Introduction

Ozanimod regulates lymphocyte egress from the spleen and lymph nodes into the systemic circulation. The histologic changes which occur in the lymph nodes of patients on these therapies is unknown.

Aims & Methods

We aimed to describe histologic changes in lymph nodes from patients with UC who were treated with ozanimod and underwent subsequent colectomy due to treatment-refractory disease. This retrospective study included patients with UC undergoing total colectomy for treatment-refractory disease who were treated with ozanimod within the 2 months prior to colectomy and a cohort of patients with UC undergoing colectomy who did not have ozanimod exposure. Histology of the lymph nodes from the mesentery of colectomy specimens were reviewed blindly by a hematophatologist (JXC) and an expert GI pathologist (CRW). Histopathological parameters were scored and 2-tailed student’s unpaired t-test was used to determine significance between groups. Demographic and clinical data were recorded.

Results

From our series of 45 patients treated with ozanimod, 6 (13%) required surgery for treatment-refractory disease. Colectomy specimen data were available for 5 patients (1 patient had surgery at an outside center). Lymph node specimens from 6 control patients with UC who had colectomy were also examined. Demographic and clinical data are summarized in Table 1. The duration of ozanimod therapy prior to surgery ranged from 6 to 24 weeks. Histologic examination of lymph nodes showed that patients treated with ozanimod had significantly greater extent of dilated sinuses (p=0.03) and greater degrees of sinus histiocytosis (p=0.03) compared with control patients. In addition, there was a tendency towards more Castleman-like angiotrophic hyperplasia, plasma cell infiltration and subcortical interfollicular expansion in ozanimod treated patients (not statistically significant).

Conclusion

This study identifies unique histologic changes in the lymph nodes of patients with UC treated with ozanimod. These changes could be in keeping with the known mechanism of action of ozanimod and suggests that other inflammatory pathways were driving their disease activity in these patients. The significance of the changes, particularly the Castleman-like features, needs to be further investigated.

Disclosure

NAC has served as a consultant for Iterative Health, Takeda and Seres Pharmaceuticals and has received travel support from Pfizer.
CRW, JXC, DC, NMG, and NKC, have no relevant disclosures.
DTR has received grant support from Takeda; and has served as a consultant for AbbVie, Alimentiv Inc., Altrubio, Amgen, Arena Pharmaceuticals, Aslan Pharmaceuticals, Boston Consulting Group, Boehringer Ingelheim Ltd., Bristol-Myers Squibb, Buhlmann Diagnostics Corp., Celgene, ClostraBio, Connect BioPharma, Datos Health, EcoR1, Ferring Pharma, Genentech/Roche, Gilead Sciences, IBD RPM dba Chronicles Health, IAG, Iterative Health, Janssen Pharmaceuticals, Kaleido Biosciences, Lilly Eli & Co, Menten AI, Pfizer, Prometheus Biosciences, Reistone Biopharma, Sangamo Therapeutics, Shanghai Pharma Biotherapeutics USA, Syneos, Takeda, Target RWE, Techlab Inc., and Trellus Health.

Introduction

Celiac disease (CeD) is triggered by gluten peptides that bind to HLA-DQ2 or -DQ8 in the small intestine leading to gluten specific Th1 T cell expansion and villous atrophy. The oral transglutaminase 2 inhibitor Zed1227 blocks the deamidation of gliadin peptides, a prerequisite for effective gliadin antigen presentation. The CEC-3 clinical trial demonstrated that Zed1227 effectively prevented mucosal damage in 160 CeD patients in remission challenged with 3 g gluten daily for 6 weeks (Schuppan D et al, NEJM 2021).

Aims & Methods

We analyzed regulatory T cell (Treg) gene expression pre and post gluten challenge in the 100 mg/d Zed1227 vs placebo treated patients using RNAseq from the patients’ small intestinal biopsies (Dotsenko V et al, Nat Immunol 2024). We focused on genes of Treg subtypes and related cells. Subanalysis was performed via different gene set enrichments for Treg subsets, regulatory pathways and cell types. Genes that were enhanced in favorable vs unfavorable villous height to crypt depth (V/C) ratio outcomes, also after placebo treatment, were analyzed. We further analyzed pre-disposing genes before challenge, favoring a beneficial or negative post challenge V/C outcome.

