Myopathies Inflammatoires, nouveaux Myopathies Inflammatoires, nouveaux concepts, nouveaux traitementsconcepts, nouveaux traitements

Olivier BenvenisteDepartment of Internal Medicine

Institute of MyologyPitié-Salpêtrière Hospital

Paris

First myositis classification

1. Symmetrical proximal muscle weakness;2. Muscle biopsy abnormalities :

1. Muscle fiber destruction and regeneration; 2. Perivascular and interstitial inflammatory infiltrates with muscle fiber

destruction. 3. Elevation of CPK, Transaminases, LDH or aldolase activity;4. Electromyography changes:5. Typical skin rash.

• DEFINITE: any 4 of the criteria• PROBABLE: any 3 of the criteria

Neurology, 1995

EMG, MRI, auto-Abs

IMNM

Necrosis + regeneration without inflammation

New classification of myositides

• Dermatomyositis, 30% paraneoplastic

• Inclusion body myositis

• Polymyositis

• Overlap myositis (Troyanov)– Myositis associated to a connective tissue disease– Myositis with associated Abs (PmScl, Ku …)– Myositis with specific Abs (anti-synthetases, anti-SRP…)

• Immune mediated necrotizing myopathies (Hoogendijk)with anti-SRP+, anti-HMGCoA Reductase+ (post-statines), or paraneoplastic

First attempt of classification based on autoantibodies

Medicine, 2005

Use of commercial line blot assays

12 Abs

15 Abs

MDA‐5TIF‐1γ

CancerJo‐1

PL‐7

PL‐12

EJ

OJ

Ku

PM‐Scl

U1‐RNP

SAE

HMGCR

SRP

Mi‐2NXP2

Overlap

 Myositis

Derm

atomyositis

Immune M

ediated Necrotizing M

yopathy

Inclusion Body Myopathy

5’‐Nucleotidase

KS

Zo

YRS

ASA

ILDCancer

MDA‐5TIF‐1γ

CancerJo‐1

PL‐7

PL‐12

EJ

OJ

Ku

PM‐Scl

U1‐RNP

SAE

HMGCR

SRP

Mi‐2NXP2

Overlap

 Myositis

Derm

atomyositis

Immune M

ediated Necrotizing M

yopathy

Inclusion Body Myopathy

5’‐Nucleotidase

KS

Zo

YRS

ASA

ILDCancer

First description

1980

31%

Target of anti-Jo-1 Abs

Inhibition of histidyl-tRNA synthesis

Effect Kinetic

First series of cases

Myositis + interstitial pneumonia + Raynaud’s phenomenon + mechanic’s hands + arthritis = anti-synthetase syndrome

n=29-19 anti-Jo-1-4 anti-PL7-6 anti-PL12

Anti-synthetase Abs

• anti-aminoacyl-t-RNA-synthetase Abs:- Anti-JO1 (histidyl t-RNA),- PL7 (threonyl t-RNA), - PL12 (alanine t-RNA), - OJ (isoleucil t-RNA),

- EJ (glycyl t-RNA) etc…

• ANA

• Line blot assay

J Rheumatol 2012

• Follow-up: 4,5 years

– No need of DMARD: 14 patients (29%)

– Need of DMARD: 34 patients (71%)

• Predictive factors of DMARD need:

– Mechanic’s hands: p=0.02

– high CK (6000 vs. 1000): p=0.002

– NSIP score (7 vs. 4): p=0.04

– TLV (57% vs. 70%): p=0.02

PINS

233 patients

First description of Pathology

n=11

Perymisium disease (IMPP): fragmentation and inflammation (rich in macrophages)

Specificity and sensitivity of pathological criteria for anti-Jo-1+ patients

• Paris’ series of muscle biopsies: n=53• Berlin’ series of muscle biopsies: n=19• Controls

