs, etc.

Vitamin D, Obesity (? diet)

Smoking, organic solvents

Genes(HLA,....)

The MS dogma

immune activation

innate and adaptive responses

focal inflammation

BBB breakdown

oligodendrocyte toxicity & demyelination

Acute axonal transection and loss

“autoimmune endophenotype”

axonal plasticity &

remyelination

delayed neuroaxonal loss and gliosis

Gd-enhancement

T2 & T1 lesions

brain & spinal cord atrophy

release of soluble markers

Clinical Attack

Disease Progression

Clinical Recovery

pathobiology

clinical outcomes

biomarkersPremature Ageing

Genetics Environment Chance

VIRUS(EBV, HERVs)

.

Epidemics or clusters of MS

• No documented cases of MS

on the Faroe Islands until

after World War II

• 55 cases since 1940

• Occupied during World War

II

• Authors concluded that this

was evidence of an MS

epidemic caused by an agent

introduced by the troops

• However a number of

concerns remain

The annual incidence of MS (per 100 000

inhabitants) in the Faroe Islands since 1940

Kurtze et al 1993

0

2

4

6

8

10

12

1940 1945 1950 1955 1960 1965 1970 1975 1980 1985 1990

Relapsing and Remitting Multiple Sclerosis: Pathology of the Newly Forming Lesion

Barnett & Prineas. Ann Neurol 2004;55:458–468

Magnetization Transfer Changes in the Normal Appearing White Matter Precede the Appearance of Enhancing Lesions in Patients with Multiple Sclerosis

Filippi et al. Ann Neurol 1998;43:809-814

Bermel et al. Ann Neuol 2012.

Predictors of long-term outcome in MSers treated with interferon beta-1a

REBOUND ACTIVITY AFTER NATALIZUMAB/FINGOLIMOD WITHDRAWAL

Rigau et al. Neurology 2012;79:2214-6.Alroughani et al. BMJ Case Rep. 2014 Oct 15;2014. pii: bcr2014206314.

REBOUND AFTER NATALIZUMAB WITHDRAWAL

Rigau et al. Neurology 2012;79:2214-6.

Serafini et al. J Neuroimmunol. 2017 Jun 15;307:14-17.

Massive intracerebral Epstein-Barr virus reactivation in lethal

multiple sclerosis relapse after natalizumab withdrawal.

● Highly-active RRMS, severe

neurologic impairment (EDSS 7)

● Treated with natalizumab - EDSS 4.5

● Due to severe depression, stopped

Nz after 37 infusions.

● 3½ months later rapid disease

worsening

● Brain MRI showed >50 T2-lesions,

mostly Gd-enhancing

● JCV-PCR -ve in CSF

● Rapidly worsened, died d17

● PM active MS rebound

● JCV-PCR -ve in brain

Which virus?

Infectious agents in MS

. Ramagopalan et al 2009

MS IM

Ramagopalan et al, 2011

Pearson r = 0.70, p=0.000025

Infectious Mononucleosis and MS

Infectious mononucleosis

Handel et al. 2010.

Small OR19,390 MS patients and 16,007 controls, p < 10-54

EBV Seropositivity titres

99.2% vs 90.2%

. Ascherio et al, 2000

Odds ratio of MS in subjects seronegative for EBV

Ascherio et al, 2007

Primary infection with the EBV and risk of MS

• Nested case-control study including from over 8 million military personnel with serum stored in the Department of Defense Serum Repository.

Levin et al. Ann Neurol 2010.

MS

Controls N = 610

N = 30510/305 (3.3%) EBV –ve

32/610 (5.2%) EBV –ve 10/28 (35.7%) EBV –ve

10/10 (100%) EBV –ve

• MS risk is extremely low among individuals not infected with EBV, but it

increases sharply in the same individuals following EBV infection.

.Levin et al. Ann Neurol 2010.

“Evidence” or “lack of evidence”

The ugly fact

“The great tragedy of Science; the slaying of a beautiful hypothesis by an ugly fact.”

Thomas Henry Huxley

Viral serologies in children with MS

Banwell et al. Lancet Neurology, Sept. 2007

?

Coherence with prior knowledge

Compston & Coles, Lancet 2008.

Epidemiology

worldwide distribution & migration studies

Genetics of MS: the rate of MS in females is increasing

1Orton SM et al. Lancet Neurol 2006;5:932–936.

Smoking is a risk factor for MS

Handel et al. PLoS One. 2011 Jan 13;6(1):e16149.

Ramagopalan et al. Arch Neurol 2011; 68:469-72.

Biological plausibility

EBV & Disease Activity

Farrell et al. Neurology 2009

EBNA-1

NOT

VCA or EA

Dysregulated EBV infection in the MS brain

Serafini et al. J Exp Med. 2007 Nov 26;204(12):2899-912.