Results

93% of the top 100 most significant regulatory genes were upregulated in Zed1227-treated patients compared to those treated with a placebo. These regulatory genes included TGF-beta signaling genes such as Smad7 and MERTK, cholesterol- and fatty acid related genes, such as ACAT1 and NPC1L1, specific autophagy/apoptosis related genes such as VPS35, SQSTM1, BMF, and inhibitory genes like SOCS2. Zed1227 treated patient samples with a maintained post challenge V/C ratio showed evidence for upregulated iTreg genes. Interestingly, Treg genes from placebo-treated subjects were upregulated in correlation with better inflammatory control under gluten challenge compared to worse control.
Moreover, in pre-challenge duodenal samples we identified protective genes that help maintain tolerance during gluten challenge, as reflected by a better post challenge V/C ratio. Examples are ubiquitin ligase RNF167, BAD, FOXN3, BAG1 and CLAUDIN15, whereas other genes like IRF9, CD96 and HLA-/TAP1 were predictive of a more pronounced V/C ratio decline after gluten exposure.

Conclusion

Our data derived from superbly analyzed pre- and post challenge duodenal biopsies demonstrate an active anti-inflammatory immune modulation, largely Treg cell mediated, in CeD in patients prior to and during gluten challenge. Zed1227 treatment potently activates this regulatory response. The balance of several beneficial vs detrimental predisposing Treg-related genes may play a causative role in the variable sensitivity of CeD patients to gluten exposure. Our data support future Treg based therapies to attenuate inflammation in CeD and other (intestinal) autoimmune diseases.

References

Schuppan, D., Mäki, M., Lundin, K. E. A., Isola, J., Friesing-Sosnik, T., Taavela, J., Popp, A., Koskenpato, J., Langhorst, J., Hovde, Ø., Lähdeaho, M. L., Fusco, S., Schumann, M., Török, H. P., Kupcinskas, J., Zopf, Y., Lohse, A. W., Scheinin, M., Kull, K., Biedermann, L., … CEC-3 Trial Group (2021). A Randomized Trial of a Transglutaminase 2 Inhibitor for Celiac Disease. The New England journal of medicine, 385(1), 35–45. https://doi.org/10.1056/NEJMoa2032441
Dotsenko, V., Tewes, B., Hils, M., Pasternack, R., Isola, J., Taavela, J., Popp, A., Sarin, J., Huhtala, H., Hiltunen, P., Zimmermann, T., Mohrbacher, R., Greinwald, R., Lundin, K. E. A., Schuppan, D., Mäki, M., Viiri, K., & CEC-3 Investigators (2024). Transcriptomic analysis of intestine following administration of a transglutaminase 2 inhibitor to prevent gluten-induced intestinal damage in celiac disease. Nature immunology, 25(7), 1218–1230. https://doi.org/10.1038/s41590-024-01867-0

Disclosure

V.D. and K.V. received funding from Dr. Falk Pharma to Tampere University to conduct the study. B.T., T.Z., R.M. and R.G. are employees of Dr. Falk Pharma. The data presented here are the subject of patent applications EP24173619.8 and EP24173615.6 filed by Dr. Falk Pharma, and B.T., T.Z., R.M., R.G., V.D. and K.V. are inventors on these applications. M.H. and R.P. are employees of Zedira. J.T. is a consultant for Jilab Oy and Dr. Falk Pharma. K.E.A.L. is a consultant for Amyra, Bioniz Pharmaceuticals, Chugai Pharmaceutical, Dr. Falk Pharma, Itrexon Actobios, TOPAS Therapeutics and Takeda California. D.S. is the data and safety monitor for Boehringer Ingelheim (Phil.) and is a consultant for the Dr. Falk Pharma, Takeda, Immunic, Sanofi and TOPAS Therapeutics. J.I. is the owner of Jilab Oy. M.M. is the founder, owner and Chair of the Board of Maki HealthTech (MHT). MHT receives Management/Advisory Affiliation fees from Dr. Falk Pharma and other funding not related to the research from Topas Therapeutics, Calypso Biotech, Vaccitech, ImmunogenX, Equillium and Immunic. MHT holds patents (patent number 7361480 (United States) and European Patent Office Number 1390753) licensed to Labsystems Diagnostics from where MHT receives royalties via Tampere University Hospital. All other authors declare no competing interests.