– DM: n=17– IMNM: n=21– sIBM: n=16

Collaboration with:Yves Allenbach, Baptiste HervierWerner Stenzel

1. Perifascicular necrosis (not observed in DM nor PM)

2. Perifascicular atrophy (DM like)

1 2

3. Perimysial fragmentation (alcaline phosphatase)

4. Perifascicular deposition of C5b9 at the sarcolemnal level

C5b9

3 4

5. Perifascicular HLA class I renforcement (DM like)

6. Perifascicular infiltrates with endomysial invasion (PM like)

CD8+

5 6

HLA I

Table 2: Perifascicular pattern in Jo-1 and DM patients

Pathologic features

DM

(n=20)

Jo-1

(n=19)

Myofiber necrosis in PF regions 7 (35%) 15 (79%)**

Myofiber atrophy in PF regions 17 (85%) 12 (63%)*

Perimysial fragmentation 9 (45%) 14 (74%)

Perimysial inflammatory infiltrates 20 (100%) 19 (100%)

HLA enhancement in PF regions 17 (85%) 15 (79%)

Sarcolemmal positivity for C5b9 in PF regions 10 (50%) 14 (74%)

*p <0.05; **p <0.01 calculated after multivariate analysis

NOD.Idd3/5 mice immunized with murine or human Jo-1 develop muscle inflammation and interstitial lung disease

Conclusion 1

• Clinico-pathological sign assembly defining an homogenous group

of patients

• Specific biomarkers = anti-synthetase autoantibodies

• Model in mice

• Correlation between biomarker levels and disease activity

Define an independent disease:

The anti-synthetase disease!

• Not a syndrome, not a PM nor a DM!

Criteria for anti-synthetase disease

Item Sub-Item(s) Weight/Score

Inflammatory myopathy - Proximal weakness- High CK level- Compatible muscle pathology

Interstitial Lung Disease - NSIP- UIP

Skin - Mechanic’s hands- Rash

Raynaud’s phenomenon

Joint pain - Arthralgia- arthritis

Antisynthetase autoAbs Anti-Jo-1 (PL1), PL7, PL12, OJ, EJ…

To be determined: score with its specificity and sensitivity

MDA‐5TIF‐1γ

CancerJo‐1

PL‐7

PL‐12

EJ

OJ

Ku

PM‐Scl

U1‐RNP

SAE

HMGCR

SRP

Mi‐2NXP2

Overlap

 Myositis

Derm

atomyositis

Immune M

ediated Necrotizing M

yopathy

Inclusion Body Myopathy

5’‐Nucleotidase

KS

Zo

YRS

ASA

ILDCancer

First description

• PS3-273 / #261 - Redefining the immune histolochemical pattern of Anti-SRP auto-antibody positive patients: a subgroup presents significant inflammation.Yves Allenbach (Berlin, Germany)

• Signal Recognition Particule

• ANA

• Commercial line blot assay

Anti-SRP Abs

54

TranslocationER

First series of cases

• 13 PM patients

• « Some of these cases were unusually severe and/or of rapid onset »

• « Anti-SRP antibodies may serve as a marker for a second (after Jo1),

distinct subgroup of adult PM »

– 7 patients with severe myopathy – ± cardiomyopathy (30%)– High CK level (> 10 000 U/L) – Sometimes skin rash or interstitial lung disease– Muscle fiber necrosis and regeneration and little or no

inflammationC5b9HE

EMG, MRI, auto-Abs

IMNM

Necrosis + regeneration without inflammation

P 0 002

PATHOGENIC ROLE OF ANTI-SRP AUTOANTIBODIES IN IMMUNE-MEDIATED NECROTIZING MYOPATHY

Running title: PATHOGENICITY OF ANTI-SRP AUTOANTIBODIES

Laurent Drouot,1,2* Coralie Bloch-Queyrat,3* Louiza Arouche-Delaperche,4,5 Yves Allenbach,3,4,5 Jérémie

Martinet,1,2,6 Thierry Maisonobe,7 Serge Herson,3,4 Lucille Musset,8 Gillian Butler-Browne,5 Olivier