Follow-up studies

1. Torkildsen O, et al. Upregulation of Immunoglobulin-related Genes in Cortical Sections

from Multiple Sclerosis Patients. Brain Pathol. 2009 Oct 16. [Epub ahead of print]

2. Willis SN, et al. Epstein-Barr virus infection is not a characteristic feature of multiple

sclerosis brain. Brain. 2009 Dec;132(Pt 12):3318-28.

3. Peferoen LA, et al. Epstein Barr virus is not a characteristic feature in the central nervous

system in established multiple sclerosis. Brain. 2010 May;133(Pt 5):e137. Epub 2009 Nov

16.

4. Lassmann et al. Brain. 2011 Sep;134(Pt 9):2772-86. Tzartos et al. Neurology. 2012 Jan

3;78(1):15-23.

5. Tzartos et al. Neurology. 2012 Jan 3;78(1):15-23.

6. Serafini et al. J Neuropathol Exp Neurol. 2014 Jul;73(7):729-31.

7. Serafini et al. Brain. 2013 Jul;136 (Pt7):e233. doi: 10.1093/brain/aws315.

8. Han et al. Molecular signature of Epstein-Barr virus infection in multiple sclerosis brain

lesions. ECTRIMS Online Library. Oct 27, 2017; 200600.

Innate immune activation is a hallmark of the active MS lesions

Tzartos et al., Neurology 2012.

Innate immune activation is a hallmark of the active MS lesions

Tzartos et al., Neurology 2012.

Intrathecal oligoclonal IgG bands (OCBs)

1. Rand KH, et al. (1998) Molecular approach to find target(s)

for oligoclonal bands in multiple sclerosis. J Neurol

Neurosurg Psychiatry 65:48-55.

2. Bray PF, et al. (1992) Antibodies against Epstein-Barr

nuclear antigen (EBNA) in multiple sclerosis CSF, and two

pentapeptide sequence identities between EBNA and

myelin basic protein. Neurology 42:1798-804.

3. Cepok S, et al. (2005) Identification of Epstein-Barr virus

proteins as putative targets of the immune response in

multiple sclerosis. J Clin Invest 115:1352-60.

4. Rand KH, et al. (2000) Epstein-Barr virus nuclear antigen-1

(EBNA-1) associated oligoclonal bands in patients with

multiple sclerosis. J Neurol Sci 173:32-9. C+ / S-

Analogy

Axthelm et al. Ann Neurol 2010

Japanese Macaque Encephalomyelitis:

A Spontaneous Multiple Sclerosis–like Disease in a Nonhuman Primate

HTLV-1 myelopathy

Experimental evidence

N Engl J Med 2008;358:676-88.

Please note rituximab is the only licensed anti-EBV drug!

Baker et al. EBioMedicine. 2017 Feb;16:41-50.

Saha & Robertson. DOI: 10.1158/1078-0432.CCR-10-2578 Published May 2011

EBV & B-cell

biology

Sir Bradford-Hill: Criteria for Causation

Bradford-Hill A. The environment and disease: association or causation? Proc Royal Soc Med 1966; 58:295.

1. CONSISTENCY AND UNBIASEDNESS OF FINDINGS - Yes (not 100%)

2. STRENGTH OF ASSOCIATION – ? / Yes (RR ~ 2 to 3)

3. TEMPORAL SEQUENCE - Yes

4. BIOLOGICAL GRADIENT (DOSE-RESPONSE RELATIONSHIP) - ? (not relevant to infections)

5. SPECIFICITY – No (not 100% other putative autoimmune diseases also associated with

EBV)

6. COHERENCE WITH BIOLOGICAL BACKGROUND AND PREVIOUS KNOWLEDGE - No

7. BIOLOGICAL PLAUSABILITY - Yes

8. REASONING BY ANALOGY - Yes

9. EXPERIMENTAL EVIDENCE - No

EBV is the cause of MS, but we don’t know how it causes MS!

Dual-viral hypothesis

Charcot Project: viral aetiology

HIV and lower risk of MS: beginning to unravel a mystery using a record-linked database study

Nexø et al. Epidemiology 2013; 24:331-2

Treatment of HIV and Risk of Multiple Sclerosis

Gold et al. JNNP August 4, 2014 as 10.1136/jnnp-2014-307932.

Raltegravir → RRMS (INSPIRE STUDY)ClinicalTrials.gov ID: NCT01767701

Endogenous retroelements and autoimmune disease

Volkman & Stetson. Nat Immunol 2014

HERV-W-Env Protein Pathogenicity

HERV-W-Env protein

The envelope protein of HERV-W

Typically not expressed in healthy individuals.

Abnormal expression triggered by environmental factors (EBV…)

Appears to be involved in Multiple Sclerosis pathogenesis.