Boyer,1,2,6 Olivier Benveniste3,4,5

1 Inserm, U905, Rouen, France

2 Normandy University, IRIB, Rouen, France

3 Assistance Publique - Hôpitaux de Paris, Pitié-Salpêtrière University Hospital, Department of Internal

Medicine and Clinical Immunology, Hospital University Department: inflammation, immunopathology and

biotherapy (DHU i2B) Paris, France

4 Sorbonne Universités, University Pierre et Marie-Curie-Paris 6, Paris, France

5 Myology Research Center UMR 974, Inserm, U974, Paris, France

6 Rouen University Hospital, Laboratory of Immunology, Rouen, France

7 Assistance Publique - Hôpitaux de Paris, Pitié-Salpêtrière University Hospital, Department of

neuropathology, Paris, France

8 Assistance Publique - Hôpitaux de Paris, Pitié-Salpêtrière University Hospital, Laboratory of

Immunochemistry & Autoimmunity, Paris, France

Patient’s sera Purified IgG

Purifier anti-SRP Purifier anti-SRPIncubated with

rSRP (p54)

MonoclonalAnti-SRP

2nd Antibody

Human muscle (p54)

1 and 3: colomn affinity-purified human anti-SRP

2 and 4: commercial goat anti-SRP Ab

Atrophic effect of anti-SRP Abs on human myotubes

• PS3-278/#311 Effects of auto-antibodies anti- signal recognition particle (SRP) and anti-Hydroxyméthylglutaryl-CoA reductase (HMGCR) on muscle cells. Louiza Arouche-Delaperche (Paris, France)

*** P<0.001

** P<0.01, *** P<0.001

* P<0.05, ** P<0.01, *** P<0.001

C57BL/6 Rag-/- mice

*** P<0.001

HE

anti-human IgG Ab

anti-H-2Kb Ab(MHC-I)

Anti-C5b9

Anti-NCAM

Merge

Anti-SRP purified IgG

Anti-SRP aAbs from IMNM patients can:

1. Recognize their muscle molecular target at the level of the ER

2. Trigger in vitro atrophy of differentiated myotubes

3. Induce a muscle disease after passive transfer to recipient mice

Anti-SRP are pathogenic

Conclusion 2

• Clinico-pathological sign assembly defining an homogenous group

of patients

• Specific biomarkers = anti-SRP autoantibodies

• Pathogenicity of the anti-SRP autoantibodies

• Model in mice

• Correlation between biomarker levels and disease activity

Define an independent (humoral mediated) disease:

The anti-SRP disease!

• Not a syndrome, not a PM nor a DM!

MDA‐5TIF‐1γ

CancerJo‐1

PL‐7

PL‐12

EJ

OJ

Ku

PM‐Scl

U1‐RNP

SAE

HMGCR

SRP

Mi‐2NXP2

Overlap

 Myositis

Derm

atomyositis

Immune M

ediated Necrotizing M

yopathy

Inclusion Body Myopathy

5’‐Nucleotidase

KS

Zo

YRS

ASA

ILDCancer

Arthritis, Sept 2010

• 225 patients

• 38 necrotizing myopathies- 4 anti-synthetase- 6 anti-SRP

- 16 anti-p200/100

• ELISA HMGCR : 100% + patients anti-p200/100

• Specificity :

Immunoprecipitation

W blot

Medicine 2014

Characteristics of the patients

Parisn=45

Baltimoren=50

Age (year) 49 ± 22 52 ± 16

Patients < 16 5 2

Women 81% 62%

Statines + 44% 72.7%

First signs:- Muscle weakness: 87%- Isolated increase of CK: 13% (n=5)

•Age: 11-77 years old

•Majority of – Women

– Statine free patients

•Heterogeneous myopathic presentation– Asymptomatic (high CK): 13%

– Rapidly progressive (<6 mo): 47%

– Slowly progressive (LGMD like): 20%

•Immunosuppressant resistance

Conclusions: HMGCoAR+ patients from Paris

Auto-Abs and dermatomyositis

Anti-Mi-2

• Ac anti-Mi-2 :

• 1st description in1976, USA (Reichlin M, Clin. Immunol. Immunopathol. 1976):• Only DM, 20% of DM…• DM « dermatitis », corticosensitive• Few or no association with cancer

• Complexe Mi-2/NuRD :

• Epigenetic regulator• x fonctions

Ramirez J, Epigenetics, 2009

Arthritis 2006

• Negative predictive value: 93%• OR = 18 [95% IC 8-40]

Selva-O’Callaghan, Curr Opin Rheumatol, 2010

Rheumatology 2010

p155/140 = TIF1-γ = TRIM33 = Ret-fused gene 7 = PTC 7 = ectodermin

Arthritis 2005

Rheumatology 2010

p140 = melanoma differentiation-associated gene 5 = MDA5

J AM Acad Dermatol, 2011

• Fatigue, weight loss (-10 kg en 2 mo.)

• No fever

• Arthralgia (hands)

• Mechanic hands

• Palpebral oedema

• Dyspnea NYHAII, caugh+++

• Myalgia

37 years old patient

20

30

40

50

60

70

80

90

100

mai-11 Aout 2011 oct-11 janv-12 mars-12 mai-12 aout 2012 janv-13 juil-13

CVFCPTDLCO/VATest MarchePaO2

CT 60 CT 60MTX MTX CYP 5X

PE 5X

CT 60 CT 50 15 10 8

CICLOSPORINE

93-100%

65-100%

40-85%

20-50%

Death: 12-37%

In France: 6/28 (35%)

Hamaguchi al. 2012

5 series of anti-MDA5 patients

Mi2

Tif-1γ

MDA5

Gono T, Rheumatol. 2010Hoshino K, Rheumatol. 2010Hamaguchi Y, Arch Dermatol. 2011Hall JC, Arthritis Care Res. 2013

Pred 60 mg

7

IVIg

AZA 100

3815

N

360

Sept2008

Dec2008

May2009

Nov2011

Jan2012

Feb2013

May2011

Oct2009

5

//

Relapse

100150

Myalgia+++Swallowing

//

Livedo Ecchymosis

Ulcerations

Feb2012

Mar2012

MTX 20

Jun2012

14

Fistulisationcalcification

T2 STIR

12/2008 12/2011 04/2012Calcifications

Three patients with anti-NXP2 Abs

Dermatomyositis with anti-NXP2-AbAssociation with cancers ?

Arthritis & Rheumatology 13

MDA‐5TIF‐1γ

CancerJo‐1

PL‐7

PL‐12

EJ

OJ

Ku

PM‐Scl

U1‐RNP

SAE

HMGCR

SRP

Mi‐2NXP2

Overlap

 Myositis

Derm

atomyositis

Immune M

ediated Necrotizing M

yopathy

Inclusion Body Myopathy

5’‐Nucleotidase

KS

Zo

YRS

ASA

ILDCancer

Neurology 2014

• Finger flexor or quadriceps weakness, and

• Endomysial inflammation, and

• Invasion of nonnecrotic muscle fibres or rimmed vacuoles

→ 90% sensitivity and 96% specificity

Aims: diagnosis criteria and outcomes for clinical trials

Acta Myologica, 2011; 30: 103‐8

Definite IBM

(n=17)

Possible IBM

(n=19)

PM/DM

(n=7)

Dystrophies

(n=8)

Controls

(n=6)p62 100% 33% 14%

(PM)0% 0%

TDP43 100% 33% 0% 0% 0%

SMI 31 93% 8% 0% 12.5%(Bethlem)

0%

Ubiquitin 81% 33% 28.5%(PM/DM)

12.5%(Dysf)

0%

Beta A4 12.6% 0% 0% 0% 0%APP 12.5% 0% 0% 0% 0%SMI 310 6% 8% 0% 0% 0%

Fine-tuning of the pathological diagnosis

Natural history

OnsetDiagnosis

=Walk support

Wheelchair Death

5 y. 9 y.