Activation of TLR4 pathway

by HERV-W-Env

Immune system

➢ Inflammation

➢ Autoimmunity

Non-immune cells

➢ Endothelial cells: inflammatory

responses

➢ Schwann cells: inflammatory

responses

➢ Oligodendrocytes precursor cells:

differentiation / remyelination blockade

GNbAC1A monoclonal humanized antibody

neutralizing HERV-W-Env

Successful Phase I and Phase IIa clinical trials in MS indication

Currently in Phase IIb efficacy clinical trial

HERV-W-Env

HERV-W-Env – TLR4 signaling pathway

Perron H et al. Virology. 2001;

Rolland A et al. J Immunol. 2006;

Kremer D, et al. Ann Neurol. 2013

Duperray A et al. Int Immunol. 2015;

Madeira et al. 2016, J Neuro Immunol;

Faucard et al. 2015, Ebiomedic;

Curtin et al. 2016, MS Relat DisordSlide courtesy : Hervé Perron

▪ Phase I Study completed in January 2012/validated July 2012

Excellent safety profile; No immunogenicity; PK is dose linear; Half-life compatible with

monthly administration

GNbAC1 a Humanized IgG4 antibody

neutralizing HER-W Env in Clinical trials

Curtin et al. Clin. Ther. 2012

▪ Phase IIa 1 year Study in MS patients with monthly infusions completed in March 2014:

promising data for GNbAC1.

▪ Excellent safety profile; No immunogenicity; MRI stability and no progression, notably

in PMS

▪ Safe mode of action validated in patients: No modification of any physiological

immune function in one-year treated patients (Normal profile of immune cell sub-

popuplations and responses to Immunity test panel in all patients…)

▪ Beyond expected simple effects of an “toxin-neutralizing” antibody.

Curtin et al. Mult. Scler. 2014

▪ Phase IIb efficacy Study Started in 2016: 10 European countries; 320 patients;

ascending doses (6, 12, 18 mg/Kg) and placebo; 1 year Monthly injections;

patients.

▪ Final 1-year results expected in March 2018.

Slide courtesy : Hervé Perron

HERV-W genomic structure as sequenced from MSRV virions

May antiretroviral drugs inhibit the expression of HERV-

W genome when activated ?

Slide courtesy : Hervé Perron

HERV-W endogenous retroviruses and MS

Dolei, MSJ 2018, Vol. 24(1) 42–47.

Targeting HERVs

BioEssaysVolume 35, Issue 9, pages 794-803, 17 JUL 2013 DOI: 10.1002/bies.201300049http://onlinelibrary.wiley.com/doi/10.1002/bies.201300049/full#bies201300049-fig-0001

INSPIRE: Raltegravir (Isentress) Pilot Study in Relapsing MS

change in gradient

change

(in means)

V1

V2

(screening

before

visit)V3 V4 V5 V6 V7

V8 after

Raltegravir

dispensed

A statistically significant

change in means is not in

this situation consistentwith a reduction inoutcome values due to

intervention.Raltegravir → RRMS (INSPIRE STUDY)ClinicalTrials.gov ID: NCT01767701

Slide courtesy : Julian Gold

PREVENTION

DISEASE

MODIFICATION

1. Epidemiologists

2. Virologists

3. Genomics

4. Bioinformatics

5. Immunologists

6. Neurologists

7. Pharmaceuticals

EBV

? mutations

Conclusion: ‘The Charcot Project’- EBV & HERVs

Early infection

Late infection

Asymptomatic

seroconversion

Infectious

mononucleosis

At risk MS

vD/Sunlight Obesity

Genetics

Vaccine

IM Rx

Anti-EBV

HAART

HERVs

GNbAC1

Smoking

Diet

Arthur Schopenhauer

(1788 –1860)

All truth passes through three stages:

• It is ridiculed

• It is violently opposed

• It is accepted as self-evident

Is there a “Black Swan” flying in?

AcknowledgementsQMUL:

Ute Meier

Monica Marta

Sreeram Ramagopalan

Ruth Dobson

Jo Topping

Georgina Burrow

Cosimo Maggiore

Hadi Amir-Maghzi

Chris Hawkes

Klaus Schmierer

David Baker

Jack Cuzick

Nick Wald

David Holden

Oxford:

George Ebers

Sreeram Ramagopalan

Adam Handel

Giulio DeSanto

Epidemiology, Oxford:

Raph Goldacre

Michael Goldacre

David Yeates

The Albion Centre, Sydney:

Julian Gold

Hubert Maruszak

UCL:

Robin Weiss

Rachel Farrell

Jeremy Garson

VU Amsterdam:

Jaap Middeldorp

Sandra Amor

Edinburgh:

Dorothy Crawford

Karen McCauley

Aarhus University:

Tove

Christiansen