61 y. 66 y. 75 y. 80 y.

• 71 patients received Pred ± IVIg or MTX or Azat, during 3.5 years• 65 patients were untreated and were finally less severely disabled!

sIBMsIBMsIBMsIBMsIBMsIBMsIBMsIBMsIBMsIBM

sIBMsIBMsIBMsIBMsIBMsIBMCtrlCtrlCtrl

sIBM

CtrlCtrl

Ctrl

Ctrl

CtrlCtrl

CtrlCtrlCtrl

CtrlCtrlCtrl

sIBM

CtrlCtrl

CtrlCtrl

CtrlCtrlCtrl

sIBMsIBM

sIBMsIBM

IL-8

CCL-

3

CXCL

-10

CXCL

-9

IL-1

RA

IL-1

2

CCL-

2

sIBM: Th1 Signature and Treg deficiency

Positive Predictive Value

91%

Hierarchical clustering analysis of the 7

significant parameters after Benjamini-

Hochberg correction

Th1 SignatureLuminex analysis on serum samples

FoxP3CD4Dapi

Y Allenbach: PlosOne 2014

Allenbach et al., Am J Pathol 2009

Myosin in IFA

D0 D7 D24D14

Purified myosin in CFA +

Pertussis toxin Myosin in IFA

First Model of Autoimmune Experimental Myositis

0

0.5

1

1.5

2

2.5

3

3.5

Gastrocnemius Quadriceps Triceps

*

*

0

0.5

1

1.5

2

2.5

3

3.5

Gastrocnemius Quadriceps Triceps

EAM with Treg DepletionEAM Control

EAM and Treg depletionEAM l

**

Transfer

Effect of Rapamycin in our model

PBS 1mg 3mg PBS 1mg 3mg

2.5E7

B c

ells

T ce

lls

CD

4+

CD

8+

PBSRapa 3mg

Cel

l cou

nt

1.5E7

0.5E7

% o

f Tre

gs

PBS Rapa 3mg

N Prevel: Plos One 2014

Inclusion criteria:

18 y.o.Defined IM

Exclusion Criteria:• Allergy to rapamycin

• Intolerance to rapamycin

Rapamycin or placebo

0,3 mg/Kg

For 12 months

n=44

Pre-studyobservation

D0 D10 M1 M2 M3 M6 M12M9

Clinical Evaluation of Muscle Strength• MRC scale• RMI scale• Walton scale• IWCI• IBMFRS

Clinical Research Evaluation• Myometric study of quads• Whole body IRM

TOLERANCE• Clinical evaluation• Biological evaluation

Mode D’action• Facs• Dosage of cytokines• Treg

MRI

Translational Medicine 2012 DGOS-Inserm

MRI

Efficacy and Safety of Bimagrumab/BYM338 at 52 Weeks on Physical Function, Muscle Strength, Mobility in sIBM Patients (RESILIENT)

Phase 2, 3: 240 patientsSponsor: Novartis Pharmaceuticals ClinicalTrials.gov Identifier: NCT01925209

ClinicalTrials.gov

AcknowledgementsInternal MedicinePitié-SalpêtrièreParis

Y AllenbachB HervierA RigoletS Herson

Institute of MyologyPitié-SalpêtrièreParis

B EymardP LaforetT StojkovicA Behin

Neuro-muscular CentreOxford

D Hilton-Jones

NeuropathologyLa CharitéBerlin

W Stenzel

NeuropathologyPitié-SalpêtrièreParis

T MaisonobeS LouisN Romero

ImmunologyInserm U 905Rouen

L DrouotO Boyer

Team: Inflammatory MuscleInserm U 974Pitié-SalpêtrièreParis

F MingozziE MasatN PrevelL AroucheD Amelin